Las Palmas Medical Center

Based on a review of documentation and an interview with staff, the governing body failed to ensure that contracted services were furnished in accordance with the specifications of their contract.

Findings:

During the review of credentialing files for 7 anesthesia providers (staff #A20 through #A26 ) performing services at the hospital under contract, 3 of the 7 providers (#A21, #A22, #A24) did not possess the certifications required of their contract.

The Professional Service Agreement for West Star Anesthesia Services stated, in part (beginning on page 14):

3. Description of Duties

...

Q. Skills: Each Contractor's Representative must be able to provide certain technical skills, including but not limited to:

...

v. The management of problems in cardiac and respiratory resuscitation;

* Staff A21 had received basic life support certification and advanced cardiac life support certification from an online provider, with no documentation of a return demonstration of skills.

* Staff A22 had received advanced cardiac life support certification from an online provider, with no documentation of a return demonstration of skills.

* Staff A24 had received basic life support certification and advanced cardiac life support certification from an online provider, with no documentation of a return demonstration of skills.

Review of the Health & Safety Institute and the National Safety Council website found at http://news.hsi.com/onlineonlycpr reveals that, No major nationally recognized training program in the United States endorses certification without practice and evaluation of hands-on skills.

According to the Occupational Safety and Health Administration (OSHA) online training alone does not meet OSHA first aid and CPR training requirements. Further guidance can be found at https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=INTERPRETATIONS&p_id= .

In an interview with staff A27 on 3-21-19 (Chief Medical Officer and Anesthesiologist by training), staff A27 agreed that basic life support and advanced cardiac life support was required by the West Star Anesthesia contract and that the above staff had not provided a return demonstration of skills for their certifications.

The above was confirmed in an interview with the CEO and other administrative staff on the afternoon of 3-21-19.

Based on review of facility documentation and staff interview, the facility failed to obtain appropriate physicians orders for all episodes of restraint.

Findings:

Facility based policy entitled, PC 210_ Restraints stated in part,

5. Order for Restraint

a. 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 to be used and behavior-based criteria for release.

Review of the medical record for Patient #A19 at Del Sol, revealed the following:

* This patient was in a behavioral restraint of soft restraints to the right and left upper extremities on 02/05/19 from 1520 until 1620 related to aggressive behavior.

* There was a physician order on 02/05/19 1527 at for a chemical restraint for 4 hours with the clinical justification of combative, physical aggression, and destructive. This order did not indicate that the patient was in physical restraints.

* A separate physician order was entered on 02/05/19 at 1525 that stated, Place soft physical restraint to BUE.

* However, this order did not specify clinical justification for the restraint, the duration of use, and/or the and behavior-based criteria for release.

In an interview on 03/20/19 staff members #A32 and #A33 confirmed the above findings that the above order to implement a behavioral physical restraint of Patient #19 on 02/05/19 did not include all the elements of a complete physician order for restraint per policy and regulations.

According to a physician note dated 02/04/19 involving Patient #A19 at Del Sol, At 18:10 (6:10 PM), patient found face down on the hallway in front of the initial exam room being held in place by 2 El Paso Police Department officers and for (four) security officers. Patient is finally attempting to escape. Patient is acutely psychotic and aggressive at this time. [Physician] is also on scene evaluating patient with me and recommends the use of IM Benadryl, Haldol, and Ativan.

In an interview on February 20, 2019 with the hospital Director of Quality Utilization (staff 8 D) confirmed that no physician order was obtained for the personal restraint conducted on February 4, 2019 on Patient #A19.

Based on a review of documentation and interview, the facility failed to ensure that the patient who is restrained was monitored by a physician, other licensed independent practitioner, or trained staff at an interval determined by hospital policy.

Findings:

Facility based policy entitled, PC 210_ Restraints stated in part,

7. Monitoring the Patient in Restraints

a. Patients are assessed by an RN immediately after restraints are applied to assure safe application of the restraint.

b. An RN will assess the patient at least every 2 hours. The assessment will include:

1) Signs of injury associated with restraint, including circulation of affected extremities

2) Respiratory and cardiac status

3) Psychological status including level of distress or agitation, mental status and cognitive functioning

4) Needs for range of motion, exercise of limbs and systematic release of restrained limbs are being met

5) Hydration/nutritional needs are being met

6) Hygiene, toileting/elimination needs are being met

7) The patient's rights, dignity, and safety are maintained

8) Patient's understanding of reasons for restraint and criteria for release from restraint

9) Consideration of less restrictive alternatives to restraint

Review of the medical record for Patient #A17 at Las Palmas revealed, patient was in a behavioral restraint (soft all extremities) on 10/03/18 from 2310 until after 0800 on 10/04/18. Nursing staff documented safety/rights/dignity maintained verified every 15 minutes. There was no nursing documentation of assessment including: signs of injury associated with restraint, including circulation of affected extremities, respiratory and cardiac status, psychological status including level of distress or agitation, mental status and cognitive functioning, needs for range of motion, exercise of limbs and systematic release of restrained limbs are being met, hydration/nutritional needs are being met, hygiene, toileting/elimination needs are being met, patient's understanding of reasons for restraint and criteria for release from restraint, and/or consideration of less restrictive alternatives to restraint. The assessment of these element is to be completed by nursing every 2 hours a patient is in restraints.

In an interview on 03/20/19 with staff members #A30 and A31 they confirmed that the every 2 hours assessment components were not reflected in the medical record for this patient who was restrained for over eight hours.

Based on a review of documentation and interview, the facility failed to ensure that when restraint or seclusion is used, there was documentation in the patient's medical record of the 1-hour face-to-face medical and behavioral evaluation if restraint or seclusion is used to manage violent or self-destructive behavior.

Findings:

Facility based policy entitled, PC 210_ Restraints stated in part,

9. Face-to-face assessment by a Physician or LIP:

a. A face-to-face assessment by a physician or LIP, RN or physician assistant with demonstrated competence, must be done within one hour of restraint/seclusion initiation or administration of medication to manage violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others. At the time of the face-to-face assessment, the LIP/physician/RN/PA will :

1) Work with staff and patient to identify ways to help the patient regain control

2) Evaluate the patient's immediate situation

3) Evaluate the patient's reaction to the intervention

4) Evaluate the patient's medical and behavioral condition

5) Evaluate the need to continue or terminate the restraint or seclusion

6) Revise the plan of care, treatment and services as needed

Base on a review of documentation, 3 of 3 patients (Patients #A17 and #A18 at Las Palmas and Patient #A18 at Del Sol) had behavioral restraints implemented that did not have a 1-hour face-to-face medical and behavioral evaluation documented. These 3 patients had physician notes indicating the patient was in a behavior restraint. However, the documentation did not include the patient's reaction to the intervention, assessment of their medical and behavioral condition, and/or the need to continue or terminate the intervention.

In an interview with staff members #A30 and A31 on 03/20/19, they confirmed that the electronic record had a template for the 1 hour face to face evaluation, but that staff were not utilizing it to document all the components of the assessment per the facility policy.

Based on interview and record review, the Del Sol's Pre-operative nurses failed to obtain physician's orders for the placement of Peripheral Intravenous catheters and the administration of lactated ringers for 2 .(Patients #1 and #4) of 4 patients.

Findings:

Review of Patient #1's pre-operative orders, on the morning of 3/19/19, reflected an order for the administration of Vasopressin Injection IV (Intravenous Catheter). Patient # 1C did not have an order for the insertion of the IV.

Review of Patient #4C's pre-operative orders, on the morning of 3/19/19, reflected an order for the administration of Zofran IV, Morphine IV and Lactate Ringers IV. Patient # 4C did not have an order for the insertion of the IV.

The facility did not provide the requested policy for the need to clarify the physician's order for the insertion of the IV.

During an interview on the morning of 3/19/19, on the pre-operative unit Staff #24, RN confirmed the finding.

Based on observation, interview, and record review, the pharmacies at Del Sol and Las Palmas campus failed to store and dispense medications in a safe manner when multi-dose liquid and nonaqueous medications were not identified as to the expiration date for that product.

Findings:

Observations during a tour of the Del Sol pharmacy on the afternoon of 3/19/19 revealed, the following multi-dose medications that had been opened and were not labeled when they were opened or when they would expire:

Dexamethasone 0.5 mg/ 5 ml

Cyprohetatine Chloride Syrup (had medication residue on the outside of the glass bottle)

Promethazine Oral (had medication residue on the outside of the glass bottle)

Propranolol 20mg/5ml oral

During an interview on the morning of 3/19/19, in the Del Sol facility's pharmacy, when asked about the labeling of opened multi-dose medications, Staff #3C, Pharmacy technician stated, ...We label when they will expire, 14 days, I guess ....

During an interview on the afternoon of 3/19/19, in the Del Sol facility's pharmacy, Staff #5C, Pharmacy Director stated, ... We don't label the medications when they are opened; we use the manufacturer's expiration date .... Staff #5C confirmed the facility did not have a policy for the labeling and dating of opened multi-dose medications.

