HCA Florida Memorial Hospital

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

Based on observations, staff interviews, and document review of electronic medical records and faciity wound care policies, the facility failed to ensure consistent implementation of the nursing care plan intervention related to pressure wound dressing changes for two (Patient #1 and Patient #3) of 6 sampled patients who were reviewed for wound management. Failure to ensure that wound dressing changes occurred as ordered could lead to the deterioration of a patient's wound, prolonged hospitalization and infections.

The findings include:

1) Patient #1 was admitted on [DATE] and discharged on [DATE] with altered mental status (AMS), morbid obesity, congestive heart failure, chronic renal failure, status post prolonged hospital stay at another acute care facility, respiratory failure, fever, and hypoxia. Patient #1 had a re-admission to the facility documented on 01/28/21 for an abnormal hemoglobin that required transfusions on 1/29/21, 2/3/21, and 2/15/21.

A review of the medical record documentation of admission assessment/ shift assessment notes, dated 01/11/2021 at 8:00 AM included skin alteration existed with an abrasion to lower back. Red/ moist/ smooth/ shallow wound base was visible as documented. Open area was marked as 'Yes'. Partial thickness with no measurement recorded. Pressure injury immobility related to sacrum present on admission, wound base visible skin was not intact and graded as a Stage II pressure injury. [Document on Page 9 submitted.] No wound management documented with this assessment and a photograph was included in the medical record.

Interviews were conducted with the wound management team Employee C, Registered Nurse (RN) and Employee D, RN on 04/14/2021 at 9:14 AM. Both staff members stated that the nurse on the unit performed the wound care dressing changes for each patient. The wound care team rounded on patients as needed.

Interviews were conducted with Employee C, RN Wound Care, and Employee D, RN Wound Care on 04/14/2021 at 10:51 AM. Employee D, RN Wound care stated that the wound care team saw a new consult usually by the next day and based on the wound care nurse protocols implemented interventions that the physician would order, and the floor nursing staff would perform the wound care dressing changes as ordered.

The following Admission/Assessment notes were reviewed as dated:

1/11/2021 at 1:15 PM-Wound Management Program (WMP) notes documented, Patient off floor at time of rounding on 5 C. Will follow up for consult at a later date. 1/12/2021 at 8:00 AM documented existing wound as yes. [Page 25 submitted]

1/12/2021 at 1:26 PM [Page 26 submitted] a note Entered by Employee D, RN Wound Management Program notes-Patient resting supine in bed. Consulted primary nurse. Images observed to chart. Will place temporary wound care orders. Alginate to all sites for now. Additional supplies provided and left at bedside. WMP nurse to follow up at a later time. [Page 27 added note] Continue supportive and preventative care.

1/12/2021 at 1:55 PM [Page 27 submitted] Frequency documented as every two days Melgisorb Ag (Dressing) apply to coccyx and left back. Cover with DSD (dry sterile dressing). Additional instructions: Cleanse open wounds to coccyx region and left lower back wounds with normal saline, pat dry with gauze apply Melgisorb Ag to open wounds cover with dry sterile dressing. Change every 2 days and as needed (PRN) spoilage. (Wound Care Nurse) Protective Barrier cream two times a day (BID) and with every incontinence episode. Keep clean and dry.

1/12/21 at 8:14 PM [Page 29 submitted]-documented skin alteration exist. Documented existing wound [Page 30]. [Facility printer for documents printed on 4/15/2021 was off date and confirmed printing the documentation for the surveyor date printed as 1/22/2021 at 12:17 AM by the Director of Informatics by review and interview on 4/15/2021 at 8:25 AM.]

1/13/2021 at 8:00 AM assessment Page 33- Skin alteration present/exists. Page 34 existing wound documented as yes.

1/13/2021 at 2:04 PM [Page 37 submitted]- Wound Management Program Notes- at 2:06 PM by Employee D, RN Patient is off the floor for hemodialysis treatment. WMP nurse to follow up at a later time. Continue wound care orders as per Meditech. Continue supportive and preventative care.

1/13/2021 at 7:00 PM-Skin alteration present/exist was documented by shift nurse. [Page 38 and Page 39 submitted] Documented existing wound. [No wound dressing change note.]

1/14/2021 at 1:00 AM-[page 41] documented on assessment skin alteration present/exists. Abrasion thighs bilateral active with tissue type worst was Pink/red/[DIAGNOSES REDACTED]/intact. Skin intact, blanchable documented no for open areas. Superficial for the skin abrasions medial thigh.

1/14/2021 at 8:01 AM-[Page 43]- Admission/shift assessment indicated skin alterations present lower back, thighs bilateral and a pressure injury related to sacrum active and present on admission to the facility. Dressing was documented intact. Date of last dressing change was documented 1/11/2021 at 5:00 PM which indicated a time frame greater than every 2 days for this dressing change and Meditech orders to be followed.

1/14/2021 at 2:26 PM [Page 47]-Wound Management program notes indicated by Employee D, RN Patient resting in bed upon arrival. Noted Bariatric (low air loss) LAL surface. WMP role explained. Patient immediately refused stating that is old. But what you can do is see about my IV burning in my arm. Patient holding arm in the air at the time. Primary nurse consulted and made aware. WMP nurse will follow up at a later time. Continue wound care. [No documented wound care was provided.]

1/14/2021 at 7:10 PM [Page 50] Admission/shift assessment reviewed-skin alteration present exists. This nurse documented a No under existing wound demonstrated inconsistent documentation from the above skin alteration present and existed.

1/15/2021 at 8:00 Am [Page 54] indicated wound present. No documented wound interventions evident.

1/15/2021 at 20:00 hours- [Page 58] indicated patient had a present/existing skin condition and indicated wound present.'[Page 59] No wound/dressing change documented.

The pattern of repeated skin assessment continued on [Page 69] skin alterations exists, wound present on page 70 dated 01/16/2021 at 9:05 PM. [No identified wound dressing changed provided as dated 1/16/21.]

01/17/2021 at 7:20 AM [Page 73] documented admission/shift assessment pressure injury immobility related to sacrum. Present on admission. Dressing intact and date of last dressing change was documented 1/16/2021 at 5:00 PM. Mepilex dressing, no area calculated. [Page 74] documented wound present. Total dependence documented on 1/17/ at 6:05 PM. At 7:55 PM documented on [Page 80] skin alteration present/exists and wound existing.

1/18/2021 at 11:59 AM [Page 84] Nutritional Assessment documented under intake: Physical Assessment: Per RN shift assessment 1/17/2021. Pressure-related wound to sacrum. No stage documented. Wound management has been unable to assess wound yet this admission.

1/18/2021 at 1:01 PM [Page 86] skin alteration present/exists and wound [Page 87] documented skin breakdown education and wound care. On 01/18/2021 at 8:15 PM documented Existing wound. [Page 90 & Page 93]

1/19/2021 at 5:17 PM [Page 98] Dressing to coccyx clean dry and intact. Left below knee amputation, right foot partial amputation.

A review of Patient #1's medical record for admission assessment, dated 01/28/2021 at 11:53 PM was conducted and it was documented 'Skin alteration: Pressure injury immobility related to posterior back middle. Open area Yes. Skin intact no.' No measurement for advanced wound. Sacral wound documented. An interview with the Director of Informatics was conducted on 04/14/21 at 1:45 PM. She confirmed that wounds identified on admission should have documented measurements.

An initial wound care management consult was triggered by the physician order and included a documented wound care note entered by Employee C, RN (Wound Care Nurse) dated 02/03/21 at 4:46 PM. The documented note included a Stage 3 pressure injury with Deep Tissue Injury (DTI) component. Measured at 16.5 cm X 14.0 cm X 0.5 cm depth. Stage 3 pressure injury to coccyx with congestion to base, dry wounding, DTI component with deep purple and maroon skin discoloration, highly likely to evolve. Wounding dry to touch. The WMP recommendations included to change every three days hydrocolloid dressing change to sacrococcygeal; change from foam dressing as needed for soilage. Every 3 days preventative dressing to back DTI's; barrier cream to gluteal folds and perineum.

