**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 41334 Based on observation, interview and record review the facility failed to maintain a current, accurate and complete medical record for 1 out of 3 patients reviewed. (Patient #1) Findings include: Record review documented that Patient #1 presented to the ED ( Emergency Department) on 10/14/2022 via EMS (Emergency Medical Services). The Emergency Department provider note dated 10/14/2022 reads, This is a [AGE] year old female patient who presents to the ER via EMS. EMS states the patient has the patient was sent in by her significant other for chest pain. They noted her to be lethargic, sweating. They believe the pain started last night. Patient is oriented to person. She will answer some questions. She does point to her chest and tell me she has chest pain. On assessment she is noted to have abdominal pain. She is tachycardic. EMS reports other vital signs are within normal limits other than heart rate. Review of physician orders dated 10/14/2022 at 1658 (4:58 PM) reads, Levophed 4 mg (milligrams)/250 ( milliliters) D5W ( an intravenous sugar solution), maintain MAP ( mean arterial blood pressure) 65-75 mmHg ( millimeters of mercury) initial rate if MAP less than 50 :10 mcg( micrograms) /min ( minute), if MAP is less than 60 mmHg titrate( increase) 1 mcg/min every 2 minutes, Maximum rate 30 mcg/min. Review of the physician orders dated 10/14/2022 at 1926 ( 7:26 PM) reads, Dopamine 400 mg Milligrams/D5W 250 ml, Initial rate 5 mcg ( micrograms)/kg( kilogram)/min( minute) titrate by 2.5 mcg/kg/min every 15 minutes. Maintain MAP between 60-65 mmHg. Maximum rate 20 mcg/kg/min. Review of the Medication administration record document that Staff A, Registered Nurse ( RN) hung the Levophed at 1658 ( 4:58 PM) there is no documented rate of the initial rate. Review of the Medication Administration Record documented that Staff A, RN hung the Dopamine at 7:26 PM. Review of the vital signs for blood pressure( BP) documented the following blood pressures: at 6:45 PM BP was 50/30, MAP of 36, at 6:48 PM BP was 50/38, MAP 42, at 7:05 PM B/P was 57/41, MAP 46, at 7:35 PM BP was 65/47, MAP 53, at 7:39PM B/P was 60/45, MAP 50, at 7:55PM B/P was 49/28, MAP 35, at 7:58PM B/P was 79/47, MAP 57, at 8:04 PM B/P was 75/49, MAP 57, at 8:10 PM B/P was 63/48, MAP 53, at 8:15 PM B/P was 74/50, MAP 58, at 8:19PM B/P was 67/51, MAP 56, at 8:25 B/P was 37/22, at 8:28 PM B/P was 64/49, at 8:30PM B/P was 64/49, at 8:35 PM B/P was 64/49, at 8:39 PM B/P was 65/47, at 8:40 PM B/P was 54/30, at 8:42 PM B/P was 55/34, at 8:44 PM B/P was 55/30, and at 8:46 PM B/P was 55/30. There were no additional blood pressures documented in the medical record. Review of the nursing documentation there were no entries in the medical record for titrating the Levophed or Dopamine. During an interview conducted on 12/20/2022 at 11:00 AM, Staff B, Registered Nurse ( RN) stated, I worked triage that day that she ( Patient #1) came in, we had 6 ambulances come in at the at the same time that day. She (Patient #1) was stable with abdominal pain. She was placed immediately into a bed. At first, she was assessed as an ESI (Emergency severity index) of 2 , but once she became unstable, when her blood pressure dropped she would have been bumped up to a ESI of 1. It is not appropriate for us to have no evidence of levophed or dopamine titration in the documentation. We should document titrations of medications per the doctor's orders in the medical record. During an interview conducted on 12/20/2022 at 11:15 AM, Staff C, RN stated, We do have an area where we will document titration of medications and we should always document those. I was not aware that they weren't documented on this patient. They should have been. During an interview conducted on 12/21/2022 at 10:04 AM, Staff A, RN, stated, I took care of [Patient #1's name], It was busy that day and my charge nurse was very helpful. [Medical Doctors name] was at nurses station and I would have a conversation and let him know about any concerns or developments and he would give new orders for her (Patient #1). I should have done the documentation about her drips (levophed and dopamine) and I can't tell you how much of anything that this patient was on based on my charting. I did titrate these medications and she was on maximum doses, but because I didn't document it I can't tell how much that was or when I did the titrations. I should have done that documentation. Review of the policy and procedure titled Assessment and Reassessment approval date 10/2022 reads, Purpose: 1. To establishing multidisciplinary process for obtaining appropriate and necessary information about each individual seeking entry into the facility for treatment and services.4. To Establish criteria for the reassessment of patients. 5. To determine the care, treatment, and services that will meet the patient's initial and continuing needs. Policy: A. General 2. Each patient seeking care or treatment in the emergency department shall receive an assessment by qualified individual so that a plan of care can be developed to best meet the needs of the patient. 6. Patient Needs will be reassessed throughout the course of care, treatment, and services. The frequency of reassessment is based on his or her plan of care or changes in his or her condition. Reassessment is also based on the patients diagnosis, desire for care, treatment, and services, response to previous care, treatment, and services, discharge planning needs, and his or her setting requirements. 3. Emergency Department: f. Patients are assessed Based on the triage priority. Nursing care is evaluated on a continual basis to determine the progress or lack of progress toward patient outcomes and patient goal attainment. Reevaluation is documented and plan of care is revised as appropriate prior to discharge of patient and according to patients needs and goals. Reevaluation may include, but is not limited to, recheck of vital signs, any change in status, and that there is no change in status from any previous evaluation. G. Reassessments shall be done anytime there is the following: 2) a significant change in vital signs, 3). to evaluate a treatment intervention.

29257 Based on interview and medical record, policy and procedure review the facility failed to ensure safe operation of equipment according to hospital policy. Failure of Medical Technologist to use medical scanning wand per hospital policy for 1 patient (Patient# 1). Findings: During a medical record review patient # 1 came to the Emergency Department (ED) at the facility on 12/29/2020 at 11:05 PM with a complaint of back pain. A Magnetic Resonance Imaging (MRI) was completed on 12/30/2021 at 2:19 AM. During an interview with patient 1 on 5/27/2021 at 3:10 PM, patient # 1 stated, When the pulsing started from the MRI, I started to feel a burning on my side. As the test continued the burning got worse and I began to scream and kick my feet. The test was stopped. I reached down to where I felt the burning and found an electrode that was not removed prior to the MRI. The area of skin was red and very sore. Upon review of my medical records, there was no notation of the injury which occur during the MRI. During a medical record review of documentation of Staff L, MRI Technologist, stated, When the scan started the patient started screaming wildly and banging on the side of the machine. The patient told me something was burning him. Patient # 1 pulled up his shirt, and I saw 4-5 more electrodes that had not been removed prior to MRI. I had not used the wand prior to the MRI. Patient # 1 had a reddened area from removing the electrodes, but I saw no injury and did not complete an incident report. During a record review of hospital policy titled Screening of Individuals Entering MRI, with an approval date of 06/2020. The objective of policy is noted, To maintain a safe environment in the MRI unit. Under section labeled screening is noted, All patients will be scanned with metal detection wand prior to entering Zone IV. Under section noted, precautions taken to prevent patient burns during scan is noted, Technologist will ensure all leads are off the patient before entering the exam room. During an interview on 5/28/2021 at 10:20 AM, with Staff J, Director of Radiology, stated, It is my expectation that if a patient reports pain and requires to be removed from the MRI unit, an incident report is to be filed. In the case of Patient # 1, no incident report was filed.

17500 Based on record review, review of the facility's Policy and Procedures, and staff interviews, the facility failed for 1 of 10 patients (Patient #1) to have the registered nurse(s) evaluate the care provided and to implement appropriate nursing measures to provide cardiac telemetry monitoring. Findings: During an interview on 5/10/2017 at 1:24 PM with the Director of Nursing Administration, Staff A, he stated, when there is an order for cardiac telemetry, strips are run every 4 hours and these strips are placed in the patient's medical record, and reviewed by the physician. There are not any monitoring strips in Patient #1's medical record. Continued interview regarding any training/in servicing of staff regarding telemetry monitoring to ensure that staff would place documentation in the patient's record, and report changes in patient's rhythm to the nurse, had not been done. Also audits to ensure that the facility was in compliance had not been done according to Staff A. Medical record review on 5/10/2017 at 12:40 PM revealed that the physician ordered on 3/19/2017 at 6:25 AM, for Patient #1 to have Cardiac Telemetry Monitoring. The process is for the staff to place the telemetry monitor on the patient and strips are run every 4 hours and placed on the chart. Medical record review did not reveal any telemetry strips for Patient #1. Review of the facility's Policy and procedures titled Telemetry Monitoring revealed the following:: Scope: Departments providing telemetry monitoring for inpatient and observation status patients. Policy: Continuous cardiac monitoring is available 24 hours a day, 7 days a week, based on the physician order for cardiac monitoring in accordance with the guidelines described in this policy. Monitor Technicians (MT) will be responsible for continuous monitoring and communicating changes in patient's rhythm to the nurse. Monitor Technician Responsibilities. The Monitor Technician will print the electronic worksheet at the beginning of each shift and utilize the worksheet throughout their shift to track patients and pertinent information. Cardiac rhythms are printed and documented on admission and at 4 hour intervals, for any rhythm and/or rate changes, and as requested by the nurse for changes in patient condition. Suggested times are 0700, 1100, 1500, 1900, 2300 and 0300.

