HCA Houston Healthcare Kingwood

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

Based on record review and interview, the Medical Executive Committee (Med Exec) failed to implement, and enforce bylaws, rules and regulations to carry out its responsibilities by ensuring 1 of 1 physicians' (# K) described the patients' condition, and full course of hospital, care and treatment for 1 of 10 patients reviewed.

Findings Include:

Physician (#K) failed to include updates of patient (#2)'s current medical and physical changed of the patients' condition in the physicians' progress notes.

Physician (#K) failed to update and include all of patient (#2)'s hospitalization conditions and treatments in the discharge summary.

Physician (#K) failed to complete medical records as required.

Facility Policy:

Part Three: General Responsibility For Conduct of Care

Part 3.1 Generally

The HCA Houston Healthcare Medical Staff Rules and Regulations, amended October 23, 2019, reads, A member of the Medical Staff shall be responsible for the medical care and treatment of each patient in the hospital, for the prompt completeness and accuracy of those portions of the medical record for which he is responsible, for necessary special instructions, and for transmitting reports of the condition of the patient to the referring Practioner, and if any, to relatives of the patient.

7.0 GENERAL

The admitting practitioner shall be designated as the attending practitioner unless an order is written at any time during the hospitalization for another practitioner to assume care of the patient.

The attending practitioner shall be responsible for the preparation of a complete and legible medical record for each patient. All patient medical record entries must be dated, timed and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures. Its contents shall be pertinent and current.

7.3 PROGRESS NOTES

7.3.1 GENERALLY

Pertinent progress notes, sufficient to permit continuity of care, shall be recorded at the time of observation. Final responsibility for an accurate description in the medical record of the patient's progress rests with the attending Practitioner. Each of the patient's clinical problems responsible for this admission should be clearly identified in the progress notes and correlated with specific orders, as well as results of tests and treatment.

Progress notes by the attending Practitioner must be written daily on acutely and critically ill patients and on those where there is difficulty in diagnosis or management of the clinical problem.

Medical Record Reviewed:

Review 09/17/2020 at 3:00 PM of the Initial Admission nursing assessment dated [DATE] @19:30 indicated the patient was ambulatory with 1 person assist, and had a previously removed right great toe nail, no drainage to nail bed. The Skin integrity impairment risk was Yes; Existing wound: No.

The nursing assessment 07/07/2020 at 20:00 identified Press injur immobility related Posterior Heal right ...Purple/maroon/deep red ...Stage 1 pressure injury. Also, Sacrum ... Pink/red/[DIAGNOSES REDACTED]/intact ... Stage 1 pressure injury. The assessment identified ambulation as Supervised/assist.

NE1 Photographic Wound Documents dated 07/8/2020 and 07/23/2020 were labeled with Patient #2's information, location Sacrum, Stage 3, Non-intact Skin, Exudate-serous, amount-moderate. 07/08/2020. No physician signature, date, time or agreement of pressure ulcer finding.

Nursing 07/10/2020 at 20:00 identified Press injur immobility related Posterior Heal right and Sacrum as Unstageable. It also indicated ambulation was now No.

Nursing assessment 07/11/2020 at 20:00 identified Press injur immobility related Posterior Heal right ...Opaque serum filled blister ... Stage 2 pressure injury and Sacrum as Red/moist/smooth/shallow .... Stage 2 pressure injury. Additionally, Posterior Heal Left ...Pink/red/[DIAGNOSES REDACTED]/intact ... Stage 1 pressure injury. It also indicated ambulation was now Bedrest.

Nursing assessment 07/13/2020 at 08:00 identified Sacrum ...Red/moist/bumpy/ granulation .... Stage 3 pressure injury.

Nursing assessment 07/18/2020 at 20:00 identified Press injur immobility related Press injur immobility related Posterior Heal right and Posterior Heal left as Unstageable. Sacrum as Yellow slough .... Stage 3 pressure injury.

Nursing assessment 07/20/2020 at 20:00 identified Press injur immobility related Posterior Heal right, Press injur immobility related Posterior Heal left and Sacrum all as Red/moist/smooth/shallow .... Stage 2 pressure injury.

Nursing assessment 07/22/2020 at 16:10 identified Press injur immobility related Posterior Heal right, Press injur immobility related Posterior Heal left ...Black/tan eschar ...Unstageable. Sacrum ...Yellow slough .... Stage 3 pressure injury.

Nursing assessment 07/23/2020 at 20:00 identified Press injur immobility related Posterior Heal right ...Stage 3 pressure Injury, Press injur immobility related Posterior Heal left ...Black/tan eschar ...Unstageable. Sacrum ...Yellow slough .... Stage 3 pressure injury. Photo of the sacral wound 7/23/2020 measured the open area at 13 cm wide by 6.5 cm long. No depth measurement was provided.

Review on 09/30/2020 of attending physician (#K) documented progress notes daily from 07/01/2020 through discharge date [DATE] identify the skin condition exclusively as RT FOOT CELLULITIS. The daily physician notes do not describe the cellulitis nor any other skin integrity issue including the multiple open areas that progressed during the hospital stay.

Review on 09/30/2020 of physician (#K)'s discharge summary dated 07/24/2020 read discharge date [DATE], Hospital course: PT STABLE. The patient was discharged on ,d+[DATE]//2020. Also FEVER RT FOOT CELLULITIS, ARTERIAL DOPPLERS/ SEVERE PVD/ LIKELY TO TREAT WITH CONCERVATIVE TREAT FOR NOW. WILL REQUEST DR. DAVIS CONSULT, PODIATRY PLAN NOTED. WILL REPEAT CXR/CLINICAL IMPROVEMENT which is word for word from the 07/07/2020 through 07/23/2020 daily progress notes.

Interview:

During an interview 09/30/2020 at 11:00 AM, Staff P, Chief Medical Officer stated it was the responsibility of the attending physician to address and document patient conditions, treatments and progress in the medical record and discharge summary. Staff P, Chief Medical Officer confirmed, after review of patient (#2)'s medical record that physician (#K) had not documented the patient conditions, treatments and progress in the medical record and discharge summary as required.

During an interview 09/30/2020 at 1:00 PM, Staff A, Director of Quality stated after review of patient (#2)'s medical record confirmed that no documentation was found from attending physician (#K) that identified the decubiti, treatments or progress in the medical record and discharge summary as required. She further stated, We dropped the ball on this one.

Interview on 9/30/2020 at 1:00 pm. with the Director of 5 North Medical Surgical Unit Employee ID #F confirmed the Photographic Wound Documents dated 7/08/2020 and 07/23/2020 had no physician signature, date or time and the physician should have signed and acknowledged the assessment.

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

Based on interview and record review the facility Governing Body failed to enforce and ensure it's own Policy and Procedures were followed in that nursing staff caring for wound care patients did not follow the wound and skin care guidelines and protocols in 1 of 10 records reviewed (Patient ID #2).

Findings:

Registered Nurse failed to:

Failed to reposition patient every 2 hours

Failed to complete skin assessments/alterations every shift

Failed to notify physician of skin injury

Failed to consult Wound Care RN,

Failed to take required photographs for staging of wound

Failure to document wound measurements including length width & depth

Failed to use proper pressure support surfaces (mattresses) as indicated

Policy Reviewed:

Review on 9/29/2020 at 11:00 a.m. of the facility's current policy titled Wound and Skin Care Guidelines, Policy Stat ID: 02 Last Revised 12/2018 reads in part:

Purpose: 1. To identify patients who have wounds or at high risk of skin breakdowns and to describe the process and documentation format of wound and skin assessment. 2. To provide guidelines for proper management and care of skin breakdown. 3. To provide guidelines for proper wound irrigation and application of appropriate dressing material. 4. To ensure continuity of applied dressing(s) and initiation of wound care protocols as ordered by the physician. 5. To provide intervention for prevention of skin breakdown.