A review of the medical record was conducted with the Director of Informatics on 04/14/2021 at 1:22 PM revealed that dressing changes performed by nursing could not be provided for at least six days of Patient #1 admission to the facility. The facility could not provide that the intervention ordered was actually completed for Patient #1 as ordered. On 2/3/21, the sacral wound was assessed as a stage 2 pressure injury. Dressing changes were not documented as completed for 2/4/21, 2/7/21, 2/10/21, 2/13/21, 2/16/21, 2/19/21. On 2/19/21, Patient #1 expired.

2) A review of the medical record for Patient #3 was conducted and documented that Patient #3 was admitted to the facility on on 03/26/21 at 11:30 AM for a complaint of altered mental status and Urinary Tract Infection (UTI). Patient #3 had a documented medical history that placed the [AGE]-year-old patient at risk for the development of wounds which required a thorough assessment for wound development. Risk factors included UTI, Diabetes, deep vein thrombosis and arthritis per past medical history.

An interview was conducted with Employee A, RN on 04/13/2021 at 1:26 PM. She stated that she was covering for the nurse who cared for Patient #3 at the time but would attempt to provide information related to a wound identified for Patient #3. She confirmed that Patient #3 had a pressure wound, orders were present; however, she was not sure how to look up the past wound documentation when asked.

An interview was conducted with Employee B, RN on 4/13/21 at 1:45 PM about the wound care for Patient #3. She was not able to identify a wound dressing change that was referred to by staff as dressing changed on 4/12/2021 at midnight. Employee B, RN printed the orders for the wound intervention documented as Cleanse with Normal Saline, 4 X 4. The wound care note was obtained provided by and revealed that the wound care was ordered on [DATE] at 5:23 PM by the wound management team (Employee C, RN and Employee D, RN). The wound care plan included a documented frequency to be completed every 2 days and as needed. Apply Melgisorb Ag to right buttock, sacrum, and cover with Optifoam.

A review of the admission assessment/ shift assessment that indicated the presence of a wound on Patient #3 was documented by Employee F, RN on 3/28/21 at 3:53 PM. The note reviewed read, Sacral wounds cleaned and dressings clean/dry/intact.

A review of the medical record for Patient #3 was conducted for the wound dressing change referenced in the medical record note printed on 04/14/21 at 12:05 PM. The note included Pressure injury immobility related Sacrum. This wound was documented as an active wound with dressing documented dry and intact. Date of the last dressing change was documented as 04/12/21 at midnight. This documented wound care dressing change could not be provided as requested by the surveyor.

A review of the medical record for Patient #3 documented on 04/06/21 at 12:30 PM by Employee D, RN Wound Care, Triggered by follow up for wound care visit. Patient Care Technician at bedside for assistance with turning and repositioning. Patient resting in Accumax surface. Wound care nurse role was explained, and patient was agreeable to visit. The assessment indicated generalized poor skin turgor and tensile strength. Sacrococcygeal: Fissure noted. Measured 2.0 cm X 0.4 cm. Moist, mild [DIAGNOSES REDACTED] and a bit blanchable. Melgisorb ag applied and sacral dressing applied.

A review of the medical record admission assessment/ shift assessment form included an entered wound care note dated 4/14/21 documented by Employee C, RN and included Sacrococcygeal: Fissure noted. The wound measured 2.0 cm X 0.4 cm, moist and mild [DIAGNOSES REDACTED] bit blanchable. Melgisorb ag applied and sacral dressing applied. Closed scarring to sacrum. Presents as pinhole sized scar/hole. Fissure to perineum 3.8 cm long, superficial wounding, moist and small amount of serosanguinous drainage noted.

The facility could not provide the referred to 04/12/21 midnight dressing change documented after multiple times requested and multiple reviews conducted by the (Assistant Director of Nursing) ADON and the Director of Informatics who was interviewed on 4/15/2021 at 8:25 AM. They confirmed that the facility did not provide a completed and documented plan of care with interventions for Patient #3's wound management.

On 4/15/21 at 8:25 AM, an interview was conducted with the ADON, Director of Nursing (DON), and the Director of Informatics confirmed the facility could not provide documented evidence that all wound team/ physician ordered wound interventions occurred as ordered for Patient #1 and Patient #3 two out of six patients reviewed for the presence of wound care needs being met.

An interview was conducted with the ADON on 4/15/2021 at 8:41 AM. She stated that she agreed that the facility failed to demonstrate by medical records reviewed for Patient #3 that nursing staff followed the plan of care for wound treatments.

A policy review conducted of policy identification number 86 included that it applied to medical personnel involved in the photographing of pressure-related skin breakdown for the medical record at the facility. Purpose to provide visual record to document within the patient's chart the initial condition/ impairment of the patient's skin and healing progression for inpatients at the facility.

A policy review was conducted of policy identification number 50 which included the interdisciplinary policy that the facility staff would assess, plan and implement, and evaluate the care of those patients at risk for skin breakdown or admitted with skin impairment. At line 7, it was documented that subsequent wound measurements of pressure ulcers should be obtained weekly as part of the nursing assessment.

A policy review was conducted of policy stat identification number 71 Wound Care Program and indicated at line 3 that Ordered dressing changes will be the responsibility of the staff nurse unless specified otherwise by a physician order for the wound nurse only to perform dressing changes.

Based on record review, policy review, and employee interviews, the facility failed to provide a safe Discharge Plan, which resulted in a readmission to another facility for 1 of 3 patients reviewed for discharge planning. (Patient #1, Hospital B)

The findings include:

Patient #1 was admitted to Hospital A on 05/12/2020 as a voluntary patient for psychiatric needs. Patient #1 completed therapy at Hospital A and was waiting for appropriate placement in the community. Records from Hospital A showed Patient #1 had mental and physical needs. Patient #1 had a community caseworker and resided in an Assisted Living Facility (ALF) prior to admission at Hospital A. Patient #1 is wheelchair bound due to a below the knee amputation on the right side. Records from Hospital A showed Patient #1 had low sodium levels and needed medical attention on 06/02/2020. Hospital A could not provide this type of medical attention. Patient #1 was transferred to Hospital B for appropriate medical attention on 06/02/2020. On review of Hospital A's records for Patient #1, all policies and procedures were followed, resulting in an appropriate transfer and discharge of Patient #1 from Hospital A.

A record review of Patient #1 at Hospital B revealed the patient arrived on 06/02/202 at 06:35pm by rescue from Hospital A for low sodium levels. Labs results on 06/02/202 at 07:04pm showed Patient #1's sodium level was 123. The Emergency Physician consulted an Admitting Physician for admission for Hyponatremia (low sodium) at 08:30 pm. The Admitting Physician admitted Patient #1 for Hyponatremia and medical clearance under a 23-hour observation.

On 06/03/2020 at 07:30am, Patient #1's labs showed a corrected sodium level of 134. The in-patient physician discharged Patient #1 for corrected sodium levels.

On 06/03/2020 at 11:45am, the nursing notes showed Employee #6, Registered Nurse (RN), noted in Patient #1's record that Hospital A was contacted to notify them that the patient was ready for discharge.

On 06/03/2020 at 11:59am, the Case Management notes for Patient #1 showed Employee #5, Case Manager (CM), noted:

-SW attempted to contact patient; no answer.

-Unable to assess current mental status

-Information obtained from medical records

-Discharge barriers: None or N/A

-Patient goals and preferences after discharge: home

-Based on information gathered, is it likely that the patient's care needs can be met in the environment from which he/she entered the hospital? Yes

-If a caregiver is needed, is there a caregiver available, willing and capable to provide care? Not needed

Community Services needed: None

(photographic evidence obtained)

On 06/03/2020 at 12:04pm, the nursing notes showed Employee #6, RN noted in Patient #1's record, the patient's caregiver contacted the RN and stated the caregiver would pick the patient up at 2:30 pm.

On 06/03/2020 at 02:15pm, the nursing notes showed Employee #6, RN noted in Patient #1's record, the patient's caregiver was at the hospital to pick up the patient.

An interview was conducted with Employee #5, CM and the Director of Case Management on 06/23/2020 at 09:05am. Employee #5 stated she tried to call the phone number in the patient's demographic information of the medical record. Employee #5 stated Patient #1 had no other needs besides psychiatric care, and there were no physical needs. Employee #5 stated her documentation on 06/03/2020 was correct for Patient #1.