17500 Based on observation, interviews, record review, and policy review the facility failed to provide a safe environment that includes notification of family in timely manner of change in condition for 1 ( patient #1) and supervison for falls for 2 ( patient #1 and #8) of ten patients reviewed. Findings: Patient #1: was admitted to the Intensive Care Unit (ICU) on 04/28/2015 for acute respiratory failure, stabilized and was transferred to the Cardiac/telemetry floor on 04/29/2015. She was on high risk fall precautions, on Ativan 0.5 mg for anxiety/depression, and Tramadol (Ultram) 50 mg twice a day (BID) for chronic neck pain. During an interview on 06/26/2015 at 1:00 PM,with the daughter of patient #1, revealed that she was not notified of her mother ' s fall, hip fracture and the test ordered for her mom as the Computed Tomography (CT) of the brain and a X-ray of the right hip until after these procedures were completed. When she called the facility herself to speak to the nurse inquiring about her mother, was than she was notified of what had happened. During an interview on 06/25/2015 at 1:30 PM with Registered Nurse A (RN) revealed that when asked if the bed alarm was on for patient #1 on 04/30/2015, she stated the bed alarm was not on or sounding for patient #1 when I found her on the floor on 04/30/2015 at approximately 8:00 AM. During an interview with Dr. A, on 06/25/2015, revealed that she did not receive a call from nursing staff on the morning of 06/30/2015 for patient #1 for pain medications, and if she had received a call she would have returned it, and if she is unavailable that she has additional physician coverage that could have been contacted to obtain an order for pain medications. Review of Nursing Notes, (Clinical Documentation Record), dated 04/29/2015 at 9:00 PM, revealed a Nursing Assessment for: Fall precautions. Patient encourage to call for assists when need but is forgetful. On Fall Protocol. Frequent rounding. Additional fall precautions include signs outside the door, armbands and on chart. Further fall precautions also included assisting with both mobility and toileting. Having patient have non slip footwear on, and bed alarm. Review of nurse ' s notes on 04/30/2015 at 6:00 AM revealed that patient #1's bed alarm was ringing. Patient was up out of bed, almost pulled intravenous site again. Patient stated that she was having anxiety, and she can't help it. Patient encouraged to go to bed, and this nurse helped the patient back to bed, and gave Ativan 0.5 mg to help patient's anxiety. Charge nurse made aware and consulted situation throughout the night regarding patient. Further review of nurse ' s notes on 04/30/2015 at 8:00 AM revealed that patient #1 was found on the floor near the white information board in her room by staff. Physician notified and orders for a Computed Tomography (CT) of the brain and a X-ray of the right hip due to the patient's complaint of pain in the head and right hip pain, which the X-ray confirmed a Fracture of the right Femur. Post fall assessment started. Patient # 8: Patient # 8 was admitted to the emergency room for a complaint of a respiratory problem. patient # 8 was then admitted to the respiratory floor. Observation, record review and interview on 06/25/2015 at 10:00 AM on the Cardiac/Telemetry Floor of patient #8 revealed that she was on fall precautions, but there was not any signage posted on her door to alert staff. During an interview on 06/25/15 at 10:15 AM, with patient #8's nurse, confirmed that there was not any signage on her door alerting that she was a fall precaution, and that should have been, since she is at risk for falls. Record review of the facility's policy titled, Fall Prevention dated 06/15, showed that a fall risk assessment is to be done by staff on admission, every shift, change in patient condition and when an a fall occurs. IF a patient is assessed to be at high risk for a fall, additional interventions includes sign at door. Should a fall occur both the Physcian and family should be notified.

17500 Based on observations, interviews and record reviews, the registered nurse(s) failed to evaluate the care provided and to implement appropriate nursing measures to prevent falls for 2 of 10 patients( Patient #1& #8), and to obtain a physician order to provide pain medication timely for 1 patient ( patient#1) of 10 reviewed. Findings: Patient #1: was admitted to the Intensive Care Unit (ICU) on 04/28/2015 for acute respiratory failure, stabilized and was transferred to the Cardiac/telemetry floor on 04/29/2015. She was on high risk fall precautions, on Ativan 0.5 mg for anxiety/depression, and Tramadol (Ultram) 50 mg twice a day (BID) for chronic neck pain. During an interview on 06/25/2015 at 1:30 PM with Registered Nurse A (RN) revealed that when asked if the bed alarm was on for patient #1 on 04/30/2015, she stated the bed alarm was not on or sounding for patient #1 when I found her on the floor on 04/30/2015 at approximately 8:00 AM. During an interview with Dr. A, on 06/25/2015, revealed that she did not receive a call from nursing staff on the morning of 06/30/2015 for patient #1 for pain medications, and if she had received a call she would have returned it, and if she is unavailable that she has additional physician coverage that could have been contacted to obtain an order for pain medications. During an interview on 06/26/2015 at 1:10 PM with the daughter of patient #1, revealed that her mother has been on Tramadol 50 milligrams twice a day (BID) before she entered this facility, and has been on this medication for a long time for chronic neck pain. She further stated that her mother did not receive and pain medication coverage ordered to elevate her pain until late that afternoon on 04/30/2015. Review of the nursing documentation of 04/30/2015 for patient #1 did not reveal that she received any pain medication to elevate her pain until a telephone order at 3:05 PM that was obtained for Morphine Sulfate 1 mg. and was administered with a pain scale 7 to 10. Six and one half (6 1/2) hours after her fall and three and on half (3 1/2) hours after confirmation of a right fracture of her femur. Review of nursing notes, (Clinical Documentation Record), dated 04/29/2015 at 9:00 PM, revealed a Nursing Assessment for: Fall precautions. Patient encourage to call for assists when need but is forgetful. On Fall Protocol. Frequent rounding. Additional fall precautions include signs outside the door, armbands and on chart. Further fall precautions also included assisting with both mobility and toileting. Having patient have non slip footwear on, and bed alarm. Review of nurse' s notes on 04/30/2015 at 6:00 AM revealed that patient #1's bed alarm was ringing. Patient was up out of bed, almost pulled intravenous site again. Patient stated that she was having anxiety, and she can't help it. Patient encouraged to go to bed, and this nurse helped the patient back to bed, and gave Ativan 0.5 mg to help patient's anxiety. Charge nurse made aware and consulted situation throughout the night regarding patient. Further review of nurse ' s notes on 04/30/2015 at 8:00 AM revealed that patient #1 was found on the floor near the white information board in her room by staff. Physician notified and orders for a Computed Tomograpy (CT) of the brain and a X-ray of the right hip due to the patient's complaint of pain in the head and right hip pain, which the X-ray confirmed a Fracture of the right Femur. Post fall assessment started Patient # 8 was admitted to the emergency room for a complaint of a respiratory problem. Patient # 8 was then admitted to the respiratory floor. Observation, record review and interview on 06/25/2015 at 10:00 AM on the Cardiac/Telemetry Floor of patient #8 revealed that she was on fall precautions, but there was not any signage posted on her door to alert staff. During an interview on 06/25/15 at 10:15 AM, with patient #8's nurse, confirmed that there was not any signage on her door alerting that she was a fall precaution, and that should have been, since she is at risk for falls. Record review of the facility's policy titled, Fall Prevention dated 06/15, showed that a fall risk assessment is to be done by staff on admission, every shift, change in patient condition and when an a fall occurs. IF a patient is assessed to be at high risk for a fall, additional interventions includes sign at door. Should a fall occur both the Physician and family should be notified.

17500 Based on observation, staff interviews and record review, the nursing staff failed to provide supervision to two of ten (#1 and # 8) sampled patients of patient care needs for fall precautions and pain medications. Findings: Patient # 1: During an interview on 06/25/2015 at 1:30 PM with Registered Nurse A (RN) revealed that when asked if the bed alarm was on for patient #1 on 04/30/2015, she stated the bed alarm was not on or sounding for patient #1 when I found her on the floor on 04/30/2015 at approximately 8:00 AM. During an interview with Dr. A, on 06/25/2015, revealed that she did not receive a call from nursing staff on the morning of 06/30/2015 for patient #1 for pain medications,or that patient had a fall. If she had received a call she would have returned it, and if she is unavailable that she has additional physician coverage that could have been contacted to obtain an order for pain medications. Review of Nursing Notes, (Clinical Documentation Record), dated 04/29/2015 at 9:00 PM, revealed a Nursing Assessment for: Fall precautions. Patient encourage to call for assists when need but is forgetful. On Fall Protocol. Frequent rounding. Additional fall precautions include signs outside the door, armbands and on chart. Further fall precautions also included assisting with both mobility and toileting. Having patient have non slip footwear on, and bed alarm. Review of nurse ' s notes on 04/30/2015 at 6:00 AM revealed that patient #1's bed alarm was ringing. Patient was up out of bed, almost pulled intravenous site again. Patient stated that she was having anxiety, and she can't help it. Patient encouraged to go to bed, and this nurse helped the patient back to bed, and gave Ativan 0.5 mg to help patient's anxiety. Charge nurse made aware and consulted situation throughout the night regarding patient. Further review of nurse ' s notes on 04/30/2015 at 8:00 AM revealed that patient #1 was found on the floor near the white information board in her room by staff. Physician notified and orders for a Computed Tomography (CT) of the brain and a X-ray of the right hip due to the patient's complaint of pain in the head and right hip pain, which the X-ray confirmed a Fracture of the right Femur. Post fall assessment started. Review of Nursing Notes, (Clinical Documentation Record), dated 04/29/2015 at 21:00 PM revealed a Nursing Assessment for: Fall precautions which included a bed alarm. patient encourage to call for assists when need but is forgetful. On Fall Protocol. frequent rounding. Review of nurses notes on 04/30/2015 at 8:00 AM revealed that patient #1 was found on the floor near the white information board in her room by staff. Physician notified and orders for a Computed Tomograpy (CT) of the brain and a X-ray of the right hip due to the patient's complaint of pain in the head and right hip pain, which the X-ray confirmed a fracture of the right femur. Post fall assessment started. During an interview on 06/25/2015 at 2:30 PM with Registered Nurse #1 (RN) revealed that when she was asked if she called patient #1's daughter right after her fall and before she received the CT and X-ray of the right hip, she stated I called her afterward, later that morning around 11:00 AM. During an interview on 06/25/2015 at 2:30 PM with Registered Nurse A, she stated I was told by the night shift nurse that the bed alarm was on for patient #1, and I did not check the alarm myself to see if it was on. During an interview on 06/25/2015 at 1:30 PM with Registered Nurse #B revealed that when asked if the bed alarm was on for patient #1 on 04/30/2015, she stated the bed alarm was not on or sounding for patient #1 when I found her on the floor on 04/30/2015 at approximately 8:00 AM. During an interview on 06/26/2015 at 1:00 PM, with the daughter of patient #1, revealed that her mother has been on Tramadol 50 milligrams twice a day (BID) before she entered this facility, and has been on this medication for a long time for chronic neck pain. She further stated that her mother did not receive and pain medication coverage ordered to elevate her pain until late that afternoon on 04/30/2015. Review of the nursing documentation of 04/30/2015 for patient #1 did reveal that she did not receive any pain medication to relieve her pain until a telephone order at 3:05 PM, that was obtained for Morphine Sulfate 1 mg. Which was administered with a pain scale 7 to 10. Six and one half (6 1/2) hours after her fall and three and on half (3 1/2) hours after confirmation of a right fracture of her femur. patient # 8: Observation on 06/25/2015 at 10:00 AM on the Cardiac/Telemetry Floor of patient #8 revealed that she was on fall precautions, but there was not any signage posted on her door to alert staff. During an interview on 06/25/15 at 10:15 AM with patient #8's nurse confirmed that there was not any signage on her door alerting that she was a Fall Precaution, and that should have been, since she is at risk for falls. Review of the facility's Policy and procedure titled Fall prevention revealed the following: if patient has fall risk, an assessment will be conducted each shift, change in condition, and when a fall occurs. There are additional interventions for high risk falls as an alert, which is a an armband, signs and flagging the chart. There are other interventions used as a bed alarm. should a fall occur, notify Physcian and family.

14628 Based on staff interviews, facility document review, and patient record review, the facility failed to have an effective governing body to ensure that the facility provided Nursing Services to ensure patient safety; and ensure accountibility of the Medical Staff in assessing the need for wound care. For these reasons, the Condition of Governing Body was found to be out of compliance. These failures present a substantial probability to adversely affect all patients' physical health, safety and well-being. Findings: Referance A0338: Based on medical record review and medical staff interview the facility failed for 1 of 10 patients, (Patient #1), to ensure the accountability of the medical staff to evaluate and provide treatment to prevent the development of pressure sore beneath a CAM boot Refference A0385: Based on interview and record review the facility failed for 1 of 10 patients, (Patient #1), to ensure nursing supervision to prevent pressure sores and to develop and implement a care to prevent the the development of pressure sores.

