CMS-HCA-Florida-Lawnwood-Hospital

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Based on policy review, clinical record review and interview it was determined the facility failed to ensure quality of nursing care provided to each patient is in accordance with established standards of practice of nursing care, chapter 464.003(5). This failure affected 4 of 7 sampled patients (Patient #2, #4, #5, and #7) as evidenced by failure to reassess pain as specified in the facility policies and procedures and failure to follow prescription parameters for pain management.

The findings included:

Facility policy titled Assessment and Reassessment Plan revised 08/2017 documents the patient will be assessed and reassessed for pain according to the hospital policy for pain management.

Facility policy titled Pain Management revised 08/2017 documents All patients will be reassessed for pain within one hour after pain treatment/interventions have been administered.

Clinical record reviews conducted on 06/12/18 and 06/14/18 revealed the following:

1) Physician's Orders for Patient #2 dated 06/07/18 documents Percocet 5/325 mg every four hours as needed for pain level 4-6 and Morphine Sulfate 15 mg IR every 4 hours as needed for pain level 7-10.

Review of the Mediation Administration Records and Assessment and Reassessments documentation indicates the facility staff administered pain medication with disregard to pain level parameters and in some instances the facility staff failed to reassess the patient's pain level to monitor effectiveness of the drug administration.

On 06/09/18 at 1:25 AM the patient received Percocet for a pain level of 8

On 06/09/18 at 8:13 AM Percocet was administered and there is no evidence of pain reassessment

On 06/09/18 at 3:48 PM Percocet was administered and there is no evidence of pain reassessment

On 06/09/18 at 8:47 PM Percocet was administered for pain level of 7

06/10/18 at 2:18 AM Percocet was administered for pain level of 7

06/11/18 at 1:29 PM Percocet was administered for pain level 7

06/11/18 at 8:36 PM Percocet was administered for pain level 9

06/12/18 10:31 Percocet was administered for pain level 9

On 06/08/18 at 5:23 PM Morphine was administered and there is no evidence of pain reassessment

On 06/09/18 at 11:09 AM Morphine given for pain level of pain 6

On 06/09/18 at 6:37 Morphine given for pain level of 5

On 06/10/18 at 11:25 AM Morphine given and there is no evidence of pain reassessment.

The record provides no documentation as to why the parameters were not followed.

2) Patient #7 has physician's order dated 06/08/18 for Percocet 5/325 mg every four hours for pain scale 4-6.

On 06/08/18 at 12:38 AM, the patient received Percocet 5/325 for pain level of 8. The record has no explanation as to why the deviation from the prescription parameters.

3) Patient #4 has physician's order dated 03/18/18 for Toradol 15 mg every six hours for pain. On 03/18/18 at 10:23 AM the patient received the prescribed Toradol and there is no evidence of pain reassessment.

4) Patient #5 has physician's order dated 05/27/18 for Toradol 15 mg every six hours for pain. On 05/2718 at 11:03 PM the patient received the prescribed Toradol and there is no evidence of pain reassessment.

Interview with The Vice President of Quality and Risk Management and The Director of Patient Safety conducted on 06/14/18 at approximately 11:30 AM confirmed the nursing staff did not follow the prescribed parameters for pain medication administration and confirmed the entries lacking nursing reassessment after administration of pain medications.

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview and record review, the facility failed to ensure the nursing staff provided the necessary care and services for wound care for 2 of 10 sampled patients (Patient # 1 and # 2) as evidenced by the staff failure to perform the prescribed wound care as ordered and failed to use acceptable standards of nursing practice for infection control to prevent cross contamination during wound care.

The findings included:

1) Review of the clinical record for Patient # 1 disclosed the patient was admitted to the facility on [DATE] with a diagnosis of Chronic right foot complex wound, osteomyletitis. The patient also has a history of receiving intravenous antibiotics for bilateral Diabetic foot ulcers, amputations of the 2nd, 3rd and 4th toes on the right foot. The patient is currently on contact isolation. A 06/13/17 physician order, prescribed for the patient to receive Wet to Dry dressing with Betadine packing daily and as needed.

An observation of the wound care for Patient # 1 was conducted on 06/14/17 with Staff A and Staff C, Registered Nurses. The Quality Coordinator was also present during the wound care observation. Staff A donned two pair of gloves and proceeded to remove the old dressing from the left and right foot of Patient # 1. Upon removing and discarding the old dressings on both feet, the nurse removed one pair of the gloves she had donned. She then donned another pair of gloves over the first pair and proceeded to clean around the left foot wound and then the right foot wound with Normal Saline Solution (NSS) soaked gauze. She then obtained another NSS soaked gauze and proceeded to clean the inside of the wound on the left foot. She obtained another NSS soaked gauze and proceeded to clean the inside of the wound on the right foot. She then used a Betadine soaked gauze and proceeded to clean inside the right foot, padded around inside the wound twice with the Betadine soaked gauze. She went to the left foot and used a Betadine soaked gauze and wiped around inside surface of the wound and padded the inside of the wound three times with the gauze. She packed the wound on the left foot with gauze saturated with NSS. She then packed the wound on the left foot with two gauze soaked with NSS. She then wrapped the left wound with Kerlix, double folding an area of the Kerlix over the wound and proceeded to wrap Kerlix around the foot and ankle. Staff A then applied Kerlix to the right foot dressing as well. The staff continued to alternate between two wounds using the same gloves, cleaning, dressing and packing the wounds. The staff did not utilize acceptable standards of practice for wound care and infection control or perform the entire dressing care on one wound. She did not remove her gloves and perform hand hygiene before proceeding to perform wound care on the second wound to prevent cross-contamination between wounds.

An interview was conducted with Staff A, following the observation at 12:55 PM to review, the nurses technique of alternating between wounds with the same gloves and the enhanced possibility of cross contamination of infections with the method utilized by the nurse.

Another interview was conducted on 06/14/17 at 12:57 PM with the Clinical Coordinator, Staff B, who confirmed the accepted practice for wound care on multiple wounds is to perform one wound care dressing at a time, remove your gloves and wash your hands before proceeding to the second wound.

After reviewing the electronic record and the prescribed wound care, the wound care observation revealed the nurse did not perform the prescribed wound care. The nurse packed the wound with Normal Saline Solution dressing, not the Betadine packing as prescribed.

An interview was conducted on 06/14/17 at 2:25 PM with the Quality Coordinator, who was also present during the wound care observation. She confirmed that the nurse did not perform the prescribed wound care. The nurse provided Normal Saline Solution packing to the wounds instead of the prescribed Betadine packing, she cleaned with Betadine.

2) Review of the clinical record for Patient # 2 disclosed that the patient was admitted on [DATE] from home with a chief complaint of fever. The patient was admitted with eight (8) wounds/skin issues and 5 of the wounds are identified on the patient's bilateral lower extremities which are black in color, gangrene located on the Right Heel, Left Foot, Left Medial Leg and Left Lateral Leg. On 03/21/17 an order was obtained for daily wound care to the bilateral lower extremities of painting wounds with Betadine then wrap with cast padding and spandage.

Review of the wound care provided from 05/13 through 05/29/17, revealed that the facility was unable to provide evidence the wound care for the lower extremities was performed as prescribed on 5 of 16 times on 05/14, 05/15, 05/16, 05/19 and 05/23. During the simultaneous review of the electronic record and interview with the Vice President Quality Management, Quality Coordinator and the Clinical Coordinator, Progressive Care Unit (PCU), they confirmed on the above five dates, they were unable to locate evidence that the wound care was performed by the nurses.

An interview was conducted on 06/15/17 at 10:50 AM with the Wound Care Nurses revealed that they were initially performing the Wound Vac wound care three times a week and the other wound care for the hip and lower extremities wounds were performed by the floor nurses. The lower extremity wounds were dry with eschar covering. The WCN stated the patient's legs and toes were extremely dry with eschar and looked like her toes, etc. would fall off at any moment.

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy reviews, clinical record reviews and interviews it was determined the facility failed to ensure quality of nursing care provided to each patient is in accordance with established standards of practice of nursing care, chapter 464.003(5) for 3 of 6 sampled patients (Patient #3, #5, and #6) as evidenced by failure to accurately assessed skin conditions and wounds and failure to follow physician orders for medication administration as specified in the facility policies and procedures.

The findings included:

1) Facility policy titled Medication ordering and Administration dated 10/2016 documents Only medications needed to treat the patient are ordered. There is a diagnosis, condition, or indication for each medication ordered if not apparent. All as needed or PRN orders must be quantified. The intended indication must be stated. PRN orders with stated indication for use will be profiled and documented in the Medication Administration Record (MAR) as directed by the provider. Medications are to be documented on the patients' medication administration record (eMAR).

1a) Clinical record review conducted on 10/26/2016 revealed Patient #3 was admitted to the facility on [DATE]. Physician's Order dated 10/20/2016 documents Lopressor 2.5 mg intravenously every six hours as needed for heart rate above 110. The record indicates Patient #3 met the parameter for medication administration on the following dates: 10/20/2016 at 4:25 PM with heart rate 111; 10/21/2016 heart rate 114; 10/21/2016 heart rate 116; 10/21/2016 heart rate 113; 10/22/2016 heart rate 111 and on 10/23/2016 heart rate 115. Further review of the medication administration record and nurses' notes failed to provide evidence the medication was administered as ordered or an explanation as to why the doses were held.

Interview with the Quality Coordinator on 10/26/2016 at 11:01 AM, who navigated the electronic record, confirmed the Lopressor was not given on the identified dates and times noted above and was not able to locate nursing documentation as to why the medication was not administered as ordered.

1b) Clinical record review of Resident #5 on 10/26/2016 revealed a Physician's Order for Labetalol 10 mg intravenously every four hours as needed for systolic blood pressure greater than 150 dated 08/27/2016. The record indicates Patient #5 had blood pressure reading of 159/103 on 09/20/2016 at 8:08 AM. The record failed to provide evidence the medication was administered or documentation as to the rationale why it was not given.

Interview with The Quality Coordinator conducted on 10/26/2016 at approximately 1:50 PM confirmed the Labetalol was not given.

2) Facility policy titled Wound Management dated 08/2016 documents Purpose to provide a standard of care for the management of wounds healing by secondary intention and to promote healing and reduce further injury to tissue. Wound assessment and documentation: documentation of complete wound assessment, which requires removal of the dressing, will be done on admission, unless contradicted and at least weekly thereafter. Wound measurements are to be done at least weekly. Complete wound assessment includes location, dressing type and status, wound type, wound color, drainage amount, drainage color, wound odor, hardening around wound, presence of black or gray eschar, presence of tunneling, and status of surrounding tissue.