During the interview, Patient #1's medical record was reviewed. It was discovered the demographic information for Patient #1 was the same as the emergency contact listed for the patient. Employee #5 admitted the patient and the emergency contact had the same phone number, and it was possible she called the emergency contact and not the patient during her phone attempt to assess the patient.

In the interview with Employee #5 and the Director of Case Management, they both stated Patient #1 remained in the Emergency Department (ED) after being admitted on observation status by the Admitting Physician. They stated this was not uncommon when there are no available beds in the hospital. They explained Employee #5 was a Case Manager assigned to the ED, to assist with Case Management needs in the ED.

Employee #5 stated she did not attempt to see Patient #1, because of documented patient behaviors in the nursing notes. She confirmed that she should have assessed the patient in person according to the facility's policy and procedures. She stated she did not know Patient #1 was wheelchair bound.

A second interview with the Director of Case Management was conducted on 06/23/2020 at 11:49am. The Director admitted Employee #5 did not meet the expectation for Case Managers in the case of Patient #1. The Director stated this case is not their standard of patient care, and she recognized that. She stated it was expected that Case Managers conduct a full assessment on all patients; this was not acceptable and Employee #5, should have seen the patient. The Director confirmed Employee #5's Discharge note was incomplete and not appropriate for Patient #1. The Director stated that the Case Manager was supposed to round on every observation patient daily and confirmed this did not occur with Patient #1. The Director confirmed the facility policy and procedures relating to discharge planning was not followed.

In an interview, on 06/23/2020 at 03:47pm with the Director of Nursing (DON), she explained her expectation of discharging a patient that included proper education and understanding of discharge to the appropriate level of care. She would expect a Case Manager to see a patient in person.

Review of Policy and Procedures titled Discharge Planning revealed all patients identified as high risk patients admitted to Hospital B have the right to receive a Case Manager for individualized assessment of their needs for continuity of care upon discharge to the community or an alternate level of institutional care that is appropriate. The Case Management Department will screen all admissions for the following high-risk patient identification, diagnosis and at-risk populations which may require in-depth discharge planning assistance. (photographic evidence obtained)

After discharge of Patient #1 at Hospital B on 06/03/2020 at 02:15pm to a boarding home without a wheelchair ramp, the patient was visited by her community Case Manager. The patient was found sitting in her wheelchair outside the boarding home and appeared drugged or sedated. The patient was taken to Hospital C on 06/03/2020 at 07:16pm by Rescue for altered mental status. Records from Hospital C showed Patient #1 was admitted for patient placement and is currently still a patient, awaiting appropriate placement in the community.

Based on observations, record reviews and staff interviews, the hospital failed to protect and promote patient rights as evidenced by the failure to properly notify a patient after receiving a grievance. In addition, the hospital failed to notify the patient of the hospital's decision, actions taken to investigate the grievance, the results of the grievance, or the date of completion for the grievance for 1, (#1) out of 10 patients sampled for grievances (A123).

The hospital failed to follow policy in care of the patient with chest pain and placing the patient in the appropriate setting for monitoring 1 of 10 patients sampled, resulting in the potential for adverse outcomes for all patients presenting to the Emergency Department (ED) (A144).

The hospital failed to treat and document changes in a patient's condition by a physician for 1 (#1) out 10 patients sampled ( A359).

The hospital failed to plan and ensure nursing care was provided for each patient, evidenced by the hospital failure to monitor and assess a patient that came into the Emergency Department for chest pain for 1 out of 10 patient records sampled ( A385, A 396).

The hospital failed to have completed patient records which include all practitioners' orders, nursing notes, and vital signs for Patient #1, out of 10 records sampled (A467).

The cumulative effect of these systemic problems resulted in the facility's inability to protect and promote each patients' rights as required by the Patients' Rights Condition of Participation (CoP).

Based on observation, record reviews and staff interviews, the hospital failed to properly notify a patient after receiving a verbal grievance. In addition, the hospital failed to notify the patient of the hospital's decision, actions taken to investigate the grievance, the results of the grievance, or the date of completion for the grievance for 1 (#1) out of 10 patients sampled.

The findings include:

A review was conducted of a grievance dated 11/17/2017 from Patient #1, who called the hospital at 3:44 PM and spoke with Risk Management staff and voiced the following concerns:

1) Patient reported, I was having a heart attack and was left in the ER hallway for 3 hours before anyone realized what was going on.

2) Patient reported she was told by a female physician that they were just waiting for the labs to return, but the patient said no labs were taken.

3) Patient reported at that time labs were performed, it was already determined she had a blockage & a heart catheterization was needed.

4) Patient reported that the Cardiologist apologized to her & said the delay should have never happened.

A review of the hospital investigation conducted by Employee F, Registered Nurse (RN) on 11/21/2017 at 11:25 AM for the grievance received by Patient #1 revealed (which she documented): It does appear from the patient medical record that the patient did not have labs draws for 3 hours, which resulted in delay of her care.

A review of the grievance investigation conducted by Employee L, (MD) on 12/8/2017 at 3:30 pm, documented: A review of Patient #1's record reveals there was a delay in blood draw and this was embarrassing and detrimental to patient's safety.

An interview with Employee G, Physicians' Assistant (PA) on 1/9/2018 at 5:15 PM, confirmed that before today (1/9/2018), the facility had not discussed with him the delay in care to Patient #1, which she experienced while under his care. He stated, I was just told today that this patient's care was being reviewed. I see so many patients on a daily basis, there is no way I could remember her care.

A review of the facility's grievance report for Patient #1 revealed documentation was not entered to verify the physician was notified, nor was the patient who made the grievance contacted. Upon further review of the grievance, the type of event was listed as a communication error, instead of the correct event of delay in care.

An interview with Employee A, Risk Manager (RM), on 1/9/2018 at 1:35 PM confirmed the grievance for Patient #1 was not entered correctly and was listed as a communication error, and should have been documented as a delay in care, and an Incident Report should have been completed. The RM also confirmed the hospital was to send the patient a letter within 7 days of receiving the grievance, but could not find the letter or documentation that Patient #1 was ever notified of the hospital's acknowledgment of the grievance.

A review of the facility's Incident/Accident Reports revealed no incident or event report was done with the concerns made by Patient #1.

A review of the Hospital Patient Complaint/Grievance Resolution Policy Stat # 79 E, effective date 9/20/93 and revised 10/10/16 reads: A verbal complaint is a grievance if it cannot be resolved at the time of the complaint by staff present, if it is postponed for later resolution, if it requires investigation, and/or if it requires further action for resolution. All grievances will be investigated promptly, but occasionally, a grievance is complicated and may require and extensive investigation. All grievances will be resolved within 45 days of initiating the grievance.

An interview with the Hospital Risk Manager on 1/9/2018 at 2:05 PM confirmed the grievance for Patient #1 was over 45 days, and had not been resolved. In addition, the RM confirmed Patient #1 had not been notified of the status of the grievance. She stated, It was an oversight on our part and I can't find the letter where the patient has been contacted.

Based on patient record reviews and staff interviews, the facility failed to follow policy in care of the patient with chest pain, failed to document changes in a patient's condition by a physician and placing the patient in the appropriate setting for monitoring for 1 of 10 patients sampled (Patient #1), resulting in the potential for adverse outcomes for all patients presenting to the Emergency Department (ED).

The findings include:

A closed record review for Patient #1 revealed the patient arrived at Memorial Hospital Jacksonville Emergency Department on 11/9/2017 at 12:57 PM via Emergency Medical System (EMS).

A review of the EMS Run Sheet dated 11/9/2017 revealed Patient #1 had complaints of chest pain, 9 out of 10 with the pain going from her back to her chest.

A review of Nursing Triage Assessment performed by Employee H, Registered Nurse (RN) on 11/9/2017 at 12:57 PM revealed Patient #1 had chest pain x 2-3 days, with nausea and vomiting, shortness of breath (SOB), and also complained of neck, back/head/jaw pain x 2 days. The patient pointed to the middle of her chest and stated, Heavy like someone is sitting on me.The patient made complaints her pain was a numeric pain scale of 10 and described it as, the worst pain ever.