Policy: 1. Responsible personnel: a. Licensed nursing personnel, i. Primary RN - assessment each shift and on admission, ii. Charge RN - assist in identification of wounds and staging of ulcers as appropriate, iii Wound Care RN - assist in identification of wounds, staging of ulcers and treatments recommendations.

Assessment: 1. Patients will be assessed upon admission to the nursing unit and within 24 hours of admission into the hospital. Skin will continue to be assessed every 12 hours for breakdown or signs of being at risk for breakdown. 2. Pressure Injury risk is completed upon admission and every 12 hours ....4. c. i. For Stage 3 Stage 4 and Unstageable pressure injury another licensed professional should be consulted prior to documentation of the wound in the medical record to verify proper wound stage and Wound Care Nurse Should be consulted ....5. Pictures of the wounds are taken at admission, upon development of a new pressure injury, and weekly on Wednesdays to document the wound status, a photo is attached to the NE1 Photographic Wound Documentation sheet and placed in the patient's chart.

Reassessment: 1. All patients should be reassessed at least every 12 hours. 2. If wounds are present during any of the assessment findings, notify the MD and begin to activate the Pressure Injury Treatment Algorithm or Non-Pressure Treatment Algorithm.

Treatment: 1. Treatment and prevention is based on skin assessment and/or wound assessment findings c. For Dressing and treatment of existing wounds, i. Follow the physicians order for the type and frequency of treatment and consult Wound Care Nurse if appropriate, ii. For Pressure injury, if no prior treatment orders are written, refer to the Pressure Injury Treatment Algorithm (Appendix4) ... ...Utilize the appropriate treatment based on wound assessment, iii. Removal of necrosis is necessary for proper wound management. 1. Contact MD and consult Wound Care Nurse if necrotic tissue (tissue that is yellow, white, grey, green, tan, brown or black) is present in any wound.

Prevention: Patient at risk of developing Pressure Injuries or those who have been admitted to the hospital with existing wounds, the following interventions should be put into place. A. Minimize or eliminate friction and sheer, vi. Use pressure support surfaces (mattresses or overlays) as indicated, a. Appendix 2 describes the appropriate mattress selection for patients with respect to mobility, moisture and risk assessment, b. Utilize the algorithm to select the appropriate surface for patient. C. Patients in bed iii. At a minimum the patient should be turned at least every 2 hours.

Record Review:

Record Review on the morning of September 30, 2020

Routine Daily Care Form along with Vice President of Quality, Employee ID # A confirmed patient admitted [DATE] to discharge date July 24, 2020 documented the patient was turned 21 times with either a 1 or 2 person assist during her 26-day admission.

Records Reviewed of Daily Skin Alteration Assessments:

Patient Veronica Simons was hospitalized [DATE] through 07/24/2020 for a total of 26 days. Record reviewed documented that patient ID # 2 did not receive every 12-hour shift skin assessments on 12 of those days and 1 day with no assessments.

Date AM Shift PM Shift

06/28/2020 n/a admit initial

06/29/2020 No Yes

06/30/2020 No Yes

07/02/2020 No Yes

07/03/2020 Yes No

07/07/2020` No Yes

07/11/2020 No Yes

07/12/2020 No No

07/16/2020 Yes No

07/17/2020 Yes No

07/18/2020 Yes No

07/19/2020 Yes No

07/21/2020 Yes No

07/22/2020 Yes No

Review of nursing notes and daily assessments for the hospitalization period along with the Vice President of Quality, Employee ID #A did not find any documentation of notification of the primary attending physician of the skin injury related to patient ID #2's sacrum decubitus.

Review of Physician Orders along with the Vice President of Quality failed to document a consult for the wound care nurse and no order was documented for an air mattress to reduce pressure point for patient ID #2

Review of NE1 Photographic Wound Documentation forms along with Director of 5th floor medical Surgical Floor, Employee ID #F identified 2 forms. Sacral wound was first identified on 7/08/2020 and was identified as pressure injury immobility related sacrum. Not present on admission, related factors: incontinent - bowel/bladder

7/8/2020 - NE1 Photographic Wound Document was labeled with Patient ID #2 information, location - Sacrum, Stage 3, Non-intact Skin, Exudate - serous, amount - moderate. No Nurse signature, date or time. No physician signature, date, time or agreement of pressure ulcer finding was documented. No identification of whether ulcer present on admission. Picture was attached.

7/23/2020 - NE1 Photographic Wound Document labeled with Patient ID #2 information, location - Sacrum, Stage 3, Non-intact Skin, Exudate - serous, amount - moderate. No physician signature, date, time or agreement of pressure ulcer finding. No identification of whether ulcer present on admission. Picture attached.

Interviews:

Interview with Employee ID #A confirmed patient was identified at risk of skin injury on admission and there was no additional documentation in the patient's records of turning or repositioning of the patient every 2 hours. Employee ID #A stated the nursing electronic records are charted by exception and routine expected care is not charted. No additional documentation was received prior to exit of the survey. Employee ID #A confirmed nursing shift daily skin alteration assessments were not completed as required and should have been completed by the registered nurse every shift.

Employee ID #A stated that the nursing staff when they identified patient with high risk for skin breakdown or patients with skin injuries they are to follow the facility's Wound and Skin Care Guidelines and the Pressure Injury Treatment Algorithm. Employee ID #A stated the nurse does not need to have a physician's order to activate the skin care protocol. Employee ID#A stated that the wound nurse is not always involved unless there is a consult that is needed. The nursing staff are trained to care for wounds, staging, dressing, packing and identifying.

Employee ID #A stated the nurse should communicate with the physician about skin breakdown and let the physician know about wounds. If the nurse or physician needs the wound care nurse to evaluate or treat the wound the nurse can consult her or the physical may place and order to consult the wound care nurse.

Employee ID #A confirmed that at a Stage III wound the patient's doctor should have been notified, patient should have been on an air mattress bed and confirmed the patient was on a basic air mattress which is rated for up to a Stage II decubitus.

Interview on 9/30/2020 at 1:00 pm. with the Director of 5 North Medical Surgical Unit Employee ID #F confirmed every 2-hour position changes were not documented, no order was entered for wound care nurse, no documentation that the attending physician was notified of sacral wound injury, no higher-level air mattress was ordered when Stage III sacral wound was identified. Employee ID #F also confirmed the wound pictures were not taken per the wound care protocol and the documentation of the wound assessment was not completed with all elements necessary including the length, width depth, tissue type, nor was there a signature by the physician , a date and time documented where he reviewed the findings and agreed with the wound assessment. Employee ID #F confirmed there were only two NE 1 Photographic Wound Documents one dated 7/08/2020 and 07/23//2020 that had no Nurse signature or date or time of assessment and no physician signature, date or time and the physician should have signed and acknowledged the assessment. Employee ID # confirmed the pictures should be done on the date the injury was identified and then every Wednesday which is wound Wednesday.

Based on record review and interview the hospital failed to ensure patient rights by giving a medication the family refused. In one out of ten patients sampled (#1)

Findings:

Record review of Patient #1's, Nursing Notes dated 04/20/19 by the unit Charge RN. The son and wife of patient #1 requested that Ativan not be given to the patient again as it caused severe confusion.

Record Review of Patient #1's Medical Record dated 4/20/19 showed that an allergy for Ativan was documented on the Allergy section of Medication Administration Record (MAR). The system did not log the staff member name just the date. It was also noted on 4/20/19 that the patient's family requested he not receive the medication Ativan due to it causing severe confusion written by Charge Nurse.