14628 Based on medical record review and medical staff interview the facility failed for 1 of 10 patients, (Patient #1), to ensure the accountability of the medical staff to evaluate and provide treatment to prevent the development of pressure sore beneath a CAM boot Findings: Reference A0247: Based on medical record review and medical staff interview the medical staff failed for 1 of 10 patients, (Patient #1), to evaluate and provide treatment to prevent the development of pressure sore beneath a CAM boot. The CAM boot remained on the patient for 8 days before the skin beneath the CAM boot was evaluated by a physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 14628 Based on medical record review and medical staff interview the medical staff failed for 1 of 10 patients, (Patient #1), to evaluate and provide treatment to prevent the development of pressure sore beneath a CAM boot. The CAM boot remained on the patient for 8 days before the skin beneath the CAM boot was evaluated by a physician. Findings: Review of the medical record for patient #1 revealed an office visit History and Physical written on 11/05/2013 by Dr. #1 an orthopedic surgeon. The History and Physical was written as part of an outpatient surgical work up for patient #1. Review of the History and Physical revealed that the patient was to have surgery to repair a closed bimalleolar left ankle fracture suffered following a fall at home. Review of the physical examination of the ankle revealed Inspection: fracture blisters, blood, and swelling. Under Plan: R/B discussed will proceed with OTIF, discussed compliance, elevation and possible loss of limb . Review of the medical record for patient #1 revealed an emergency room Provider Report dated 11/07/2013 Pt was scheduled for a left ankle ORIF with Dr. #1 this morning and pt. had elevated BP at the outpatient surgical center this morning prior to her scheduled surgery. Pt was given 1 L NS, 10 mg Hydralazine, 10 mg Metoprolol and 1 mg Dilaudid with no improvement in her BP. Pt. arrived via EMS on stretcher, BP 222/86. Pt denies chest pain, dyspnea, weakness or stroke like S/S. Pt is verbal and states she lives alone, has no PCP, has no family here, pt ' s friend at bedside states they try to help as much as possible. Per Dr. #1 at bedside, pt. found on the floor in her own feces last week after a slip and fall and was Dx with an unstable ankle fracture. Dr. #1 has arranged for pt. to have ORIF at All Saints outpatient surgery center. Pt. states she takes no medications and has been taking Aleve for pain. Pt states she has history of HTN years ago ; 6 years ago she was able to stabilize her BP and tool herself of her BP medication. Pt ' s only C/O today is a little pain to her ankle . DNVI LLE. (Distal Neurovascular Intact . Review of the Extremities Assessment section revealed Stabilization boot in place to LLE, DNVI with no edema to the foot. Review of the medical record did not reveal the ER physician or the ARNP ever removed the boot to evaluate the fracture blisters. Review of the medical record for patient #1 revealed ER nursing notes/ED Final Patient Record revealed under Rapid Initial Assessment Pt from Dr. #1 with c/o uncontrolled HTN was scheduled to have ankle fracture repaired this AM. Additionally, under Objective Assessments the record revealed Boot noted to LLE . On page 2 of 7 under Physical Findings the Integumentary Assessment revealed WDP: Yes (WDP=within defined parameters) Review of page 6 of 7 under Assessment Parameters revealed the Integumentary assessment to be Skin warm, dry and intact, No complaints of lesions, rash, wounds, bruises, petechial or abrasions . Review of the complete ER medical record failed to demonstrate that the boot was ever removed and the ankle/fracture blisters were assessed or that there were any treatment plans developed for the care of the fracture blisters. Review of the physician orders written in the ER revealed any orders related to the care and treatment of the fracture wounds. Review of the ER medical records for patient #1 did not reveal that Dr. #1 provided any orders related to the utilization of the CAM [NAME] Boot or instructions on the care of the fracture blisters. The medical record did not reveal that any of the ER staff had contacted Dr. #1 for orders or instructions on the utilization of the CAM [NAME] Boot or instructions on the care of the fracture blisters. Review of the History and Physical written on 11/07/2013 by Dr. #2 a Hospitalist and the attending physician for patient #1 revealed the following admission diagnosis Left ankle fracture, uncontrolled hypertension, UTI, Arthritis, Anemia. Possibly chronic no obvious blood loss, Possible acute renal failure with stage 3 and 4, and hyperglycemia. The treatments plan included Admit, IV fluids, IV antibiotics, Pain management, follow up with orthopedics for surgery, Hemoglobin A1c, Iv fluids and monitor kidney functions and EKG, normal sinus rhythm Patient is medically stable for surgical intervention with calculated moderate risk of perioperative morbidities, [NAME] tried to reach the family to get more information about the patient ' s home medications and medical issues, Ppi, and On Lovenox until surgery. Review of the Physical Exam revealed under Extremities: moves all, no edema, under Musculoskeletal: full range of motion, normal inspection, and under Skin: intact, no gross abnormalities. Review of the History and Physical did not reveal any reference to the two fracture blisters or any assessment of the conditions of the patient ' s skin under the boot. Review of the Hospitalist progress note for 11/08/2013 did not reveal any reference to the fracture blisters or the condition of the skin covered by the boot. The Physical exam section revealed under Extremities: moves all, no edema, under Musculoskeletal: full range of motion, normal inspection, and under Skin: intact, no gross abnormalities. Review of the Assessment/Plan section revealed the following note As per orthopedics they do not plan to do surgery for now, objective discharge and do that as outpatient. Review of the Hospitalist ' s progress note for 11/09/2013 did not reveal any reference to the fracture blisters or the condition of the skin covered by the boot. The Physical exam section revealed under Extremities: moves all, Normal capillary refill, normal range of motion, no edema, under Musculoskeletal: normal inspection, Lt leg with dressing/ 3/5 rt side ok and under Skin: dry, intact. The assessment did not address the fracture blisters or the condition of the skin under the boot. Review of the Hospitalist ' s progress note for 11/10/2013 did not reveal any reference to the fracture blisters or the condition of the skin covered by the boot. The Physical exam section revealed under Extremities: left empress left ankle dressing/, under Musculoskeletal: normal inspection, Lt leg with dressing/ 3/5 rt side ok and under Skin: dry, intact. The assessment did not address the fracture blisters or the condition of the skin under the boot. Review of the Hospitalist ' s Discharge Summary, (discharge was canceled), for 11/11/2013 did not reveal any reference to the fracture blisters or the condition of the skin covered by the boot. The Physical exam section revealed under Extremities: left hemiparesis left ankle dressing/, under Musculoskeletal: normal inspection, Lt leg with dressing/ 3/5 rt side ok and under Skin: dry, intact. The assessment did not address the fracture blisters or the condition of the skin under the boot or provided any discharge instructions related to the care of the fractures blisters. Review of the Hospitalist ' s progress notes for 11/12/212, 11/132013, and 11/14/2013 did not reveal any reference to the fracture blisters or the condition of the skin covered by the boot. The Physical exam section revealed under Extremities: left hemiparesis left ankle dressing, under Musculoskeletal: normal inspection, Lt leg with dressing 3/5 rt side ok and under Skin: dry, intact. The assessment did not address the fracture blisters or the condition of the skin under the boot. Review of the Assessment/Plan section for 1112/213 revealed a note Discussed case with Dr. #1 who is willing to do her surgery at the hospital but previously patient had elevated blood pressure and her blood pressures are still a bit to high will recheck labs and add Terazosin at hs ideally the plan would be to have surgery on Thursday the 14th. Review of the Physical exam section of the Hospitalist ' s progress note for 11/15/2013 revealed under Extremities: left hemiparesis left ankle dressing/, under Musculoskeletal: normal inspection, Lt leg with dressing/ 3/5rt side ok and under Skin: dry, intact Review of the Assessment/Plan section revealed the following note dated 11/15/2013 Patient status post open reduction internal fixation of left ankle and debridement of her fracture blisters after several days of good blood pressure control, patient had significant elevation of her medication prior to surgery, had a family conference with case management and the plan is to have the patient go home with family care and outside help as well, remove the Foley catheter and blood pressure monitoring, family understands the risk of aspiration, the patient has dysphasia, they will be trying to get her back to Canada. Review of the progress notes for 11/16/2013 and 11/17/2013 and the Discharge Summaries for 11/17/213 and 11/18/2013 did not reveal any references to the fracture blisters or the condition of the surrounding skin. Review of the Orthopedic Consultation performed on 11/14/2013 by Dr. #1 revealed On her examination, her CAM walker removed with the family present. She had fracture blisters initially. She has skin atrophic changes noted of the lower extremity. She has palpable dorsal pedis pulse. The Ulna boot that I have placed on the patient has since been removed. The swelling has decreased. There is diffuse ecchymosis throughout. I had a discussion with the son, the severity of this fracture, both the duration and the fact that she had fracture blisters and her hypertension, strict non-weight bearing will be necessary. Review of the nursing admission assessment for on 11/07/2013 at 1116 under the INTEGUMENTARY EVALUATION revealed the Skin Appearance: Appropriate for patient, Skin Temp: Warm, Skin Moisture: Dry, Skin Turgor: Good, Mucous Membrane: Dry. The assessment revealed Under WOUND/ULCER EVALUATION revealed Type #1 Blister Location: Lt Ankle x 2, Wound Evaluation: Non-open, Surrounding Tissue Evaluation: Normal, Wound Bed: Clear, Dressing: Ace Wrap with FZ Boot, Drainage Amount: None Review of admission nursing note date 11/07/2013 at 1321 revealed Received pt. Alert and Oriented times 3. No c/o pain or discomfort at present. IV patent infusing ABT at present. Left leg walking boot in place. Pt. vague with answering questions at present. Received pain med in ER. Friend with pt. Will observe. Review of a nursing note written 11/07/2013 at 1647 revealed Spoke to Dr. #1. Dr. #1 stated that he was supposed to do surgery on pt ' s leg today, but he could not because he BP was elevated. Stated he will not see her at the hospital here but will on an outpatient basis when she is discharged .