It was also found that the patient stayed in the hallway area versus placing the patient in an ED Bay/Room for monitoring.

A review of Patient #1's Vitals Signs Data Sheet revealed no nursing documentation was recorded for vital signs, nor assessments for Patient #1, from 11/9/2017 at 12:57 PM until 11/9/2017 at 4:58 PM.

A review of the Hospital Standards of Care reads: Implement Emergency Department chest pain guideline orders, EKG to be done within 10 minutes, Record rhythm identification and mount monitor strip every 30 minutes x 2, then every hour and as needed (PRN). Vital signs are to be taken every 30 minutes x 2, then PRN and vital signs are to be taken every 30 minutes to 1 hour after giving any Intramuscular (IM) or Intravenous (IV) pain medications.

An interview with Employee F, RN, on 1/9/2018 at 4:07 PM, confirmed no documentation could be found in Patient #1's record of vitals signs, nor nursing assessment being conducted from 12:57 - 4:58 PM on 11/9/2017 for Patient #1, and it should have been done every 30 minutes, according to Emergency Operating Procedures.

A review of the facility's Policy and Procedures for Chest Pain (Care of a Patient with) (# 09), effective date 10/1/1987 last revised date of 4/7/2017 reads, Procedures: place patient on oxygen therapy, draw blood for lab studies and point of care testing, carry out orders by physician as soon as possible. Required documentation: record vital signs as indicated and after administration of medications, Monitor EKG and patient's condition.

An interview with Employee E on 1/9/2018 at 2:40 PM, confirmed he reviewed the record for Patient #1 and she was never placed on oxygen, nor had documentation of any care from the nursing staff from time of entry on 11/9/2017 at 12:57 PM until 11/9/2017 at 4:58 PM.

A review of Patient #1's record revealed no other documentation or care was given to Patient #1 until 11/9/2017 at 2:49 PM, when Employee K, (MD) Medical Doctor, was notified by the patient that she was in pain and hadn't received care. Employee K then ordered stat labs to be drawn and a repeat EKG, which revealed a positive Troponin level and Abnormal EKG, and required emergency heart catheterization and stent placement.

A review of the physician's documentation for Patient #1's heart catheterization dated 11/9/2017 at 4:37 PM revealed MD

elected to take her to the cath lab urgently, because of ongoing chest pain. Findings included: Left ventricular systolic function was normal. Ejection fraction was estimated in the range of 55% to 60 % and stent.

An interview with Employee E, (MD) on 1/9/2018 at 2:51 PM confirmed Patient #1 did not receive the proper care and treatment for almost 2 hours after arriving to the emergency room with chest pain, per facility operating procedure for a patient arriving with complaints of chest pain. Employee E confirmed Patient #1 needed Troponin level done due to her age and her type of complaint of chest pain and stated, I don't know why it wasn't done. That's an anomaly. The Employee was asked if the hospital had a certain time frame where the Troponin level should be drawn and he said a patient should be seen and treated by the physician within 10 minutes from arrival.

An interview with Employee D, Physicians' Assistant (PA), conducted on 1/9/2018 at 5:30 PM confirmed he did not document his assessment with Patient #1 on 11/9/2017 and did not follow the hospital procedure for chest pain for Patient #1. He stated, I don't know why I didn't run the test, unless she complained of something different when I saw her. Employee D confirmed the Nursing Assessment and EMS Run Sheet both revealed the patient was experiencing chest pain of 9/10 out of 10, and did not receive the proper emergent treatment.

Based on review of clinical records, staff interviews and a review of hospital documentation for the care and services provided in the Emergency Department (ED), the hospital's Quality Assurance and Performance Improvement (QAPI) Program failed to monitor the effectiveness and safety of services and quality of care, when there was known non-compliance with Patient #1, who was experiencing chest pain of 9 out of 10, and did not receive the proper emergent treatment and should have had labs (Troponin level) done, due to her age and her type of complaint of chest pain resulting in a finding of a condition. The hospital's QAPI Program also failed to take action when there was known non-compliance with Employee D, Physicians' Assistant (PA), who did not document his assessment with Patient #1 on 11/9/2017, did not follow the hospital procedure for chest pain, and did not follow the plan of care for chest pain for Patient #1, which was his scope of practice.

The findings include:

A review of Patient #1's clinical record was conducted. Patient #1 was seen on 11/9/2017 at 12:57 PM in the ED and triaged as emergent for frequent assessment and was placed in the ED hallway bed. Patient #1 had chest pain x 2-3 days, with nausea and vomiting, shortness of breath (SOB), and also complained of neck, back/head/jaw pain x 2 days. The patient pointed to the middle of her chest and stated, My chest is heavy like someone is sitting on me. The patient made complaints the pain would radiate to her back/neck/jaw with a numeric pain scale of 10.

The patient was not documented as being seen by a physician and nursing on 11/9/2017 at 12:57 PM until 11/9/2017 at 4:58 PM. No labs were evidenced as being ordered upon admission.

An interview with Employee F, RN, on 1/9/2018 at 4:07 PM confirmed no documentation could be found in Patient #1's record of vital signs, nor nursing assessment being conducted from 12:57 - 4:58 PM on 11/9/2017 for Patient #1, and it should have been done every 30 minutes, according to Emergency Operating Procedures.

Further review of Patient #1's record revealed no other documentation or care was given to Patient #1 until on 11/9/2017 at 2:49 PM, when Employee K, (MD) Medical Doctor was notified by the patient that she was in pain and hadn't receive care. Employee K, then ordered stat labs to be drawn and a repeat EKG, which revealed a positive Troponin level and abnormal EKG, and required emergency heart catheterization and stent placement.

An interview with Director of the ED, MD on 1/9/2018 at 4:13 PM, confirmed he reviewed the record for Patient #1 and she was never placed on oxygen, nor had documentation of any care from the nursing staff from time of entry on 11/9/2017 at 12:57 PM until 11/9/2017 at 4:58 PM. He explained any Physician that saw a patient was to document in the patient's record, and no documentation could be found in Patient #1's record. Patient #1 should have been assessed frequently related to her cardiac event.

An interview with Employee D, Physician Assistant (PA) was conducted on 1/9/2018 at 5:30 PM confirmed he did not document his assessment with Patient #1 on 11/9/2017 and did not follow the hospital procedure for chest pain for Patient #1.

Interview with the Hospital Risk Manager on 1/9/2018 at 2:05 PM, indicated although it was identified on 11/21/17 that hospital procedure for chest pain was not followed, resulting in a delay in care for Patient #1 and it was identified as a concern. They did not complete an Incident/Event report nor monitored to ensure compliance after the event experienced by Patient #1. The Hospital RM confirmed the grievance for Patient #1 was over 45 days and had not been resolved. In addition, the RM confirmed Patient #1 had not been notified of the status of the grievance. She stated, It was an oversight on our part and I can't find the letter where the patient has been contacted.

An interview with Employee G, Physicians' Assistant (PA) on 1/9/2018 at 5:15 PM, confirmed that before today (1/9/2018), the facility had not discussed with him the delay in care to Patient #1, which she experienced while under his care. He stated, I was just told today that this patient's care was being reviewed. I see so many patients on a daily basis, there is no way I could remember her care. He also explained that he does not have time to document his assessments.

A review of the facility's grievance report for Patient #1 revealed documentation was not entered to verify the physician was notified, or the patient who made the grievance was contacted. Upon further review of the grievance, the type of event was listed as a communication error instead of the correct event of delay in care. The Risk Manager, on 1/9/2018 at 1:35 PM, explained the grievance for Patient #1 was not entered correctly, was listed as a communication error, and was documented as a delay in care with an Incident Report, which should have been completed. The RM also stated the hospital was to send the patient a letter within 7 days of receiving the grievance, but could not find the documentation that Patient #1 was ever notified of the hospital's acknowledgment of the grievance.

The hospital's investigation failed to identify that the Physicians' Assistant for Patient #1 did not document his assessment.

An interview with Director of the ED, MD, on 1/9/2018 at 6:21 PM revealed the expectation of the PA responsibilities is any PA can see patients and should document on those patients when they are seen. They are to put orders in. He stated, There has not been an issue with documentation before today, but obviously, it's something we now know we have to look at. He also explained that he will address the delay in care to Patient #1 with the PA immediately.