Observations during a tour of the Las Palmas pharmacy on 3/21/19 at 9:20 a.m. with Staff #11C, Pharmacy Director, the following multi-dose bottles of medicines were observed:

- Diuril 237 ml: opened date of 8/18/18, and no written expiration date.

- Senna Syrup 237 ml: opened date of 5/8/18 and expiration date of 5/1/19.

In an observation on 3/21/19 at 9:50 a.m., an unidentified opened multi-dose bottle of medicine was found without the opened date.

In an interview on 3/21/19 at 9:20 a.m., Staff #11C stated we don't have facility policy and procedures for drug storage and labeling, but there's a process. He stated facility followed the USP (United States Pharmacopeia) 795 and 800 standards.

In an interview on 3/21/19 at 9:50 a.m., Staff #11C stated, there was an update with the USP 795 and 800 standards and facility will update the process today. He stated the facility followed the BUD (beyond-use date) and once the multi-dose bottle of medicine was opened, the BUD, or the expiration date was 6 months from opened date. He also stated the unidentified opened multi-dose bottle of medicine will be thrown out immediately since facility did not know when the opened date was.

Review of facility provided copy of Compounding nonsterile preparations: USP <795> and <800> with the release date of October 1, 2017, reflected the BUD for nonaqueous formulation as 6 months.

Based on observations, interviews, and record reviews, Las Palmas facility failed to ensure that the specific food and dietetic services organization requirements were met when:

(A) facility's dietary department failed to provide services in a clean and sanitary environment.

(B) staff did not properly cover their hair or mustache for acceptable hygiene practices.

Findings:

(A) The following observations on the morning of 3/18/19, in the Las Palmas kitchen, revealed:

-The inner lid of the ice machine had a black sticky residue under the lid.

- A wet mop was sitting on the floor.

- Dried food debris was noted on the food mixer, can opener blade and gears, under the cabinets, on an opened bag of disposable spoons, on a bulk sugar container and copious amounts of food on the sides of the tilt sautT pan.

- Old dried food grease was splattered and dripping down the wall behind the grill.

- The tile in front of the tilt sautT pan was missing large amounts of grout, making the floor not cleanable.

- The floor drains were dirty with dark material and old food debris.

During an interview on the afternoon of 3/18/19, in the facility's kitchen, Staff #12C, Registered Dietitian confirmed the findings.

(B) In an observation in the kitchen service area (Las Palmas) on 3/18/19 at 1:24 p.m., Staff #14C, Cook, had a mustache and was working without a beard restraint.

In an interview on 3/18/19 at 1:24 p.m. with Staff #16C, Kitchen Director, regarding the requirement for beard restraints, she stated it's not a full beard, so it's okay.

In an observation in kitchen service area (Las Palmas) on 3/18/19 at 1:52 p.m., an unidentified female staff was observed wearing a hairnet without covering her bangs.

In an observation in kitchen service area (Del Sol) on 3/19/19 at 9:40 a.m., 3 unidentified male staff with beard and/or mustache were observed with no beard restraints.

In an interview on 3/19/19 at 9:58 a.m. with Staff #15C, Kitchen Director, he stated even mustaches must be covered in the kitchen service areas, and also it's the state law and must follow the TFER (Texas Food Establishment Rule) rule.

Review of facility provided policy from the Food & Nutrition Services Department Personal Hygiene with most recent approval date of 5/30/17 revealed in part:

- Purpose: To prevent the spread of food borne illness

- Policy: Employees will practice good personal hygiene habits at all times while on duty

- Procedure: 1.b. Hair nets and/or caps worn at all times

There was no information in the policy related to covering of beards/mustaches.

Review of TFER, last revised October 2015, under rule 228.43(a) stated in part ...food employees shall wear hair restraints such as hats, hair covering or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food ...

Based on humidity and temperature documentation records, and staff interview, the facility failed to ensure they followed their plan of correction to ensure that the temperature and humidity levels were maintained in an acceptable range in the operating rooms and procedure rooms.

The facility maintenance and engineering staff did not frequently monitor the humidity and temperature readings throughout the day while procedures were being performed in the rooms as per their approved plan of correction. Documentation on the temperature and humidity logs only had documentation of the temperature and humidity at the beginning of a treatment day and had no documentation of the effects of adjustments when they were made by environmental services.

Cross refer to tag A0726

Based on review of documentation, tour of the facility, and interview, it was determined that the hospital failed to monitor the temperature and humidity in areas of the hospital that requires temperature and humidity control. Failure to ensure humidity levels are maintained in the operating rooms and all procedure rooms place all patient's safety at risk during the procedure. Low humidity levels can increase the risk of electrostatic shock in the surgical room and procedure rooms.

Findings:

According to an article entitled Relative Humidity Levels in the Operating Room Joint Communication to Healthcare Delivery Organizations 2015 it was stated in part:

Relative humidity may affect the operation of some electro-medical equipment used in the OR, particularly with older model electro-medical equipment. This equipment may malfunction unexpectedly. Too low humidity levels may also impact calibration. Larger electrostatic discharge (ESD) pulses may create a risk of destruction of parts, premature failure, and erratic behavior of software that is confusion from ESD pulses. And, in an environment where humidity is low, a person can more easily become charged and receive an electrostatic shock when coming in contact with medical equipment.

Facility policy entitled Temperature and Relative Humidity Monitoring Policy and Log stated in part Temperature and humidity levels are continuously monitored using an (automated system and/or local monitors.) The Las Palmas Del Sol Healthcare System will maintain Humidity and Temperature in accordance with Title 25 Texas Administrative Code Chapter 133-subchapter 133.169¬. NFPA 99 2012 and the Association of Surgical Technologist (AST) a 20% RH as the lower limit for anesthetizing locations. Las Palmas Del Sol will take corrective action to maintain 30-60% RH, but will not intervene to stop procedures until the RH is below 20% at the Physician's discretion ...

PROCEDURE:

HUMIDITY:

The relative humidity of air supplied to all required areas requiring monitoring will be done daily prior to the start of the first case by either the Facilities Engineering Department, if automated systems are provided or the department staff for local monitors. When possible, central adjustments will be made to maintain relative humidity within 30%-60%.

OR/Procedural Areas:

Escalation of out-of-range readings will be done using the following escalation process:

A. Level 1: Readings are obtained by the individual responsible for monitoring the room prior to a procedure or during daily checks in supply areas and recorded on the Room Temperature and Humidity Log. Any relative humidity reading found unacceptable/out of range will initially require adjustment of the thermostat in the individual room. Temperature and humidity will be re-checked within an hour. Corrective action should be documented on the Room Temperature and Humidity Log. If the parameters are within range, no further action is required. If the parameter continues to be out of range, and the temperature is set to the design specification in Table B, Facilities Engineering is to be notified by phone.

B. Level 2: Alerts received by Facilities Engineering from the system or from the individual room for out of range relative humidity levels exceeding 1 hour will require the validation of the temperature setting. If the relative humidity is out of range and the temperature setting is within the range as described in Table B, Facilities Engineering staff will respond to that room and/or the supply air handling unit for possible further corrective actions. Actions taken should be documented on the Room Temperature and Humidity Log. Departmental Leadership should also be made aware of potential issue.

C. Level 3: In the event Facilities Engineering is unable to bring relative humidity back to an acceptable range, the temperature setting is within the described range in Table B, a risk assessment should be performed by the Proceduralist/Surgeon, OR Staff/Supervisor, Anesthesia Staff to determine if the out of range levels could negatively affect patient care. If the temperature setting in the room is out of the design range as described in Table B, a decision to continue and any actions taken should be documented on the Room Temperature and Humidity Log. Procedures in progress can be completed.

D. Level 4: For continued out of range relative humidity levels, when the temperature setting is within the described range in Table B or moisture accumulation on the walls or horizontal surfaces, the room should be closed until the issue is corrected. Any actions taken should be documented on the Room Temperature and Humidity Log. ...

TEMPERATURE:

OR/Procedure Areas

If the temperature is found to be out of range in an OR/procedural area, the physician should be notified to determine if the levels could negatively affect patient care. If the physician opts to proceed with the case, this should be documented on the Room Temperature and Humidity Log.

Facility Document entitled Del Sol Medical Center-PROACTIVE RISK ASSESSMENT 2018 dated 12/05/2018 stated:

Describe the Issue: Humidity issues in OR, L&D OR and Cath Lab seen when physician requesting lower temperatures see increase above acceptable range based on ASHRAE 170-2008. Humidity issues also evident during cold weather months' decrease in humidity levels <30%. At present running low temperatures to increase humidity levels but unsuccessful and decreasing temperatures from approved range.

Arguments in support of the issue-why things should remain the same: None-everyone is in agreement that we must do what is needed to maintain relative humidity levels between 30 and 60%. If RH level goes below 30% you increase risk of fire due to dry air and some older equipment may not function appropriately, due to age of some equipment. Not sure if issues will be seen.

Arguments against the Issue-why things should change: The problem is low humidity can impact surgical equipment and increase fire risk for patients and staff. Ventilation requirements under Title 25 Texas Administrative Code 133 are that the humidity must be between 30% and 60%. Based on ASHRAE 170-2008 risk would be minimal to none. RH% below 30% is not in compliance with Title 25 Texas Administrative Code Chapter 133.