14628 Based on interview and record review the facility failed for 1 of 10 patients, (Patient #1), to ensure nursing supervision to prevent pressure sores and to develop and implement a care to prevent the the development of pressure sores. Findings: Reference A0392: Based on record and staff interviews the facility failed for 1 of 10 patients( Patient #1) the registered nurse(s) failed to evaluate the care provided and to implement appropriate nursing measures to prevent the development of pressure sores on the left foot following a fracture. Reference A0396: Based on staff interviews and record review the facility failed to for 1 of 10 patients, (patient #1), to develop, implement and revise an individualized Plan of Care with known fracture blisters beneath a CAM. walking boot.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 14628 Based on record and staff interviews the facility failed for 1 of 10 patients( Patient #1) the registered nurse(s) failed to evaluate the care provided and to implement appropriate nursing measures to prevent the development of pressure sores on the left foot following a fracture. Findings: Review of the medical record for patient #1 revealed an office visit History and Physical written on 11/05/2013 by Dr. #1 an orthopedic surgeon. The History and Physical was written as part of an outpatient surgical work up for patient #1. Review of the History and Physical revealed that the patient was to have surgery to repair a closed bimalleolar left ankle fracture suffered following a fall at home. Review of the physical examination of the ankle revealed Inspection: fracture blisters, blood, and swelling. Under Plan: R/B discussed will proceed with OTIF, discussed compliance, elevation and possible loss of limb . Interview with Dr #1 on 1/2/14 revealed that he transferred the patient to the ER so that her blood pressure can be brought under control and then be discharged so the surgery could be done in the ASC. Review of the medical record for patient #1 revealed an emergency room Provider Report dated 11/07/2013 Pt was scheduled for a left ankle ORIF with Dr. #1 this morning and pt. had elevated BP at the outpatient surgical center this morning prior to her scheduled surgery. Pt was given 1 L NS, 10 mg Hydralazine, 10 mg Metoprolol and 1 mg Dilaudid with no improvement in her BP. Pt. arrived via EMS on stretcher, BP 222/86. Pt denies chest pain, dyspnea, weakness or stroke like S/S. Pt is verbal and states she lives alone, has no PCP, has no family here, pt. ' s friend at bedside states they try to help as much as possible. Per Dr. #1 at bedside, pt. found on the floor in her own feces last week after a slip and fall and was Dx with an unstable ankle fracture. Dr. #1 has arranged for pt. to have ORIF at All Saints outpatient surgery center. Pt. states she takes no medications and has been taking Aleve for pain. Pt states she has history of HTN years ago ; 6 years ago she was able to stabilize her BP and tool herself of her BP medication. Pt ' s only C/O today is a little pain to her ankle . DNVI LLE. (Distal Neurovascular Intact . Review of the Extremities Assessment section revealed Stabilization boot in place to LLE, DNVI with no edema to the foot. Review of the medical record did not reveal the ER physician or the ARNP ever removed the boot to evaluate the fracture blisters. Review of the medical record for patient #1 revealed ER nursing notes/ED Final Patient Record revealed under Rapid Initial Assessment Pt from Dr. #1's with c/o uncontrolled HTN was scheduled to have ankle fracture repaired this AM. Additionally, under Objective Assessments the record revealed Boot noted to LLE . On page 2 of 7 under Physical Findings the Integumentary Assessment revealed WDP: Yes (WDP=within defined parameters) Review of page 6 of 7 under Assessment Parameters revealed the Integumentary assessment to be Skin warm, dry and intact, No complaints of lesions, rash, wounds, bruises, petechial or abrasions . Review of the complete ER medical record failed to demonstrate that the boot was ever removed and the ankle/fracture blisters were assessed or that there were any treatment plans developed for the care of the fracture blisters. Review of the physician orders written in the ER revealed any orders related to the care and treatment of the fracture wounds. Review of the ER medical records for patient #1 did not reveal that Dr. #1 provided any orders related to the utilization of the CAM [NAME] Boot or instructions on the care of the fracture blisters. The medical record did not reveal that any of the ER staff had contacted Dr. #1 for orders or instructions on the utilization of the CAM [NAME] Boot or instructions on the care of the fracture blisters. Review of the History and Physical written on 11/07/2013 by Dr. #2, a Hospitalist, and the attending physician for patient #1 revealed the following admission diagnosis Left ankle fracture, uncontrolled hypertension, UTI, Arthritis, Anemia. Possibly chronic no obvious blood loss, Possible acute renal failure with stage 3 and 4, and hyperglycemia. The treatments plan included Admit, IV fluids, IV antibiotics, Pain management, follow up with orthopedics for surgery, Hemoglobin A1c, Iv fluids and monitor kidney functions and EKG, normal sinus rhythm Patient is medically stable for surgical intervention with calculated moderate risk of perioperative morbidities, [NAME] tried to reach the family to get more information about the patient ' s home medications and medical issues, Ppi, and On Lovenox until surgery. Review of the Physical Exam revealed under Extremities: moves all, no edema, under Musculoskeletal: full range of motion, normal inspection, and under Skin: intact, no gross abnormalities. Review of the History and Physical did not reveal any reference to the two fracture blisters or any assessment of the conditions of the patient ' s skin under the boot. Review of Nursing Notes, (Clinical Documentation Record), dated 11/07/2013 at 1116 revealed a Nursing Admission Assessment for: Integumentary WDP: N INTEGUMENTARY EVALUATION: Skin Appearance: Appropriate for Patient Skin Temp: Warm Skin Moisture: Dry Skin Turgor: Good Mucous Membrane: Dry WOUND/ULCER EVALUATION: Type #1: Blister Location:: Lt Ankle x 2 Wound Eval: Non-Open Surround Tissue Eval: Normal Wound Bed: Clear Dressing: Ace Wrap with FX Boot Drainage Amt: None Review of the nursing documentation for the Admission Evaluation did not reveal if the wound, (Blisters) were evaluated for size. The record revealed that the wound bed was clear but did not reveal if the dressing was removed, but did indicate that an ACE wrap was used with the CAM boot. The evaluation did not reveal if the wound bed was clear for both blisters or only one. The location on the left ankle of each blister was not documented. Review of a nursing note written 11/07/2013 at 1647 revealed Spoke to Dr.#1. Dr. #1 stated that he was supposed to do surgery on pt. ' s leg today, but he could not because he BP was elevated. Stated he will not see her at the hospital here but will on an outpatient basis when she is discharged . Review of the medical record did not reveal that the nurse or a member of the nursing staff contacted the admitting physician to discuss the treatment of the wound or to obtain treatment orders for preventing a deterioration of the wounds. Review of Nursing Notes, (Clinical Documentation Record), dated 11/08/13 at 08:10 revealed a Nursing Integumentary Evaluation revealed the following: Integumentary WDP: N Integumentary Evaluation: Skin Appearance: Appropriate for Patient Skin Temp: Warm Skin Moisture: Dry Skin Turgor: Good Mucous Membrane: Moist Wound /Ulcer: Y Incisions: N New Onset of Skin Breakdown: N Function of Bed/Mattress: Pressure Redistribution WOUND/ULCER EVALUATION: Type #1: Blister Location:: Lt Ankle x 2 Wound Eval: Non-Open Surround Tissue Eval: Normal Review of the Nursing Evaluation did not reveal if the wound, (Blisters) were evaluated for size. The record did not reveal if the wound beds were still clear or not reveal if the dressing was removed or changed or was not present. The location on the left ankle of each blister was not documented. Review of Nursing Notes, (Clinical Documentation Record), dated 11/08/2113 at 2000 revealed a Nursing Integumentary Evaluation that revealed: Integumentary WDP: Y Review of the Shift nursing assessment revealed that an Integumentary evaluation was not completed due to answering Y, (Yes), to the above. Review of the nursing documentation on did not reveal if the wound, (Blisters) were evaluated at all during the shift. Review of Nursing Notes, (Clinical Documentation Record), dated 11/09/2013 at 09:39 revealed a Nursing Integumentary Evaluation revealed the following: Integumentary WDP: N Integumentary Evaluation: Skin Appearance: Appropriate for Patient Skin Temp: Warm Skin Moisture: Dry Skin Turgor: Fair Mucous Membrane: Moist Wound /Ulcer: Y Function of Bed/Mattress: Pressure Redistribution WOUND/ULCER EVALUATION: Type #1: Blister Location:: Lt Ankle x 2 Wound Eval: Non-Open Surround Tissue Eval: Normal Wound Bed: Pink Dressing: No Dressing Type #2: Ecchymosis Location: Left Knee Wound Eval: Non-open Surrounding Tissue Eval: Normal: Wound Bed: Purple, Pink Dressing: No Dressing Review of the nursing documentation for the Admission Evaluation did not reveal if the wound, (Blisters) were evaluated for size. The record revealed that the wound bed was Pink but did not reveal any information related to the dressing or if the CAM boot was on. The location on the left ankle of each blister was not documented. The development of the Ecchymosis skin located on the left knee was not evaluated as to cause or extent. There was not any documentation that the patient ' s physician was notified or treatment orders were obtained. Review of the assessment on 11/09/2013 at 2146 was essentially the same as the one at 0939. The medical record did not reveal that the physician was not notified of the second wound are identified. Review of Nursing Notes, (Clinical Documentation Record), dated 11/10/2013 at 1004 revealed a Nursing Integumentary Evaluation revealed the following: Integumentary WDP: N Integumentary Evaluation: Skin Appearance: Appropriate for Patient Skin Temp: Warm Skin Moisture: Dry Skin Turgor: Fair Mucous Membrane: Moist Wound /Ulcer: Y Function of Bed/Mattress: Pressure Redistribution WOUND/ULCER EVALUATION: Type #1: Blister Location:: Lt Ankle x 2 Wound Eval: Non-Open Surround Tissue Eval: Normal Wound Bed: Pink Dressing: No Dressing Type #2: Ecchymosis Location: Left Knee Wound Eval: Non-open Surrounding Tissue Eval: Normal: Wound Bed: Purple, Pink Dressing: No Dressing Review of the nursing documentation did not reveal if the wound, (Blisters) were evaluated for size or changes. The record revealed that the wound bed was Pink but did not reveal why dressing was removed or indicate if CAM boot was on. The location on the left ankle of each blister was not documented. The medical record did not reveal any physician orders for the treatment of the wounds or if the physician were ever notified. The assessment did not reveal if wound #2 had changed from the last assessment. Review of Nursing Notes, (Clinical Documentation Record), dated 11/11/2013 at 2200 revealed a Nursing Integumentary Evaluation revealed the following: Integumentary WDP: N Integumentary Evaluation: Skin Appearance: Appropriate for Patient Skin Temp: Warm Skin Moisture: Dry Skin Turgor: Fair Mucous Membrane: Moist Wound /Ulcer: Y Incisions: N New Onset of Skin Breakdown: N Function of Bed/Mattress: Pressure Redistribution WOUND/ULCER EVALUATION: Type #1: Blister Location:: Lt Ankle x 2 Wound Eval: Non-Open Surround Tissue Eval: Normal Wound Bed: Pink Dressing Mepilex Type #2: Ecchymosis Location: Left Knee Wound Eval: Non-open Surrounding Tissue Eval: Normal: Wound Bed: Purple Review of the nursing documentation for the Admission Evaluation did not reveal if the wound, (Blisters) were evaluated for size or changes. The record revealed that the wound was dress with Mepilex but did not reveal that a physician was notified of the wound or that an order for using Mepilex for wound care was ordered. The record did not reveal if the CAM boot was on the patient. The location on the left ankle of each blister was not documented. The record did not reveal that the physician was notified of the wound on the knee or that any treatment orders were obtained by the nursing staff. Review of Nursing Notes, (Clinical Documentation Record), dated 11/11/2013 at 0750 revealed a Nursing Integumentary Evaluation that