Record review of Patient #1's, MAR on 4/23/19 at 00:59 AM revealed that the RN Employee #2 administered Ativan and documented an override to bypass the warning to not administer due to allergy.

Record review of MAR on 4/24/19 at 8:50 PM revealed that the RN Employee #2 administered Ativan and documented an override to bypass the warning to not administer due to allergy.

Record review of the facility's policy titled, Medication: Administration, General, dated 06/19 section procedure for nursing, showed the following:

+ Verify drugs to be administered with the prescriber's order. Refer to the MAR and ensure that the dose is correct, and that allergy, sensitivity, or diagnosis does not contraindicate use of the drug.

+ The individual administering the medication should complete the following:

+ Verifies that no contraindication exists.

+ If the medication is not given (e.g. it may be held at the authorized personnel's discretion or refused by the patient), document in MAR,

Interview with Quality Director and Quality Manger on 7/3/19 at 09:00 AM. The Quality Manager stated, There is no policy for nurses, for adding an allergy after a medication has been ordered. Nor, is there is a process for holding a medication or discontinuing it after an allergy has been documented.

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

Based on record review and interview of facility personnel, the facility failed to ensure prior to administering a medication that the patient did not have a documented allergy to the medication for one of ten patients sampled (#1)

Findings:

Record Review of Patient #1's Medical Record showed Ativan was ordered on [DATE] and given at twice on 04/18/19 at 07:00 AM and 11:00 PM for agitation.

Record Review of Patient #1 Medical Record dated 4/20/19 showed that an allergy for Ativan was documented on the Allergy section of Medication Administration Record (MAR). The system did not log the staff member name just the date.On 4/20/19 the charge nurse noted that the patient's family requested he not receive the medication Ativan due to it causing severe confusion.

Record review of Patient #1's MAR on 4/23/19 at 00:59 AM revealed that the RN Employee #2 administered Ativan and documented an override to bypass the warning to not administer due to allergy.

Record review of Patient #1's MAR on 4/24/19 at 8:50 PM revealed that the RN Employee #2 administered Ativan and documented an override to bypass the warning to not administer due to allergy.

Record Review of Patient #1's chart showed that Employee #2 did not call the Medical Doctor to verify order before giving the medication.

Interview with Quality Director and Quality Manger on 7/3/19 at 09:00 AM. The Quality Manager stated, There is no policy for nurses, for adding an allergy after a medication has been ordered. Nor, is there is a process for holding a medication or discontinuing it after an allergy has been documented.

Based on record review and interview the facility failed to ensure that the pharmaceutical services were meeting all the patients needs by not having a policy in place to prevent patient's from receiving a medication that has been noted after admission as an allergy.

Record review of the facility's policy titled, Medication: Administration, General, dated 06/19 showed the following:

The pharmacist is responsible for verifying the accuracy, completeness, and appropriateness of the medication ordered by the physician.

Record review of the facility's policy titled, Medication: Administration, General, dated 06/19 section procedure for nursing, showed the following:

Verify drugs to be administered with the prescriber's order. Refer to the MAR and ensure that the dose is correct, and that allergy, sensitivity, or diagnosis does not contraindicate use of the drug.

The individual administering the medication should complete the following: verifies that no contraindication exists.

If the medication is not given (e.g. it may be held at the authorized personnel's discretion or refused by the patient), document in MAR.

Interview with Employee #3 Pharmaceutical Clinical Manager on 7/3/19 at 10:30 AM. Employee #3 explained that the Pharmacist who gets the order is supposed to acknowledge it. This did not occur and each pharmacist after that also bypassed the order. When asked why this occurred and why the Ativan was not taken out of the system after it was written that the patient was allergic to it. She said that the pharmacist should only be bypassing the acknowledgement if he/she had a pending clarification. When asked why after an allergy was entered did the pharmacist not put the medication on hold. She said that the pharmacist should have. The Pharmaceutical Clinical Manager was asked for the policy on allergy entry after admission during stay. She stated, We do not actually have a policy for that.

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

Based on interview and record review, the facility failed to ensure 1 of 5 sampled patients was protected from possible abuse and neglect upon discharge (Patient # 6.).

The facility failed to make a timely referral to Adult Protective Services (APS) per policy.

Findings include:

TX 399

Record review of Patient # 6's admission History & Physical Exam, dated 08-06-17 , read: ...This is a case of a [AGE]-year-old male who presented to the emergency room (ER) after a fall. This patient has multiple medical problems ... Per patient, he fell 2 days prior to admission and had been on the floor for that duration and was brought to the ER by emergency medical services (EMS)with the patient covered in feces and urine. The patient has a bilateral below the knee amputation (BKA), wheelchair bound. The patient lives with the ex-wife and per EMS, the family notified EMS only today and the patient has been on the floor for 2 days. The patient has multiple wounds to both lower extremity stumps...Assessment & Plan: 1 .... Case management consultation for home situation and possibly discharge planning ... (8-06-17).

Interview on 04-18-18 at 1:45 p.m., with Case Manager # 9 she stated Patient # 6 had 2 sons. They wanted nothing to do with their father because he kept going back to his ex-wife. The sons were not able to help him because of this ex-wife. The sons told Case Manager # 9 they felt the ex-wife supplied their father illegal drugs. The ex-wife was the provider of services for Patient # 6. This information was not documented in the case management notes.

Review of Patient # 6's clinical record revealed he was admitted on [DATE] . Record review of case management notes revealed a referral to Adult Protective Services (APS) was not made until the day of discharge on 08-25-17:

8/25/17 (11:44 a.m. by Case Manager # 9) spoke with ( ) at APS due to concern for safe discharge plan to home. He said they will follow pt upon discharge ...

Patient # 6 was transported from the facility on that same day (8/25/17) at 2:46 p.m. to his ex-wife's home.

Interview on 04-18-18 at 1:45 p.m. with Case Manager # 9 she stated an APS referral was the responsibility of nursing, case management; whomever comes in contact with the patient. They make the referral to APS and document it in their notes. She was unsure of the timeframe.

Review of facility policy titled Adult Protective Services Referral, dated 4/2012, read:

...Purpose: To initiate an investigation of possible abuse/neglect of an adult. To protect the rights of an adult who is unwilling/unable to protect himself/herself from a potentially dangerous environment ...

Policy: The ( facility) Case Management Department or other healthcare provider with knowledge of (sic) will initiate Adult Protective Services investigation whenever information regarding possible abuse/neglect is given to individuals of that department by family, co-workers, patients and/or any other source.

Procedure: When the information of alleged abuse/neglect is received by Case Manager ...that person will immediately contact APS with a report ...

Interview on 04-18-18 at 3:15 p.m. with Vice President of Quality # 1, she stated the APS referral should have made shortly after the information about the home situation was obtained in the ER.

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

Based on record review and interview, the medical staff failed to ensure 5 of 5 discharged patients had timely History & Physical (H & P) examinations or Discharge Summaries (DC) documented per Medical Staff Bylaws and Rules/Regulations (Patient # 6, 7, 8, 9,10):

Findings include:

TX 399

Record review on 4/18/18 of five (5) closed records revealed the following:

Three (3) closed records lacked timely admission H & P Examinations:

Patient # 7 was admitted [DATE]: H & P was dictated 8/24/17; signed 9/17/17

Patient # 10 was admitted [DATE]: H &P exam signed on 7/24/17

Patient # 8 was admitted [DATE]; H & P exam was dictated 8/22/17; signed 8/24/17

Three (3) closed records lacked timely Discharge (DC) Summaries:

Patient # 6 had no discharge summary (Vice President of Quality #1 unable to locate)

Patient # 9 was discharged [DATE]; DC Summary signed on 10/26/17

Patient #8 was discharged [DATE]; DC Summary signed on 10/26/17

Interview on 04-18-18 at 3:30 p.m. with Vice President of Quality # 1 she stated H & Ps must be completed within 24 hours of admission and Discharge Summaries within 30 days following patient discharge.