2a) Clinical record review conducted on 10/26/2016 revealed Patient # 5 developed a wound to the sacrum. The record indicates the wound was first identified on 09/08/2016 measuring 3 cm in length, 2 cm in width and zero centimeters in depth. The clinical record failed to provide evidence complete wound assessments were conducted from 09/09/2016 thru 09/20/2016. There is no evidence of weekly measurements or changes in treatment or interventions to manage the progression of the wound. On 09/21/2016, the date scheduled for the patient discharge, the wound was assessed as unstageable, covered with tan slough and measuring 4 cm in length and 2.5 cm in width.

Further review of the record revealed Patient #5 was prescribed Santyl ointment daily to the sacrum wound on 09/21/2016. Discharge instructions dated 09/24/2016 document treatment to the sacrum wound with zinc oxide and Mepilex dressing. The facility failed to update treatment plan on the discharge instructions.

Interview with The Quality Coordinator and The Director of Patient Safety conducted on 10/26/2016 at approximately 1:50 PM revealed a complaint was recorded and investigated by the director of the unit. Patient #5's discharge was held, a plastic surgery consult was obtained and the patient was discharged on [DATE]. The Quality Coordinator who was navigating the electronic record confirmed there is no evidence of comprehensive wound assessment including measurements from 09/09/2016 thru 09/21/2016; evidence of changes in treatment to manage the worsening of the wound from 09/11/2016 thru 09/21/2016; or evidence the patient received updated discharge instructions for wound care.

2a) Clinical record review conducted on 10/26/2016 revealed Patient #6 was admitted to the facility on [DATE]. Present on admission form dated 10/17/2016 documents the patient had right lateral leg skin breakdown and an ulcer to the right lateral foot. Nursing shift assessments dated 10/17/2016 through 10/25/2016 failed to document complete wound assessments including measurements of the ulcer to the right foot. Treatment orders to the right foot ulcer were obtained two days later, on 10/19/2016 with Santyl ointment.

Further review of the record indicates Patient #6 was discharged home on 10/25/2016; discharge instructions did not address wound care.

Interview with The Quality Coordinator, who navigated the electronic record, on 10/26/2016 at approximately 2:35 PM confirmed the discrepancies on the wound assessment; the lack of wound measurements and evidence of discharge instructions addressing the wound care at home.

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, staff interview and clinical record review, the facility staff failed to implement the fall plan of care for 2 of 10 sampled patients (Patient # 7 and # 10).

The findings include:

1) Review of the clinical record for Patient # 7 disclosed that the patient was admitted to the facility on [DATE] with a diagnosis which included Acute Cerebrovascular Hemorrhagic Stroke. An initial nursing assessment was completed on 05/06/16 and the patient was identified as high risk for falls. The plan of care identified issues for falls and assistance with activity of daily living as concerns for the patient. The interventions for the plan of care included assist with activities of daily living, toileting program, bed and chair alarm and transfer/ambulate with assistance at all times.

An observation of the patient was conducted on 05/20/16 at 12:30 PM. The patient was out of bed in his wheelchair. There was no chair alarm observed on the patient's wheelchair at this time. There was a noted alarm pad resting on the patient's bed.

An interview was conducted with the Rehab Clinical Manager on 05/20/16 at 12:35 PM who confirmed the patient did not have the chair alarm on his wheelchair. She further noted that the alarm was lying on the patient's bed.

An interview was conducted with the Physical Therapist at 12:40 AM who reports that the patient just had therapy and was returned to his room.

An interview with the Occupational Therapist was conducted on 05/20/16 at 12:55 PM. The therapist stated that the patient is to have his call bell within reach and is to have the alarm on his chair when he is out of bed. She further stated that she worked with the patient from 10:00 AM to 11:00 AM on 05/20/16. The patient was already out of bed in the wheelchair when she got the patient for occupational therapy. The patient had physical therapy prior to the OT. She confirmed the patient did not have the chair alarm on his wheelchair when she worked with the patient in therapy. She stated she also observed the patient in his room at approximately 12:00 PM. She said she saw the patient scooting around in his wheelchair, headed toward the bathroom in his room. She stated she assisted the patient to transfer to the toilet. She stated that patient did not have the chair alarm on that time either.

2) Review of the clinical record for Patient # 10 disclosed that the patient was admitted to the facility on [DATE] with diagnosis of Odontoid fracture. The initial nursing assessment was completed on 05/10/16 and the nurse determined that the patient was a high risk for falls. The patient is alert and oriented in all spheres. The plan of care identified issues of falls as a concern for the patient. The interventions identified on this plan of care included the following falling precautions: Call bell within reach; bed alarm; signage and nonskid socks.

The facility's administrative records identified that the patient sustained a fall on 05/12/16 at 3:50 AM. Review of the post fall assessment of the 05/12/16 fall noted that the patient did not have an alarm in place at the time of the fall. The post fall investigation/debriefing documenting that the bed alarm was not indicated for this patient.

An interview with the Trauma Clinical Coordinator was conducted on 05/20/16 at 11:40 AM. The CC confirmed that the nurse documented on the post fall assessment that the bed alarm was not indicated for this patient but the plan of care documented that the patient was to have the bed alarm. She also confirmed the patient did not have the bed alarm in place at the time of the patient's fall.

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Based on documentation review and staff interviews, the facility failed to ensure the provision of services within the specialized capabilities and capacity of the hospital. This affected one (1) of 20 Emergency Department (ED) sampled patients whose medical records were reviewed, Patient #1, who was not accepted when on behlf of the patient a transfer request for emergency care and services was made. The services request was available at the time at Lawnwood Regional Medical Center.

The findings include:

Review of the facility license revealed the facility offers itself to the general public as providing services which includes Vascular as well as it is a Level 2 Trauma Center.

Review of the facility policy titled Florida EMTALA Transfer Policy, policy number EMT001.002 revealed: 'to establish guidelines for either accepting an appropriate transfer from another or providing appropriate transfer to another facility of an individual with an emergency medical condition (EMC) who requests or requires a transfer for further medical care and follow-up to a receiving facility ... ' . The policy included: 'A hospital with specialized capabilities or facilities shall accept from a transferring hospital an appropriate transfer of an individual with an EMC who requires specialized capabilities if the receiving hospital has the capacity to treat the individual'; Under 1c. Higher Level Of Care: 'A higher level of care should be the more likely reason to transfer an individual with and EMC that has not been stabilized. The following are examples of higher level of care: i. A receiving hospital with specialized capabilities or facilities that are available at the transferring hospital ...must accept an appropriate transfer of an individual with an EMC who requires specialized capabilities or facilities if the hospital has the capacity to treat the individual'.

Further review of this policy under 3. Authority to Accept a Transfer revealed: 'The Emergency Physician and the Hospital CEO or designee, such as the administrator on call or the house supervisor are the ONLY individuals authorized to accept or refuse the transfer of an individual from another facility on behalf of the receiving hospital.' Under 5 - 3. 'The on-call physician does not have the authority to refuse an appropriate transfer on behalf of the facility'.

Patient #1 did not physically present to Lawnwood Regional Medical Center (Hospital B) the ED (Emergency Department) on 7/29/15. Review of the documentation provided by Hospital B revealed Hospital A (transferring hospital) called Hospital B on 07/29/2015 at 00:23 AM related to a patient (#1) who had sustained an Arterial Bleed to the left forearm. The documented preliminary diagnosis Brachial Artery Laceration x 2 with Arterial Bleed to lower muscle. The form also document additional Information of: left arm and bilateral feet second degree burns, abdomen burns, No radial pulse to left. The Trauma doctor was contacted (consulted) at 0029 AM. Documented under the section on the Form for accept or decline is the patient was declined for transfer. The nurse documented on this Form: '2 units O-negative blood; Diaphoretic. At 00:34 AM; a call was made to ED director related to transfer being declined ...awaiting further details. Review of the Detailed Report for Declining Transfers revealed: The services being requested is Trauma. Under detailed reason transfer was declined is: 'Trauma MD (physician) states patient needs burn center ...MD declined ...Call to ED Director ...he called the medical trauma director ...the medical trauma director called ED director back stating to allow patient to go to Hospital D (which is in another county). There is no evidence Patient #1 was accepted by a physician at Hospital B for emergency services/further treatment and stabilization. Review of the license for Hospital A disclose it does not have Vascular nor Burn services on its Invertory of Services provided.

Interview with the Director of Ethics and Compliance on 9/1/15 at approximately 9:18 AM revealed: Hospital B's (Lawnwood Regional Medical Center) trauma surgeon told Hospital A he could treat the laceration and didn't have the capability to treat burns.

Interview with the Director of Nursing Administration on 9/01/15 at approximately 9:20 AM revealed Lawnwood Regional Medical Center can treat burns that are not extensive, but typically if extensive, would transfer such patients out to a Burn Center. She doesn't know if Patient #1 had extensive burns or not. Sample selection review substantiates the administrator's statement regarding the capability and capacity to render care for non-extensive burns. The Director of Ethnics and Compliance said this trauma Surgeon is no longer on medical staff anymore but has moved up North. The surgeon's last day working at Hospital B was 7/29/15 as per the Chief of Nursing Officer.

Interview with the ED Director on 9/01/15 at approximately 9:38 AM revealed patients being transferred in go through the facility's ransfer Center, which would call the ED charge nurse; the ED physicians would speak to the transferring physician and they usually accept the patient. If there is an issue with accepting a transfer-in, the staff would notify the CNO (Chief nursing officer) or designee / AOC =administrator on call; If the patient was a trauma patient, they would consult with the surgeon on the phone. The ED Director said for Patient

#1, both Hospital A and Hospital B surgeons spoke together and agreed Patient #1 would be better served at a Burn Center. The ED Director said they spoke of sending the patient to Hospital D (in another county) but the patient actually went to Hospital C (another local hospital). The ED Director said the administrator on call was called but did not answer the phone at the time the Transfer Center called.

Interview with the ED Medical Director on 9/1/15 at approximately 10:05 AM revealed Patient #1 should have been accepted as we had the capability and capacity at the time. He said Lawnwood Regional Medical Center could assess the Patient, treat and transfer out if necessary for the burns.

Review of Hospital B's ED clinical file, dated 7/29/15 at 01:00 AM, revealed Patient #1 presented to their ED with chief complaint of Wound Evaluation. The patient is triaged as Emergent / level 2 according to the triage notes. The nurse documented left brachial two open lacerations, abdominal burn redness noted, left arterial bleed. The nurse documented the wound as: laceration; minor burn. The nurse documented the patient was given 2 units of blood. The physician assessed the patient and documented a Primary Impression of Vascular Injury left Upper extremity and condition Critical. The patient was air-lifted to Hospital C, after being declined transfer to Hospital B.

Review of Hospital C's ED record for Patient #1 revealed: according to the triage nurse documentation, Patient #1 arrived on 7/29/15 at 01:56 AM via helicopter for Brachial Arm Laceration; superficial burns to abdomen. The ED physician documented chief complaint as: chemical burn and laceration to arm; burn type & severity of 1st degree; laceration related to explosion. Hospital C's Trauma Surgeon documented: seen with 2nd degree burn which are scattered to left arm and abdomen and also a deep laceration to left forearm which is actually bleeding. The skin examination includes: scattered 2nd degree burn left forearm and few to abdomen. The physician documented, the patient was taken to the Operating room immediately for left arm laceration repair (02:10 AM). Review of the Discharge summary revealed on 7/30/15, the patient was discharged with wound healing well, with good arm pulse and a blister to the abdomen.