Based on patient record reviews and staff interviews, the facility failed to treat and document changes in a patient's condition by a physician for Patient #1, out 10 patients records sampled.

The findings include:

A closed record review for Patient #1 revealed the patient arrived at Memorial Hospital Jacksonville Emergency Department on 11/9/2017 at 12:57 PM via Emergency Medical System (EMS).

A review of the EMS Run Sheet dated 11/9/2017 revealed Patient #1 had complaints of chest pain, of 9 out of 10 with the pain going from her back to her chest.

A review of Nursing Triage Assessment performed by Employee H, Registered Nurse (RN) on 11/9/2017 at 12:57 PM revealed Patient #1 had chest pain x 2-3 days, with nausea and vomiting, shortness of breath (SOB), and also complained of neck, back/head/jaw pain x 2 days. The patient pointed to the middle of her chest and stated, My chest is heavy like someone is sitting on me. The patient made complaints the pain would radiate to her back/neck/jaw, with a numeric pain scale of 10 and is described as the worst pain ever.

A review of facility orders for Patient #1 revealed Employee G, Physicians' Assistant (PA) assessed the patient and entered orders, but no documentation could be found of the assessment conducted by the employee.

A review of Patient #1's record revealed no other documentation or care was given to Patient #1 until on 11/9/2017 at 2:49 PM, when Employee K, (MD), Medical Doctor was notified by the patient that she was in pain and hadn't received care. Employee K then ordered stat labs to be drawn and a repeat EKG, which revealed a positive Troponin level and Abnormal EKG and required emergency heart catheterization and stent placement.

A review of the physician's documentation for Patient #1's heart catheterization dated 11/9/2017 at 4:37 PM revealed, Patient comes in with severe chest pain. Normal EKG and weekly + Troponin. We elected to take her to the cath lab urgently, because of ongoing chest pain. Findings include: Left ventricular systolic function was normal. Ejection fraction was estimated in the range of 55% to 60 % and stent.

An interview with Employee E, (MD) on 1/9/2018 at 2:51 PM confirmed Patient #1 did not receive the proper care and treatment for almost 2 hours after arriving to the emergency room with chest pain per facility operating procedure for a patient arriving with complaints of chest pain. Employee E confirmed Patient #1 should have had Troponin level done due to her age and her type of complaint of chest pain and stated, I don't know why it wasn't done. That's an anomaly. The Employee was asked if the hospital had a certain time frame where the Troponin level should be drawn and he said a patient should be seen and treated by the physician within 10 minutes from arrival.

An interview with Employee D, Physicians' Assistant (PA), conducted on 1/9/2018 at 5:30 PM confirmed he did not document his assessment with Patient #1 on 11/9/2017, and did not follow the hospital procedure for chest pain for Patient #1. He stated, I don't know why I didn't run the test, unless she complained of something different when I saw her. Employee D confirmed the Nursing Assessment and EMS Run Sheet both revealed the patient was experiencing chest pain of 9/10 out of 10 and did not receive the proper emergent treatment.

A review of the facility's Policy and Procedures for Chest Pain (Care of a Patient with) (# 09), effective date 10/1/1987 last revised date of 4/7/2017 reads, Relieve pain, anxiety, and provide close observation until serious cardiac or pulmonary involvement is ruled out.

The RN or Paramedic will provide monitoring and care appropriate for the patient with chest pain until serious cardiac or pulmonary involvement is ruled out. Patients presenting with chest pain or angina equivalent symptoms will be treated as emergent. Symptoms include: Chest pain; pressure; tightness; fullness; shortness of breath without obvious primary upper respiratory symptoms; dizziness; syncope; palpitations; epigastric pain, particularly in women, and drug overdose. Any of the above symptoms with or without arm pain or numbness and tingling, nausea/or vomiting and upper back pain. Critical requirements for safety are listed as EKG; Rapid assessment of patients' signs and symptoms, to rule out impending Myocardial infarction, or other cardiac or pulmonary crisis. Oxygen therapy, medications for relief of pain, Cardiac monitoring. Procedures: place patient on oxygen therapy, draw blood for lab studies and point of care testing, carry out orders by physician as soon as possible. Required documentation: Record vital signs as indicated and after administration of medications, Monitor EKG and patient condition.

A review of the Hospital Standards of Care reads: Implement Emergency Department Chest Pain guideline orders,

EKG to be done within 10 minutes; Record rhythm identification and mount monitor strip every 30 minutes x 2, then every hour and as needed (PRN). Vital signs are to be taken every 30 minutes x 2, then PRN and vital signs are to be taken every 30 minutes to 1 hour after giving any Intramuscular (IM) or Intravenous (IV) pain medications.

A review of the Hospital Emergency Department order set for chest pain revealed when a patient complains of chest pain, the following is to be completed: Patient is to have nothing by mouth, obtain blood pressures; continuous pulse oximetry; cardiac monitoring; EKG; Saline Lock; Oxygen administration; blood draw for Troponin level; complete chemistry; chemistry 8; complete blood count with differential, and chest x-ray.

Based on observations, record reviews and staff interviews, the hospital failed to plan and ensure nursing care was provided for each patient, as evidenced by the hospital's failure to monitor and assess a patient that came into the Emergency Department for chest pain for 1 out of 10 patient records sampled ( A385).

The facility failed to have organized nursing services that provide 24-hour nursing services, evidenced by the failure of a Registered Nurse to assess a patient in the emergency room with chest pain (A396).

The hospital also failed to have completed patient records, which include all practitioners' orders, nursing notes, and vital signs for Patient #1, out of 10 records sampled.

The cumulative effect of these systemic problems resulted in the facility's inability to provide nursing services by a registered nurse as required by the Condition of Participation (CoP) for Nursing Services.

Based on patient record reviews, and staff interviews, the hospital failed to plan and ensure nursing care was provided for each patient, as evidenced by the hospital's failure to monitor and assess a patient that came into the Emergency Department for chest pain for 1 out of 10 patient records sampled. (Patient #1)

The findings include:

A closed record review for Patient #1 revealed the patient arrived at Memorial Hospital Jacksonville Emergency Department on 11/9/2017 at 12:57 PM via Emergency Medical System (EMS).

A review of the EMS Run Sheet dated 11/9/2017 revealed Patient #1 had complaints of chest pain, of 9 out of 10 with the pain going from her back to her chest.

A review of Nursing Triage Assessment performed by Employee H, Registered Nurse (RN) on 11/9/2017 at 12:57 PM revealed Patient #1 had chest pain x 2-3 days, with nausea and vomiting, shortness of breath (SOB), and also complained of neck, back/head/jaw pain x 2 days. The patient pointed to the middle of her chest and stated, Heavy, like someone is sitting on me. The patient made complaints her pain was a numeric pain scale of 10 and described it as the worst pain ever.

A review of Patient #1's Vitals Signs Data Sheet revealed no nursing documentation was recorded for vital signs or assessments for Patient #1 from 11/9/2017 at 12:57 PM until 11/9/2017 at 4:58 PM.

A review of the Hospital Standards of Care reads: Implement Emergency Department chest pain guideline orders,

EKG to be done within 10 minutes; Record rhythm identification and mount monitor strip every 30 minutes x 2, then every hour and as needed (PRN). Vital signs are to be taken every 30 minutes x 2, then PRN and vital signs are to be taken every 30 minutes to 1 hour after giving any Intramuscular (IM) or Intravenous (IV) pain medications.

An interview with Employee F, RN, on 1/9/2018 at 4:07 PM confirmed no documentation could be found in Patient #1's record of vitals signs, nor nursing assessment being conducted from 12:57PM - 4:58 PM on 11/9/2017 for Patient #1, and it should have been done every 30 minutes, according to Emergency Operating Procedures.

A review of the facility's Policy and Procedures for Chest Pain (Care of a Patient with) (# 09), effective date 10/1/1987 last revised date of 4/7/2017 reads: Procedures: place patient on oxygen therapy, draw blood for lab studies and point of care testing, carry out orders by physician as soon as possible. Required documentation: record vital signs as indicated and after administration of medications, monitor EKG and patient's condition.