Mitigation: What could you do to decrease risk? Portable humidifiers are being considered for use to lower (sic-raise) the humidity. Installation of permanent humidifiers has been approved for funding and looking to make corrections starting around March 2019. If humidity levels are at or below 30% the engineering staff will notify the charge nurse on duty and steps will be taken to adjust temperature to correct issue.

Conclusion: Installation of permanent humidifiers targeted for start of March 2019, we are changing the monitors in these areas to ones that can be calibrated and installation of building automated system that monitors temperature, humidity and pressure relationships for each invasive procedure room.

Monitoring: Engineering staff will monitor temperature and humidity three times per day and adjustments to temperature will be made.

Review of Temperature and Humidity Log for the Cardiac Catheter Lab at Las Palmas Hospital for the month of February 2019 revealed the following:

The log stated:

Temperature (Optimum Range 68-75 F)

Humidity (30-60%). This was scratched out and hand written in: (20-60%)

If temperature/humidity out of range appropriate action must be taken and documented.

The temperature for the entire month ranged from 56-66 F. Under Actions Required, it was noted daily: Dr. Ok with Room Temp. Engineering called.

Humidity for the entire month ranged from 20--59%. Handwritten on the bottom of the log was Humidity change per engineering. No documentation was provided to the survey team to explain the rationale behind the change in humidity parameters. Temperatures and humidity levels were only documented at the beginning of the day.

In an interview with the Clinical Coordinator of the Las Palmas Cardiac Catheter Lab on 3/19/19, the out of range humidity/temperatures for the catheter lab were confirmed.

Review of Temperature and Humidity Logs for Cardiac Catheter Labs 1 and 3 for the months of February through March 20, 2019 revealed the following:

Catheter Lab #1 for the month of February 2019 had humidity ranging from 5% to 39%. When humidity was out of range, it was noted that Facilities notified and temperature was adjusted. No follow up documentation was noted after temperature was adjusted.

Catheter Lab 1 for the month of March 1st through 20, 2019 had humidity ranging from 5% to 34% (10 out of 20 days < 20%). Again Facilities notified and temperature was adjusted. No follow up documentation was noted after temperature was adjusted.

Catheter Lab #3 for the month of February 2019 and March 1st thru 20th 2019 had appropriate humidity and temperature levels. These levels were only documented in the morning, once a day; contrary to the plan described in the Proactive Risk Assessment, 2018.

The following Operating Room Temperature and Humidity logs at Del Sol Hospital for the month of February 2019 were reviewed:

OR Main had humidity ranging from 22 % to 40%. (20 of 28 days the humidity level was < 30%). Only 3 days of the month had Actions Required listed as work order. This OR had no listed parameters for temperature and only had a maximum level of humidity (60%).

OR # 1 had humidity levels ranging from 17% to 56%. (16 of 28 days' humidity was < 30%). Temperature range was appropriate between 68-75 F.

OR # 2 had humidity levels ranging between 14% to 40%. (20 of 28 days' humidity was < 30%). Temperature levels (recommended at 68-75 F) ranged from 50 degrees to 68 F. It was noted multiple times Humidifier left in room.

OR # 3 had humidity levels ranging between 13% and 53%. (18 of 28 days' humidity was < 30%). Temperature levels ranged between 55 degrees to 68 F. It was noted multiple times Humidifier left in room.

OR # 4 had humidity levels ranging between 15% and 50%. (18 of 28 days' humidity was < 30%). Temperature levels ranged between 55 degrees to 68 F. It was noted multiple times Humidifier left in room.

Trauma Room # 5 had humidity levels ranging between 10% and 32%. (22 of 28 days' humidity was < 30%). Temperature levels were appropriate. It was noted multiple times Humidifier left in room.

OR # 6 had humidity levels ranging between 12% and 50%. (18 of 28 days' humidity was < 30%). Temperature levels were appropriate. It was noted multiple times Humidifier left in room.

Room # 7 (no indication of type of room was provided) had humidity levels ranging between 16% and 44%. (16 of 28 days' humidity was < 30%). Temperature levels ranged between 60 degrees to 70 F. It was noted multiple times Humidifier left in room.

OR # 8 had humidity levels ranging between 14% and 50%. (19 of 28 days' humidity was < 30%). Temperature levels ranged between 60 degrees to 73 F. It was noted multiple times Humidifier left in room and Maintenance notified.

OR # 9 had humidity levels ranging between 15% and 44%. (14 of 28 days' humidity was < 30%). Temperature levels ranged between 58 degrees to 73 F. It was noted multiple times Humidifier left in room.

OR # 10 had humidity levels ranging between 13% and 45%. (17 of 28 days' humidity was < 30%). Temperature levels ranged between 60 degrees to 71 F. It was noted multiple times Humidifier left in room.

CT Room # 1 had humidity levels ranging between 21% and 40%. (20 of 28 days' humidity was < 30%; 2 days were not checked for temperature or humidity). Temperature levels ranged between 66 degrees to 75 F. Twice it was noted that a work order was placed to correct humidity.

Radiology Room had humidity levels ranging between 14% and 32%. (22 of 28 days' humidity was < 30%). Temperature levels ranged between 55 degrees to 68 F. It was noted multiple times Called engineering for humidity.

Ultra Sound # 1 had humidity levels ranging between 21% and 43%. (2 of 28 days' humidity was < 30%). Temperature levels ranged between 55 degrees to 68 F. Temperature was within range.

Ultra Sound # 2 had humidity levels ranging between 23% and 45%. (3 of 28 days' humidity was < 30%). Temperature levels were appropriate. It was noted multiple times Called @ temp.

Anesthesia Work Room had humidity levels ranging between 22% and 59%. (19 of 28 days' humidity was < 30%). Temperature levels ranged between 40 degrees to 72 F (log had no designated range.) Temperature not recorded February 1st thru 4th. Humidity not recorded February 1st thru 3rd. It was noted several times Work order called.

Ortho Supply Room had humidity levels ranging between 15% and 55%. (20 of 28 days' humidity was < 30%). Temperature Log had no designated range. It was noted multiple times Humidifier left in room and work order called.

OR Supply Room had humidity levels ranging between 23% and 50%. (18 of 28 days' humidity was < 30%). Temperature log had no designated range. It was noted multiple times Humidifier left in room and work order.

OR Sterile Care had humidity levels ranging between 15% and 33%. (27 of 28 days' humidity was < 30%). Temperature log had no designated range. It was noted multiple times work order called.

OR Sterile Neuro Room had humidity levels ranging between 16% and 42%. (21 of 28 days' humidity was < 30%). Temperature log had no designated range. It was noted multiple times work order called.

Review of Medical Executive Committee Meeting Minutes for the month of December 2018 revealed no mention of awareness of temperature/humidity issues in the surgical areas. In interviews with executive staff on 3/21/19, it was admitted that while the issue was discovered in December and a plan was made to mitigate the problem, the plan was not followed and low humidity continued to put patients and staff at risk.

Interview with Environmental Services at Del Sol, in the conference room on 3/20/19, revealed, there was no documentation that the environmental staff monitored the humidity and temperature controls multiple times during the day when the humidity and temperature was out of range as per their plan developed on 12/5/18. They further acknowledged the temperature and humidity levels were only documented at the beginning of the day in the operating rooms and procedure rooms and there was no documentation the environmental staff monitored the temperature and humidity throughout the days while patient surgeries and procedures were occurring.

Review of the OR Temperature and Humidity Logs (#1-10) at Las Palmas for February 2019 revealed the following readings. This form indicated the Optimum temperature range was 68-75 degree Fahrenheit and Humidity was 20-60%. In an interview on 03/20/19, engineering staff member #35 verified the facility standard is 30-60% and the form being used for that month was an old version that did not reflect the actual standard for humidity.

OR #1 had humidity levels ranging from 17 % to 47 % (16 of 28 days' humidity was < 30%). Temperature range was appropriate between 58.1 to 70.4 F. There was no documentation that the physician was notified to determine if the levels could negatively affect patient care. There was only one action note that engineering was contacted regarding the readings (on 02/18/19). Multiple dates (18 of 28 dates) had documentation that the temperature was reduced for humidity control noted on the form, however the humidity was in an appropriate range (30-60 %) on 6 of those dates, indicating there was no necessity to adjust the temperature.

OR # 2 had humidity levels ranging from 25 % to 56 % (1 of 28 days' the humidity was < 30%). Temperature range was appropriate between 65.5 to 69 F. There was no documentation that the physician was notified to determine if the levels could negatively affect patient care. Multiple dates (18 of 28 dates) had documentation that the temperature was reduced for humidity control noted on the form, however the humidity was in an appropriate range (30-60 %) on 17 of those dates, indicating there was no necessity to adjust the temperature.

OR # 3 had humidity levels ranging from 33 % to 59 % (No days had humidity < 30%). Temperature range was appropriate between 59.5 to 86.5 F. There was no documentation that the physician was notified to determine if the levels could negatively affect patient care. There was only one action note that engineering was contacted regarding the readings (on 02/16/19). Multiple dates (18 of 28 dates) had documentation that the temperature was reduced for humidity control noted on the form, however the humidity was in an appropriate range (30-60 %) on all 18 of those dates, indicating there was no necessity to adjust the temperature.