Review of audio-tape provided of the 7/29/15 transfer call revealed Hospital a, via the Transfer Center, called Hospital B to request a transfer of patient #1 to Hospital B. The physician conversation includes: Hospital A - 'left arm with vascular bleeding, no pulse arm, can't see where the vessel is lacerated, Scattered second degree burns belly, not much, both feet with 2nd degree burns on tops noncircular down to toes; Needs burn care but needs laceration care first'. Hospital B's trauma surgeon replied: recommend sending to a Trauma and Burn Center. The Trauma Surgeon at Hospital A declined the transfer of Patient #1 saying the patient needs a Burn Center otherwise I'd have to address this and kick him out. The Transfer Center then intercepted and said 'will call Hospital D as recommended by trauma surgeon, as critical'. The Transfer Center said to Hospital b's ED nurse: you are declining the patient? The nurse asked the trauma surgeon if the patient was declined and the trauma surgeon agreed and the nurse answered the patient is being declined transfer to Hospital b.

Further interview with the Chief Nursing Officer, the Director of Patient Safety / Risk Manager, and the ED Nurse Director revealed they concurred, Patient #1 should have been accepted by the facility based on service capability and capacity.

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy review, clinical record review and staff interviews the facility failed to ensure the quality of nursing care provided to each patient is in accordance with established standards of practice of nursing care, chapter 464.003(5) F.S. for 5 of 10 sampled patients (Patient #1, #2, #4, #5 and #6) as evidenced by failure to accurately assessed skin conditions and wounds; failure to follow physician orders for wound care and Failure to reassess pain as specified in the facility policies and procedures for 1 of 10 sampled patients (Patient #5).

The findings include:

Facility policy titled ssessment and Reassessment Plan last revised 05/2014 documents, at the time of admission the initial assessment is the responsibility of the Registered Nurse. The information gathering includes skin integumentary/Integrity/Ulcer risk assessment. Patient assessment/reassessment documented in the CPCS by a nurse in the inpatient areas will compare the patient physical findings to defined parameters. If the physical findings match the defined parameters for the body system, the nurse will chart Y to query WDP. If any of the physical findings within the system is outside of the defined parameters, the clinician will document ONLY the physical findings outside the defined parameters.

Facility policy Surgical Wound Dressing documents Surgical wound care dressing changes will be performed at least daily or as indicated by the physician's order. Documentation of wound assessment will include the following: wound site, dressing type, dressing status (CHANGED), wound type, wound condition, measurements, color, drainage and any additional wound comments.

Facility policy Wound Management: Wound Healing by Secondary Intention documents The purpose is to provide a standard of care for the management of wounds healing by secondary intention and to promote healing and reduce further injury to tissue. Wound assessments and Documentation:

1. Documentation in CPCS of complete wound assessment, which requires removal of the dressing, will be done on admission and at least weekly thereafter. A complete assessment is done when any of the following conditions are present:

a. Dressing change

b. When the integrity of the dressing is compromised

c. When the secondary dressing becomes wet.

2. Complete wound assessment includes the following descriptors: Location, Dressing type, Wound type, Wound color, length, width, depth, documentation of wound location and status of dressings will be documented each shift assessment when a complete wound assessment is not completed and dressings are to be removed only for the purpose of changing the dressing and not solely for assessment documentation.

(1) Electronic clinical record review, conducted on 07/30/14 while accompanied by the Clinical Coordinator, revealed the following:

Patient #1 was admitted to the facility on [DATE] with a pressure wound to the hip/buttocks area as documented on the initial nursing assessment.

The Nursing shift assessment dated [DATE] at 8 PM does not contain evidence of an accurate skin assessment per policy, and documentation of the wound identified on admission.

(2) Patient #2 was admitted to the facility on [DATE] with two graft wounds, one to the left lower leg and one donor site wound to the left thigh. Review of random nursing shift assessments for Patient #2 failed to provide evidence the graft and donor sites were included and documented as part of the skin assessments: on 07/18/14 (AM); 07/19/14 (AM and PM); 07/20/14 (AM and PM); 07/21/14 (AM); 07/22/14 (AM); 07/23/14 (AM); 07/28/14 (AM) and 07/29/14 (PM).

(3) Patient #4 was admitted to the facility on [DATE]. Physician Order dated 07/21/14 documents wound care consult. Wound care consult dated 07/22/14 documents the patient developed an open area to the sacrum measuring 3.5 cm in length by 4 cm in width. The wound care recommendations document gently cleanse and pat dry, apply small amount of Remedy Z guard to the peeling skin to the sacrum and cover with border dressing every three days and as needed.

Review of Nursing shift Assessments dated 07/21/14, 07/22/14, 07/23/14 and 07/24/14 failed to yield evidence of the wound assessment of the sacrum. The wound was completely omitted from all the shift documented assessments.

(4) Patient #6 was admitted to the facility on [DATE]. Physician's Order dated 01/04/14 documents wound care with Kerlex and Normal Saline every day. Review of the Nursing Shift Assessments and Nurses Notes dated 01/05/14 thru 05/27/14 failed to provide evidence the treatment was provided daily as ordered. The nursing assessments failed to document daily assessment for the buttock wound and progression of the wound.

In addition the patient's clinical record documents discrepancies regarding the type of wound to the left buttock. operative report dated [DATE] documents abscess wound to the left buttock was found to be a large hematoma. operative report dated [DATE] documents patient has a decubitus ulcer which continues to be contaminated with stool. Wound Care Consult dated 01/23/14 documents the wound is a hematoma, status post incision and drainage. Nursing shift assessments dated 01/10/14 documents the wound to the buttocks is non-pressure related; Nursing shift assessment dated [DATE] documents the wound is a stage IV pressure ulcer; Nursing shift assessment dated [DATE] documents stage III to the left buttocks. Physician's progress notes dated 06/28/14 documents Stage IV to coccyx now healed.

Physician's order dated 06/28/14 documents wound care consult for stage I was being documented, but it is more a stage II, Please evaluate. The record presents no evidence the wound consult ordered 06/28/14 was completed as of 07/30/14.

Interview with The Director of Trauma Intensive Care and Trauma Step-Down Unit conducted on 07/30/14 at 3:04 PM revealed Patient # 6 had an abscess to his buttocks; it was not a pressure ulcer. The Director acknowledges the documentation of the wound and treatment is not consistent or accurate. In addition, The Director explained the documentation related to a stage I and II pressure ulcer on 06/28/14 may have been an error, and when the wound nurse followed up there was no wound and therefore no documentation.

(5) Patient #5 was admitted to the facility on [DATE]. Medication Administration Record dated 07/29/14 and 07/30/14 documents the patient was medicated for pain with Oxy IR 10 mg by mouth on 07/29/14 at 4:53 AM and 10:48 PM and on 07/30/14 at 2:20 AM. In addition the patient was medicated with Dilaudid 1 mg intravenously on 07/29/14 at 11:11 AM and 8:30 PM and on 07/30/14 at 12:07 AM. The record provides no evidence a pain reassessment was completed as per facility protocol, subsequent to the administration of pain medication. Facility policy titled Pain Management documents All PRN analgesia administered will be documented on the medication administration record. All patients will be reassessed for pain within one hour after pain treatment/interventions have been administered.

Interview with The Clinical Coordinator, who was navigating the electronic record, with the surveyor, conducted on 07/30/14 at approximately 3:30 PM, revealed the electronic system has multiple areas for documentation; The Coordinator was not able to locate and provide evidentiary documentation for the concerns identified above.

Interview with The Assistant Director of Nursing, The Director of Trauma Intensive Care and Step-down and The Quality Coordinator was conducted on 07/31/14 at approximately 11:30 AM. The management staff reviewed the clinical records for Patients #1, #2, #4, #5, and #6 and no additional documentation was provided related to the skin assessments, provision of wound care and pain reassessments identified above.

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Based on clinical record review, facility record review and staff interviews, the facility failed to ensure the emotional health and well being, personal privacy, dignity and comfort for 1 of 10 sampled patients (#5) whose clinical records were reviewed.

The findings include:

The facility policy and procedure titled: Restraint and Seclusion (11/20/10), Patient Rights and Responsibilities (11/19/11) and Baker Act (12/20/12) policy specifies:

The definition applies regardless of the care setting (e.g., general medical unit, ED, pediatric unit, psychiatric unit etc.) or precipitating factors (psychiatric, medical or behavioral).

The scope of Patient Rights and Responsibilities and Baker Act is Organization Wide and Hospital Wide specifies:

The definition applies regardless of the care setting (e.g., general medical unit, ED, pediatric unit, psychiatric unit etc.) or precipitating factors (psychiatric, medical or behavioral).

Limiting the use of restraints for behavioral use to emergency or crisis situations when a patient ' s behavior becomes aggressive, presenting an immediate, serious danger to the patient ' s safety or that of others when alternatives have proven ineffective. This applies to all areas of the facility including all outpatient areas where restraints are applied.

1) On 06/11/2013 during the review of the clinical record for patient #5 it was disclosed the patient presented to the Emergency Department (ED) on 12/30/11 at 9:52 PM. The Chief Complaint per documentation on the the Encounter Record: Psych Related.

The patient was brought to the ED by a law enforcement officer, based on the Baker Act, for involuntary psychiatric examination and evaluation.

At 11:16 PM RN #1 documents the patient's level of consciousness to be: awake , alert , agitated, and anxious; the associated signs & symptoms: depressed mood, agitated, flat affect, Suicidal Ideation's (SI) and Homicidal Ideation's (HI); the suicide precautions taken: security near patient; can see patient from nursing station; a sitter is with the patient and placed in Psych-Safe Room.

At 11:32 PM RN #1 documents a Summary Note:

Received into room 25 from Triage; Assessments completed. Patient stripped of all of her belongings, placed in bag, labeled and put at nursing station. Blood and urine specimens obtained and sent to lab. Patient refused to give urine specimen.

The RN continued to write, verbal order given: mini catheter patient for urine specimen. Patient refused to follow direction and was screaming about wanting her clothes back. I tried to explain the policy about clothes but patient became hostile. The patient got out of bed and tried to grab me. Officer #1 came to my assistance. She failed to comply with the officer's orders to return to her bed. She gritted her teeth and started talking louder, moving further away from her bed and out of her room.

At the time of clinical record review there was no physician's order found or provided for catherization of patient #5; nor was one provided up to and or at the time of the exit conference.

The facility's Investigative Reports and Contractual Agreements reviewed revealed Officer #1 is a hospital contracted security employee.