An interview with Employee E on 1/9/2018 at 2:40 PM, confirmed he reviewed the record for Patient #1 and she was never placed on oxygen, nor had documentation of any care from the nursing staff from time of entry on 11/9/2017 at 12:57 PM until 11/9/2017 at 4:58 PM.

Based on record reviews and interviews with staff, the hospital failed to have completed patient records which include all practitioners' orders, nursing notes, and vital signs for 1 (#1) out of 10 records sampled.

The findings include:

A closed record review for Patient #1 revealed the patient arrived at Memorial Hospital Jacksonville Emergency Department on 11/9/2017 at 12:57 PM via Emergency Medical System (EMS).

A review of the EMS Run Sheet dated 11/9/2017 revealed Patient #1 had complaints of chest pain, of 9 out of 10, with the pain going from her back to her chest.

A review of Nursing Triage Assessment performed by Employee H, Registered Nurse (RN) on 11/9/2017 at 12:57 PM revealed Patient #1 had chest pain x 2-3 days, with nausea and vomiting, shortness of breath (SOB), and also complained of neck, back/head/jaw pain x 2 days. The patient pointed to the middle of her chest and stated, My chest is heavy like someone is sitting on me. The patient made complaints the pain would radiate to her back/neck/jaw, with a numeric pain scale of 10 and is described as the worst pain ever.

A review of facility orders for Patient #1 revealed Employee G, Physicians' Assistant (PA), assessed the patient and entered orders, but no documentation could be found of the assessment conducted by the employee.

A review of Patient #1's record revealed no other documentation or care was given to Patient #1 until 11/9/2017 at 2:49 PM, when Employee K, (MD) Medical Doctor, was notified by the patient that she was in pain and hadn't received care. Employee K then ordered stat labs to be drawn and a repeat EKG which revealed a positive Troponin level and abnormal EKG, which required emergency heart catheterization and stent placement.

An interview with Employee D, Physicians' Assistant (PA) was conducted on 1/9/2018 at 5:30 PM, who confirmed he did not document his assessment with Patient #1 on 11/9/2017, did not follow hospital procedure for chest pain for Patient #1. He stated, I don't know why I didn't run the test unless she complained of something different when I saw her. Employee D confirmed the Nursing Assessment and EMS Run Sheet both revealed the patient was experiencing chest pain, of 9 out of 10, and did not receive the proper emergency treatment.

An interview with Employee F, RN, on 1/9/2018 at 4:07 PM confirmed Employee D, PA should have filled out a Medical Screening Exam when he assessed Patient #1, which was not found in the patient record.

An interview with Employee E, MD on 1/9/2018 at 4:13 PM, confirmed any Physician that saw a patient was to document in the patient's record and no documentation was found in Patient #1's record that was assessed by Employee D.

A review of Nursing Triage Assessment performed by Employee H, Registered Nurse (RN) on 11/9/2017 at 12:57 PM revealed Patient #1 had chest pain x 2-3 days, with nausea and vomiting, shortness of breath (SOB), and also complained of neck, back/head/jaw pain x 2 days. The patient pointed to the middle of her chest and stated, Heavy, like someone is sitting on me. The patient made complaints her pain was a numeric pain scale of 10 and described it as the worst pain ever.

A review of Patient #1's Vitals Signs Data Sheet revealed no nursing documentation was recorded for vital signs or assessments for Patient #1 from 11/9/2017 at 12:57 PM until 11/9/2017 at 4:58 PM.

A review of the Hospital Standards of Care reads: Implement Emergency Department chest pain guideline orders,

EKG to be done within 10 minutes; Record rhythm identification and mount monitor strip every 30 minutes x 2, then every hour and as needed (PRN). Vital signs are to be taken every 30 minutes x 2, then PRN and vital signs are to be taken every 30 minutes to 1 hour after giving any Intramuscular (IM) or Intravenous (IV) pain medications.

An interview with Employee F, RN, on 1/9/2018 at 4:07 PM confirmed no documentation was found in Patient #1's record of vitals signs, nor Nursing Assessment being conducted from 12:57PM - 4:58 PM on 11/9/2017 for Patient #1, and it should have been done every 30 minutes, according to Emergency Operating Procedures.

A review of the facility's Policy and Procedures for Chest Pain (Care of a Patient with) (# 09), effective date 10/1/1987 last revised date of 4/7/2017 reads: Required documentation: record vital signs as indicated and after administration of medications; Monitor EKG and patients' condition.

An interview with Employee E, on 1/9/2018 at 2:40 PM confirmed he reviewed the record for Patient #1 and she was never placed on oxygen, nor had documentation of any care from the nursing staff from time of entry on 11/9/2017 at 12:57 PM until 11/9/2017 at 4:58 PM.

Based on record review and interview, the facility failed to ensure a systemic plan of correction for assessing complications of intravenous (IV) therapy and implementing safe treatment to prevent injuries for 1 (#1) of 11 patients.

The findings include:

Patient # 1 has a history of Quadriplegia and sustained severe swelling and blisters to their left hand and arm on 4/29/17 at 3:56 AM, when Employee # B, an RN, applied hot compresses without a barrier to their arm.

A review of the medical record for Patient #1 revealed no orders for the application of heat compresses.

An interview was conducted with Employee F, Nurse Director, on 6/19/2017 at 2:38 PM. Employee F stated, We are meeting as a team; Root Cause Analysis (RCA) is currently in process. The RCA actually began; I know I found out about the incident on May 1, 2017. I interviewed the patient, started interviewing the staff that were on and intimately involved; I reviewed the variance. I spoke with the patient's mother and spoke multiple times with Risk Management. The Risk Management and Quality team initiated that. I have not yet presented this information in a Safety Committee. Employee F stated that she has been discussing the event with the IV and warm compresses since the last meeting in huddles, that staff will not make warm compresses on this unit. No additional information to reinforce nursing skills on IV infiltration, discontinuing an IV site and the application of heat compresses to a patient was presented and made available as part of the facility-wide correction.

Interviews were conducted with Employee C, Staff Nurse, on 6/19/2017 at 3:17 PM and Employee D, Staff Nurse on 6/19/2017 at 2:19 PM, and each employee could not independently verify a new in-service, huddle or additional education related to IV assessment and management. On the 6/6/17 visit to the facility, there were no corrective actions documented. Only Employee F, Nurse Director, could present real time in-service documentation that specifically outlined the assessment and use of warm compresses for an infiltrated IV site on 6/19/2017. A review of the second floor unit huddle information only had one discussion documented since April 23, 2017 to 6/19/2017 that was reviewed. This huddle only referenced a vascular access for PICC line insertions.

An interview was conducted with the Chief Nursing Officer on 6/19/17 at 6:12 PM, she could not confirm there was a new educational plan already in place. She stated, We would have our implementation; update the policy to move away from Lippincott; add to our IV competency and how to manage IV infiltration. Educate current staff using our educators on the unit. Then, we would address education with oncoming staff and new staff; what is key; we have a new device and people are educated to the why; and you know nurses, it has to be there. We have to get out there and follow-up when they ask questions. Before we go to change the process and does it make sense to do an assessment every four hours, if we are looking at the IV when we are using it, we will make sure that we have the best practice.

There was no information received from Quality Management upon request to support a documented response to educate nursing staff about IV infiltration, discontinuing an IV site and reassessing the implemented intervention for outcome.

A385

Based on record review and interviews, the facility failed to follow acceptable standards of care and practice in the removal of a plastic adhesive dressing that resulted in skin removal; failed to apply a warm compress correctly to 1 (#1) of 11 sampled patients; failed to document nursing intervention for Patient #1; failed to follow physician orders for Patient #11. These failures resulted in harm to Patient #1, resulting in severe swelling and blisters to the patient's left hand, which led to the Condition of Participation for Nursing.

The findings include:

See A 396

Based on record review and interviews, the facility failed to (1) ensure the development and implementation of a safe care plan to treat an IV infiltration. An unsafe practice resulted in severe swelling and blisters to the left hand of 1 (#1) of 11 sampled patients, who was desensitized; an inappropriate technique to remove an IV dressing to Patient #1 resulted in removal of skin from the left arm; (2) failed to discontinue intravenous fluids as ordered by the Physician for Patient #11.