OR # 4 had humidity levels ranging from 31 % to 57 % (No days had humidity < 30%). Temperature range was appropriate between 65.5 to 69 F. There was no documentation that the physician was notified to determine if the levels could negatively affect patient care. Multiple dates (12 of 28 dates) had documentation that the temperature was reduced for humidity control noted on the form, however the humidity was in an appropriate range (30-60 %) on all 12 of those dates, indicating there was no necessity to adjust the temperature.

OR # 5 had humidity levels ranging from 30 % to 54.1 % (No days had humidity < 30%). Temperature range was appropriate between 65 to 71.5 F. There was no documentation that the physician was notified to determine if the levels could negatively affect patient care. Multiple dates (16 of 28 dates) had documentation that the temperature was reduced for humidity control noted on the form, however the humidity was in an appropriate range (30-60 %) on all 16 of those dates, indicating there was no necessity to adjust the temperature.

OR # 6 had humidity levels ranging from 30 % to 49 % (No days had humidity < 30%). Temperature range was appropriate between 65.7 to 69 F. There was no documentation that the physician was notified to determine if the levels could negatively affect patient care. Multiple dates (17 of 28 dates) had documentation that the temperature was reduced for humidity control noted on the form, however the humidity was in an appropriate range (30-60 %) on all 17 of those dates, indicating there was no necessity to adjust the temperature.

OR# 7 had humidity levels ranging from 21 % to 49 % (2 dates had humidity < 30%). Temperature range was appropriate between 62.5 to 69 F. There was no documentation that the physician was notified to determine if the levels could negatively affect patient care. Multiple dates (20 of 28 dates) had documentation that the temperature was reduced for humidity control noted on the form, however the humidity was in an appropriate range (30-60 %) on 19 of those dates, indicating there was no necessity to adjust the temperature.

OR # 8 had humidity levels ranging from 19 % to 44 % (8 dates had humidity < 30%). Temperature range was appropriate between 65.8 to 68.3 F. There was no documentation that the physician was notified to determine if the levels could negatively affect patient care. Multiple dates (15 of 28 dates) had documentation that the temperature was reduced for humidity control noted on the form, however the humidity was in an appropriate range (30-60 %) on 11 of those dates, indicating there was no necessity to adjust the temperature. On 02/22/19 the humidity of 20 % and the 02/25/19 the humidity of 20 % had no actions noted.

OR # 9 had humidity levels ranging from 20 % to 44 % (10 dates had humidity < 30%). Temperature range was appropriate between 59.9 to 68.2 F. There was no documentation that the physician was notified to determine if the levels could negatively affect patient care. Multiple dates (15 of 28 dates) had documentation that the temperature was reduced for humidity control noted on the form, however the humidity was in an appropriate range (30-60 %) on 9 of those dates, indicating there was no necessity to adjust the temperature.

OR # 10 had had humidity levels ranging from 25 % to 49 % (3 dates had humidity < 30%) for 02/01/19 to 02/08/19. OR #10 was closed for construction on 02/08/19. Temperature range was appropriate between 58.6 to 64.5 F. There was no documentation that the physician was notified to determine if the levels could negatively affect patient care. Multiple dates (8 of 8 dates) had documentation that the temperature was reduced for humidity control noted on the form, however the humidity was in an appropriate range (30-60 %) on all 5 of those dates, indicating there was no necessity to adjust the temperature.

In an interview on 03/20/19, staff member #A35 confirmed for the Las Palmas the humidity values are 30-60% and the OR staff was using the wrong form that had the value of 20-60 % indicated. For March 2019 the OR #1-10 log reflected the correct humidity values of 30-60 %. Staff member #A35 also verified that the temperature did not need to be adjusted if the humidity reading is within normal limits. Review of the March 2019 Temperature and Humidity logs revealed that the appropriate humidity values of 30-60 % were obtained.

In an interview on 03/20/19, staff member #A36 Interim Administrative Director of Surgical Services and #A37 Director of Surgical Services confirmed that the staff in OR #1-10 were not properly completing the Temperature and Humidity Logs per facility policy in February 2019. Per staff member #A36 starting to record the temperature and humidity from the readings obtained in the engineering department starting the week of 02/18/19, so the temperature reading would be more accurate and consistent.

On 03/20/19, staff members A#35 , A36, and A37 confirmed the above findings regarding the temperature and humidity logs for ORs #1-10 at Las Palmas.

Based on observation and interview, the facility failed to ensure a sanitary environmental practices to avoid sources and transmission of infectious and communicable diseases.

Findings:

During a tour of the 3rd floor at Del Sol facility the morning of 3/19/2019, the follow was observed,

Patient room 312A was missing the veneer around the rim of the bedside table with visible exposed raw wood.

Patient room 319A had worn varnish on the surface area and corners of the bedside table with visible exposed raw wood.

Patient room 322B had worn varnish on the surface area and corners of the bedside table with visible exposed raw wood.

Patient room 335A had 6 exposed screws on the right entry wall.

Patient room 433 bathroom sink had exposed gray/black residue and sealant protruding around the perimeter of the sink.

Baseboards were visibly soiled with black marks throughout the 3rd floor

This was confirmed in an interview with Staff #5, Roster B.

Based on interview and record review, the facility failed to provide surgical services in a sanitary environment when the Del Sol Facility's Endoscope Processing system and Surgical Instrument Washer's routine maintenance were not being performed according to the Manufacturer's recommendation.

Findings:

An observation during a tour of the Del Sol Facility's Sterile Processing Department, on the morning of 3/19/19, revealed a yellow and white substance along the door and at the base of the facility's surgical instrument washer.

During an interview on the morning of 3/19/19, in the facility's sterile processing department, when asked for the routine preventative maintenance of the surgical instrument washer and the Endoscope Processing System, Staff #7C, Sterile Processing Supervisor verified the parts of the washer that were being cleaned but failed to provide documentation that the preventative maintenance was being performed as scheduled. Staff #7C stated, the Steris Manufacturer conducts the routine maintenance on the Endoscope Washer, ...We call them out if we need something ...

Review of the facility provided Reliance EPS Endoscope Processing System routine maintenance manual reflected,

...3.1 Verify debris screen in chamber is clean and in good condition .... 1x/day

3.2 Perform a D-SHORT cycle every 54 hours

3.3 Clean chamber rotary spray arm assembly 1x/week ...

3.5 Clean plastic surfaces and processor exterior panels 1x/week

3.6 Clean steel surfaces 1x/day ...

5.1 Clean endoscope processing support rotary spray arm assembly 1x/week

5.2 Clean three draining holes at bottom of control handle boots using a thin wire or compressed air 1x/week

5.3 Clean draining holes in bottom of Reliance CDS Chemical Delivery System using a thin wire or compressed air 1x/week

5.4 Clean venting orifice of two Allen hex screws from Reliance CDS using compressed air 1x/week ...

5.8 Verify flexible silicone tubing of Flow Units is in good condition (not brittle, discolored, cracked, yellowish). Verify Flow Unit adapters and ports are in good condition 1x/week

Review of the facility provided Steris Washer Manufacturer's cleaning instructions reflected, ...5.4 Clean washer/disinfector exterior (see Section 6.6) Once a Week.

Based on interview and record review, the facility failed to provide surgical services in a safe manner when the anesthesiologist documented a patient's operative information before the patient had arrived into the operating room.

Findings:

Review of a Del Sol Hospital Surgical Patient#1C's operative report, dated 3/19/19 at 12:30 pm, reflected, ...Ventilation controlled, Position Supine, Pressure points checked and padded, and eyes taped .... had been documented as having been completed. Patient #1C was still in the pre-operative unit and the items had not been completed.

The facility failed to provide a requested policy for the appropriate documenting of surgical procedures.

During an interview on the morning of 3/19/19, in the Pre-operative surgical unit, Staff #2C confirmed the findings.

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

Based on review of facility policy, review of medical records and staff interview, the facility failed to ensure each patient was able to exercise their patient's rights.

Findings included:

Facility Policy titled Patient Rights stated in part, Purpose: The commitment to treat all patients with respect and dignity is an obligation of every HCA colleague and a fundamental principle of being part of HCA. We recognize the diverse backgrounds and cultural needs of our patients and strive to foster an inclusive environment through the provision of culturally competent care ...

Procedure: All patients are to be treated in a manner that preserves their dignity, autonomy, self-esteem, civil rights and involvement in their own care.

The patient rights notification at a minimum will address the following ... The right to receive considerate and respectful care, including consideration of cultural, spiritual, psychosocial and personal values, beliefs and preferences.

Review of the medical record for patient #1 revealed patient #1 was admitted to the facility on [DATE] for a 37-week intrauterine pregnancy. Patient #1's admission record dated 10/1/18 at 4:15 pm stated in part, Cultural/Spiritual Practices:

Practices to Incorp [incorporate] in Care: Yes

ANNOTATIONS: NO MEN IN ROOM ...