revealed: Integumentary WDP: Y Review of the Shift nursing assessment revealed that an Integumentary evaluation was not completed due to answering Y, (Yes), to the above. Review of the nursing documentation on did not reveal if the either wound #1, (Blisters), or wound #2, (Ecchymosis) were evaluated at all during the shift. The medical record did not reveal if the physician was notified or if treatment orders were obtained. The record did not reveal if Mepilex was still being used as a dressing. Review of Nursing Notes, (Clinical Documentation Record), dated 11/11/2013 at 1900 revealed a Nursing Integumentary Evaluation that revealed: Integumentary WDP: Y Review of the Shift nursing assessment revealed that an Integumentary evaluation was not completed due to answering Y, (Yes), to the above. Review of the nursing documentation on did not reveal if the either wound #1, (Blisters), or wound #2, (Ecchymosis) were evaluated at all during the shift. The medical record did not reveal if the physician was notified or if treatment orders were obtained. The record did not reveal if Mepilex was still being used as a dressing. Review of Nursing Notes, (Clinical Documentation Record), dated 11/12/2013 at 0800 revealed a Nursing Integumentary Evaluation that revealed: Integumentary WDP: Y Review of the Shift nursing assessment revealed that an Integumentary evaluation was not completed due to answering Y, (Yes), to the above. Review of the nursing documentation on did not reveal if the either wound #1, (Blisters), or wound #2, (Ecchymosis) were evaluated at all during the shift. The medical record did not reveal if the physician was notified or if treatment orders were obtained. The record did not reveal if Mepilex was still being used as a dressing. Review of Nursing Notes, (Clinical Documentation Record), dated 11/12/2013 at 1641 revealed a Nursing Integumentary Evaluation that revealed: Integumentary WDP: Y Review of the Shift nursing assessment revealed that an Integumentary evaluation was not completed due to answering Y, (Yes), to the above. Review of the nursing documentation on did not reveal if the either wound #1, (Blisters), or wound #2, (Ecchymosis) were evaluated at all during the shift. The medical record did not reveal if the physician was notified or if treatment orders were obtained. The record did not reveal if Mepilex was still being used as a dressing. Review of Nursing Notes, (Clinical Documentation Record), dated 11/13/2013 at 0702 revealed a Nursing Integumentary Evaluation that revealed: Integumentary WDP: Y Review of the Shift nursing assessment revealed that an Integumentary evaluation was not completed due to answering Y, (Yes), to the above. Review of the nursing documentation on did not reveal if the either wound #1, (Blisters), or wound #2, (Ecchymosis) were evaluated at all during the shift. The medical record did not reveal if the physician was notified or if treatment orders were obtained. The record did not reveal if Mepilex was still being used as a dressing. Review of Nursing Notes, (Clinical Documentation Record), dated 11/13/2013 at 2032 revealed a Nursing Integumentary Evaluation that revealed: Integumentary WDP: Y Review of the Shift nursing assessment revealed that an Integumentary evaluation was not completed due to answering Y, (Yes), to the above. Review of the nursing documentation on did not reveal if the either wound #1, (Blisters), or wound #2, (Ecchymosis) were evaluated at all during the shift. The medical record did not reveal if the physician was notified or if treatment orders were obtained. The record did not reveal if Mepilex was still being used as a dressing. Review of Nursing Notes, (Clinical Documentation Record), dated 11/14/2013 at 0730 revealed a Nursing Integumentary Evaluation that revealed: Integumentary WDP: Y Review of the Shift nursing assessment revealed that an Integumentary evaluation was not completed due to answering Y, (Yes), to the above. Review of the nursing documentation on did not reveal if the either wound #1, (Blisters), or wound #2, (Ecchymosis) were evaluated at all during the shift. The medical record did not reveal if the physician was notified or if treatment orders were obtained. The record did not reveal if Mepilex was still being used as a dressing. Review of Nursing Notes, (Clinical Documentation Record), dated 11/14/2013 at 2015 revealed a Nursing Admission Assessment for: Integumentary WDP: N INTEGUMENTARY EVALUATION: Skin Appearance: Appropriate for Patient Skin Temp: Warm Skin Moisture: Dry Skin Turgor: Good Mucous Membrane: Dry Wounds/Ulcer: Y Incisions: N New Onset Skin Breakdown: N WOUND/ULCER EVALUATION: Type #1: Blister Location:: Lt Ankle x 2 Wound Eval: Unable to Assess Comments Boot on LT Foot Type #2: Ecchymosis Location: Left Knee Wound Eval: Left Knee Surround Tissue Eva; Red Type #3: Ecchymosis Location: RT AC Wound Eval: Non-Open Surrounding Tissue Eval: Warm, Red, Swollen. Review of the medical record revealed that the description of wound #3 was first described in this evaluation, contrary to stating No to New Onset of Skin Breakdown in the evaluation. The medical record revealed that surrounding tissue for wound #2 is now red. Review of the Orthopedic Consultation performed on 11/14/2015 by Dr. #1 revealed On her examination, her CAM walker removed with the family present. She had fracture blisters initially. She has skin atrophic changes noted of the lower extremity. She has palpable dorsal pedis pulse. The Ulna boot that I have placed on the patient has since been removed. The swelling has decreased. There is diffuse ecchymosis throughout. I had a discussion with the son, the severity of this fracture, both the duration and the fact that she had fracture blisters and her hypertension, strict non-weight bearing will be necessary. Review of photographs taken on 11/14/2014 in the presence of Dr. #1 revealed two fractures blister, one on the medial aspect of the ankle measuring 7 CM by 8 cm and one on the lateral side measuring 6 cm x 9 cm. The photographs revealed defuse ecchymosis from the lower top of her foot to mid-calf coming down of the back of leg to the top of her heel. Review of the medical record did not reveal any nursing assessment that described the conditions of the foot/ankle/leg or a plan of care to guide the treatment for the wounds.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 14628 Based on staff interviews and record review the facility failed to for 1 of 10 patients, (patient #1), to develop, implement and revise an individualized Plan of Care with known fracture blisters beneath a CAM. walking boot. Findings Review of the medical record for patient #1 revealed an office visit History and Physical written on 11/05/2013 by Dr. #1 an orthopedic surgeon. The History and Physical was written as part of an outpatient surgical work up for patient #1. Review of the History and Physical revealed that the patient was to have surgery to repair a closed bimalleolar left ankle fracture suffered following a fall at home. Review of the physical examination of the ankle revealed Inspection: fracture blisters, blood, and swelling. Under Plan: R/B discussed will proceed with OTIF, discussed compliance, elevation and possible loss of limb . Interview with Dr #1 on 1/2/2013 at 11:00 AM revealed that he transferred the patient to the ER so that her blood pressure can be brought under controll and then be discharged so the surgery could be done in the ASC. Review of the medical record for patient #1 revealed an emergency room Provider Report dated 11/07/2013 Pt was scheduled for a left ankle ORIF with Dr. #1 this morning and pt. had elevated BP at the outpatient surgical center this morning prior to her scheduled surgery. Pt was given 1 L NS, 10 mg Hydralazine, 10 mg Metoprolol and 1 mg Dilaudid with no improvement in her BP. Pt. arrived via EMS on stretcher, BP 222/86. Pt denies chest pain, dyspnea, weakness or stroke like S/S. Pt is verbal and states she lives alone, has no PCP, has no family here, pt. ' s friend at bedside states they try to help as much as possible. Per Dr. #1 at bedside, pt. found on the floor in her own feces last week after a slip and fall and was Dx with an unstable ankle fracture. Dr. #1 has arranged for pt. to have ORIF at All Saints outpatient surgery center. Pt. states she takes no medications and has been taking Aleve for pain. Pt states she has history of HTN years ago ; 6 years ago she was able to stabilize her BP and tool herself of her BP medication. Pt ' s only C/O today is a little pain to her ankle . DNVI LLE. (Distal Neurovascular Intact . Review of the Extremities Assessment section revealed Stabilization boot in place to LLE, DNVI with no edema to the foot. Review of the medical record did not reveal the ER physician or the ARNP ever removed the boot to evaluate the fracture blisters. Review of the medical record for patient #1 revealed ER nursing notes/ED Final Patient Record revealed under Rapid Initial Assessment Pt from Dr. #1's with c/o uncontrolled HTN was scheduled to have ankle fracture repaired this AM. Additionally, under Objective Assessments the record revealed Boot noted to LLE . On page 2 of 7 under Physical Findings the Integumentary Assessment revealed WDP: Yes (WDP=within defined parameters) Review of page 6 of 7 under Assessment Parameters revealed the Integumentary assessment to be Skin warm, dry and intact, No complaints of lesions, rash, wounds, bruises, petechial or abrasions . Review of the complete ER medical record failed to demonstrate that the boot was ever removed and the ankle/fracture blisters were assessed or that there were any treatment plans developed for the care of the fracture blisters. Review of the physician orders written in the ER revealed any orders related to the care and treatment of the fracture wounds. Review of the ER medical records for patient #1 did not reveal that Dr. #1 provided any orders related to the utilization of the CAM [NAME] Boot or instructions on the care of the fracture blisters. The medical record did not reveal that any of the ER staff had contacted Dr. #1 for orders or instructions on the utilization of the CAM [NAME] Boot or instructions on the care of the fracture blisters. Review of the History and Physical written on 11/07/2013 by Dr. #2, a Hospitalist, and the attending physician for patient #1 revealed the following admission diagnosis Left ankle fracture, uncontrolled hypertension, UTI, Arthritis, Anemia. Possibly chronic no obvious blood loss, Possible acute renal failure with stage 3 and 4, and hyperglycemia. The treatments plan included Admit, IV fluids, IV antibiotics, Pain management, follow up with orthopedics for surgery, Hemoglobin A1c, Iv fluids and monitor kidney functions and EKG, normal sinus rhythm Patient is medically stable for surgical intervention with calculated moderate risk of perioperative morbidities, [NAME] tried to reach the family to get more information about the patient ' s home medications and medical issues, Ppi, and On Lovenox until surgery. Review of the Physical Exam revealed under Extremities: moves all, no edema, under Musculoskeletal: full range of motion, normal inspection, and under Skin: intact, no gross abnormalities. Review of the History and Physical did not reveal any reference to the two fracture blisters or any assessment of the conditions of the patient ' s skin under the boot. Review of Nursing Notes, (Clinical Documentation Record), dated 11/07/2013 at 1116 revealed a Nursing Admission Assessment for: Integumentary WDP: N INTEGUMENTARY EVALUATION: Skin Appearance: Appropriate for Patient Skin Temp: Warm Skin Moisture: Dry Skin Turgor: Good Mucous Membrane: Dry WOUND/ULCER EVALUATION: Type #1: Blister Location:: Lt Ankle x 2 Wound Eval: Non-Open Surround Tissue Eval: Normal Wound Bed: Clear Dressing: Ace Wrap with FX Boot Drainage Amt: None Review of the nursing documentation for the Admission Evaluation did not reveal if the wound, (Blisters) were evaluated for size. The record revealed that the wound bed was clear but did not reveal if the dressing was removed, but did indicate that an ACE wrap was used with the CAM boot. The evaluation did not reveal if the wound bed was clear for both blisters or only one. The location on the left ankle of each blister was not documented. Review of a nursing note written 11/07/2013 at 1647 revealed Spoke to Dr.