The findings include:

(1) Patient # 1 has a history of Quadriplegia. Interview with the mother for Patient #1 on 6/5/17 at 9:47 am revealed that the Registered Nurse placed a hot compress directly on her son's skin that resulted in blisters.

A review of the medical record for Patient #1 revealed that on 4/29/2017 at 7:15 AM, nursing staff documented under skin alteration, the following: Blister anterior hand left with a visible wound base that is blanchable and determined to be a partial thickness wound which is approximated.

On 4/29/17 at 7:27 AM, it was documented on Patient Assessment, Patient #1 IV infiltrated on left hand, swelling and blisters.

On 5/01/17 at 1:17 PM, it was documented for IV assessment that, this RN observed left hand blisters while the wound care nurse was applying dressing. Director of the floor notified of hand blisters. Pictures taken and put on chart.

A review of the medical record for Patient #1 revealed no order for the application of a heat compress.

Review of skin protocol for Patient #1 documents at line 5 to avoid hot water.

Review of pictures of the patient's left arm and hand revealed severe edema with blisters and an open wound to their left arm.

A review of the facility provided Lippincott Procedures for heat application revealed the following: Heat applied directly to the patient's body raises tissue temperature. It also enhances the inflammatory process. You should apply direct heat cautiously for patients with impaired sensation. Noted under applying warm compress or pack includes to apply the compress or pack gently to the affected site. After a few seconds, lift it and check the skin for excessive redness, maceration, or blistering. When you are sure that the compress or pack is not causing a burn, assess the patient's skin at regular intervals. Remove the device if the skin shows excessive redness, maceration, or blistering or if the patient experiences pain or discomfort. After 15 to 20 minutes or as ordered, remove the compress or pack.

An interview was conducted with Employee D, Charge Nurse on 6/19/2017 at 2:19 PM for Patient #1. She was asked about the direct application of heat to a Quadriplegic patient that resulted in blisters to the patient's hand. She stated the following: On that morning Employee E, the patient's staff nurse, had been assigned to Patient #1. The patient had a new wound on his left hand. She found out in report that morning from Employee B that the patient had an infiltrated IV and that when Employee B removed the tape from the IV site, some of the patient's skin came off.

An interview was conducted with Employee F, Nursing Services Director, on 6/7/17 at 10:15 am. Employee F stated that they do a huddle every day on day shift and will stay and catch night shift. She stated, I would tell the Charge Nurse what to discuss. A recent discussion was about documentation and when to change IV sites. Employee F stated, We had an IV infiltrate and we completed Root Cause Analysis (RCA). The team that was involved in the incident came in and the incident was discussed. The discussion was about not using heat packs, but they did not have an official discussion, as they were still doing Root Cause Analysis. She stated that when everything was in place, they would do education.

An interview was conducted with Employee F, Nursing Services Director on 6/19/2017 at 2:38 PM, She stated, I found out about the incident on May 1, 2017. I interviewed the patient, started interviewing the staff that were on and was intimately involved; I reviewed the variance. I spoke with the patient's mother and spoke multiple times with Risk Management. The Risk Management and Quality team initiated the process for correction. I have not yet presented this information in a Safety Committee. The Surveyor asked the Clinical Director about the plan of correction. Employee F stated that she was discussing that since the last meeting in huddles, that staff will not make warm compresses on this unit. The facility could provide no evidence of documentation for systemic correction to prevent injury to patients resulting from interventions for IV infiltrations.

A telephone interview was conducted with Employee B, previous staff nurse, on 6/22/17 at 12:58 PM, related to the skin blisters that resulted from direct heat to the skin of Patient #1 due to an Intravenous Infiltration (IV). He stated, Patient #1 had an IV infiltration. During my shift, his IV infiltrated on his left hand. It was a little bit swollen; I took out the IV, elevated his arm and put a warm compress on it. We did not have warm compresses on the floor. I made sure that it was not too hot and I asked the patient about it. I asked him if he wanted me to take the warm towel off; initially, I put a towel between the skin and the bag. I took it off and I asked him are you sure it is not too hot? I changed the compress; I would soak them in the warm water again, wrench it, and put them in the bag. I did this about four times. The next nurse came on; I gave report and then Monday morning, I got the call; either morning or afternoon, I got the call about skin burns. We do not have an official warm compress on the floor; we have ice packs. I put warm towels in a bag. That is what we usually do. The towels are little wash cloths that we get and put them under warm water. We get the warm water from the Kitchen or Nutrition room. The warm water came from the Nutrition room sink. The last interaction with Patient #1 was about when I changed the compress. He looked up and looked back down. This was before 6:00 AM. I just know that he got burns; the Nurse Director told this to me. I have used this approach in the past. IV infiltration is what I thought it was. I did not document. I forgot to document that I took an IV out and put a new one in.

(2) An observation was made on 6/19/17 at 2:53 PM while conducting an interview with sampled Patient #11. The observation was of an IV pump turned on, connected to the IV port for Patient #11 and was observed infusing at 10 milliliters an hour; observed in handwritten orange marker on the IV bag infusing is D5 1/2 NS at 50 milliliters an hour. The documented infusion rate on the IV bag connected to the IV pump and the observed infusion setting on the IV flow pump did not match.

An observation was made on 6/19/17 at 2:53 PM and a review of the medical record for Patient #11 was conducted with Employee A, the primary nurse for Patient #11. It was revealed that there was no order for IV continuous fluid at this time.

A second interview by phone was conducted with Employee A, the primary nurse for Patient #11, on 6/19/2017 at 4:20 PM, the Assistant Director of Nursing (ADON) was also present during the interview with Employee A, and she was asked about the IV infusion for Patient #11. Employee A stated, I called the attending Physician and spoke to her and she is not comfortable with IV running through that port. She does not think that it was her service that the nurse talked to at the time. Yes, there was an order running of D5 + normal saline that was supposed to be at 50 milliliters an hour that was discontinued; but the fluid was turned down to10 milliliters an hour.

An interview was conducted with the ADON on 6/19/2017 at 4:25 PM about Patient #11 and the interview with Employee A, RN. The ADON confirmed that there should be an order for IV fluids running and this should have been addressed.

A review of Patient #11's printed orders and Medication Administration Record (MAR) for continuous infusions revealed that Dextrose 5% 0.45% saline 1,000 ML was discontinued on 6/18/17 at 4:49 PM. This was also confirmed by the ADON on 6/19/17 at 4:20 PM, that if there is an IV infusion running, there should be an order for the infusion.

Based on observation, interview and record review, the facility failed to ensure that drugs were administered by order of a physician or other qualified practitioner for 1 (Patient #11) out of 11 sampled patients for an IV infusion of Dextrose 5% 1/2 normal saline, which was observed administered without an order.

The findings include:

An observation was made on 6/19/17 at 2:53 PM while conducting an interview with sampled Patient #11. The observation was of an IV pump turned on, connected to the port for Patient #11 and was observed infusing at 10 milliliters an hour. The documented infusion rate on the IV bag connected to the IV pump and the observed infusion setting on the IV flow pump did not match.

An interview was conducted with Employee A, primary nurse for Patient #11 on 6/19/17 at 3:09 PM, at which time she confirmed that the IV solution for Patient #11 was running all day. She stated that during shift change, it has been reported to her that it was normal saline and should be at 20 milliliters an hour to keep the vein open (KVO).

Based on observation on 6/19/17 at 2:53 PM, and a review of the medical record for Patient #11 with Employee A, the IV fluid that was observed running at the time is not a physician ordered continuous infusion.

A second interview by phone was conducted with Employee A on 6/19/2017 at 4:20 PM. The Assistant Director of Nursing (ADON) was also present during the interview and Employee A was asked about the IV infusion for Patient #11 and she stated, I called the Attending and spoke to her and she is not comfortable with IV running through that port. She does not think that it was her service that the nurse talked to at the time. Yes, there was an order running of D5 + normal saline that was supposed to be at 50 milliliters an hour that was discontinued; but the fluid was turned down to 10 milliliters an hour.

An interview was conducted with the ADON on 6/19/2017 at 4:25 PM about Patient #11, and the interview with Employee A, and she confirmed that there should be an order for IV fluids running and this should have been addressed.