Record review of facility's Medical Staff Bylaws:, dated 2017, read: ...

12. ARTICLE TWELVE: HISTORY AND PHYSICAL EXAMINATION: A complete admission history and comprehensive physical examination shall be the responsibility of the attending Practitioner and shall be recorded in the chart or available within twenty-four (24) hours of admission as an inpatient/observation patient and prior to undergoing any invasive or operative procedures, even on weekends and holidays. This report should include all pertinent findings resulting from assessment of all the systems of the body...:

Record review of facility Medical Staff Rules & Regulations , dated 2-22-17, read: ...7.6.1 Discharge Summary : (a) in General: A discharge summary must be recorded for all patients. The summary must concisely recapitulate the reason for hospitalization , the significant findings...the procedures performed and treatment rendered....7.9 Completion of The Medical Record...If the record still remains incomplete thirty(30) days following discharge, it shall be considered a delinquent record..

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

Based on interview and record review, the facility failed to complete an accurate discharge planning evaluation on admission for 1 of 5 sampled discharged patients (Patient # 6 ).

Findings include:

TX 399

Record review of Patient # 6's admission History & Physical Exam, dated 08-06-17 ,read: ...This is a case of a [AGE]-year-old male who presented to the emergency room (ER) after a fall. This patient has multiple medical problems ... Per patient, he fell 2 days prior to admission and had been on the floor for that duration and was brought to the ER by emergency medical services (EMS) with the patient covered in feces and urine. The patient has a bilateral below the knee amputation (BKA), wheelchair bound. The patient lives with the ex-wife and per EMS, the family notified EMS only today and the patient has been on the floor for 2 days. The patient has multiple wounds to both lower extremity stumps...Assessment & Plan: 1 .... Case Management consultation for home situation and possibly discharge planning ... (8-06-17) .

Record review of Patient # 6's admission Discharge Planning Evaluation, dated 8/7/2017 included the following screening question: ... Based on information gathered is it likely that the person's care needs can be met in the environment from which he/she entered the hospital ? The documented answer was Yes.

Interview on 04-18-18 at 1:45 p.m. with Case Manager#9 , she said based on the information provided in the admission H & P [that this patient had been left on the floor for 2 days and brought in covered with urine & feces] this question should have been answered No.

Case Manager # 9 went on to say the person completing this discharge planning evaluation had access to the H & P and would have known that information.

Record review of facility policy titled Discharge Planning, dated 02/2016, revealed a description of the facility wide discharge planning process. The policy stated within 24 hours of admission to the facility, the patient's primary nurse, and case manager/social worker (CM/SW) complete an initial screening evaluation of patient's discharge needs. Working with the patient/family and members of the interdisciplinary health care team, the CM/SW identifies and develops a preliminary discharge plan and goals...

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

Based on record review and interview, the facility failed to conduct a secondary discharge assessment within 48 hours of admission per facility policy for 1 of 5 sampled discharged patients ( Patient # 6).

Findings include:

TX 399

Record review of facility policy titled Discharge Planning, dated 02/2016, read:1. Within 24 hours of admission to the facility, the patient's primary nurse, and case manager/social worker (CM/SW) complete an initial screening evaluation of patient's discharge needs. 2. During initial screening, if certain high risk triggers are noted ( indicating complex discharge needs), a secondary discharge assessment will be completed by the CM/SW within 48 hours of admission. (See Appendix 1: High Risk Triggers)... Review of Appendix 1 revealed the following listed as high risk triggers: ...suspected neglect...lack of support system... high risk /post hospital..functional status...

Record review of Patient # 6's admission History & Physical Exam, dated 08-06-17 , read: ...This is a case of a [AGE]-year-old male who presented to the ER after a fall. This patient has multiple medical problems ... Per patient, he fell 2 days prior to admission and had been on the floor for that duration and was brought to the ER by EMS with the patient covered in feces and urine. The patient has a bilateral below the knee amputation (BKA), wheelchair bound. The patient lives with the ex-wife and per EMS, the family notified EMS only today and the patient has been on the floor for 2 days. The patient has multiple wounds to both lower extremity stumps...Assessment & Plan: 1 .... Case management consultation for home situation and possibly discharge planning ... (8-06-17).

Further review of Patient # 6's record revealed he was admitted on [DATE] and discharged on [DATE]. An initial Discharge Planning Evaluation , dated 8-07-17 at 11:10 a.m. was completed. There was no secondary Discharge Planning Evaluation completed for Patient # 6.

Interview on 04-18-18 at 1:45 p.m. with Case Manager#9 , she said suspected neglect and lack of support system were considered high-risk triggers and a secondary Discharge Planning Assessment should have been completed.

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

Based on interview and record review, the facility failed to operationalize its policy and procedure to ensure 1 of 1 grievance brought to the facility's administrative staff was responded to in writing in a timely manner. Patient #1

Findings:

Review on 03/27/2017 of Patient #1's clinical record ( Demographic data) revealed he was admitted on [DATE] with presenting signs and symptoms of shortness of breath and chest pain.

Review of the Patient's discharge summary dated 10/26/2016 revealed, the patient with a history of Hypertension, Diabetes Mellitus presented to the ER with shortness of breath and chest pain on 09/13/2016. He was found to have Acute bilateral extensive saddle pulmonary embolism.

On 03/27/2017 the following allegations written as a complaint was investigated related to Patient #1 who was a patient at the facility from September 13, 2016 to September 27th 2016:

Patient's spouse was treated with lack of respect, concerns and request for information were ignored. Questions and concerns were not taken seriously.

Patient Intravenous site was sore, friend notified staff. Staff was resentful of notification.

There are safety risks to patients. On September 25, 2016 there were significant neglect regarding patient's mobility, education needs, and prescriptions in the patient's planned discharged which cause him to remain an extra night in the facility.

A sequential compression device (SCDs) was applied to the patient's legs prior to an ultra sound for deep vein thrombosis. Patient had TPA September 2016 to treat pulmonary embolism. A nurse said the SCDs were contraindicated.

Patient was put at risk for falls. A nurse encourage the patient to use toilet in the room with the nurse's assistance. Patient was instructed not to get out of bed until evaluated by the physical therapist. Physical therapist recommended use of a bedside commode.

The call button in the patient's room was broken along with several other patients' rooms. Patient's call light was not repaired until patient's spouse complained.

Review of the Facility's record revealed documentation of a written complaint dated September 26, 2016 which was e-mailed to the facility's Former Chief Nursing Officer.

The complaint outlined some of the above allegations. In the facility's complaint, the complainant documented the following: Please consider this letter a formal complaint regarding the care of my husband.

ON 03/27/2017 at 10:00 a.m the Surveyor requested documentation from the Facility's AVP for Quality ( C) of investigation done by the facility regarding the formal complaint e-mailed to the facility regarding Patient #1. None was provided.

Interview on 03/27/2017 at 11:40 a.m with the facility's AVP for Quality (C) revealed she had spoken to the former CNO who is no longer hired by the facility. She said the CNO told her, she had received the complaint from the family, that she had met with the complainant but after speaking with the complainant she thought the issues were addressed. She said the facility has no record of formal response to the grievance. She said at the approximate time of the complaint, the facility had changed their grievance process in that the Director for the unit is responsible for investigating the complaint and writing the response letter. The letter is then sent to Administration where the Chief Nursing Officer is responsible for reviewing and signing off on the letter. She said the Facility's Administrative Assistant was responsible for coordinating the process.