#1. Dr. #1 stated that he was supposed to do surgery on pt. ' s leg today, but he could not because he BP was elevated. Stated he will not see her at the hospital here but will on an outpatient basis when she is discharged . Review of the medical record did not reveal that the nurse or a member of the nursing staff contacted the admitting physician to discuss the treatment of the wound or to obtain treatment orders for preventing a deterioration of the wounds. Review of Nursing Notes, (Clinical Documentation Record), dated 11/08/13 at 08:10 revealed a Nursing Integumentary Evaluation revealed the following: Integumentary WDP: N Integumentary Evaluation: Skin Appearance: Appropriate for Patient Skin Temp: Warm Skin Moisture: Dry Skin Turgor: Good Mucous Membrane: Moist Wound /Ulcer: Y Incisions: N New Onset of Skin Breakdown: N Function of Bed/Mattress: Pressure Redistribution WOUND/ULCER EVALUATION: Type #1: Blister Location:: Lt Ankle x 2 Wound Eval: Non-Open Surround Tissue Eval: Normal Review of the Nursing Evaluation did not reveal if the wound, (Blisters) were evaluated for size. The record did not reveal if the wound beds were still clear or not reveal if the dressing was removed or changed or was not present. The location on the left ankle of each blister was not documented. Review of Nursing Notes, (Clinical Documentation Record), dated 11/08/2113 at 2000 revealed a Nursing Integumentary Evaluation that revealed: Integumentary WDP: Y Review of the Shift nursing assessment revealed that an Integumentary evaluation was not completed due to answering Y, (Yes), to the above. Review of the nursing documentation on did not reveal if the wound, (Blisters) were evaluated at all during the shift. Review of Nursing Notes, (Clinical Documentation Record), dated 11/09/2013 at 09:39 revealed a Nursing Integumentary Evaluation revealed the following: Integumentary WDP: N Integumentary Evaluation: Skin Appearance: Appropriate for Patient Skin Temp: Warm Skin Moisture: Dry Skin Turgor: Fair Mucous Membrane: Moist Wound /Ulcer: Y Function of Bed/Mattress: Pressure Redistribution WOUND/ULCER EVALUATION: Type #1: Blister Location:: Lt Ankle x 2 Wound Eval: Non-Open Surround Tissue Eval: Normal Wound Bed: Pink Dressing: No Dressing Type #2: Ecchymosis Location: Left Knee Wound Eval: Non-open Surrounding Tissue Eval: Normal: Wound Bed: Purple, Pink Dressing: No Dressing Review of the nursing documentation for the Admission Evaluation did not reveal if the wound, (Blisters) were evaluated for size. The record revealed that the wound bed was Pink but did not reveal any information related to the dressing or if the CAM boot was on. The location on the left ankle of each blister was not documented. The development of the Ecchymosis skin located on the left knee was not evaluated as to cause or extent. There was not any documentation that the patient ' s physician was notified or treatment orders were obtained. Review of the assessment on 11/09/2013 at 2146 was essentially the same as the one at 0939. The medical record did not reveal that the physician was not notified of the second wound are identified. Review of Nursing Notes, (Clinical Documentation Record), dated 11/10/2013 at 1004 revealed a Nursing Integumentary Evaluation revealed the following: Integumentary WDP: N Integumentary Evaluation: Skin Appearance: Appropriate for Patient Skin Temp: Warm Skin Moisture: Dry Skin Turgor: Fair Mucous Membrane: Moist Wound /Ulcer: Y Function of Bed/Mattress: Pressure Redistribution WOUND/ULCER EVALUATION: Type #1: Blister Location:: Lt Ankle x 2 Wound Eval: Non-Open Surround Tissue Eval: Normal Wound Bed: Pink Dressing: No Dressing Type #2: Ecchymosis Location: Left Knee Wound Eval: Non-open Surrounding Tissue Eval: Normal: Wound Bed: Purple, Pink Dressing: No Dressing Review of the nursing documentation did not reveal if the wound, (Blisters) were evaluated for size or changes. The record revealed that the wound bed was Pink but did not reveal why dressing was removed or indicate if CAM boot was on. The location on the left ankle of each blister was not documented. The medical record did not reveal any physician orders for the treatment of the wounds or if the physician were ever notified. The assessment did not reveal if wound #2 had changed from the last assessment. Review of Nursing Notes, (Clinical Documentation Record), dated 11/11/2013 at 2200 revealed a Nursing Integumentary Evaluation revealed the following: Integumentary WDP: N Integumentary Evaluation: Skin Appearance: Appropriate for Patient Skin Temp: Warm Skin Moisture: Dry Skin Turgor: Fair Mucous Membrane: Moist Wound /Ulcer: Y Incisions: N New Onset of Skin Breakdown: N Function of Bed/Mattress: Pressure Redistribution WOUND/ULCER EVALUATION: Type #1: Blister Location:: Lt Ankle x 2 Wound Eval: Non-Open Surround Tissue Eval: Normal Wound Bed: Pink Dressing Mepilex Type #2: Ecchymosis Location: Left Knee Wound Eval: Non-open Surrounding Tissue Eval: Normal: Wound Bed: Purple Review of the nursing documentation for the Admission Evaluation did not reveal if the wound, (Blisters) were evaluated for size or changes. The record revealed that the wound was dress with Mepilex but did not reveal that a physician was notified of the wound or that an order for using Mepilex for wound care was ordered. The record did not reveal if the CAM boot was on the patient. The location on the left ankle of each blister was not documented. The record did not reveal that the physician was notified of the wound on the knee or that any treatment orders were obtained by the nursing staff. Review of Nursing Notes, (Clinical Documentation Record), dated 11/11/2013 at 0750 revealed a Nursing Integumentary Evaluation that revealed: Integumentary WDP: Y Review of the Shift nursing assessment revealed that an Integumentary evaluation was not completed due to answering Y, (Yes), to the above. Review of the nursing documentation on did not reveal if the either wound #1, (Blisters), or wound #2, (Ecchymosis) were evaluated at all during the shift. The medical record did not reveal if the physician was notified or if treatment orders were obtained. The record did not reveal if Mepilex was still being used as a dressing. Review of Nursing Notes, (Clinical Documentation Record), dated 11/11/2013 at 1900 revealed a Nursing Integumentary Evaluation that revealed: Integumentary WDP: Y Review of the Shift nursing assessment revealed that an Integumentary evaluation was not completed due to answering Y, (Yes), to the above. Review of the nursing documentation on did not reveal if the either wound #1, (Blisters), or wound #2, (Ecchymosis) were evaluated at all during the shift. The medical record did not reveal if the physician was notified or if treatment orders were obtained. The record did not reveal if Mepilex was still being used as a dressing. Review of Nursing Notes, (Clinical Documentation Record), dated 11/12/2013 at 0800 revealed a Nursing Integumentary Evaluation that revealed: Integumentary WDP: Y Review of the Shift nursing assessment revealed that an Integumentary evaluation was not completed due to answering Y, (Yes), to the above. Review of the nursing documentation on did not reveal if the either wound #1, (Blisters), or wound #2, (Ecchymosis) were evaluated at all during the shift. The medical record did not reveal if the physician was notified or if treatment orders were obtained. The record did not reveal if Mepilex was still being used as a dressing. Review of Nursing Notes, (Clinical Documentation Record), dated 11/12/2013 at 1641 revealed a Nursing Integumentary Evaluation that revealed: Integumentary WDP: Y Review of the Shift nursing assessment revealed that an Integumentary evaluation was not completed due to answering Y, (Yes), to the above. Review of the nursing documentation on did not reveal if the either wound #1, (Blisters), or wound #2, (Ecchymosis) were evaluated at all during the shift. The medical record did not reveal if the physician was notified or if treatment orders were obtained. The record did not reveal if Mepilex was still being used as a dressing. Review of Nursing Notes, (Clinical Documentation Record), dated 11/13/2013 at 0702 revealed a Nursing Integumentary Evaluation that revealed: Integumentary WDP: Y Review of the Shift nursing assessment revealed that an Integumentary evaluation was not completed due to answering Y, (Yes), to the above. Review of the nursing documentation on did not reveal if the either wound #1, (Blisters), or wound #2, (Ecchymosis) were evaluated at all during the shift. The medical record did not reveal if the physician was notified or if treatment orders were obtained. The record did not reveal if Mepilex was still being used as a dressing. Review of Nursing Notes, (Clinical Documentation Record), dated 11/13/2013 at 2032 revealed a Nursing Integumentary Evaluation that revealed: Integumentary WDP: Y Review of the Shift nursing assessment revealed that an Integumentary evaluation was not completed due to answering Y, (Yes), to the above. Review of the nursing documentation on did not reveal if the either wound #1, (Blisters), or wound #2, (Ecchymosis) were evaluated at all during the shift. The medical record did not reveal if the physician was notified or if treatment orders were obtained. The record did not reveal if Mepilex was still being used as a dressing. Review of Nursing Notes, (Clinical Documentation Record), dated 11/14/2013 at 0730 revealed a Nursing Integumentary Evaluation that revealed: Integumentary WDP: Y Review of the Shift nursing assessment revealed that an Integumentary evaluation was not completed due to answering Y, (Yes), to the above. Review of the nursing documentation on did not reveal if the either wound #1, (Blisters), or wound #2, (Ecchymosis) were evaluated at all during the shift. The medical record did not reveal if the physician was notified or if treatment orders were obtained. The record did not reveal if Mepilex was still being used as a dressing. Review of Nursing Notes, (Clinical Documentation Record), dated 11/14/2013 at 2015 revealed a Nursing Admission Assessment for: Integumentary WDP: N INTEGUMENTARY EVALUATION: Skin Appearance: Appropriate for Patient Skin Temp: Warm Skin Moisture: Dry Skin Turgor: Good Mucous Membrane: Dry Wounds/Ulcer: Y Incisions: N New Onset Skin Breakdown: N WOUND/ULCER EVALUATION: Type #1: Blister Location:: Lt Ankle x 2 Wound Eval: Unable to Assess Comments Boot on LT Foot Type #2: Ecchymosis Location: Left Knee Wound Eval: Left Knee Surround Tissue Eva; Red Type #3: Ecchymosis Location: RT AC Wound Eval: Non-Open Surrounding Tissue Eval: Warm, Red, Swollen. Review of the medical record revealed that the description of wound #3 was first described in this evaluation, contrary to stating No to New Onset of Skin Breakdown in the evaluation. The medical record revealed that surrounding tissue for wound #2 is now red. Review of the Orthopedic Consultation performed on 11/14/2013 by Dr. #1 revealed On her examination, her CAM walker removed with the family present. She had fracture blisters initially. She has skin atrophic changes noted of the lower extremity. She has palpable dorsal pedis pulse. The Ulna boot that I have placed on the patient has since been removed. The swelling has decreased. There is diffuse ecchymosis throughout. I had a discussion with the son, the severity of this fracture, both the duration and the fact that she had fracture blisters and her hypertension, strict non-weight bearing will be necessary. Review of the medical record for patient #1 revealed that on 11/07/2013 at 2100 that interventions, (Plan of Care) were developed to prevent the development of pressure sores. The patient was determined to be a low risk of developing pressure sores, (Braden Risk Scale of 16 or low). The interventions included: Manage moisture. Avoid drying of the skin Manage Nutrition. Maintain god hydration Manage friction and shear No massage of reddened bony prominence Reposition Q2hrs and PRN Offer toileting when turning. Pericare PRN Use moisture barrier: body wash and lotion routinely Maximal remobilization-up in chair for meals when appropriate Protect (offload) heels Use turn sheet to reduce friction/shear HOB <30 degrees unless medically contraindicated Consider pressure relieving surface (if bed or chair bound) Provide education on pressure ulcers to patient and family Assess nutrition status.Obtain nutrition consult PRN Review of the medical record on 11/08/2013 at 0810 revealed the following was added to the skin care plan: Use foam wedges for 30 degree lateral positioning Consider trapeze if indicated Monitor all body folds for moisture, yeast, rash, irritation. Review of Nursing Notes, (Clinical Documentation Record), dated 11/09/2013 at 09:39 revealed a Nursing Integumentary Evaluation revealed the following: Integumentary WDP: N Integumentary Evaluation: Skin Appearance: Appropriate for Patient Skin Temp: Warm Skin Moisture: Dry Skin Turgor: Fair Mucous Membrane: Moist Wound /Ulcer: Y Function of Bed/Mattress: Pressure Redistribution WOUND/ULCER EVALUATION: Type #1: Blister Location:: Lt Ankle x 2 Wound Eval: Non-Open Surround Tissue Eval: Normal Wound Bed: Pink Dressing: No Dressing Type #2: Ecchymosis Location: Left Knee Wound Eval: Non-open Surrounding Tissue Eval: Normal: Wound Bed: Purple, Pink Dressing: No Dressing Review of the medical record did not reveal that the patient ' s care plan was updated to reflect the development of new area of Ecchymosis, (wound #2). Review of the medical record revealed that the care plan remained essentially the same from the time first developed to the time of surgery. Review of the medical record did not reveal the fracture blisters or the areas, (Now two areas), of Ecchymosis, (areas wound #2 and Wound #3), were ever incorporated into the resident ' s care plan or that a treatment plan was ever developed to prevent skin breakdown. Review of photographs taken on 11/14/2013 in the presence of Dr. #1 revealed two fractures blister, one on the medial aspect of the ankle measuring 7 CM by 8 cm and one on the lateral side measuring 6 cm x 9 cm. The photographs revealed defuse ecchymosis from the lower top of her foot to mid-calf coming down of the back of leg to the top of her heel. Review of the medical record did not reveal any nursing assessment that described the conditions of the foot/ankle/leg or a plan of care to guide the treatment for the wounds. :