There were two males present during patient #1's C-section [Caesarean Section], a certified registered nurse anesthetists [CRNA] and a neonatal nurse practitioner [NNP]. She did not approve the NNP to be present during her procedure. The facility failed to comply with her wishes.

In an interview with staff #5 on the afternoon of 1/14/19, staff #5 stated, I asked [nursing staff] what the practice was. Our NICU [neonatal intensive care unit] team said, 'We always meet the patient before.' I asked if there was anything documented regarding that, they did not have any. When asked if there was any pre-assessment or discussion regarding the NNP being male with patient #1 prior to the procedure, staff #5 stated, There's nothing documented as far as that. I reached out to the NNP to see what kind of documentation there was before. Staff verbalized that normally the staff would introduce themselves but not necessarily document.

Based on a review of documentation, the director of nursing failed to be responsible for the operation of the nursing service, as nursing staff failed to follow facility policies and procedures.

Findings were:

Patient #1 had a rectal temperature of 101.8 degrees Fahrenheit at 11:32 am on 5-8-17. The patient was medicated with acetaminophen 650mg orally at 1:22 pm for fever, per doctor's order. The patient's temperature was reassessed at 3:32 pm and measured 100.0 Fahrenheit (orally). No other record of reassessment of patient #1's temperature was found.

The patient's vital signs were reassessed at the following times while in the emergency department:

* 5-8-17 at 12:00 pm

* 5-8-17 at 2:00 pm

* 5-8-17 at 3:00 pm

* 5-8-17 at 3:32 pm (including temperature)

* 5-8-17 at 4:32 pm

* 5-8-17 at 5:29 pm

* 5-8-17 at 7:30 pm

* 5-8-17 at 11:30 pm

* 5-9-17 at 3:30 am

* 5-9-17 at 6:15 am (and subsequently transferred from the ER to the Intensive Care Unit)

Facility policy titled Documentation Policy states, in part:

Policy:

...

B. 3. Level II patients: vital signs to be done upon arrival, and then q1 hour [every hour] with temperature done every 4 hours or upon discharge if patient leaves in less than 4 hours. If patient is unstable and requires closer monitoring due to condition, medication administration or interventions/treatments vital signs to be documented every 15 minutes with temperatures every 4 hours of upon admission to hospital if in ED less than 4 hours.

C. Medication Administration:

...

2. Effects of medication should be assessed and documented in nurse's notes after administration.

3. The type of documentation required is related to the type of medication administered.

Antipyretics: patients' temperature to be documented in vital signs 30 minutes to 1 hour after administration of antipyretic.

The above was confirmed in an interview with the Chief Nursing Officer and Director of Clinical Informatics on the afternoon of

11-13-18.

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

Based on interview and record review, the facility failed to comply with Texas Dog Laws when the facility failed to inform local authorities when two patients presented to the emergency room with dog bites. (Patients #G8 and G9)

Findings Include:

Review of the facility's medical records logs reflected:

On 2/28/2017, Patient #G9, a [AGE] year old female presented to the emergency room with a complaint of a dog bite.Pt [patient] was walking home, and 'she saw the dog running towards her after the dog was playing with its owners' ...puncture wound noted to right calf. Minor bleeding note...

On 12/24/16, Patient #G8, a [AGE] year old male presented to the emergency room with a complaint of a dog bite. Bit [sic] to left forearm by pts dog... two puncture wounds noted to left forearms...

During an interview on 4/19/17, in the facility conference room, Staff #G17, the Quality Director, stated, We don't have to report the dog bites.

Review of the El Paso Texas Dog Law www.texasdogbiteinjurylaw.com/texas-cities-animal-ordinances.php reflected ...Anyone who suffers an animal bite or scratch that breaks the skin should contact El Paso animal Services and state authorities within 24 hours of the incident...

Based on a review of documentation and interview, the facility failed to protect and promote each patient's rights. As evidence by:

1. Failing to provide an emotionally safe environment. Cross refer to A0144.

2. Failing to ensure the patient right to be free from the inappropriate use of restraint, by allowing hospital employed/contracted staff to utilize handcuffs as restraints in the Emergency Department. Cross refer to A0154.

3. Failing to ensure that the use of restraint was in accordance with the order of a physician or other licensed independent practitioner who is responsible for the care of the patient as specified under º482.12(c) and authorized to order restraint or seclusion by hospital policy in accordance with State law. Cross refer to A0168.

4. Failing to ensure the use of restraint included written modification to the patient's plan of care. Cross refer to A0166

5. Failing to ensure that unless superseded by State law that is more restrictive--

(i) Each order for restraint or seclusion used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others may only be renewed in accordance with the following limits for up to a total of 24 hours: (A) 4 hours for adults 18 years of age or older. Cross refer to A0171.

6. Failing to ensure that restraint incidents had documented face-to face evaluations within 1 hour after the initiation of the restraint to evaluate:

1. The patient's immediate situation;

2. The patient's reaction to the intervention;

3. The patient's medical and behavioral condition; and

4. The need to continue or terminate the restraint or seclusion.

Cross refer to A0179

7. Failing to ensure that for restraint episodes, the patient medical record includes a description of the patient's behavior and the intervention used. Cross refer to A0185.

8. Failing to ensure that for restraint episodes, the patient medical record included, alternatives or other less restrictive interventions attempted (as applicable). Cross refer to A0186.

9. Failing to ensure that for restraint episodes, the patient medical record included, the patient's condition or symptom(s) that warranted the use of the restraint or seclusion. Cross refer to A0187.

10. Failing to ensure that for restraint episodes, the patient medical record included. the patient's response to the intervention(s) used, including the rationale for continued use of the intervention. Cross refer to A0188.

11. Failing to ensure that patients had the right to safe implementation of restraint or seclusion by trained staff. Cross refer to A0194.

Based on observation, interview and record review the facility failed to protect and promote each patient's rights when a patient was not given a bath for four days, restraints were not care planned and a patient was restrained for nine days without alternative interventions being attempted and the facility was using a medical restraint for a patient being restrained for behavioral issues.

Cross Refer to A144, A154 and 166

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

Based on observation, interview and record review the facility failed to provide an emotionally safe environment when a patient requested a shower and was not provided access to a shower for four days. (Patient G#16)

Findings include:

An observation on the morning of 4/19/17 in the facility emergency room revealed Patient #G16 was under a protective order of custody, a security guard was standing outside the patient's door.

During an interview on the morning of 4/19/17 in the facility emergency room , Patient #G16 when asked if he had been offered a shower or had asked for a shower stated, I asked for one but wasn't given one ....I need a shower ...I smelt myself and nearly knocked myself over ...

The facility was informed Patient #G16 was requesting a shower on the morning of 4/19/17.

During an interview on the morning of 4/20/17 in the facility emergency room , Staff #G16, emergency room Director when asked if Patient #G16 had received a shower stated,...he went to court today ...he got a shower at around 7:00 this morning ....I asked for him to get a shower yesterday too... When asked if he had gotten one yesterday, Staff #G16 stated, I don't know.

Review of Patient #G16 medical records reflected a [AGE] year old male admitted on [DATE] at 11:40 a.m. was given a shower on 4/20/17 at 7:15 a.m. There was no further documentation to reflect he was offered or given a shower.

The facility did not provide a policy for the hygiene of patients held in the emergency room over 24 hours.

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

Based on a review of documentation and interview, the facility failed to ensure the patient right to be free from the inappropriate use of restraint. According to the Centers for Medicare Interpretive Guidance: The use of handcuffs, manacles, shackles, other chain-type restraint devices, or other restrictive devices applied by non-hospital employed or contracted law enforcement officials for custody, detention, and public safety reasons are not governed by this rule. The use of such devices are considered law enforcement restraint devices and would not be considered safe, appropriate health care restraint interventions for use by hospital staff to restrain patients.

Findings included:

Facility based policy entitled, PC 210 Restraints stated in part,

Exceptions to the Definition of Restraints:

3) Use of Handcuffs:

The use of handcuffs and other restrictive devices used by law enforcement who are not employed or contracted by the facility for custody, detention or other public safety reasons, and not for the provision of healthcare, is not governed by these standards. However the use of such devices are considered law enforcement restraint devices and would not be considered safe, appropriate health care restraint interventions for use by hospital staff to restrain patients.

Based on interview and review of documentation, the facility was inappropriately utilizing handcuffs as a method of restraint, often applied by off duty police officers who were contracted employees of the facility. This use of handcuffs as a restraint is not considered a safe, appropriate health care restraint interventions for use by hospital staff to restrain patients and is not permitted per facility policy and CMS regulations.

In an interview on 04/20/17, staff member #A42 stated that the few restraints they had observed in Del Sol Emergency Department occurred during Code Strongs when all free staff including nurses, security, and the off duty police officers responded. This staff member was asked about the use of handcuffs during Code Strongs in the Emergency Department at the Del Sol campus. The staff member replied that the off duty police officers at the facility apply handcuffs in a code strong scenario. They added once the patient is in handcuffed, security personnel will stand to the side to monitor the patient. Usually the off duty police officer takes over.