Interview on 03/27/2017 at 12:42 p.m. with the Former Chief Nursing Officer (G) revealed she remembered talking to the Patient's wife. She said the wife was concern about the care of the Patient's SCDs (sequential compression device) and call light issues. She said she followed up with the Director of the unit who assured her that the concerns were handled and that she was not aware of any other issues.

She said all conversation with the Patient's wife was in person or via the telephone. She said the facility's grievance process included responding to the complainant in writing. She stated I did not write or respond back to her in writing.

Review of the Facility's current Patient Grievance and Complaint Management Policy, # 60, originated 07/2015 and revised 12/2016 directed staff as follows:

A written complaint is always considered a grievance, whether from an inpatient, out patient, released /discharged patient or their representative. A written complaint also includes those complaints received via electronic mail or facsimile. Regardless of the form in which a complaint is received, whenever a patient or patient's representative requests a response from the facility, the issue is defined as grievance.

(5) In resolution of the grievance , a written notice of decision must be provided to the complainant that contains the name of the facility contact person, the steps taken on behalf of the patient to investigate the grievance, the result of the grievance investigation and date of completion.

The facility failed to fully implement an effective system for controlling infections and communicable disease. The facility failed to ensure:

1. Staff and physicians appropriately utilized personal protective equipment (PPE) while in in the operating room(OR).

2. Staff cleaned / disinfected the OR per policy between cases.

3. Storage of clean and sterile supplies per professional standards.

Findings include:

TX 628

Appropriate Use of PPE in OR:

Observation on 01-14-16 at 11:40 a.m. in OR # 7 revealed various facility staff preparing for Patient #1's surgical procedure ( ventral hernia repair). Patient # 1 was in the room at this time and laying on the OR table. The following observations were made:

*Registered Nurse (RN) # 6 entered the room and obtained a pair of exam gloves from a box on the wall. One of the gloves fell on the floor. RN # 6 picked up the contaminated glove from the floor and put it on. Wearing this same contaminated glove, RN # 6 proceeded to prep Patient #1's abdomen prior to the surgical incision.

*RN # 7 was repositioning various equipment in the room. Long cables fell to the floor from a cart that contained an unknown piece of patient equipment. RN # 7 retrieved the contaminated cables from from the floor and placed them into the equipment draw without properly wiping with a disinfectant.

*Certified Registered Nurse Anesthesist (CRNA) # 8 failed to have his face mask properly tied and secured at the back of his neck. The lower ties were visibly loose. CRNA # 8 tugged at the bottom of his face mask below his mouth multiple times before and during the procedure.

*CRNA # 8 unwrapped the laryngoscope blade and went directly and touched the computer screen. He then donned gloves without first performing hand hygiene.CRNA # 8 proceeded to intubate Patient # 1.

*RN # 6 and Surgeon # 9 both failed to have their hair properly secured under their head coverings. Both had visible hair at the nape of their necks.

Review of facility policy titled: Surgical Attire, dated 08/14, read: ..Purpose: To provide guidelines for the appropriate use, care, and handling of attire worn in the restricted and semi restricted area of the surgery department...Procedure:...2. head and facial hair, including sideburns and neckline, should be covered when in the semi-critical areas of the surgical suite ...8. Wear a single mask in surgical environment where open sterile supplies or scrubbed persons may be located. A mask should cover both mouth and nose and be secured in a manner that prevents venting..13...a. Gloves should be selected & worn..( sterile/unsterile) depending on tasks to be performed..b. Gloves must be changed..after contact with contaminated items...

Review of Perioperative Standards & Recommended Practices ( Association of periOperative Registered Nurses (AORN) 2012, read: ...Recommendation ...V1a...A mask that is securely tied at the back of the head and behind the neck decreases the risk of healthcare personnel transmitting nasopharyngeal and respiratory microorganisms to patients or the sterile field...

Review of facility policy titled Hand Hygiene, dated 08/13, read: Procedures: 1. Indications for handwashing and hand antisepsis:...C. Decontaminate hands before having direct contact with patients...H..Decontaminate hands after contact with inanimate objects, including medical equipment, in the immediate vicinity of the patient...I. Decontaminate hands after removing gloves... ...

Disinfecting of the OR between cases:

Observation on 01-14-16 at 11:20 a.m. in OR # 7 revealed Patient Care Assistant (PCA) # 13 and OR Aide # 14 cleaning and disinfecting the OR between cases.

OR Aide # 14 was observed wiping down the equipment with disposable disinfectants wipes. Continued observation failed to reveal OR Aide # 14 removing the pad from the OR table. He did not wipe underneath the OR pad or the OR table itself underneath the pad with disinfectant.

Interview with OR Aide # 14 directly upon finishing the cleaning, he stated I try my best to clean under the pad and the table; especially if it is a bloody case because blood can seep down. We are supposed to pick up the pad and wipe it with disinfectant wipes.

Continued observation of the cleaning of OR # 7 revealed PCA #13 mopping the OR floor. He was not wearing shoe covers. During the procedure, PCA # 13 walked over an area of the floor with blood stains and proceeded to retrace his steps over an area he had already mopped. PCA # 13 exited OR # 7 and proceeded down the hall wearing the same shoes ; no shoe covers.

Interview at the time of observation with RN # 6, she stated staff should wear shoe covers when cleaning the OR and remove the shoe covers immediately prior to leaving the room.

Review of facility policy titled Infection Control/OR Cleaning, dated 08/14, read: ...Purpose: To establish a consistent process for providing a clean environment for the surgical patient and reduce exposure to infectious waste.. Procedure:...3. Between surgical cases: ...C. All equipment and furniture used during the procedure..will be cleaned with a hospital approved disinfectant D. the floor will be damp mopped last using a clean mophead with a hospital-approved disinfectant....2. Appropriate protective barriers ( gloves, gowns, eyewear, masks, shoe covers) will be utilized when indicated....

Storage of clean & sterile patient supplies:

Observation during tour of the surgical services area on 01-14-16 at 10:30 a.m. revealed a supply closet. Inside the closet the following observations were made:

* two(2) large pieces of uncovered foam padding located directly on the floor.

* wire shelving that contained multiple packages of instruments and sterile patient supplies.

* the air temperature in the room felt very warm. There was no thermometer observed in the room.

During an interview at the time of observation with the Interim Director of Surgical Services # 15, she stated the foam padding was used for patient positioning and should not be stored uncovered, on the floor. She discarded it.

The Interim Director of Surgical Services went on to say the supplies in the closet were used for surgeries using the DaVinci robot in the OR next to the supply closet. She confirmed there was no thermometer in the supply room and the temperature was not being monitored.

Review of facility policy titled: Storage of Sterile Supplies and Sets, dated 03-14-14, read: All sterile instrument sets, peel packs, supplies used the OR shall be stored in accordance with the following procedure:...VII. The environmental conditions should be maintained at 68-72 degrees with a humidity of between 30% - 60%..

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

Based on observation, interview and record review, the facility's nursing staff failed to evaluate patient's condition while receiving care in 1 of 3 sampled patients. # Patients 1,2 & 7

Findings:

Patient #1

An interview was made by the Surveyor with Patient #1 by telephone on 10/08/2015 at 4:11 p.m. revealed that she verified the contents of the complaint details filed to the State Agency as stated on Intake #TX 394. Patient #1 said All what I have written about my stay at this Facility were all true, they gave me pain medicine at the back room where other people could see me; no staff would even come to check me how I was doing after giving the medicine in my vein.

Review of Patient #1 closed Medical Records revealed that she came to the emergency room on [DATE] due to abdominal pain; a Medical Screen Exam performed at 10:00 a.m. an initial pain assessment performed at 11:01 a.m. by Staff RN (11). Staff RN (11) administered Morphine 4 mg/ml via IV or Intravenous at 11:31. A pain reassessment record noted while in emergency room at 13:40.