The RN wrote the patient was restrained, moved to her bed and was handcuffed for her safety and staff safety. Officer #2 spoke with the patient while assisting with placing the patient in handcuffs. House Supervisor aware of the incident.

The clinical record review for patient #5 did not disclose a physician's order for the patient to be restrained as medically determined and assessed to be necessary, per the Regulatory Requirements at 42 CFR part 482.13.

A review of the Grievance Log at approximately 12:00 PM on 6/10/13 finds patient #5 made a visit to Lawnwood Regional Medical Center & Heart Institute on 01/25/12 to file a grievance with the Risk Manager (RM) regarding Patient Rights. The patient's concerns were as follows:

RN was rude and would not allow her to keep undergarments on.

RN told police to cuff the patient.

Police officer pinned patient to the stretcher.

After police officer removed the Handcuffs patient stated she noticed the RN trying to communicate with a non English speaking family. The patient suggested the RN get an interpreter. The RN replied, do you want to be cuffed again.

The facility's Investigative Records documents and substantiates, the patient was restrained face down on the Stretcher by two male officers. The contracted employee, officer #1, with the assistance of a second officer #2 placed handcuffs (HC) on the wrists (both) of patient #5. The handcuffs were then attached to the side rails (2).

The patient wore only a hospital gown, opened to the back, no undergarment and was in the line of site of the security / officers and all staff in the ED.

At the time of the survey the patient's medical record lacked documentation of a clinical assessment for the use of restraints / Handcuffs.

Handcuffs are law enforcement restraint devices which are not clinically considered safe, appropriate healthcare restraint intervention or for use to restrain patients, and at the time the patient was handcuffed. The facility staff failed to follow the hospital's Restraint and Seclusion policy.

The facility's Policy requires the completion of a Form titled Observation Checklist for Suicide Precautions Patient Safety and/or Rights & Dignity, to ensure patient safety, rights, dignity, privacy, and comfort. At the time of the medical record review the medical record did not contain the required documented Checklist / Form, or evidence of an Assessment for the need to restrain the patient; nor were these documents provided up to and at the time of the exit conference.

The medical record review disclosed, the patient was catheterized by RN #1 while her wrists were in handcuffs and attached to the siderails. The medical record lacked documentation of a verbal or written order for the Mini Catheterization.

The reason documented by the nurse for the use of handcuffs, patient refused to follow direction and was screaming about wanting her clothes back ..... ... ... ... . The patient got out of bed and tried to grab me .. .. .. .. She failed to comply with the officers orders to return to her bed. She gritted her teeth and started to talk louder moving further away from her bed and out her room.

The facility failed to provide care in a manner that promotes emotional wellbeing, with respect and dignity, privacy and comfort.

Show Text of Violation

Based on clinical record review, facility record reviews and staff interviews, the facility failed to ensure there was adequate and appropriate clinical justification for the use of restraint, and the restraint use was not in accordance with accepted standards of practice and hospital policy Patient Rights: Restraints and Seclusion; This failure affected 1 of 1 sampled patients (#5) who was restrained.

The findings include:

The facility policy and procedure titled: Restraint and Seclusion (11/20/10), Patient Rights and Responsibilities (11/19/11) and Baker Act (12/20/12) policy specifies:

The definition applies regardless of the care setting (e.g., general medical unit, ED, pediatric unit, psychiatric unit etc.) or precipitating factors (psychiatric, medical or behavioral).

Limiting the use of restraints for behavioral use to emergency or crisis situations when a patient ' s behavior becomes aggressive, presenting an immediate, serious danger to the patient ' s safety or that of others when alternatives have proven ineffective. This applies to all areas of the facility including all outpatient areas where restraints are applied.

The scope of Patient Rights and Responsibilities and Baker Act is Organization Wide and Hospital Wide.

Scope:

This policy applies to healthcare professionals in the facility who have direct responsibility in the ordering, assessment, care planning, application/implementation of restraint, monitoring and care of the restrained patient. This policy is applicable to all age groups of patients from the neonate to the geriatric patient.

Purpose:

To provide for the safety of all patients, staff and visitors.

To identify those at risk for restraint and provide for alternatives to restraint use.

To provide guidelines for the use of restraints in the acute care setting, the circumstances under which such use shall be permitted, and the procedure to be followed when alternatives have been exhausted and proven ineffective in maintaining patient safety.

To ensure the development of a culture that understands any restraint use poses a significant threat to the patient which may include the loss of life or limb.

Responsibility:

Medical Staff, Chief Executive Officer, Department Managers, Risk Manager, Nursing Supervisors, Nursing Staff and Clinical Support Personnel.

Organization Philosophy:

Patient safety and regulatory compliance in the use of restraints depends heavily on a correct determination about whether such use is clinically justified and for what purpose (e.g. medical - surgical vs. behavioral) the restraint is being applied. To apply restraints without sufficient justification or to incorrectly deem their use to be for medical/post-surgical care and thereby implement less stringent procedures for monitoring the patient and having Licensed Independent Practitioner (LIP) oversight of the use, endangers the patient and threatens the compliance status of the hospital. Therefore, only specially trained staff (i.e. RN's, ARNPs, or PAs or physicians) should make the determination, based on a comprehensive assessment, of the purpose for which restraint is being applied and every decision should be subject to a review of its appropriateness using the most conservative criteria. Every inappropriate use of restraints (including extended use without clinical justification) should be investigated.

The policy includes but is not limited to the following: Ensuring every inappropriate use of a restraint, including extended use without clinical justification, should be subject to root cause analysis as a near miss.

The use of restraints within this organization is therefore limited to those situations with adequate and appropriate clinical justification and adequate human resources to meet the needs of patients requiring restraint as a therapeutic intervention. -- -- -- -- -- -- -- .

Restraints are to be used as an unusual and temporary measure when the Physician/Nursing assessment deems it necessary and other available techniques or interventions have failed. It is also the intent that whenever restraints are applied, that they be removed as soon as possible.

-- -- -- -- -- --- -- --- --- --- -- -- --.

The use of restraint to control violent behavior is governed by the behavioral management standards, even if the other medical/post surgical factors are present - when there is any doubt , the behavioral management requirements should be followed and;

> Use of less restrictive alternatives have been evaluated or were unsuccessful.

Behavioral use of restraints: Restraints used in an emergency or crisis situation when a patient's behavior becomes aggressive or violent, presenting an immediate, serious danger to the patient's safety or that of others.

The three factors that must be present when restraints are used for behavior management:

> They are used only as an emergency measure and,

> They are reserved for those occasions when severely aggressive, combative or destructive behavior places the patient, staff or others in immanent danger; and,

> The least restrictive measure that will assure the patient's or other's safety is a restraint or

seclusion.

Persons will not be restrained in a prone position. Prone containment will be used only when required by the immediate situation to prevent imminent serious harm to the person or others. To reduce the risk of positional asphyxiation, the person will be repositioned as quickly as possible.

Exceptions to the definition of restraints:

Use of handcuffs and or other restrictive devices used by law enforcement who are not employed or contracted by the hospital or custody, detention or other public safety reasons, and not for the provision of healthcare. These are not considered restraints.

Policy:

Leadership at Lawnwood Regional Medical Center and Heart Institute is dedicated to fostering an organizational culture limiting the use of restraints to clinically justified situations only and seeks to reduce, with the ultimate goal of eliminating, the use of restraints through the following mechanisms while maintaining patient safety:

The policy includes but is not limited to the following: Ensuring every inappropriate use of restraint use of restraints, including extended use without clinical justification, should be subject to root cause analysis as a near miss

Limiting the use of restraints for behavioral use to emergency or crisis situations when a patient ' s behavior becomes aggressive, presenting an immediate, serious danger to the patient ' s safety or that of others when alternatives have proven ineffective. This applies to all areas of the facility including all outpatient areas where restraints are applied.

Ongoing assessment and reassessment of the patient in restraint to ensure the patient ' s rights, safety well-being and dignity are protected and the patient is released from restraint at the earliest possible time.

A risk factor for restraint/seclusion includes the patient is exhibiting aggressive, combative or destructive

Behavior that places the patient/staff/ in immediate danger, alternatives are initiated to decrease the likelihood of the patient being restrained. This should be placed in the plan of care for the patient being at risk for the use of behavioral restraints.

Second Tier of Review:

Prior to the application of restraint a Second Tier of Review shall occur. A member of the nursing administration/ management will review the need for restraint with the RN who has determined that the least restrictive measures have been implemented have been ineffective and the patient requires restraint.

Types of Restraint/Safe Application per policy and procedure:

A. Interventions are arranged in ascending order of restriction as recognized by Lawnwood Regional Medical Center & Heart Institute (A to J).

A. Enclosure Bed

B Unanchored mittens.

C. Anchored mittens

D. Four Side rails.

E. One Limb Restrained

F. Two Limbs Restrained

G. Three Limbs Restrained

H. Four Limbs Restrained

I. Two point Hard

J. Four point Hard. Used for patient's exhibiting extremely violent behavior.

Medical Record Content/Documentation:

Immediately after restraints are applied, an assessment will be made by a RN, to ensure that the restraints were properly and safely applied so as not to cause the patient harm, pain or impair circulation. Documentation should include this assessment as well as the patient's response, and any adjustments made.

The RN must assess the patient 3 - 4 times per hour documentation is completed on paper, the RN documents a statement at the time the restraints are discontinued or at the end of current shift, verifying that 3-4 times per hour checks were performed throughout that time the patient was in restraint/seclusion.

If the patient is under continuous observation or other audio and video observation documentation of continuous observation for safety, rights and dignity may be entered at the end of the shift.

The patient is monitored by the assigned staff member (RN, LPN, Certified Nursing Assistants) for safety and confirm that the patient's rights and dignity are maintained. These checks will be documented either electronic record or on paper.

The fact that a patient's behavior warranted the use of Behavior Management Restraint or seclusion indicates a serious medical or psychological need for prompt assessment of the incident that led to the intervention, as well as psychological and physiological condition of the time of the assessment.

Education and Competency of Staff:

Staff members who have direct contact and any others who may become involved in the application of restraints must have education and training on hire and ongoing as applicable and training in the proper and safe use of restraints.

Education and Competency of Staff:

Includes all contract/agency personnel with direct patient care responsibilities.

Includes those who may become involved in restraint application, even if not direct care providers (i.e., security guards, Emergency Medical Technicians (EMTs) on the premises.

The Chief Nursing Officer (CNO) stated on 6/10/13 at 11:30 AM during an interview, off duty police officers from the ---- ------ ------- ------------ are contracted to provide security in the ED, however they are working as our employees while at the facility, and at this time they are part of the care team in the ED.

The CNO further stated, the law enforcement officers are to follow the rules and regulations of Lawnwood Regional Medical Center and Heart Institute (LRMCHI); The law enforcement officers contracted provide direct observation (line of site) of patients admitted to the ED under the Baker Act (BA). The observations are made every 15 minutes and are documented on the Observation Checklist for Suicide Precautions by the law enforcement officer, (acting at the time of observation as our employees).