Staff member #A23 stated that patients are sometimes brought to the facility Emergency Department in handcuffs while in police custody. This staff member stated that police officer will at times hand the care of the handcuffed patient off to the off duty police officer employed by the facility. This staff member was asked when the patient's handcuffs would be removed. They replied, We assess them every 15 minutes, the nurse and security talk and determine when they can be released. This staff member also confirmed that at times when a Code Strong is called for an aggressive patient, the patient will be handcuffed by the off duty police officer at the facility until calm.

Review of sample of Code Strongs recorded for the Del Sol Emergency Department for the month of March and April 2017 revealed one documented restraint involving the handcuffing of a patient which was not documented in medical records.

* A Daily Security Supervisor Pass Down report on 03/18/17 included the following, ER #36 right handcuff applied @1145 due to punching & throwing food at the wall.

It is unknown if facility security or contracted off duty police officers applied this handcuff restraint. Per facility based policy and CMS guidance, this type of employee is not permitted to apply handcuffs as a restraint.

Review of [Security Company Name] Security-Patient Restraint forms revealed 2 of 4 documented restraint incidents involving the use of handcuffs and/or shackles:

* Patient #A14 was restrained on 04/15/17 at 1200 the form stated, @ 1200 hrs EPPD brought pt into ER being very verbally abusive. Pt was cuffed by off duty EPPD [name] X 2. @ 1330 cuffs off due to pt sleeping.

04/15/17-1855 [name] applied restraints. Pt spitting at security. Constantly calling [staff member #A41] 'N' word. Trying to tip bed over. Shackles and spit mask put on pt.

04/15/17 1945 [staff name] checking restraints

04/15/17 2010-as per charge RN [name] all restraints were removed at 2010 by off duty [name]

* Patient #A17 was restrained on 04/14/17 at 2300 the form stated, Patient who is [AGE] years old was restrained (2 x) due to being aggressive. Pt. continued try to remove his I.V. As mother's permission handcuff restraints were applied.

04/15/17 pt @ 0100 was placed with one handcuff.

04/15/17 pt @ 0120 was released from other handcuff.

Documentation indicates that Patient #A14 was restrained using a handcuff by a facility contracted off duty police officer, which is against facility based policy and CMS guidance. Based on documentation it is unknown who applied the shackles to Patient #A14. It is unknown if facility security or contracted off duty police officers applied the handcuff restraint on Patient #A17.

Based on interviews and documentation review, the facility utilized handcuffs to restrain patients. At times, these handcuffs were applied by hospital contracted employees, which is not allowed. Handcuffs should only be utilized by non-hospital employees or non-contracted law enforcement officials for custody, detention, and public safety reasons. In such a scenario, the non-hospital employed or contracted law enforcement officials should maintain custody and direct supervision of their prisoner.

The above findings were confirmed in an interview on 04/20/17 with staff members #A34 and A37.

.

Based on record review and interview the facility used a restraint inappropriately when an assessment for Risk for Restraint and less restrictive alternatives were not attempted prior to placing a patient in a restraint. (Patient #G21)

Findings Include:

Review of Patient #G21's medical records revealed on 3/12/17 Patient #G21 experienced a fall. Review of physician's orders for Restraint device: Enclosure...Unsafe mobile attempts... with daily orders written from 3/12/17 through 3/22/17. Review of the facility's available interventions included 'Sitter'.

During an interview on 4/20/17 in the facility conference room, Staff #G18, Director of Advance Clinical, when asked if the facility had attempted to use a sitter, staff #G18 stated, No. While reviewing the electronic assessment for Risk for Restraint Staff #G18 confirmed the assessment form did not include all the questions to review as the facility's Restraint policy required.

Review of the facility provided document PC 210 Restraints (dated 6/30/15) reflected ...Purpose: 1. to protect the dignity and safety of inpatients...through safe restraint processes. 2. To identify patients at risk for restraint and provide alternatives to restraint use. 3. To provide guidelines for use of least restrictive interventions to avoid restraint use....The Registered Nurse performs an assessment for risk for restraint when a patient exhibits behavior that may place the patient at risk for restraint....4. Second Tier of Review....a. Alternatives attempted.

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

Based on interview and record review the facility failed to develop and keep current, a nursing care plan for each patient when interventions and reassessments were not care planned on (3) out of (3) patients reviewed for restraint care plans. (Patients #G23, G21 and G22)

Findings Include:

Review of Patient #G23's medical records revealed a [AGE] year old female admitted on [DATE] and placed on restraints on 3/10/17. The patient's care plan was not updated to reflect the implementation of the restraint.

Review of Patient #G21's medical records revealed a [AGE] year old male admitted on [DATE] and placed on restraints on 3/12/17. The patient's care plan was not updated to reflect the implementation of the restraint.

Review of Patient #G22's medical records revealed a [AGE] year old male admitted on [DATE] and placed on restraints on 1/12/17. The patient's care plan was not updated to reflect the implementation of the restraint.

During an interview on 4/20/17 in the facility conference room, Staff # 18, Director of Advance Clinical, confirmed the care plans did not include the implementation of the restraints.

Review of the facility provided document PC 210 Restraints (dated 6/30/15) reflected, ...Purpose: 1. to protect the dignity and safety of inpatients ...through safe restraint processes. 2. To identify patients at risk for restraint and provide alternatives to restraint use... 10. Care of the Patient/Plan of Care...a. The plan of care will clearly reflect a loop of assessment, intervention, and evaluation for restraint...

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

Based on a review of documentation and interview, the facility failed to ensure that the use of restraint was in accordance with the order of a physician or other licensed independent practitioner who is responsible for the care of the patient as specified under º482.12(c) and authorized to order restraint or seclusion by hospital policy in accordance with State law.

Findings included:

Facility based policy entitled, PC 210 Restraints stated in part,

POLICY:

HCA is dedicated to fostering a culture that supports a patient's right to be free from restraint or seclusion. Restraint use will be limited to clinically justified situations, and the least restrictive restraint will be used with the goal of reducing, and ultimately eliminating, the use of restraints. The facility Chief Nursing Officer (CNO) provides leadership and organizational accountability for monitoring the safety, appropriateness and necessity of restraint use.

Las Palmas Del Sol Healthcare does not provide for psychiatric/substance abuse patients and limits the use of restraints to situations where appropriate clinical justification is appropriate. At all times we strive to protect the patient's rights, dignity and safety at Las Palmas Del Sol Healthcare...

5. Order for Restraint

a. 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 to be used and behavior-based criteria for release.

1) An order for restraint may not be written as a standing order, protocol or as a PRN or 'as needed' order.

2) If a patient was recently released from restraint or seclusion, and exhibits behavior that can only be handled through the reapplication of restraint or seclusion, a new order is required.

b. If a telephone order is required, the RN must write down the order while the physician is on the phone and read-back the order to verify accuracy. The order must specify clinical justification for the restraint, the date and time ordered, the duration of use, the type of restraint and behavior-based criteria for release.

c. The treating physician is to be notified as soon as possible if another physician, (e .g. on-call physician) orders the restraint.

d. When a LIP/physician is not available to issue a restraint order, an RN with demonstrated competence may initiate restraint use based upon face-to-face assessment of the patient. In these emergency situations, the order must be obtained during the emergency application or immediately (within minutes) after the restraint is applied...

5B. Order for Restraint with Violent or Self Destructive Behavior

a. Physician orders for restraint must be time limited, and must specify clinical justification for the restraint/seclusion, the date and time ordered, duration of restraint/seclusion use, the type of restraint, and behavior-based criteria for release. Orders for restraint or seclusion must not exceed:

1) 4 hours for adults, aged 18 years and older

2) 2 hours for children and adolescents aged 9 to 17 years, or

3) 1 hour for children under 9 years

i. The time frames specified are maximums. The physician may order a shorter period of time.

ii. Staff assess, monitor, and re-evaluate the patient regularly and release the patient from restraint or seclusion when criteria for release are met.

b. To continue restraint or seclusion beyond the initial order duration, the RN determines that the patient is not ready for release and calls the ordering physician to obtain a renewal order. Renewal orders for restraint/seclusion may not exceed:

1) 4 hours for adults, aged 18 years or older

2) 2 hours for children and adolescents aged 9 to 17 years, or

3) 1 hour for children under 9 years

c. Orders may be renewed according to time limits above for a maximum of 24 consecutive hours. Every 24 hours, unless state law is more restrictive, a physician or other authorized LIP primarily responsible for the patient's care sees and evaluates the patient before writing a new order for restraint or seclusion.

There were multiple documented uses of restraints at the Del Sol campus with no physician order for restraints documented. Review of a sample of Code Strongs recorded for the Emergency Department for the month of March and April 2017 revealed several documented restraints and/or the handcuffing of patients which were not documented in medical records. The Daily Security Supervisor Pass Down reports documented the following:

* On 03/18/17 the form documented the following, ER #36 right handcuff applied @1145 due to punching & throwing food at the wall.

* On 03/23/17 at 7:08 PM the following was documented, EDO Pt tried eloping from the ER and attempted to tackle to the ground [security officer]. [Security officer] tried to restrain the PT but was sprayed with mace by PT. Subject was then restrained and taken into custody by the [police department].