Patient #1 was admitted in the afternoon of on 05/10/2015 at 15:49. A medication. Morphine 4mg IV was given at 20:35 with a Pain Score of 10/10; location is Abdomen, no pain reassessment noted in the Pain Monitor sheet, the next pain assessment was done on 05/11/2015 at 05:54 a.m. with a pain score of 8 out 10 in the abdomen that says Pre-medication no immediate pain reassessment noted.

Patient #2

Review of Patient #2 closed Medical Records revealed that she came to the emergency room on [DATE] due to abdominal pain; a Medical Screen Exam performed at 03:31 a.m. an initial pain assessment performed at 04:50 a.m. by Staff RN (10). Staff RN (12) administered Morphine 4 mg/ml via IV or Intravenous. No further pain assessment record noted while in emergency room .

Patient #7

Interviewed Patient #7 in room #7 on 10/08/2015 at 2:15 p.m., the Surveyor asked her comfort level while receiving care in the Emergency facility, she said My nurse is horrible, I had to call her and ask for pain reliever every time, nobody even comes to check how am I doing since this morning. My vital signs were not checked, and I have been awake since this morning; I do not know what are they waiting? At 2:25 p.m., while Surveyor was talking outside with Staff RN (7), Patient #7 came-out of her room and talked with the staff at the Nurses' station asking for her nurse.

Review of Patient #7 Medical Records while at the bedside revealed that she came to the emergency room on [DATE] due to stomach ache; a Medical Screen Exam performed at 06:36 a.m. The second dose of Morphine 2mg/ml via Intravenous was given at 10:51 a.m. while a third dose of Morphine at 13:11 no pain reassessment noted in her medication records.

An interview was made on 10/08/2015 at 2:20 p.m., with a Unit RN (7) the Surveyor verified with her about visit documentation related to pain of Patient #7, she said I had no chance because I also was attending with my other patients, but will document later. She had total of like 6 pain medicines already.

An interview was made on 10/08/2015 at 3:35 p.m., with a Unit RN (8) that helped the Surveyor in doing the record reviews, she confirmed no immediate reassessment was made for Patients 1, 2, and 7 after receiving their medications for pain based on the documents provided to the Surveyor.

An interview was made on 10/08/2015 at 4:20 p.m., with the Facility Quality Vice President (1) the Surveyor verified with her about the missing documentations related to pain of Patients 1,2, & 7, she said We have plan of doing an hourly audit including pain in the Emergency department but it has not been implemented yet.

Review of the facility ' s policy about Assessment/Reassessment: Pain Management Guidelines: HCA Gulf Coast Division # 600.100.016 on page 3 item 2 Reassessment (30 minutes after IV meds, 60 minutes after po meds) of Pain Intensity, Location, Quality of Pain, Onset, duration, variation, patterns, Alleviating and Aggravating Factors.

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

Based on observation, interview and record review, the facility failed to enforce policy to ensure patient rights in 1 of 3 sampled patients. Patient #1

Findings:

Patient #1

An interview was made by the Surveyor with Patient #1 by telephone on 03/11/2015 at 4:20 p.m. revealed that she verified the contents of the complaint details filed to the State Agency as stated on Intake #TX 697.

Review of Patient #1 closed Medical Records on 03/12/2015 revealed that she was admitted to the facility on [DATE] due to labor complaint, presented with contractions. Delivered a baby boy on 09/25/2014 via Caesarian Section due to ' arrest of descent ' . Patient #1 was discharged on [DATE], while the baby boy was discharged on [DATE].

Review the facility ' s complaint log revealed that Patient #1 filed complaint on 11/20/2014 stated Patient with concern that the L&D nurse caring for her caused her baby to have to spend 12 days in the NICU . Final letter due date on 01/04/2015; however, 2nd letter mailed to complainant on 02/18/2015 via Certified mail. The facility re-sent the letter to the complainant on 03/06/2015 since it came back to the facility on [DATE]. The complaint status is considered closed.

During an interview made on 03/12/2015 at 3:25 p.m., with the Risk Prevention Coordinator (6) the Surveyor verified if there was a mailed letter to the complainant, and she said Yes, the 2nd letter was certified and it has tracking number, but she did not get it. So I re-sent it via regular mail this time, using the same information in this letter. The Surveyor verified if she called patient #1 to notify delay in response, and she said No, because from the start, I already spoke with her in December 2014 and I explained the process, that every response will be sent by mail. I had to wait for our Physician to give us his review feedback about this case so we could mail that letter. It was completed 1st week of February, then so we mailed it using the same letter. Risk Prevention Coordinator (6) provided a copy of the letter mailed to Patient #1 that revealed mailing address.

Observation made by the Surveyor about the certified letter mailed to Patient #1. The address was not the same address in patient's profile.

During an interview on 03/12/2015 at 03:35 p.m. with the Facility ' s Vice President (1), the Surveyor notified her that the mailing address written on the letter is not the same address of Patient #1 in file as this was the same address that they used; she said Yes, you are right. It was to a different address, we will make sure to mail letters to the right recipient next time.

During an interview on 03/13/2015 at 08:45 a.m. with the unit staff nurse (9), the Surveyor verified when did she 1st hear this complaint of Patient #1 about her nursing care, she said For sure it was after when I came back from a vacation in October 2014. My manager told me about it.

During an interview on 03/13/2015 at 10:20 a.m. with Physician staff (7), the Surveyor told him there was no written statement about the Patient #1 as part of the facility response to grievance after he reviewed her medical case; he said Yes, I did the review. I wondered this patient filed complaint 2 months after she was discharged . None, there is no report made, nobody asked me to create one after reviewing it.

Review of the facility ' s policy about Customer Feedback Supersedes Policy Patient Complaint # 900.2218 on page 4 items 4, 5&6 Coordination of the investigation, including review and evaluation of follow-up response and preparation and communication of the final assessment. Monitor response from director/manager to be within 45 days from date of the original complaint. Patient advocate will send follow-up letter to complainant. When appropriate the Director/Manager may contact the complainant by phone, which may resolve the issue and therefore a follow-up letter is not necessary. {Sec C item #3} Resolving issues in a time fashion and communicating findings of the investigation the risk module. Documentation will include a thorough description of the incident, as well as how and/or what corrective actions were taken.

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

Based on interview and record review, the facility failed to ensure that nursing staff administered medication according to the facility policy for 1 out of 10 sampled patients (Patient #8).

Findings include:

TX 793

Review of complaint intake TX# 793 revealed that Patient #8 was admitted to the facility on [DATE] for left hip replacement. Allegations included Registered Nurse (RN) #11 refused to tell the patient what medications she was giving ...after the patient inquired ... RN #11 gave...the wrong medications...[the] patient was supposed to take Seroquel XR 50mg at night, not during the day.

Review of Patient #8's clinical record showed a [AGE]-year-old female admitted to the facility on [DATE] for left hip replacement secondary to avascular necrosis. Further review of the clinical record revealed two main issues related to medication administration:

1. No documentation of medication dose twice.

Record review of the Patient #8's Medication Administration Record (MAR) revealed the following:

? On 09/30/14 at 8:34AM, Seroquel 25mg not given ...Patient took home meds.

? On 10/01/14 at 8:49PM, Seroquel not given ...Patient takes home meds against advice.

Interview on 01/02/15 at 2:30PM with Registered Pharmacist (RPh) #8, she stated she was unable to identify the dosage of Seroquel taken by Patient #8 on 09/30/15 and 10/01/14 based on her review of the MAR documentation. She also stated she was unable to tell if the Seroquel was administered by the staff or self-administered by the patient.