The CNO further stated the RNs assess a patient in restraint every 15 minutes, and document the assessments electronically, or using the restraint packet documents Restraint Monitor for Behavioral Health Use of Restraint and the Patient Safety, Rights & Dignity Checklist; Sitters (Certified Nursing Assistants) are used upstairs on the units for the behavioral health monitoring, not in the ED. The ED Director who was present during the interview confirmed the same, stating we never use sitters in the ED.

The CNO stated, all nurses working in the ED have Crisis Intervention Prevention (CIP) training. This is an eight hour course at the time of hire. Annual updates are required.

The Director of Security stated at 11:45 AM the contracted officers have Crisis Intervention Training (CIT). Their services are paid for by Lawnwood Regional Medical Center & Heart Institute. The specialized training is designed to reduce confrontation and to calm and comfort people. The use of non-physical intervention skills as well as bodily control and physical management techniques are based on a team approach to ensure safety.

The surveyor asks if Handcuffs (HC) are used as a restraint. The CNO stated, At no time are handcuffs to be used. They (Baker Acted patients) can be transported to the ED by a Law Enforcement Officer in Handcuffs. The Handcuffs are removed once the patient is received in the ED.

The CNO stated Handcuffs are used only when a patient is under arrest. This was also verified at the time by members of the Administrative Team present (Risk Manager (RM), Quality Assurance (QA), Director of Surgery, Director of Security and the ED Director).

RN #1 who was also present during the interview identified an intervention for the risk of suicide is to assign a sitter at the bedside.

At the time of the survey the medical record lacked documentation made by the Sitter or RN #1 (who cared for the subject patient) on the Observation Checklist for Suicide Precautions, Patient Safety and/or Rights & Dignity Checklist, used while the patient (#5) was in restraint placed while in the ED.

A review of the Grievance Log revealed patient #5 made a visit to Lawnwood Regional Medical Center on 01/25/12 to file a grievance regarding Patient Rights. The patient's concerns are as follows: RN was rude and would not allow her to keep her undergarments on; RN told police to cuff the patient; Police officer pinned patient to the stretcher; After police officer removed the Handcuff, the patient stated she noticed the RN trying to communicate with a non-English speaking family; the patient suggested the RN get an interpreter, to which The RN replied, do you want to be cuffed again.

The facility ' s Investigative Report by the Risk Manager documents, the patient was restrained face down on the Stretcher. The hospital ' s contracted security employees placed Handcuffs on the patient's wrists. The handcuffs were then attached to the side rails (2). The risk manager wrote, the patient was agitated and combative. No Patient Rights were found to be violated.

The QA director stated at 1:50 PM on 6/11/13 grievances/complaints, investigative reports, restraints, are reviewed by the Grievance Committee quarterly. We check for trends. The Chief Executive Officer (CEO) and Chief Nursing Officer (CNO) will review the Grievance Log.

The QA director also stated, the last quarterly review for 2011 was April 19, 2012. The former risk manager reported the following statement to the Grievance Committee on 4/19/12: All restraints reviewed.

On 06/11/2013 during the review of the clinical record for patient #5 it was disclosed the patient presented to the Emergency Department (ED) on 12/30/11 at 9:52 PM. The Chief Complaint per documentation on the Encounter Record: Psych Related.

Review of the Report of Law Enforcement Officer Initiating Involuntary Examination (Baker Act) revealed the law enforcement officer has reason to believe said person has a mental illness pursuant to Section 394.455 (18), F. S., and because of the mental illness: a. Patient has refused voluntary examination after conscientious explanation and disclosure of the purpose of the examination. b. There is likelihood that without care or treatment the person will cause serious bodily harm to self and others in the near future, as evidenced by recent behaviors.

The ED Encounter Record documentation reveals, the patient was triaged at 10:03 PM; the Triage Nurse documents the patient denies Suicidal Ideation's (SI); the patient admits to Homicidal Ideation (HI). The patient was moved to the Treatment Area at 10:04 PM.

The ED physician documented an Assessment at 10:00 PM, in which he wrote, the chief complaint: I told my son- in- law that I would shoot him. The physician wrote the patient was found with a weapon. The past medical history: B...... and H......

The physician wrote orders at 10:13 PM for a Complete Metabolic Panel; Blood Alcohol Level; Urinalysis Reflex; Urine Drug Screen; and Complete Blood Count (CBC) with differential.

At 10:25 PM RN #1 documents her assessment of the patient. The patient was assessed as at High Risk for Suicide.

At 11:02 PM the RN began to record a Nursing Care Plan of an identified problem for the patient: being at Risk for Falls, and Alteration in Thought Processes.

At 11:16 PM the RN documents a description of the patient's Non Verbal behaviors as follows: Forced speech and hostile with others. The RN wrote: see the Baker Act paper as the plan for SI. The Level of Consciousness: Awake, alert, agitated, and anxious. The associated signs & symptoms: Depressed mood, agitated, flat affect SI and HI. The suicide precautions have been taken: Suicide Precautions; security near patient; can see patient from nursing station; a sitter is with the patient and placed in Psych-Safe Room.

At 11:32 PM the RN #1 documents a Summary Note: Received into room 25 from Triage. Assessments completed. Patient stripped of all of her belongings; placed in bag; labeled and put at nursing station. Blood and urine specimens obtained and sent to lab. Patient refused to give urine specimen.

Verbal order given, mini catheter patient for urine specimen. Patient refused to follow direction and was screaming about wanting her clothes back. I tried to explain the policy about clothes but patient became hostile. The patient got out of bed and tried to grab me. Officer #1 came to my assistance. She failed to comply with the officer's orders to return to her bed. She gritted her teeth and started to talk louder moving further away from her bed and out of her room.

The review of the patient ' s medical record did not yield evidence of a physician ' s verbal or written order for the Mini Catheterization of patient #5.

The RN wrote, the patient was restrained, moved to her bed and was handcuffed for her safety and staff safety. Officer #2 spoke with the patient while assisting with placing the patient in handcuffs. House Supervisor aware of the incident.

Medical record review for patient #5 did not yield a physician order for the patient to be restrained as medically determined to be necessary, which is required by 42 CFR Part 482. The order for the patient ' s restraint was given by the nurse, RN #1 to the security officer.

At 11:49 PM the RN recorded that she tried to give the patient Geodon, Patient states she has extrapyramidal side effects. The physician was made aware. At 02:27 AM the RN wrote the patient is refusing to sign EMTALA Form.

At 5:13 AM, RN #1 wrote an amended note which specifies the patient was restrained by police officer and handcuffed by police officer as previously recorded.

At 5:15 AM RN #1 document a second amended note, Physically restraining patient and placing the patient in handcuffs was done by ---- ------ ------- Police and not by hospital staff.

On 6/11/13 at 10:30 AM, an interview was conducted with two (2) officers. The two officers read the risk manager ' s Report of the incident. This surveyor asked, what were the behaviors exhibited by the patient that warranted the use of the restraint / handcuff. Officer #3 stated, gritting teeth, yelling and agitation.

This surveyor asked if the patient was under arrest. Officer #3 stated, the patient was being detained and added, the nurse wrote the patient grabbed her. Officer #3 added, the officers have 40 hours of Crisis Intervention Training.

The provisions of the aforementioned Restraint and Seclusion Policy and Procedure, as they relate to the events described in the facility were reviewed with the administrative staff (CNO, RM, QA, Directors of the ED, Surgery and Security). The Risk Manager and the Quality Assurance personnel stated, The police officers put handcuffs on the patient, so it was not a restraint.

It was found, at the time the patient was handcuffed, she was not a prisoner, and she was handcuffed by Lawnwood Regional Medical Center contracted security officers who were not performing police duties.

The security officers are contracted employees of the hospital, are part of the care team in the ED, therefore they are expected to follow the facility's Restraint and Seclusion Policy and Procedures. The handcuffs were used as a restraint.

Handcuffs are law enforcement restraint devices and would not be considered safe, appropriate healthcare restraint intervention for use by hospital staff to restrain patients.

At the time of the survey the clinical record lacked documentation of an order by a Qualified Licensed Practitioner, as defined in the facility policy / Bylaws, and Regulatory Requirements, for the use of any restraint.

The record lacked documentation by RN #1 of an assessment, for the use of restraint, either electronically or on the facility document / Form (Restraint Monitor for Behavioral Health Use of Restraint). The restraint was not identified on a plan of care with intervention to include alternatives, starting with the least restrictive restraints.

The Policy requires a member of the nursing administrative/ management (Second Tier/second level) to review the need for the restraint with the RN. As per the Policy, the review will be made prior to applying restraints (non - emergency). In an emergency application of a restraint, the review will be done immediately after application of the restraint.

The facility did not have supporting documentation to substantiate a review was conducted as in accordance with facility policy (Second Tier of Review and documentation by RN #1.

The risk manager failed to appropriately investigate the use of Handcuffs on patient #5. Furthermore, the risk manager failed to acknowledge the inappropriate use of restraint, and subject the incident to a Root Cause Analysis (RCA) as a Near miss as per the Restraint/Seclusion policy. As a result it was determined the risk manager failed to provide an accurate and complete report to the Grievance Committee.

Documentation of every 15 minute observations made by the contracted security officer, on the Observation Checklist for Suicide Precautions, began at 10:15 PM and ends at 11:45 PM. The patient remained in the ED through 3:54 AM.

A subsequent call to the facility was made on 6/20/13 at approximately 9:30 AM to request the Observation Checklist for Suicide Precautions monitoring that was recorded after 11:45 PM on 12/30 - 12/31/11. The facility was unable to provide any additional documentation requested.

No evidence was found, or provided, during the course of the survey to substantiate there was adequate indication and medical necessity (clinical justification) for the use of the handcuff / restraint applied to patient #5 wrists.

There was no documentation found or provided to support, the use of handcuff / restraint was required in order to render necessary healthcare and services. Based on review of the facility ' s Policy governing the use of restraint, the actions taken by the nurse RN #1 and the security officers are not in accordance with the Policy & Procedures, established standard of practice, and Patient Rights: Restraint and Seclusion, Patient Rights & Responsibilities and the Baker Act Law.

Show Text of Violation

Based on clinical record review, facility record review, staff interviews and observation it was determined the facility failed to ensure the Quality Assurance Performance Improvement (QAPI) program reflects the evaluation and analysis of security services furnished under contractual Agreement for direct line-of-site observation of patients who present to the Emergency Department under the Baker Act for psychiatric examination and evaluation. This failure affected 1 of 10 sampled patients (#5).

The findings include:

The facility policy and procedure titled: Restraint and Seclusion (11/20/10) Quality Assurance Performance Improvement Plan (QAPI) (1/2012) specifies: The purpose of this plan for improving Organizational performance is to provide a structure to evaluate the design and delivery of the services as planned by the Department Directors, the Medical Executive Committee, Administration, and the Board of Trustees.