13635 Based on record review, observation and interview, the facility failed to maintain the equipment in the laboratory by documenting the required safety tests of the refrigeration equipment necessary for the laboratory tests performed. Findings: During the laboratory tour on 7-26-11, it was discovered that the refrigerators in the laboratory had stickers on them that indicated that the last safety tests were due on 4-14-10. the Blood Bank Refrigerator did not have a inventory number on it and there was no documentation of the test for the temperature alarm for the Blood bank Refrigerator. An accumulation of dust and debris was observed behind the computers and testing equipment in the middle of the laboratory, stained ceiling tile observed in the Hematology area along with equipment sitting on stained wooden blocks and cloth towels. A cloth towel was observed in the cabinet below the sink in the corner of the laboratory and under the rubber stress mat in the Histology area. In interview with the Housekeeping Director on 7-26-11 at 2:00 PM, it was stated that he did not know why the towels were on the floor or under the sink and he was unaware of the dust behind the computer counters. Review of the test records with the maintenance department indicated that there were six pieces of equipment in the laboratory that were not listed in the maintenance log. In interview with a maintenance staff member on 7-27-11 at 9:00 AM, it was stated that they did keep electronic records but he could not find any safety tests for the Blood Bank Refrigerator or the six pieces of equipment that was not listed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 14628 Based on observations, document review and staff interviews the facility failed to ensure that Infection Control principals were followed and that the facility failed to follow their own policy for the emergency room regarding retention of specimens. FINDINGS: 1. Observation on 07/26/2011 at 9:45 AM of a patient receiving care on the 5th floor room [ROOM NUMBER] revealed that the patient had been placed in contact and droplet isolation precautions. The patient was noted to have a G-tube, Foley catheter and receiving oxygen by a nasal cannula. Observation of the Registered Nurse (RN) providing care revealed that the RN first touch the G-tube and the patient's abdomen and then touched the Foley catheter and catheter tubing and then without changing his gloves the RN removed the nasal catheter from the patient nose in the process of removing the nasal cannula the RN touch the patient's face. Following the removal of the nasal cannula the RN was observed placing a cream on a long Q-tip, (one for each nostrils) and then applying the cream to the patient's nostrils. The nasal cannula was replaced and throughout the process the RN never changed his gloves. 2. Observations of emergency room over a 3 day time frame, and various times, revealed that there was blood in tubes sitting in a holder at the Nurses station, easily accessed by patients. Observations made on 07/25/2011 at 12:05 PM (Counted approximately 12 or more tubes, some were from previous day) and again at 3:30 PM. (Counted 7 tubes in holder.) On 07/26/2011 at 9:09 AM and at 2:30 PM. (Various number of tubes in holder both observation times). On 07/27/2011 at 11:00 AM. (Noted there was only 1 tube in holder, and then 2nd tube put in holder by staff) Review of emergency room policy on retention of specimens (Effective date 06/84, and revised on 05/11.) states that the emergency room is to save tissue or other specimens but to be sent to the laboratory (Lab). If specimen testing not needed the specimen will be discarded by appropriate methods, by Lab personnel. Interview on 07/25/2011 at 12:05 PM with the Director of the emergency room , who states that they draw blood in green tube and hold in emergency room for further testing eventually discarded. The Director further stated does not need to hold tube since it is not tested again after initial I-Stat test done. Interview on 07/26/2011 at 2:30 PM with Lab coordinator, who could not find any policies in lab regarding the holding of blood in emergency room , to do further Lab. Checked I-Stat policy and no policy regarding the holding of the blood by the emergency room . Did have Lab Coordinator check the emergency room policy regarding the retention of specimens, but the Coordinator had nothing further to add. Second Interview with the Director of emergency roiagnom on [DATE] at 2:40 PM, revealed that she did not know of the policy shown to her, but would check into this policy. She further stated she would remove the blood immediately from the counter in nurses station.

27676 Based on record review and interview the facility failed to protect and promote each patient's rights. The facility failed to implement the use of restraints in accordance with safe and appropriate restraint and seclusion techniques as determined by hospital policy and procedure (A 0167). The facility also failed to report each death known to the hospital that occurs within 1 week after restraint where it is reasonable to assume that use of restraint contributed directly or indirectly to a patient's death(A 0214). As a result of these findings, the facility was found to be deficient under the Condition of Participation for Patient Rights Findings: Reference A 0167: Based on record review and interview the facility failed to implement their own policy and procedures related to restraints for 2 of 10 sampled residents (#1 and #6). Reference A 0214: Based on record review and interview the facility failed to report the death of 1 of 3 patients (#1) reviewed following the use of restraints.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 27676 Based on record review and interview the facility failed to implement their own policy and procedures related to restraints for 2 of 10 sampled residents (#1 and #6). Findings: 1.) Record review for patient #1 revealed that the patient was readmitted to the hospital on 8/21/2010 and that she was having nausea and vomiting. The record show that patient #1 had been discharged from the facility on 8/18/2010 after having surgery related to colon cancer. A note from the emergency department dated 8/21/2010 at 12:00 AM states that the patient has been vomiting for two days and called surgeon who told her to stop taking antibiotics and pain medicine and to take xanax 0.5 milligrams (mg) every 3 hours it also states that patient denies vomiting just spit up like a baby. Review of the notation for patient #1 dated 8/21/2010 at 2:47 AM reveals that the patient has a nasogastric tube and included the amount of drainage. Review of the notation for patient #1 dated 8/21/2010 at 05:30 AM [NAME] that restraints were assessed for appropriateness and alternatives and found to be appropriate. Review of the admission assessment for patient #1 dated 8/21/2010 at 7:54 AM reveals that the nurse notes that gastrointestinal (GI)/Nutrition is within defined parameters. The notation defines parameters as abdomen soft non tender without distention Bowel sounds present in all four quadrants Bowel movements with in own normal pattern, tolerating diet without nausea or vomiting. The assessment also indicates that NEW decline in Patient's ability to transfer, ambulate, feed, bathe, dress self, and communicate has not occurred Review of the note for patient #1 dated 8/21/2010 at 7:54 AM indicates a goal of Restraint free and without injury. Review of the note for patient #1 dated 8/21/2010 at 9:49 AM reveals that the patient had an oral intake of 240 cc, 100% of a solid food breakfast. Review of the notation for patient #1 dated 8/21/2010 at 10:00 reveals that the criteria for restraint release is not met. Review of the notation for patient #1 dated 8/21/2010 at 10:31 AM [NAME] an order enter in the electronic record reads ok to use soft wrist restraints to prevent pulling lines. Review of the second tier restraint assessment for patient #1 dated 8/21/2010 at 11:41 AM reveals that restraints were assessed as appropriate. Review of the notation for patient #1 dated 8/21/2010 at 2:00 PM reveals that the criteria for restraint release is not met. Review of the notation for patient #1 dated 8/21/2010 at 4:00 PM reveals that the criteria for restraint release is not met. Review of the notation for patient #1 dated 8/21/2010 at 6:00 PM reveals that the criteria for restraint release is not met. Review of the record reveals that no assessment is completed for restraints from 6:00 PM until after patient is transferred to the surgical intensive care unit. Review of the notation for patient #1 revealed an entry dated 8/22/2010 at 4:31 AM which indicates that an incident occurred and 4:19 AM. Review of the information recorded, regarding this incident revealed that the incident actually occurred on 8/21/2010 at 9:30 PM. It also indicates that the CNA (Certified Nursing Assistant) enter patient #1's room and noted a change in the patient color and called nurse. Patient #1's oxygen saturation was documented as being 54%. Review of the notation dated 8/21/2010 at 9:00 PM reveals that the nurse found the patient on arrival with vomit around mouth and with green bile. Review of the provided documentation does not reveal a date or time that the restraints for patient #1 was discontinued from admission until after transfer to intensive care. Review of the physicians progress note dated 8/23/2010 at 9:30 AM reveals that patient #1 is status post aspiration. Review of the notation for patient #1 dated 8/21/2010 at 7:54 AM reveals the intervention head of bead less that 30 degrees unless medically contraindicated. Review of the bronchoscopy results for patient #1 dated 8/23/2010 reveals that the bronchoscopy is consistent with aspiration pneumonia. Record review for patient number one reveals that the care plan has aspiration precautions implemented on 8/22/2010. During interview on 3/31/2011 at 1:20 PM with the Patient Care Assistant (PCA) who was caring for patient #1 on 8/21/2011 from 7:00 PM to 7:00 AM he stated that he seemed to remember that he had entered the room of patient #1 to care for the roommate when he noticed a gurgling, coughing respiration from the area of patient #1, he immediately checked the patient and call for assistance. During interview on 3/31/2011 at 2:00 PM with the physician who signed the restraint order written for patient #1 on 8/21/2010 at 06:45 AM he stated that he was not involved with the care of patient #1 and that he sign the order when it was presented, but had placed a question mark by his signature as he was not involved. Review of the discharge summary for patient #1 dated 9/24/2010 reveals that patient #1 had aspiration pneumonitis and passed away on 8/28/10. 