Record review of facility policy titled, Medication: Administration, General, dated 10/2012, read:

? The authorized personnel will ...observe the 'Five Rights' of medication administration: ...Right dose.

? All documentation should be completed in the electronic medication administration record.

? Self-administered drugs shall be supervised and documented by authorized personnel.

2. Failure to obtain timely physician's order for home meds.

Record review of Patient #8's Medication Administration Record (MAR) revealed:

? On 09/30/14 at 8:34AM, Seroquel 25mg not given ...Patient took home meds.

? On 10/01/14 at 8:49PM, Seroquel not given ...Patient takes home meds against advice.

Interview on 01/02/15 at 10:15AM with Nursing Director RN #3, she stated a physician's order is needed prior to the administration of a patient's home meds. The meds are then reviewed by pharmacy and stored by the nursing staff with the patient's other medications. Based on the MAR documentation on 09/30/14 and 10/01/14, she also stated she was unable to tell if the Seroquel was administered by the staff or self-administered by the patient.

Record review of Physician Order, undated, revealed, Patient Own Medication. Ordering Physician: MD #13 ...Seroquel XR 50mg tabs every 12 hours ...start 10/02/14 [at] 09:00 ...take 25mg (? tablet) by mouth at bedtime.

Record review of facility policy titled, Medications: Patient's Personal, dated 09/2013, read:

? Patient's personal drugs shall not be administered unless specifically authorized by the responsible prescribing practitioner.

? Drugs brought into the facility by patients shall not be administered unless the drugs have been absolutely identified ...by a pharmacist. [U]nless directed otherwise by the responsible practitioner, personal drugs to be administered shall be stored with drugs supplied by the facility.

Review of facility policy titled, Medication: Administration, General, dated 10/2012, read:

A medication must not be left at the bedside or self-administered unless specifically ordered by the physician. Self-administered drugs shall be supervised and documented by authorized personnel.

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

Based on interview and record review, the facility failed to implement an effective system to provide and document respiratory services to 2 of 2 sampled patients with orders for Incentive Spirometry [IS] (Patient # 5 and 8).

There was a delay in implementing Incentive Spirometry for Patient # 8; and inconsistent/inadequate documentation of IS for both Patient # 8 and Patient # 5.

Findings include:

TX # 793

Patient # 8

Record review of complaint intake TX # 793 revealed: ...no incentive spirometer was given to the patient until 36 hours after surgery...by that time the patient's oxygen saturation was 86 %...

Record review of Patient # 8's clinical record revealed she was [AGE] years old and admitted to the facility on on [DATE]. Her admission diagnosis was left hip replacement with avascular necrosis.

Further review of Patient # 8's clinical record revealed a physician order dated 09-29-14 (9:37 A.M.) : incentive spirometry.

Interview on 01-02-15 at 3:20 p.m. with Respiratory Therapy (RT) Supervisor # 7 he said it was the responsibility of the Respiratory Therapy department to initiate IS when it was ordered and also educate the patient on its use. Nursing staff collaborated by reinforcing the use of IS. RT Supervisor # 7 stated his expectation was that respiratory staff initiate incentive spirometry during the same shift in which it was ordered.

At the same time of interview, RT Supervisory # 7 reviewed Patient # 8's electronic medical record. RT Supervisor # 7 said the documentation showed there was a delay in initiating the IS for this patient. It was ordered on 09-29-15 at 9:37 a.m. but not implemented until 09-30 at 11:30 p.m., approximately 36 hours later.

RT Supervisor # 7 went on to say the RTs should document IS every shift; more frequently if the patient was not meeting the established goal. If this was the case; he would expect documentation every 4 hours.

Record review of Patient # 8's documentation of incentive spirometry revealed only 4 entries related to IS being implemented. These were: 09-30-14; 10-01-14 ( twice); and 10-02-14. All four (4) entries related to IS were made by nursing.

RT Supervisor # 7 was unable to locate any documentation of IS for Patient # 8 by the Respiratory Therapy staff during her entire admission of 09-29-14 through 10-02-14.

Continued interview with RT Supervisor # 7, he said that according to the documented inspiratory volumes recorded by nursing (750, 750, 1000) ; Patient # 8 was not meeting her post-operative goals for inspiratory volume (greater than 1.0 milliliters).

Patient # 5

Record review of Patient # 5's clinical record revealed she was [AGE] years old and admitted to the facility on on [DATE]. Her admission diagnosis was right hip fracture.

Interview on 01-02-15 at 2:50 p.m. with staff RT # 14, she stated when a patient had an order for Incentive Spirometry(IS), the RT should document the IS use once per shift. This would be recorded on the daily RT Multi Therapy Record and would include documentation of the patient's inspiratory volume.

Record review of Patient # 5's electronic medical record with RT # 14 revealed a physician order for IS dated 12-25-14. RT # 14 was unable to locate any documentation by respiratory therapy of IS use or recording of inspiratory volumes. [Later on 01-02-15, RT Supervisor # 7 located four (4) IS entries for this patient; all documented by nursing staff].

Record review of facility Cardioplulmonary policy titled Incentive Spirometry, dated 10/2013, read: ...Procedure: 1. Check Physician Order Sheet...2. explain therapy to patient...10. Record data on patients electronic medical record...

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

Based on observation, interview and record review the facility failed to ensure that 7 of 8 sampled patients (Patient ID # 7, # 8, 11, 12, 13, 14, and 15) were restrained in accordance with an appropriate order by a physician or other Licensed Independent Practitioner (LIP) per facility policy.

Several orders for restraint were either absent, incomplete, illegible, or not timed.

Findings include:

TX # 314

TX # 583

Observation on 07-16-13 during initial tour of the facility between 9:15 a.m. and

11:00 a.m. revealed the following patients in restraints:

Patient ID # 7 (third floor): bilateral soft wrist restraints

Patient ID # 8 (ICU): bilateral soft wrist restraints

Patient ID # 9 (ICCU): bilateral soft wrist restraints

All restraints were observed to be appropriately applied.

Record review on 07-17-13 of eight (8) sampled patient records revealed the following issues regarding restraint orders:

In-Patient ID # 7: admitted on [DATE]; restraints applied 07-12-13. For both orders for restraints on 07/13 and 07/14/13, the time of the order was illegible.

In- Patient ID # 8: admitted on [DATE]; restraints initially applied 07-11-13. Orders on 07/12 and 07/13 were unsigned by physician/LIP; order on 07/14/13 was not timed; order on 07/15/13 was signed but the top portion of the order was blank (no clinical justification, restraint device, time limit was listed).

Patient ID # 11 (discharged ): admitted [DATE]; nursing notes documented bilateral upper and lower extremity restraints applied in the emergency room (ER) at 7:45 p.m.; patient was agitated and severely restless. RN Staff ID # 10 was unable to locate an order for restraint in the clinical record.

Patient ID # 12 (discharged ): admitted [DATE]; restraints initially applied on 02-11-13. RN Staff ID # 10 was unable to locate an order for restraint on 02-15-13; nursing documentation showed patient was restrained at this time. The restraint order for 2-12-13 was not timed. RN Staff ID # 10 was unable to locate an order for restraint in the clinical record.

Patient ID # 13 (discharged ): admitted on [DATE]; restraints initially applied in 03-23-13. Nursing documentation revealed the patient was restrained from 3-23-13 to 03-27-13. RN Staff ID # 10 was unable to locate an order for restraint for 03-24-13 in the clinical record. In addition, the restraint order for 03-25-13 was illegible; the order for 03-26-13 was not timed.