The QAPI Plan - Outside Services: When patient care services are provided through a contract service or through an off - site healthcare organization, there will be mechanisms in place to evaluate the appropriateness of the referral service.

Scope:

This policy applies to healthcare professionals in the facility who have direct responsibility in the ordering, assessment, care planning, application/implementation of restraint, monitoring and care of the restrained patient. This policy is applicable to all age groups of patients from the neonate to the geriatric patient.

The use of restraint to control violent behavior is governed by the behavioral management standards, even if the other medical/post surgical factors are present - when there is any doubt , the behavioral management requirements should be followed.

The definition applies regardless of the care setting (e.g., general medical unit, ED, pediatric unit, psychiatric unit etc.) or precipitating factors (psychiatric, medical or behavioral).

Limiting the use of restraints for behavioral use to emergency or crisis situations when a patient ' s behavior becomes aggressive, presenting an immediate, serious danger to the patient ' s safety or that of others when alternatives have proven ineffective. This applies to all areas of the facility including all outpatient areas where restraints are applied.

The scope of Patient Rights and Responsibilities and Baker Act is Organization Wide and Hospital Wide.

Responsibility:

Medical Staff, Chief Executive Officer, Department Managers, Risk Manager, Nursing Supervisors, Nursing Staff and Clinical Support Personnel.

Organization Philosophy:

Patient safety and regulatory compliance in the use of restraints depends heavily on a correct determination about whether such use is clinically justified and for what purpose (e.g. medical - surgical vs. behavioral) the restraint is being applied. To apply restraints without sufficient justification or to incorrectly deem their use to be for medical/post-surgical care and thereby implement less stringent procedures for monitoring the patient and having Licensed Independent Practitioner (LIP) oversight of the use, endangers the patient and threatens the compliance status of the hospital. Therefore, only specially trained staff (i.e. RN's, ARNPs, or PAs or physicians) should make the determination, based on a comprehensive assessment, of the purpose for which restraint is being applied and every decision should be subject to a review of its appropriateness using the most conservative criteria. Every inappropriate use of restraints (including extended use without clinical justification) should be investigated.

The use of restraints within this organization is therefore limited to those situations with adequate and appropriate clinical justification and adequate human resources to meet the needs of patients requiring restraint as a therapeutic intervention. The management of the patient is intended to prevent injury to them, to other patients, to staff, and to prevent the destruction of property. Restraints are to be used as an unusual and temporary measure when the Physician/Nursing assessment deems it necessary and other available techniques or interventions have failed. It is also the intent that whenever restraints are applied, that they be removed as soon as possible.

The policy includes but is not limited to the following: Ensuring every inappropriate use of restraint use of restraints, including extended use without clinical justification, should be subject to root cause analysis as a near miss.

Leadership demonstrates its commitment to the aforementioned by providing and or promoting:

3. The development and promotion of preventative strategies.

4. The use of safe and effective alternatives including adequate human resources.

5. The integration of restraint/seclusion into the Performance Improvement (PI) activities of the organization, for the purpose of reducing restraint or seclusion use.

Types of Restraint/Safe Application per policy and procedure:

A. Interventions are arranged in ascending order of restriction as recognized by Lawnwood Regional Medical Center & Heart Institute (A to J).

A. Enclosure Bed

B Unanchored mittens.

C. Anchored mittens

D. Four Side rails.

E. One Limb Restrained

F. Two Limbs Restrained

G. Three Limbs Restrained

H. Four Limbs Restrained

I. Two point Hard

J. Four point Hard. Used for patient's exhibiting extremely violent behavior.

The fact that a patient's behavior warranted the use of Behavior Management Restraint or seclusion indicates a serious medical or psychological need for prompt assessment of the incident that led to the intervention, as well as psychological and physiological condition of the time of the assessment.

Education and Competency of Staff:

Staff members who have direct contact and any others who may become involved in the application of restraints must have education and training on hire and ongoing as applicable and training in the proper and safe use of restraints.

Per the policy and procedure education and competency:

Includes all contract/agency personnel with direct patient care responsibilities.

Includes those who may become involved in restraint application, even if not direct care providers (i.e., security guards, Emergency Medical Technicians (EMTs) on the premises).

One of the exceptions to the definition of restraints per facility policy:

Use of handcuffs and or other restrictive devices used by law enforcement who are not employed or contracted by the hospital or custody, detention or other public safety reasons, and not for the provision of healthcare. These are not considered restraints.

The Chief Nursing Officer (CNO) stated on 6/10/13 11:30 AM off duty police officers are contracted to provide security in the ED; they are our employees at this time. They are part of the care team in the ED. The CNO stated, the contracted officers are to follow the rules and regulations of Lawnwood Regional Medical Center and Heart Institute (LRMCHI). They are compensated for their services by LRMCHI.

Per the CNO, the law enforcement officers (contracted security personnel while on duty at the hospital) provide direct observation (line of site) of patients admitted to the ED under the Baker Act (BA). The observations are made every 15 minutes. The observations are documented on the Observation Checklist for Suicide Precautions by the contracted officer.

The CNO stated all nurses working in the ED have Crisis Intervention Prevention (CIP) training. This is an eight hour course at the time of hire. Annual updates are required.

The Director of Security stated at 11:45 AM on 06/10/2013, the contracted officers have 40 hours Crisis Intervention Training (CIT).

The surveyor asks if Handcuffs (HC) are used as a restraints. The CNO stated, At no time are handcuffs to be used. They (BA patients) can be transported to the ED by a Law Enforcement Officer (LEO) in HC. The HC are removed once the patient is received in the ED. The CNO stated HC are used only when a patient is under arrest. This was also verified at the time by members of the Administrative Team present (Risk Manager (RM), Quality Assurance (QA), Director of Surgery, Director of Security and the ED Director).

The facility records documents and substantiate patient #5 was restrained face down on the stretcher. The contracted security officer placed Handcuffs to both wrist. The handcuffs were then attached to the side rails (2).

The provisions of the aforementioned Restraint and Seclusion Policy and Procedure, as they relate to the events described in the facility documentation, were reviewed with the administrative staff (CNO, RM, QA, Directors of the ED, Surgery and Security). The RM and the QA stated, The police officers put handcuffs on the patient, so it was not a restraint.

At the time of the placement of the Handcuffs on patient #5 the contracted security officers were acting in the capacity as contracted security employees of Lawnwood Regional Medical Center & Heart Institute, held bound to the facility's Restraint Policies.

The contracted security officers are employees of the hospital and are part of the care team in the ED, therefore they are to follow the Restraint and Seclusion Policies and Procedures. Handcuffs were used to restrain patient #5 and thereby were applied as restraints. Handcuffs are not listed in the facility's Restraint & Seclusion Policy as appropriate restraint device.

At the time of survey neither the patient's medical record or facility records contained supportive evidence patient #5 was assessed for the use of restraint, starting with the least restrictive as deemed medically necessary, nor is there medical / physician's orders for the use of the restraints applied to patient #5, nor is there evidence that monitoring of the use of the restraint was performed in accordance with facility policy and regulatrory specifications.

In addition the patient was catherized for urine specimen without physician's orders; none was found in the medical record, eventhough RN #1 notes dated12/30/2011 at 11:32 PM refers to obtainig such an order; nor was one provided at the time of survey.

The facility's risk prevention analysis of the incident / occurrence failed to analyze and recognize the security officers while acting in the capacity as contracted employees of Lawnwood Regional Medical Center & Herart Institute, are bound to the facility's policy and procedures and healthcare regulatory requirements. The facility failed to recognize the contracted security employees are subject to risk prevention strategies aimed at preventing recurrent inappropriate use of restraints.

During the survey the facility was unable to provide evidence indicating the staff / employee failures were appropriately subjected to root cause analysis, and appropriate preventive measures implemented to prevent or manage the risk of future reoccurrence.

Facility staff failed to recognize handcuffs are not approved or appropriate healthcare restraint devices for patients who are not prisoners while hospitalized , and that its use is not listed in the facility's Policy under the section documenting acceptable types of hospital / healthcare restraints.

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on clinical record review and staff interviews the facility failed to ensure quality of nursing care provided to each patient is in accordance with established standards of nursing practice. This fialure affected 1 of 15 sampled patients (# 1) as evidenced by failure to reassess the patient as specified in the facility Nursing Assessment policies and procedures, and failure to follow physician orders.

The findings include:

Facility policy titled Unit Specific Assessment documents, Emergency Department, initiate Assessment upon arrival, completion time for patients assessed to have an urgent condition, thirty minutes. Re-assessments is an assessment focused on the patient ' s presenting complaint and the initial subjective and objective triage assessment. The reassessment may include some of all of the following: vital signs, a focused physical assessment, general appearance, and or response to treatment. Priority 2, reassessment to be completed every hour if there is a change in condition and upon discharge or admission .

Facility Policy titled Assessment and Reassessment Plan last revised on 02/2013 documents The purpose and objective of the assessment and reassessment process is to provide the patient the best care and treatment possible; when seeking entry into the health care setting. Emergency Department: Following stabilization and after a Medical Screening Exam is completed, the patient will be evaluated to determine frequency of reassessment. Priority 1 and 2 patients will be reassessed every hour if there is a change in condition and upon discharge or admission. Assessment and re-assessments are documented in the computer and in the nurse ' s notes of the ED record. Abnormal findings in the assessment and or re-assessment are communicated verbally and or in writing to the Emergency Department physician .

The facility Policy titled Vital signs in the ED: Normal and Abnormal, last revised on 12/20/12 documents Abnormal vital signs shall be repeated as defined by this policy. The triage nurse will be notified immediately of any abnormal vital signs and abnormal vital signs are defined as adult systolic blood pressure greater than 160 or less than 90 and diastolic blood pressure greater than 100. Oxygen saturation below 95 % shall be considered abnormal and Respirations above 20. Hourly waiting room reassessments- The reassessments may include some or all of the following: vital signs focused physical assessments, general appearance and response to interventions although a very limited reassessment to ensure that acuity has not changed. Any patient with abnormal vital signs as defined above, pain or change in vital signs will be reassessed for possible change in priority.

The review of the clinical record for patient #1 disclosed the patient arrived at the ED on 03/26/13 at 12:14 AM with complaints of shortness of breath and pedeal edema.

The Rapid Initial Assessment conducted at 12:18 AM, by Nurse #1, documents the patient's vital signs as: blood pressure 181/108 on the right arm, and 191/116 on the left arm; Respirations 24 and Oxygen saturation 92 %. Based on the findings Patient # 1 was prioritize as apriority 2 - Emergent.