A review of Patient #11's printed orders and Medication Administration Record (MAR) for continuous infusions revealed that Dextrose 5% 0.45% saline 1,000 ML was discontinued on 6/18/17 at 4:49 PM. This was confirmed by the ADON on 6/19/17 at 4:20 PM; that if there was an IV infusion running, there should be an order for the infusion.

A review of the facility provided IV therapy protocol reads that Keep Vein Open (KVO) rate is 20 milliliters an hour.

Based on observations, interviews, and facility record reviews, the facility failed to ensure the written Infection Control Policy and Procedures were implemented throughout the facility for 2 out 23 sampled patients (Patients #12 and Patient #13).

The findings include:

1). A random observation Employee A on 12/15/14 at 12:00pm while in Room #333 with the Assistant Chief Nursing Officer and the 3 West Charge Nurse revealed she was in the room drawing blood from a patient on contact isolation. Employee A's Personal Protective Equipment (PPE) was observed hanging off of her shoulders, below chest level. At 12:06pm, Employee A was observed reaching into their pockets under the isolation gown with gloved hands, after drawing blood from the contact isolation patient. Employee A proceeds to tie the top of her isolation gown with contaminated gloved hands.

An interview with Employee A on 12/15/2014 at 12:10pm revealed the facility's expectation is that staff don gown and gloves before entering the room of a patient on contact isolation. The PPE should be removed and hands shall be washed prior to leaving the room. Employee A stated that all equipment taken into the room should be disinfected with Sani-Cloth wipes before leaving the room. Employee A stated her gown fell down while she was in the room drawing blood. She stated, I am not aware of what the facility policy says I am supposed to do. The facility's policies and procedures are available for review in the Nursing Station and in the Respiratory Therapy office. I don't know how to locate the policy online.

A medical record review for Patient #12 revealed she was swabbed positive for MRSA of the nares on 12/11/4. The swab was officially resulted on 12/12/14.

An interview with the Assistant Chief Nursing Officer on 12/15/14 at 12:20pm revealed the facility does not have policy and procedural manuals in the nursing units; they are only available online throughout the facility.

An observation of Employee A on 12/15/14 at 3:12pm revealed that she is now able to locate the Infection Control and Isolation Policies online, using the facility's intranet.

A personnel file review of Employee A revealed she completed her annual Infection Control Training on 4/22/14.

2). A random observation of Employee B on 12/15/14 at 1:00pm, with the Assistant Chief Nursing Officer and the 3 Center Director, revealed Employee B, in Room 335, was in a contact isolation room without wearing an isolation gown. Employee B is observed cleaning a brown liquid substance from the floor near the bed with gloved hands. Employee B then removed his gloves and exited the room, carrying the Gluco-Monitor. Employee B returned the Gluco-Monitor to the nursing station charging base.

A medical record review of Patient #13 on 12/11/14 revealed the MRSA Screen was negative; it was verified on 12/13/14; however, the patient still remains on contact isolation.

An interview with Employee B on 12/15/14 at 1:06pm revealed that he is aware that he should have had on both a gown and gloves while in Room #335, because the patient is on contact isolation. Employee B stated that he is not sure why Patient #13 is on contact isolation; he was just helping another staff member. Employee B was asked by this Surveyor to retrieve the Gluco-Monitor and disinfect it using the facility-approved disinfectant.

An interview with the Chief Medical Officer on 12/15/14 at 1:15pm, while reviewing the medical record, revealed the culture screen should have cleared Patient #13 from contact isolation; however, the facility's policy is that a patient with a positive result less than 2 years old is placed on contact isolation. This patient had a positive result in 2013.

A personnel file review for Employee B revealed he completed his annual Infection Control Training on 7/3/14.

Reviews of the Infection Control and Isolation Policies and Procedures, with a last review date of 10/31/13, revealed facility isolation guidelines are consistent with the established recommendations of the Centers for Disease Control. Gowns will be worn to provide a barrier and prevent direct contact with a patient and their environment while under Contact Precautions. The gown shall be applied immediately prior to entering the room and removed prior to leaving the room. Additionally, gloves are required when entering any room under Contact Precautions. The use of gloves does not eliminate the necessity for hand hygiene. Gloves shall be discarded inside the room, and hand hygiene shall be performed before leaving.

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

Based on electronic medical record review and staff interviews, the facility failed to notify family or legal guardian of an alleged sexual assault for 1 (#7) of 7 sampled patients , to give them the option and information to make an informed consent to either consent, refused, or request treatment elsewhere.

The findings include:

A medical record review revealed that Patient #1 was admitted through the emergency room on [DATE] for altered mental status and schizophrenia. Patient #1 was noted with poor hygiene, disheveled and would only answer questions with short yes or no answers.

A review of the face sheet for Patient #1 revealed that there was next of kin listed, but the contact person was listed as none per Patient #1 request after being admitted through the emergency room with altered mental status and schizophrenia.

Review of the medical record revealed the admitting Psychiatrist filed for a petition for adjudication of incompetence to consent to treatment appointment of a guardian advocate on 11/16/12.

A Staff interview with the 5 South Pavilion Nurse Manager on 12/17/12 at 1:18 pm revealed that adverse incident reports follow the chain of command. The physician and patient's family are notified. She also stated that upon discharge the facility where the patient will be going is informed of any incidents or new concerns regarding the patients.

A staff interview with the Senior Vice President of Operation on 12/17/12 at 1:25 pm revealed that nurses will notify a patient's family of an adverse incident, after the chain of the command is started with the notifications within the facility.

A staff interview with 5 South Pavilion Nurse Manager on 12/17/12 at 1:50 pm revealed that the incident with Patient #1 happened after Mental Health Technician (MHT) rounds. Patient #1 and Patient #9 s rooms were located across the hall from each other. Upon entrance into the room by the MHT, Patient #9 was observed by the facility staff with his pants down around his ankles, and getting off of Patient #1. Patient #1 was reportedly naked and lying face down on the bed. The MHT immediately called for help from other staff members. The charge nurse on duty called the unit manager and the psychiatrist to report the incident. The 5 South Pavilion Nurse Manager stated that she was told that there was no family to contact information for Patient #1 in the chart. Jacksonville Sheriff Officer (JSO), Department of Children and Families (DCF), and the Sexual Assault and Rape Crisis Team were notified to see Patient #1. The 5 South Pavilion Nurse Manager stated that the facility tried to obtain consent for the examination and treatment of Patient #1 prior to her getting treatment. The admitting Psychiatrist gave the consent for the patient to receive the examination from the SARC team, after the incident. The 5 South Pavilion nurse manager stated that her priority was to ensure the patients ' safety.

A staff interview on 12/17/12 at 2:04 pm with a 5 South Pavilion staff nurse revealed that when an adverse incident occurs the staff working on the unit is notified first to alert, then the admitting physician, then the director and so on. The family or facility where patient came from will also be notified and whoever is taking care of the patient when they are not hospitalized . If the patient does not have information on the chart for family then the assisted living facility (ALF) is contacted to obtain the contact information for the patient ' s family.

On 12/17/12 at 3:28 pm, the Admitting Psychiatrist returned the call to the surveyor: He stated that he sees patients once a month through a behavioral treatment program. He was alerted by the nursing staff of a possible sexual assault on 11/9/12. The physician stated that he arrived to the hospital one hour later to evaluate the patient. The Psychiatrist stated that he reviewed the history of Patient #9 and saw that there was a history of aggression. The Psychiatrist had the police called and Patient #9 was immediately removed from the facility. He stated that he did not notify the ALF immediately. He also stated that he has seen the patient since her discharge from the hospital and that the patient is in stable condition. The Admitting Psychiatrist stated that he does not call family to notify them of incidents of this nature; that social service is supposed to contact the legal guardian and the care giver to inform them of the incidents with the patient.

A staff interview with the Director of the Pavilion on 12/18/12 at 10:41 am revealed the chart is reviewed after an adverse incident to determine who the contact person is for the patient. On the psychiatric unit, a discussion would be conducted to determine who would make the phone call for family or the care giver. The contact attempts will be documented in the chart in the nursing notes or the social worker notes depending on who is designated make the contact attempts to call the family.