Patient ID # 14 (discharged ): admitted on [DATE]. Restraints initially applied on 03-12-13; nursing documentation revealed patient was restrained from 03-12-13 to 03-14-13. RN Staff ID # 10 was unable to locate an order for restraint for 03-13-13 and 03-14-1324-13 in the clinical record. In addition, the restraint order for 03-25-13 was illegible; the order for 03-26-13 was not timed.

Patient ID # 15 (discharged ): admitted on [DATE]. Restraints initially applied on 03-13-13; nursing documentation revealed patient was restrained from 03-12-13 to 03-14-13. RN Staff ID # 10 was unable to locate an order for restraint for 03-14-13.

Interview on 07-17-13 at 2: 30 p.m. with RN Staff ID # 10 she stated that orders for restraints must be timed-limited to 24 hours and that all restraint orders must be dated and timed. The order must also include the type of restraint, clinical justification, and criteria for release.

Record review of facility policy titled Restraint and Seclusion Guidance Policy, revised 08/2011, read: ...5. An order for restraint ...must be obtained from an LIP/physician who is responsible for the care of the patient prior to the application of restraint ...The order must specify clinical justification for the restraint ...the date and time ordered, the duration of use, the type of restraint and ..criteria for release ...Order for ' Restraint with Non-Violent, Non Self-Destructive Behavior: duration of order must not exceed 24 hours ...

Based on interview and record review the Hospital failed to send a complainant a letter acknowledging their grievance per the Hospital's policy. (Patient ID# 1)

Findings include:

Interview 11/27/12 at 8:30 a.m. with the Chief Nursing Officer (CNO) revealed she was aware of a complaint regarding patient ID# 1. The CNO stated that patient ID# 1's daughter made a complaint 10/31/12 about her Father ' s heels being soft and mushy once he arrived on the Rehabilitation Unit from the Intermediate Medical Intensive Care Unit (IMU). The patient had a history of diabetes, poor circulation and loss of one toe.

Record review of a policy titled Patient / Family Complaint dated 10/2010 stated A patient grievance is a written or verbal complaint by a patient, or the patient ' s representative, regarding the patient ' s care, abuse or neglect, issues related to the hospital ' s compliance with the CMS Hospital Conditions of Participation. Procedure: Patient Advocate is responsible for: Initial response will include an acknowledgement of the complaint and will indicate that review has been initiated. Initial response letter will be mailed within seven working days of the alleged incident by the Quality Management Office.

The Quality Assurance Director (ID# 2) acknowledged 11/27/12 at 2:50 p.m. that the complainant should have been sent a letter from the hospital within 7 days acknowledging her complaint. The hospital inadvertently failed to send the 7 day letter.

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

Based on interview and record review the nursing staff failed to supervise patient care in 3 of 3 patient records reviewed on the Intensive Medical Care Unit (IMU). Records reviewed failed to:

1) Document measurements of pressure ulcers per facility policy,

2) Obtain physician orders for pressure ulcer treatments,

3) Accurately perform Braden skin risk assessment

(Patient ID#'s 1, 2, 3)

Findings include:

Record review of a policy titled Skin Care Assessment dated 6/13/11 stated: Purpose: to describe the process and documentation format for wound and skin assessment. Procedure: The Risk Assessment is completed based on criteria including sensory, perception, moisture, activity, mobility, nutrition, and friction and sheering. (If the score is 16 or less, the patient may be at risk for impaired skin integrity) ........ Document wound measurements one time per week ...

PATIENT ID# 1

Record review of the medical record for patient ID# 1 revealed he was admitted to the hospital 10/10/12 and discharged on [DATE].

A History and Physical dated 10/10/12 stated A [AGE]-year-old male presented with severe shortness of breath, and orthopnea..He was found to have decompensated systolic congestive heart failure as well as evidence of acute MI. Past Medical History: Hypertension, COPD, [DIAGNOSES REDACTED], Diabetes, Poor compliance, Peripheral neuropathy, Peripheral arterial disease, bilateral pneumonia ...Past Surgical History: Left fifth toe amputation. Plan of Treatment: The patient is being admitted to the hospital for cardiovascular surgeon evaluation.

Record review of a Cardiovascular Surgeon evaluation dated 10/11/12 stated ....Extremities: I am unable to palpate pulses in either foot .... Preparation for open heart surgery ....

The nursing staff used a Braden Risk Assessment for patient ID# 1 on 10/11/12 to evaluate the risk of developing pressure ulcers and the patient was scored at 20 or no risk of developing pressure ulcers. (According to the Hospital ' s Skin Care Assessment policy only a score of 16 or less is at risk).

The patient had open heart surgery and was transferred to the Intensive Medical Care Unit (IMU). The patient had no skin problems upon admission 10/10/12 according to the nursing shift assessments.

Nursing shift assessments noted [DIAGNOSES REDACTED] (redness) to buttocks bilaterally beginning 10/15/12 while on the IMU unit. The Nursing assessments failed to document any problems with the patient's heels while in IMU. No measurements were taken of the redness to the buttocks bilaterally. No heel protectors nor a pressure relieving mattress was ordered by the physician.

Patient ID# 1 was transferred 10/25/12 from the IMU unit to the Rehabilitation Unit on the first floor.

The nursing admission assessment on the Rehabilitation Unit noted [DIAGNOSES REDACTED] (Redness) to buttocks bilaterally, Left lower extremity monitoring due to bruise and Left foot heels [DIAGNOSES REDACTED]. No measurements were taken of the redness to the buttocks or the patients heels.

On 10/29/12 the nursing assessment noted closed blister bilateral feet. Preventative boots were provided to the patient. No measurements were documented of the patient's heels.

On 10/30/12 the nursing assessment noted Scabs bilateral heels, Bruise and closed blister on right foot and Left foot closed blister. No measurements were documented of the patient's heels.

On 10/31/12 the nursing assessment noted Closed blister bilateral heels and [DIAGNOSES REDACTED] to bilateral buttocks. No measurements were documented.

On 11/4/12 the nursing assessment noted Skin tear right buttock and [DIAGNOSES REDACTED] bilateral buttocks, Bilateral heels blister open. No measurements were documented.

On 11/6/12 the nursing assessment noted Left heel open blister and 4x4 and ace bandage. No measurements were documented and no physician order was obtained for the 4x4 and ace bandage. The Right heel open blister was not noted. No measurements were documented.

On 11/7/12 the nursing assessment noted Left heel open blister and 4x4 and ace bandage. The Right heel open blister was not noted. No measurements were documented of the patient's blisters. The patient was discharged [DATE] to a Rehabilitation Hospital.

The Quality Assurance Director acknowledged 11/27/12 at 2:50 p.m. that no measurements were documented of patient ID# 1's pressure ulcers. The Director further stated that nursing staff should have measured the patient's pressure ulcers according to hospital policy.

PATIENT ID# 2

Record review of the History and Physical revealed this 71- year- old patient was admitted to the hospital 11/22/12 with increased confusion and could not move his right side. The patient had a history of coronary artery disease, hypertension, [DIAGNOSES REDACTED] and diabetes.

Initial nursing assessments on 11/22/12 revealed no skin problems. Nursing assessments on 11/27/12 documented Stage II pressure sore on the high back, Stage II on the left thigh, and Stage I on the coccyx. The nurse applied Dueoderm to the coccyx with no physician order and no measurements were documented of the pressure ulcers.

PATIENT ID# 3

Record review of the History and Physical revealed this [AGE]-year-old patient was admitted on [DATE] for elective redo of a total hip replacement. The patient had a tracheotomy that resulted from previous history of head and neck cancer.

Initial nursing assessments on 11/13/12 revealed no skin problems Nursing assessments on 11/18/12 revealed a Stage I pressure sore on the buttocks. No measurements were documented.