The documented parameters of the patient's initial vital signs, at 12:18 AM, indicates a blood pressure, Respirations and Oxygen saturation level that are abnormal values as per the facility's policy's stated ranges of abnormal. The patient's systolic blood pressure is greater than 160 (181-left arm; 191 -right arm)); the diastolic is greater than 100 (108 - right arm; 116 - left arm); Respirations above 20 (24) and Oxygen saturation below 95% (92%). According to the stipulations of the policy these vital signs should be considered abnormal and warrants hourly reassessments in the waiting room. The reassessment for such a priority patient is to include reassment for possible change in priority condition.

The documented reassessments of patient #1 done at 1:17 AM, 2:17 AM and 2:34 AM, yield no evidence substantiating the patient's abnormal vital signs ( blood pressure, Respirations and Oxygen saturation) were reassessed as required and addressed as per facility policy.

Documentation of Nursing Assessment conducted at 4:00 AM documents the patient's respiratory status as within defined parameters. The assessment does not document actual respiratory rate value, actual oxygen saturation percentage, or documents follow up on the patient's abnormal blood pressure.

Subsequent Nursing Assessment at 7:15 AM, by Nurse #2 documents, the patient has diminished breath sounds, shallow respiration; Oxygen saturation is 89 %; Oxygen applied at 3 liters and Oxygenation improved to 98 %. The Nurse's Note at 7:15 AM also documents the following: First contact with patient; patient in bed. Low oxygenation, pulse oximeter at 89 %. Patient not on any oxygen. Patient placed on 3 liters of oxygen via nasal cannula.

During interview with (the Triage) Nurse #1, who was on duty the night of 03/26/13, conducted on 04/08/13 at 10:46 AM. The Triage Nurse stated, it was a very challenging night; the ED was full. She stated Patient # 1 was stable; she did not recall if she monitored the patient ' s vital signs and Oxygen saturations while in the waiting area, upon inquiry. The Triage Nurse stated, reassessments involve assuring patients have not left the ED and/or have not experienced changes in condition.

This Nurse missed the fact the patient ' s initial blood pressure, respiration, and oxygen saturation were abnormal as defined in the facility policy and warranted continued hourly monitoring to include physician notification of changes in the patient's condition.

During interview with The Director of Emergency Services on 04/08/13 at 12:01 PM, the Director stated, reassessments are based on the triage findings and presenting symptoms. Patient #1 ' s vital signs and oxygenation should have been reassessed by the nurse.

The Director reviewed the clinical record and stated. the patient was taken to the treatment area at 3:48 AM, at that time, the nurse documented the patient was placed on Oxygen and on the cardiac monitor. The Director was not able to locate and provide evidence of Oxygen saturation level results, or the cardiac monitoring strips.

2) Physician Orders dated 3/26/13 at 1:56 AM documents Pulse Oximetry, Oxygen and Cardiac Monitoring.

Review of the clinical record for Patient # 1 failed to yield any evidence the patient was placed on the cardiac monitor while in the ED, per physician's orders.

Facility policy titled Charting, Nursing Responsibilities last reviewed on 02/05/13, document paper documentation generated by the nursing staff will be placed in the appropriate section of the chart, e.g. rhythm strips, eMAR ' s and flow sheets.

During the interview with The Director of Emergency Services on 04/08/13 at 12:01 PM. The Director reviewed the clinical record and stated, the patient was taken to the treatment area at 3:48 AM, at that time the nurse documented the patient was placed on Oxygen and on the Cardiac Monitor. The Director was not able to locate and provide readings or the cardiac monitoring strips.

During an interview with Registered Nurse #, who cared for Patient # 1, on 04/09/13 at 8:22 AM, the Nurse stated, the night in question was extremely busy, This Nurse was not able to provide evidence of Oxygen saturation levels or vital signs reassessments documented as haven been performed by her during her shift.

3) Facility policy titled Medication Reconciliation last revised 10/2011 documents, The Medication Reconciliation process is initiated by the ED nurse or admission nurse for all inpatient admission or outpatients who convert to inpatient within 24 hours.

Admissions via the emergency room Department:

1. The ED Nurse completing the triage form will obtain a medication history including prescription, over the counter and herbal medications.

2. If the nurse is unable to obtain a complete medication history at the time of triage assessment, the home prior medication list can be updated at any time.

3. Once the decision has been made to admit the patient, the registered nurse or physician will use the ED Home/prior Medications Admission Order to reconcile the medications.

4. Once a patient is admitted to the receiving unit, the admitting RN will complete the verifying that all home/prior medications were addressed as entered into CPCS.

5. Physicians are responsible for continuing or discontinuing medications from the patient ' s prior mediation list.

Clinical record review disclosed Patient # 1 was admitted on [DATE] at 7:55 AM. Physician Order dated 03/26/13 at 4:10 PM documents Patient to take home medications

Further review of the Medication Administration Record dated 03/26/13 and 03/27/13 failed to provide evidence that home medications were reconciled as per facility policy within twenty four hours, or obtained and administered prior to the patient discharge on 03/27/13 at 3:28 PM.

Interview with the Registered Nurse who obtained the home medications and discharged the patient on 03/27/13 was not possible as reportedly this nurse is out of the countr.

Medication Reconciliation dated 03/27/13 at 1:27 PM documents Patient # 1 was taking the following medications at home, Soma 350 mg daily, Zocor 40 mg daily, Diovan/ Hctz 160/12.5 mg, Glucophage 1000 mg twice a day and Victoza 1.8 mg daily.

Interview with Registered Nurse # 2, who was assigned to care for Patient # 1, was conducted on 04/08/13 at 12:26 PM. The Nurse did not recall discussing with the patient, or obtaining, or having any concerns regarding the patient ' s home medications.

During an interview with the Chief Nursing Officer (CNO) on 04/08/13 at approximately 4:40 PM, the CNO stated., the facility policy is to reconcile home medications within twenty four hours of admission.

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on clinical record review and interview the facility failed to take actions aimed at improvement and to conduct appropriate and accurate root cause analysis. This failure has the potential to affect all patients at risk for developing pressure ulcers. A systemic failure of staff to follow the facility's standard of care for skin assessments affected 1 of 10 sampled patients (Patient # 10).

The findings include:

Review of Patient # 10 ' s clinical record was conducted on 09/20/11. Patient # 10 was admitted to the facility on [DATE] with the diagnosis, status post motor vehicle accident, passenger in rollover vehicle. Patient # 10 developed an avoidable pressure ulcer while hospitalized , based on staff failure to accurately implement the developed and established Care Plan, and to follow the facility's standards of practice.

The initial assessement records for 08/10/11 does not document any record or evidence of patient #10 having pressure ulcers at the time of admission. As of 08/18/11 the record documents the patient does not have any pressure ulcers. A Critical Care Flowsheet dated 08/19/11 documents the discovery that Patient #10 has one pressure ulcer to the left chin and one pressure ulcer to the left chest region.

Interview with the Director of Critical Care Services was conducted on 09/20/11 at 1:56 PM. The Director explained she is aware of the pressure ulcer found on patient # 10. She stated, the incident was investigated and the two nurses who took care of the patient on 08/18/11 and 08/19/11, did not follow the plan of care and the facility standard of practice and the cervical collar was not removed completely. She stated during her investigation she found out the nurses did not follow the policy and the nurses involved received disciplinary actions. She stated the wounds healed and wound care evaluated the wounds immediately. The Director stated she provided education to all of her staff and provided a copy of the meeting topics and sign in sheet.

Interview with the Clinical Educator (CE) was conducted on 09/20/11 at 2: 06PM. The Clinical Educator stated the nurses sign an attestation every shift documenting they have followed the standards of practice. She stated the hospital conducted an investigation into the development of patient #10's pressure ulcers, and they questioned the nurses who took care of the patient in the previous twenty four hours. There were two nurses involved. The CE sated the nurses documented the Collar was removed and/or skin assessment was completed in different areas of the flow sheet, in addition to completing the attestation form at the end of their shift attesting to following the facility's standard of practice. She stated the nurses documented on the assessments in the section noted Function mobility, collar brace every eight hours. The section titled comfort is completed; a check mark for bath means a complete bed bath was given and therefore, according to the facility's standard of practice, means a complete skin assessment was done. In the interdisciplinary care plan under skin, in the section titled incisions and wounds, the nurses have a yes or no section related to skin. For patient #10, this section documents skin intact and cervical collar checked with every position changed. The CE stated when the facility conducted their investigation the nurses were questioned regarding removing the collar and performing skin assessments and they both admitted to removing the collar partially. She stated the wound was discovered when placing the tracheotomy.

Interview with Registered Nurse (RN # 1), who provided care for patient #10, was conducted on 09/20/11 at 2:43 PM. She stated she took care of Patient # 10 on 08/18/11, the day before the pressure ulcer was discovered and acknowledged she did not follow hospital policy by not removing the cervical collar completely. She stated she did not assess the patient as good as she should have. The patient's daughter was in the room and she did not turn the light on.

Interview with Registered Nurse (RN # 2), who also provided care for patient #10 was conducted on 09/21/11 at 11: 05 AM. He stated he discovered the decubitus ulcer while assisting the physician with the tracheotomy. He stated the collar was removed at around noon time for the procedure. During the interview with RN #2, the stated the day in question, was odd, the physician scheduled the procedure for the morning, but then the procedure got rescheduled twice. RN # 2 stated he did not take the collar off as he was expecting the collar to be discontinued. He stated he recalled the patient preferred to have his head turn towards the left side and unless you removed the collar completely, the location of the ulcer was not visible. RN # 2 stated he did not receive disciplinary actions and he was told in the general staff meeting to be more diligent with skin assessments.

.

Interview with RN # 3 was conducted on 09/21/11 at 12:16 PM. The nurse stated she took care of patient # 10 the day before the pressure ulcer was discovered and acknowledged she did not look under the collar. She acknowledged she did not follow the policy regarding assessments. The nurses stated the policy is to remove the collar once a shift. At this time the Clinical Educator who was present during the interview stated the policy is to do a complete head to toe assessment every four hours in the intensive care setting. The RN#3 said she was suspended for a day and she received education regarding the policy during her counseling and during the staff meeting.

Review of facility records regarding the occurrence revealed the following:

The facility identified contributing factors: event severity moderate. Primary cause staff competency/education. Specific causes policies and procedures not followed. Individuals involved are noted. Wound Nurse confirmed unstageable wound. Final disposition, no adverse event; final disposition on 09/20/11 treatment provided. Corrective actions noted: wound protocol and enforced existing policy.

Show Text of Violation

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on clinical record review and staff interview the facility failed to ensure quality nursing care is provided to each patient in accordance with established standards of practice for the delivery of nursing care. This failure affected 1 of 10 sampled patients (Patient # 10).

The findings include:

Review of the clinical record for Patient # 10 conducted on 09/20/11, revealed the Patient 10 was admitted to the facility on [DATE] with a diagnosis of status post motor vehicle accident; passenger in rollover vehicle.