* On 04/12/17 the form documented the following, 1540 Code Strong ER #36 pt became combative while trying to elope and was restrained.

The facility was unable to provide documented physician orders for the above episodes of restraint.

An employee with the facility security provided the surveyors copies of the [Security Company Name] Security-Patient Restraint Form. Staff members # #A35, 36, and 42 confirmed this form was stored in the security office of this facility.

Review of [Security Company Name] Security-Patient Restraint forms revealed the following:

* Patient #A14 was restrained on 04/15/17 at 1200 the form stated, @ 1200 hrs EPPD brought pt into ER being very verbally abusive. Pt was cuffed by off duty EPPD [name] X 2. @ 1330 cuffs off due to pt sleeping.

04/15/17-1855 [name] applied restraints. Pt spitting at security. Constantly calling [staff member #A41] 'N' word. Trying to tip bed over. Shackles and spit mask put on pt.

04/15/17 1945 [staff name] checking restraints

04/15/17 2010-as per charge RN [name] all restraints were removed at 2010 by off duty [name].

* Patient #A15 was restrained on 4/19/17 at 3:00 pm, the form stated in part, At 3:00 pm patient right hand was placed under restraint, because [sic] patient #A15 was combative to staff. Restraints applied by EPPD.

* Patient #A16 was restrained on 3/31/17 the form stated in part, Pt. [patient] was brought in by EPPD [El Paso Police Department] restrained (hands and feet) due to him being uncompliant and combative. Pt. is also under the influence of an unknown substance. RN [staff# 38] approved of pt's hands and feet [4-point restraints] to be restrained to the bed. At 4:39 pm. In 15-minute intervals, staff #A39 stated, 4-point restraints checking okay starting at 5:00 pm until 8:30 pm. No monitoring was documented until midnight on 4/1/17. Staff #A38 documented 4-points restraints Cok [checking okay] in hour intervals starting at 12:00 am until 6:00 am. No monitoring was documented after 6:00 am. There was no documentation for release of restraints.

* Patient #A17 was restrained on 04/14/17 at 2300 the form stated, Patient who is [AGE] years old was restrained (2 x) due to being aggressive. Pt. continued try to remove his I.V. As mother's permission handcuff restraints were applied.

04/15/17 pt @ 0100 was placed with one handcuff.

04/15/17 pt @ 0120 was released from other handcuff.

The facility was unable to provide documented physician orders for the above episodes of restraint.

The above findings were confirmed in an interview on 04/20/17 with staff members #A34 and A37.

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

Based on a review of documentation and interview, the facility failed to ensure that unless superseded by State law that is more restrictive--

(i) Each order for restraint or seclusion used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others may only be renewed in accordance with the following limits for up to a total of 24 hours:

(A) 4 hours for adults 18 years of age or older

Findings included:

Facility based policy entitled, PC 210 Restraints stated in part,

5B. Order for Restraint with Violent or Self Destructive Behavior

a. Physician orders for restraint must be time limited, and must specify clinical justification for the restraint/seclusion, the date and time ordered, duration of restraint/seclusion use, the type of restraint, and behavior-based criteria for release. Orders for restraint or seclusion must not exceed:

1) 4 hours for adults, aged 18 years and older

2) 2 hours for children and adolescents aged 9 to 17 years, or

3) 1 hour for children under 9 years

i. The time frames specified are maximums. The physician may order a shorter period of time.

ii. Staff assess, monitor, and re-evaluate the patient regularly and release the patient from restraint or seclusion when criteria for release are met.

b. To continue restraint or seclusion beyond the initial order duration, the RN determines that the patient is not ready for release and calls the ordering physician to obtain a renewal order. Renewal orders for restraint/seclusion may not exceed:

1) 4 hours for adults, aged 18 years or older

2) 2 hours for children and adolescents aged 9 to 17 years, or

3) 1 hour for children under 9 years

c. Orders may be renewed according to time limits above for a maximum of 24 consecutive hours. Every 24 hours, unless state law is more restrictive, a physician or other authorized LIP primarily responsible for the patient's care sees and evaluates the patient before writing a new order for restraint or seclusion.

There were multiple documented uses of restraints at the Del Sol campus. Review of a sample of Code Strongs recorded for the Emergency Department for the month of March and April 2017 revealed several documented restraints and/or the handcuffing of patients which were not documented in medical records. The Daily Security Supervisor Pass Down reports documented the following:

* On 03/18/17 the form documented the following, ER #36 right handcuff applied @1145 due to punching & throwing food at the wall.

* On 03/23/17 at 7:08 PM the following was documented, EDO Pt tried eloping from the ER and attempted to tackle to the ground [security officer]. [Security officer] tried to restrain the PT but was sprayed with mace by PT. Subject was then restrained and taken into custody by the [police department].

* On 04/12/17 the form documented the following, 1540 Code Strong ER #36 pt became combative while trying to elope and was restrained.

Due to lack of documentation in the medical record or elsewhere besides the Pass Down Reports, it is unknown if the above restraints lasted less than 4 hours. Per policy and regulation any restraint lasting longer than 4 hours, requires an order renewal. These episodes also did not have physician orders present.

Review of [Security Company Name] Security-Patient Restraint forms revealed the following:

* Patient #A14 was restrained on 04/15/17 at 1200 the form stated, @ 1200 hrs EPPD brought pt into ER being very verbally abusive. Pt was cuffed by off duty EPPD [name] X 2. @ 1330 cuffs off due to pt sleeping.

04/15/17-1855 [name] applied restraints. Pt spitting at security. Constantly calling [staff member #A41] 'N' word. Trying to tip bed over. Shackles and spit mask put on pt.

04/15/17 1945 [staff name] checking restraints

04/15/17 2010-as per charge RN [name] all restraints were removed at 2010 by off duty [name].

* Patient #A15 was restrained on 4/19/17 at 3:00 pm, the form stated in part, At 3:00 pm patient right hand was placed under restraint, because [sic] patient #A15 was combative to staff. Restraints applied by EPPD.

* Patient #A16 was restrained on 3/31/17 the form stated in part, Pt. [patient] was brought in by EPPD [El Paso Police Department] restrained (hands and feet) due to him being uncompliant and combative. Pt. is also under the influence of an unknown substance. RN [staff# 38] approved of pt's hands and feet [4-point restraints] to be restrained to the bed. At 4:39 pm. In 15-minute intervals, staff #A39 stated, 4-point restraints checking okay starting at 5:00 pm until 8:30 pm. No monitoring was documented until midnight on 4/1/17. Staff #A38 documented 4-points restraints Cok [checking okay] in hour intervals starting at 12:00 am until 6:00 am. No monitoring was documented after 6:00 am. There was no documentation for release of restraints.

* Patient #A17 was restrained on 04/14/17 at 2300 the form stated, Patient who is [AGE] years old was restrained (2 x) due to being aggressive. Pt. continued try to remove his I.V. As mother's permission handcuff restraints were applied.

04/15/17 pt @ 0100 was placed with one handcuff.

04/15/17 pt @ 0120 was released from other handcuff.

Due to lack of documentation in the medical record, it is unknown if the above restraints last less than 4 hours. The restraint of Patients #A 14 and 16 appears to have lasted for over 8 hours with no physician orders or renewal present. Per policy and regulation any restraint lasting longer than 4 hours, requires an order renewal.

The above findings were confirmed in an interview on 04/20/17 with staff members #A34 and A37.

Based on review of medical records and interviews, the facility failed to comply with patient rights related to the use of restraint or seclusion. The physician ordered a restraint for the management of an agitated patient. The physician order was written to expire 24 hours from the time the restraint was initiated.

Findings were:

In a review of the following record in the conference room at Del Sol Hospital the afternoon of 4/20/17 revealed that physician orders and the restraint of patient #G23 exceeded the four (4) hour limit used for the management of violent or self-destructive behavior of an adult 18 years of age or older.

Patient # G23 with a Date of Birth of 04/12/75

Order for Restraint dated 03/10/17 at 2004.

Order expiration date: 03/11/17 at 2004.

Restraint device: Soft BUE [bilateral upper extremities]

Nurse Notes Entered: March 10, 2017 at 1956, read, patient continue to be very restless and agitated after Ativan. Haldol 5 mg IM [intramuscular] administered at this time w/security at BS [with security at bedside] holding patient in bed to keep from falling out of bed. Charge nurse calling [doctor's name] for further orders, including possible restraint order.

Nurses Notes Entered: 3/10/17 at 2004, read, Code Strong called, spoke to [doctor's name] on the phone, states to restraint [sic] patient. Will carry out as ordered.

Another Order for Restraint was dated 03/11/17 at 1913

Order expiration date 03/12/17 at 2359

Restraint device Soft BUE

Nurse Notes dated 3/11/17 at 0145 read, Woke-up non-restless at this time. 3 staff at BS, and patient became increasingly restless and agitated, fighting wrist restraints and legs up and in down on the air and over the rail.

Nurse Notes dated 3/11/17 at 0201 read, Zyprexa 5 mg IM administered as ordered, Code Strong called -security officers at BS. Continue to watch effect of Zyprexa.