2.) Record review of Physicians orders for resident #6 reveals that no physicians order is present for restraints implemented on 8/18/2010. Review of the nursing note for patient #6 dated 8/19/2010 at 5:16 AM reveals that soft wrist restraints were placed at 8:30 PM on 8/18/2010. During interview with the Risk Manager on 3/31/2010 at 3:30 PM she stated that she could not find an order for restraints for patient #6. 3.) Review of the facility's Policy and Procedure (P&P) entitled, Restraint and Seclusion, dated 2/10 revealed on page 14, section 4 entitled Orders for Restraint. According to this section, A LIP/physician order is required for restraints. The initial order must be time limited not to exceed twenty-four (24) hours, and must specify clinical justification for the restraint, the date and tome ordered, the duration of use, the type of restraint to be used and behavior-based criteria for release. Further review of this P&P revealed,For continuation of restraint usage beyond the initial 24 hours, the LIP/physician must see the patient and do a clinical assessment and in collaboration with other clinical staff, determine if continuation of restraint is warranted. Review of the facility's P&P regarding restraints revealed a section entitled, Ongoing Assessment While Patient is in Restraints. Review of this section revealed, Assessment by an RN [a Registered Nurse] will occur immediately upon application of restraint and at least every 2 hours thereafter. The RN 2-hour assessment will include at a minimum that patient safety, readiness of release from restraint and maintenance of patient rights and dignity are addressed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 27676 Based on record review and interview the facility failed to report the death of 1 of 3 patients (#1) reviewed following the use of restraints. Findings: 1.) Record review for patient #1 revealed that the patient was readmitted to the hospital on 8/21/2010 and that she was having nausea and vomiting. The record show that patient #1 had been discharged from the facility on 8/18/2010 after having surgery related to colon cancer. A note from the emergency department dated 8/21/2010 at 12:00 AM states that the patient has been vomiting for two days and called surgeon who told her to stop taking antibiotics and pain medicine and to take xanax 0.5 milligrams (mg) every 3 hours it also states that patient denies vomiting just spit up like a baby. Review of the notation for patient #1 dated 8/21/2010 at 2:47 AM reveals that the patient has a nasogastric tube and included the amount of drainage. Review of the notation for patient #1 dated 8/21/2010 at 05:30 AM [NAME] that restraints were assessed for appropriateness and alternatives and found to be appropriate. Review of the admission assessment for patient #1 dated 8/21/2010 at 7:54 AM reveals that the nurse notes that gastrointestinal (GI)/Nutrition is within defined parameters. The notation defines parameters as abdomen soft non tender without distention Bowel sounds present in all four quadrants Bowel movements with in own normal pattern, tolerating diet without nausea or vomiting. The assessment also indicates that NEW decline in Patient's ability to transfer, ambulate, feed, bathe, dress self, and communicate has not occurred Review of the note for patient #1 dated 8/21/2010 at 7:54 AM indicates a goal of Restraint free and without injury. Review of the note for patient #1 dated 8/21/2010 at 9:49 AM reveals that the patient had an oral intake of 240 cc, 100% of a solid food breakfast. Review of the notation for patient #1 dated 8/21/2010 at 10:00 reveals that the criteria for restraint release is not met. Review of the notation for patient #1 dated 8/21/2010 at 10:31 AM [NAME] an order enter in the electronic record reads ok to use soft wrist restraints to prevent pulling lines. Review of the second tier restraint assessment for patient #1 dated 8/21/2010 at 11:41 AM reveals that restraints were assessed as appropriate. Review of the notation for patient #1 dated 8/21/2010 at 2:00 PM reveals that the criteria for restraint release is not met. Review of the notation for patient #1 dated 8/21/2010 at 4:00 PM reveals that the criteria for restraint release is not met. Review of the notation for patient #1 dated 8/21/2010 at 6:00 PM reveals that the criteria for restraint release is not met. Review of the record reveals that no assessment is completed for restraints from 6:00 PM until after patient is transferred to the surgical intensive care unit. Review of the notation for patient #1 revealed an entry dated 8/22/2010 at 4:31 AM which indicates that an incident occurred and 4:19 AM. Review of the information recorded, regarding this incident revealed that the incident actually occurred on 8/21/2010 at 9:30 PM. It also indicates that the CNA (Certified Nursing Assistant) enter patient #1's room and noted a change in the patient color and called nurse. Patient #1's oxygen saturation was documented as being 54%. Review of the notation dated 8/21/2010 at 9:00 PM reveals that the nurse found the patient on arrival with vomit around mouth and with green bile. Review of the provided documentation does not reveal a date or time that the restraints for patient #1 was discontinued from admission until after transfer to intensive care. Review of the physicians progress note dated 8/23/2010 at 9:30 AM reveals that patient #1 is status post aspiration. Review of the notation for patient #1 dated 8/21/2010 at 7:54 AM reveals the intervention head of bead less that 30 degrees unless medically contraindicated. Review of the bronchoscopy results for patient #1 dated 8/23/2010 reveals that the bronchoscopy is consistent with aspiration pneumonia. Record review for patient number one reveals that the care plan has aspiration precautions implemented on 8/22/2010. During interview on 3/31/2011 at 1:20 PM with the Patient Care Assistant (PCA) who was caring for patient #1 on 8/21/2011 from 7:00 PM to 7:00 AM he stated that he seemed to remember that he had entered the room of patient #1 to care for the roommate when he noticed a gurgling, coughing respiration from the area of patient #1, he immediately checked the patient and call for assistance. During interview on 3/31/2011 at 2:00 PM with the physician who signed the restraint order written for patient #1 on 8/21/2010 at 06:45 AM he stated that he was not involved with the care of patient #1 and that he sign the order when it was presented, but had placed a question mark by his signature as he was not involved. Review of the discharge summary for patient #1 dated 9/24/2010 reveals that patient #1 had aspiration pneumonitis and passed away on 8/28/10. During interview with the risk manager on 3/30/2010 at 12:30 PM she stated that a report on patient #1 had not been filed because he was not in restraints at the time the resident had a significant decline. 2.) Review of the facility's Policy and Procedures (P&P) entitled, Restraint and Seclusion, dated 2/10 revealed a section entitled Reporting Requirements. Under this section it states that the facility must report to the Centers for Medicare/Medicaid Services the following deaths, (a) Each death that occurs while a patient is in restraint or seclusion. (b) Each death that occurs within 23 hours after the patient has been removed from restraint or seclusion. (c) Each death known to the hospital that occurs within 1 week after restraint or placement in seclusion contributed directly or indirectly to a patient's death. 'Reasonable to assume' in this context includes, but is not limited to, deaths related to restrictions of movement for prolonged periods of time, or death to chest compression, restriction of breathing or asphyxiation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 27676 Based on record review and interview the facility failed to ensure that the nursing staff kept a current care plan for 1 of 10 (#1) sampled patients who was in restraints. 1.) Record review for patient #1 revealed that the patient was readmitted to the hospital on 8/21/2010 and that she was having nausea and vomiting. The record show that patient #1 had been discharged from the facility on 8/18/2010 after having surgery related to colon cancer. A note from the emergency department dated 8/21/2010 at 12:00 AM states that the patient has been vomiting for two days and called surgeon who told her to stop taking antibiotics and pain medicine and to take xanax 0.5 milligrams (mg) every 3 hours it also states that patient denies vomiting just spit up like a baby. Review of the notation for patient #1 dated 8/21/2010 at 2:47 AM reveals that the patient has a nasogastric tube and included the amount of drainage. Review of the notation for patient #1 dated 8/21/2010 at 05:30 AM [NAME] that restraints were assessed for appropriateness and alternatives and found to be appropriate. Review of the notation for patient #1 dated 8/21/2010 at 3:07 AM reveals that the nasogastric tube drainage was 2600 CC. Review of the notation for patient #1 dated 8/21/2010 at 4:08 AM reveals that the patient is on bed rest, nasogastric tube to low intermittent suction, Normal Saline with 20 meq of potassium chloride at 150 cc per hour. Review of the note for patient #1 dated 8/21/2010 at 6:40 AM reveals a urine output of 100 cc with no out put from the nasogastric tube. Review of the admission assessment for patient #1 dated 8/21/2010 at 7:54 AM reveals that the nurse notes that gastrointestinal (GI)/Nutrition is within defined parameters. The notation defines parameters as abdomen soft non tender without distention Bowel sounds present in all four quadrants Bowel movements with in own normal pattern, tolerating diet without nausea or vomiting. The assessment also indicates that NEW decline in Patient's ability to transfer, ambulate, feed, bathe, dress self, and communicate has not occurred Review of the note for patient #1 dated 8/21/2010 at 9:49 AM reveals that the patient had an oral intake of 240 cc, 100% of a solid food breakfast. Review of the notation for patient #1 dated 8/21/2010 at 10:00 reveals that the criteria for restraint release is not met. Review of the notation for patient #1 dated 8/21/2010 at 10:31 AM [NAME] an order ok to use soft wrist restraints to prevent pulling lines. Review of the second tier restraint assessment for patient #1 dated 8/21/2010 at 11:41 reveals that restraints were assessed as appropriate. Review of the notation for patient #1 dated 8/21/2010 at 1:00 PM reveals that the Foley output was 800 cc and that no output is noted from the Asiatic tube. Review of the notation for patient #1 dated 8/21/2010 at 2:00 PM reveals that the criteria for restraint release is not met. Review of the notation for patient #1 dated 8/21/2010 at 4:00 PM reveals that the criteria for restraint release is not met. Review of the notation for patient #1 dated 8/21/2010 at 6:00 PM reveals that the criteria for restraint release is not met. Review of the notation for patient #1 dated 8/21/2010 at 6:19 PM reveals that the Foley output was 800 cc and that no output is noted from the nasogastric tube. Review of the notation for patient #1 revealed an entry dated 8/22/2010 at 4:31 AM which indicates that an incident occurred and 4:19 AM. Review of the information recorded, regarding this incident revealed that the incident actually occurred on 8/21/2010 at 9:30 PM. It also indicates that the CNA (Certified Nursing Assistant) enter patient #1's room and noted a change in the patient color and called nurse. Patient #1's oxygen saturation was documented as being 54%. Review of the notation dated 8/21/2010 at 9:00 PM reveals that the nurse found the patient on arrival with vomit around mouth and with green bile. Review of the provided documentation does not reveal a date or time that the restraints for patient #1 were discontinued from admission until after transfer to intensive care. Review of the physicians progress note dated 8/23/2010 at 9:30 AM reveals that patient #1 is status post aspiration. Review of the notation for patient #1 dated 8/21/2010 at 7:54 AM reveals the intervention head of bead less that 30 degrees unless medically contraindicated. Review of the discharge summary for patient #1 dated 9/24/2010 reveals that patient #1 had aspiration pneumonitis and passed away on 8/28/10. Review of the bronchoscopy results for patient #1 dated 8/23/2010 reveals that the bronchoscopy is consistent with aspiration pneumonia. Record review for patient number one reveals that the care plan has aspiration precautions implemented on 8/22/2010, the day after the patient aspirated. During interview with the Risk Manager on 3/30/2011 at 5:00 PM she stated that it would be appropriate for a patient with vomiting and a naso gastric tube to be on aspiration precautions.