Physician admitting orders dated 08/10/11 document, admit patient to trauma service, critical condition, consult neurosurgery. Bed rest, logroll only every two hours and reposition right side back to left side, do not remove cervical collar until cleared by neurosurgery. Collar care twice a day, neurological checks every hour one hour, nothing by mouth. Vent settings per trauma attending.

History & Physical dated 08/10/11 document, This is a [AGE] year old male who was unrestrained passenger in the back of SUV. He was thrown into the rear of the section of the SUV. He was trauma alerted to the hospital for respiratory distress. The patient arrived immobilized on transport board with a cervical collar in place. The plan of care documents the patient will be admitted to Intensive Care unit for ongoing resuscitation and then alert management, he will be maintained on spine precautions with Velcro only .

The Critical Care Flowsheet dated 08/18/11 document Patient # 10 has no pressure ulcers, however the Critical Care Flowsheet dated 08/19/11 documents the discovery that Patient # 10 has one pressure ulcer to the left chin and one pressure ulcer to the left chest region.

Physician Orders dated 08/19/11 document a request for consultation from the wound care nurse for chin wounds.

The wound/skin consult assessment dated on 08/19/11 documents the consult was received to evaluate chin wounds. The assessment/treatment notes, Patient lying in bed, on Ventilator. Patient had been wearing vista C-collar when removed, wound of left jaw line and left upper chest noted. Wound on jaw line measures 1 cm by 3 cm. Wound is 100% covered with yellow and gray slough. Patient with facial hair growth. Wound on left upper chest near clavicle. On left upper chest near center and yellow slough around edges. Approximately 50 % of pink, 50 % yellow. Both wounds are unstageable pressure ulcers. No drainage at this time for either wound. Jaw line wound is very soft. Cleaned with saline and patted dry. Mepilex border placed on left chest wound, Foley catheter secured in place. The Recommendations documented is: left jaw line unstageable pressure ulcer, clean with normal saline solution and pat dry. Check with physician regarding Santyl versus surgical debridement. Left upper chest wound, unstageable pressure ulcer: clean with normal saline solution and pat dry. Mepilex border dressing. Change every three days and as needed. Check with physician for Santyl versus surgical debridement.

Interview with the Director of Critical Care Services was conducted on 09/20/11 at 4:56 PM. The Director explained she is aware of the pressure ulcer found on patient # 10. She stated, the incident was investigated and the two nurses who took care of the patient on 08/18/11 and 08/19/11, did not follow the plan of care and the facility standard of practice and the cervical collar was not removed completely. She stated during her investigation she found out the nurses did not follow the policy and the nurses involved received disciplinary actions. She stated the wounds healed and wound care evaluated the wounds immediately. The Director stated she provided education to all of her staff and provided a copy of the meeting topics and sign in sheet.

Interview with the Clinical Educator (CE) was conducted on 09/20/11 at 2: 06PM. The Clinical Educator stated the nurses sign an attestation every shift documenting they have followed the standards of practice. She stated the hospital conducted an investigation into the development of patient #10's pressure ulcers, and they questioned the nurses who took care of the patient in the previous twenty four hours. There were two nurses involved. The CE sated the nurses documented the Collar was removed and/or skin assessment was completed in different areas of the flow sheet, in addition to completing the attestation form at the end of their shift attesting to following the facility's standard of practice. She stated the nurses documented on the assessments in the section noted Function mobility, collar brace every eight hours. The section titled comfort is completed, a check mark for bath means a complete bed bath was given and therefore, according to the facility's standar of practice means a complete skin assessment was done. In the interdisciplinary care plan under skin section, titled incisions and wounds, the nurses have a yes or no section related to skin which documents skin intact and cervical collar checked with every position changed. The CE stated when the facility conducted their investigation the nurses were questioned regarding removing the collar and performing skin assessments and they both admitted to removing the collar partially. She stated the wound was discovered when placing the tracheotomy.

Interview with Registered Nurse (RN # 1), who provided care for patient #10, was conducted on 09/20/11 at 2:43 PM. She stated she took care of Patient # 10 on 08/18/11, the day before the pressure ulcer was discovered and acknowledged she did not follow hospital policy by not removing the cervical collar completely. She stated she did not assess the patient as good as she should have. The daughter was in the room and she did not turn the light on.

Interview with Registered Nurse (RN # 2), who also provided care for patient #10 was conducted on 09/21/11 at 11: 05 AM. He stated he discovered the decubitus ulcer while assisting the physician with the tracheotomy. He stated the collar was removed at around noon time for the procedure. During the interview with RN #2, the stated the day in question, was odd, the physician scheduled the procedure for the morning, but then the procedure got rescheduled twice. RN # 2 stated he did not take the collar off as he was expecting the collar to be discontinued. He stated he recalled the patient preferred to have his head turn towards the left side and unless you removed the collar completely, the location of the ulcer was not visible. RN # 2 stated he did not receive disciplinary actions and he was told in the general staff meeting to be more diligent with skin assessments.

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Interview with RN # 3 was conducted on 09/21/11 at 12:16 PM. The nurse stated she took care of patient # 10 the day before the pressure ulcer was discovered and acknowledged she did not look under the collar. She acknowledged she did not follow the policy regarding assessments. The nurses stated the policy is to remove the collar once a shift. At this time the Clinical Educator who was present during the interview stated the policy is to do a complete head to toe assessment every four hours in the intensive care setting. The RN#3 said she was suspended for a day and she received education regarding the policy during her counseling and during the staff meeting.

Review of the facility policy titled Assessment and Reassessment Plan revealed the policy specifies the following, Nursing Services: at the time of admission the initial assessment is the responsibility of the registered Nurse. The initial assessment will be completed as soon as possible. Documentation of patient reassessment is unit specific, critical care unit ' s reassessment time of every four hours and as needed. The assessment includes skin integumentary/Integrity/Ulcer risk assessment.

Review of the policy Standard of Care/Practice-Critical Care revealed Standard of Care related to skin integrity, to perform Braden skin assessment upon admission, with any change in condition and every assessment. Initiate and maintain preventive measures, keep skin clean and dry and prevent pressure friction and shearing forces on skin.

Unit specific Standard of Care/Practice, Documentation/Assessment notes a complete head to toe assessment will be completed every four hours, or more frequently, as necessary. If changes are observed, with subsequent patient reassessments, the nurse will document these changes in CPCS at the time of the occurrence. All trauma documentation is to be completed on the trauma flow sheet; the only exceptions that need to be in CPCS are as follows: Patient admission history and physical, education, restraints and attestation of standards of care.

RN #2 and RN#3 who are knowledgeable of the facility's standards of practice relating to skin integument assessments documented the completion of care and services they did not provide. While disciplinary action and education inservice has been provided, no evidence was found or provided to substantiate a causal anlysis was conducted and a evaluation of the circumstances that contributes to the ability to violate the policy was made; nor is there evidence the facility identified and monitored other patients who are potentially at risk of having the same negative occurrence.

Respect us. Protect us. Pay us!

HCA Florida Lawnwood Hospital

15 CMS Violations since 2011-09-21

Non Immediate Jeopardy Violations

Violation Name: RN SUPERVISION OF NURSING CARE(A-0395)

Violation Name: STAFFING AND DELIVERY OF CARE(A-0392)

Violation Name: RN SUPERVISION OF NURSING CARE(A-0395)

Violation Name: ORDERS FOR DRUGS AND BIOLOGICALS(A-0409)

Violation Name: NURSING CARE PLAN(A-0396)

Violation Name: COMPLIANCE WITH 489.24(A-2400)

Violation Name: RECIPIENT HOSPITAL RESPONSIBILITIES(A-2411)

Violation Name: RN SUPERVISION OF NURSING CARE(A-0395)

Violation Name: ORDERS FOR DRUGS AND BIOLOGICALS(A-0409)

Violation Name: PATIENT RIGHTS: CARE IN SAFE SETTING(A-0144)

Violation Name: USE OF RESTRAINT OR SECLUSION(A-0154)

Violation Name: QAPI GOVERNING BODY, STANDARD TAG(A-0308)

Violation Name: RN SUPERVISION OF NURSING CARE(A-0395)

Violation Name: PATIENT SAFETY(A-0286)

Violation Name: RN SUPERVISION OF NURSING CARE(A-0395)

Respect us. Protect us. Pay us!

HCA Florida Lawnwood Hospital

15 CMS Violations since 2011-09-21

Non Immediate Jeopardy Violations

Violation Name: RN SUPERVISION OF NURSING CARE(A-0395) toolTips('.tooltip_post_id_custom_90c48ea9d673f0336e5a4c2e7e603aa8','\<p\>\<span style\=\'color\:white;padding\:1px;font\-weight\:bold;min\-width\:500px\'\>A registered nurse must supervise and evaluate the nursing care for each patient\.');

Violation Name: RN SUPERVISION OF NURSING CARE(A-0395) toolTips('.tooltip_post_id_custom_55c0a415929dfedd81df7d9b4e933010','\<p\>\<span style\=\'color\:white;padding\:1px;font\-weight\:bold;min\-width\:500px\'\>A registered nurse must supervise and evaluate the nursing care for each patient\.');

Violation Name: RN SUPERVISION OF NURSING CARE(A-0395) toolTips('.tooltip_post_id_custom_b0f7cded66f31c7f67683a4e85e17224','\<p\>\<span style\=\'color\:white;padding\:1px;font\-weight\:bold;min\-width\:500px\'\>A registered nurse must supervise and evaluate the nursing care for each patient\.');

Violation Name: PATIENT RIGHTS: CARE IN SAFE SETTING(A-0144) toolTips('.tooltip_post_id_custom_f16d13ab13bd6c61e7d3a62462b6d960','\<p\>\<span style\=\'color\:white;padding\:1px;font\-weight\:bold;min\-width\:500px\'\>The patient has the right to receive care in a safe setting\.');

Violation Name: RN SUPERVISION OF NURSING CARE(A-0395) toolTips('.tooltip_post_id_custom_33014948780dd87cb653a81a6ade80a8','\<p\>\<span style\=\'color\:white;padding\:1px;font\-weight\:bold;min\-width\:500px\'\>A registered nurse must supervise and evaluate the nursing care for each patient\.');

Violation Name: RN SUPERVISION OF NURSING CARE(A-0395) toolTips('.tooltip_post_id_custom_1565462ec6897be124c648dd05d015ff','\<p\>\<span style\=\'color\:white;padding\:1px;font\-weight\:bold;min\-width\:500px\'\>A registered nurse must supervise and evaluate the nursing care for each patient\.');

Violation Name: RN SUPERVISION OF NURSING CARE(A-0395)

Violation Name: RN SUPERVISION OF NURSING CARE(A-0395)

Violation Name: RN SUPERVISION OF NURSING CARE(A-0395)

Violation Name: PATIENT RIGHTS: CARE IN SAFE SETTING(A-0144)

Violation Name: RN SUPERVISION OF NURSING CARE(A-0395)

Violation Name: RN SUPERVISION OF NURSING CARE(A-0395)