Nurse Notes dated 3/11/17 at 0239 read, Continue to be restless & agitated, fighting w/security officer 37 min. after Zyprexa given. Haldol 5 mg IV administered this time as ordered-monitor effect of med prior to Valium for few minutes.

Nurses Note dated 3/12/17 at 0330 read, Continue to be restless off/on, legs over the rails and pulling against restraints. Precedex drip at 0.8 mcg/kg/hr. at present.

Nurse Note dated 3/12/17 at 0331 read, Ativan 2 mg administered for persistent & increasing restlessness.

Another Order for Restraint was dated 03/12/17 at 1919

Order expiration date 03/13/07 at 2359

Restraint device Soft BUE

Nurse Notes Entered: March 13, 2017 at 0800 read, Received Pt. awake A&O x1 [alert and oriented times one]. Pt disoriented, but calm, watching TV, unable to speak or voice any concerns, restraints in place secured and intact. Seizure pads in place for precautions. Pt is now on nasal cannula at 2 LT. SPO2 at 95%, no signs of resp. distress seen at the moment. PEG Tube in place, no residuals seen at the moment. Did notice increased coughing and phlegm with Jevity boluses. El Paso State support center staff at bedside. No signs of distress seen at the moment. Will continue to monitor.

Review of the above patient's medical record, revealed that the patient had a physician's order for Soft BUE restraint. Restraint orders exceeded the 4 hour limit used for the management of violent or self-destructive behavior of an adult 18 years of age or older use. Nurse's notes indicated that the patient exhibited behavior of agitation, restlessness and fighting. No documentation was observed that the use of soft BUE restraints were used as medical restraint.

The above findings were confirmed by the Risk Manager the afternoon of 4/20/17.

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

Based on a review of documentation the facility failed to ensure that restraint incidents had documented face-to face evaluation within 1 hour after the initiation of the restraint to evaluate:

1. The patient's immediate situation;

2. The patient's reaction to the intervention;

3. The patient's medical and behavioral condition; and

4. The need to continue or terminate the restraint or seclusion.

Findings included:

Facility based policy entitled, PC 210 Restraints stated in part,

9. Face-to-face assessment by a Physician or LIP:

a. A face-to-face assessment by a physician or LIP, RN or physician assistant with demonstrated competence, must be done within one hour of restraint/seclusion initiation or administration of medication to manage violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others. At the time of the face-to-face assessment, the LIP/physician/RN/PA will:

1) Work with staff and patient to identify ways to help the patient regain control

2) Evaluate the patient's immediate situation

3) Evaluate the patient's reaction to the intervention

4) Evaluate the patient's medical and behavioral condition

5) Evaluate the need to continue or terminate the restraint or seclusion

6) Revise the plan of care, treatment and services as needed...

There were multiple documented uses of restraints at the Del Sol campus. Review of sample of Code Strongs recorded for the Emergency Department for the month of March and April 2017 revealed several documented restraints and/or the handcuffing of patients which were not documented in medical records. The Daily Security Supervisor Pass Down reports documented the following:

* On 03/18/17 the form documented the following, ER #36 right handcuff applied @1145 due to punching & throwing food at the wall.

* On 03/23/17 at 7:08 PM the following was documented, EDO Pt tried eloping from the ER and attempted to tackle to the ground [security officer]. [Security officer] tried to restrain the PT but was sprayed with mace by PT. Subject was then restrained and taken into custody by the [police department].

* On 04/12/17 the form documented the following, 1540 Code Strong ER #36 pt became combative while trying to elope and was restrained.

Due to lack of documentation in the medical record or elsewhere besides the Pass Down Reports, there was no documented face-to face evaluation regarding the above restraint episodes within 1 hour after the initiation of the restraint to evaluate:

1. The patient's immediate situation;

2. The patient's reaction to the intervention;

3. The patient's medical and behavioral condition; and

4. The need to continue or terminate the restraint or seclusion.

Review of [Security Company Name] Security-Patient Restraint forms revealed the following:

* Patient #A14 was restrained on 04/15/17 at 1200 the form stated, @ 1200 hrs EPPD brought pt into ER being very verbally abusive. Pt was cuffed by off duty EPPD [name] X 2. @ 1330 cuffs off due to pt sleeping.

04/15/17-1855 [name] applied restraints. Pt spitting at security. Constantly calling [staff member #A41] 'N' word. Trying to tip bed over. Shackles and spit mask put on pt.

04/15/17 1945 [staff name] checking restraints

04/15/17 2010-as per charge RN [name] all restraints were removed at 2010 by off duty [name].

* Patient #A15 was restrained on 4/19/17 at 3:00 pm, the form stated in part, At 3:00 pm patient right hand was placed under restraint, because [sic] patient #A15 was combative to staff. Restraints applied by EPPD.

* Patient #A16 was restrained on 3/31/17 the form stated in part, Pt. [patient] was brought in by EPPD [El Paso Police Department] restrained (hands and feet) due to him being uncompliant and combative. Pt. is also under the influence of an unknown substance. RN [staff# 38] approved of pt's hands and feet [4-point restraints] to be restrained to the bed. At 4:39 pm. In 15-minute intervals, staff #A39 stated, 4-point restraints checking okay starting at 5:00 pm until 8:30 pm. No monitoring was documented until midnight on 4/1/17. Staff #A38 documented 4-points restraints Cok [checking okay] in hour intervals starting at 12:00 am until 6:00 am. No monitoring was documented after 6:00 am. There was no documentation for release of restraints.

* Patient #A17 was restrained on 04/14/17 at 2300 the form stated, Patient who is [AGE] years old was restrained (2 x) due to being aggressive. Pt. continued try to remove his I.V. As mother's permission handcuff restraints were applied.

04/15/17 pt @ 0100 was placed with one handcuff.

04/15/17 pt @ 0120 was released from other handcuff.

In an interview on 04/20/17, staff members # #A35, 36, and 42 confirmed that the [Security Company Name] Security-Patient Restraint form was stored in the security office of this facility. The form is not part of the patient medical record. The above incidents of restraint were not documented in the medical records, therefore there was no documented face-to face evaluation within 1 hour after the initiation of the restraint to evaluate:

1. The patient's immediate situation;

2. The patient's reaction to the intervention;

3. The patient's medical and behavioral condition; and

4. The need to continue or terminate the restraint or seclusion.

The above findings were confirmed in an interview on 04/20/17 with staff members #A34 and A37.

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

Based on a review of documentation and interview the facility failed to ensure that for restraint episodes, the patient medical record included: A description of the patient's behavior and the intervention used.

Findings included:

There were multiple documented uses of restraints at the Del Sol campus. Review of sample of Code Strongs recorded for the Emergency Department for the month of March and April 2017 revealed several documented restraints and/or the handcuffing of patients which were not documented in medical records. The Daily Security Supervisor Pass Down reports documented the following:

* On 03/18/17 the form documented the following, ER #36 right handcuff applied @1145 due to punching & throwing food at the wall.

* On 03/23/17 at 7:08 PM the following was documented, EDO Pt tried eloping from the ER and attempted to tackle to the ground [security officer]. [Security officer] tried to restrain the PT but was sprayed with mace by PT. Subject was then restrained and taken into custody by the [police department].

* On 04/12/17 the form documented the following, 1540 Code Strong ER #36 pt became combative while trying to elope and was restrained.

Review of [Security Company Name] Security-Patient Restraint forms revealed the following:

* Patient #A14 was restrained on 04/15/17 at 1200 the form stated, @ 1200 hrs EPPD brought pt into ER being very verbally abusive. Pt was cuffed by off duty EPPD [name] X 2. @ 1330 cuffs off due to pt sleeping.

04/15/17-1855 [name] applied restraints. Pt spitting at security. Constantly calling [staff member #A41] 'N' word. Trying to tip bed over. Shackles and spit mask put on pt.

04/15/17 1945 [staff name] checking restraints

04/15/17 2010-as per charge RN [name] all restraints were removed at 2010 by off duty [name].

* Patient #A15 was restrained on 4/19/17 at 3:00 pm, the form stated in part, At 3:00 pm patient right hand was placed under restraint, because [sic] patient #A15 was combative to staff. Restraints applied by EPPD.

* Patient #A16 was restrained on 3/31/17 the form stated in part, Pt. [patient] was brought in by EPPD [El Paso Police Department] restrained (hands and feet) due to him being uncompliant and combative. Pt. is also under the influence of an unknown substance. RN [staff# 38] approved of pt's hands and feet [4-point restraints] to be restrained to the bed. At 4:39 pm. In 15-minute intervals, staff #A39 stated, 4-point restraints checking okay starting at 5:00 pm until 8:30 pm. No monitoring was documented until midnight on 4/1/17. Staff #A38 documented 4-points restraints Cok [checking okay] in hour intervals starting at 12:00 am until 6:00 am. No monitoring was documented after 6:00 am. There was no documentation for release of restraints.

* Patient #A17 was restrained on 04/14/17 at 2300 the form stated, Patient who is [AGE] years old was restrained (2 x) due to being aggressive. Pt. continued try to remove his I.V. As mother's permission handcuff restraints were applied.

04/15/17 pt @ 0100 was placed with one handcuff.

04/15/17 pt @ 0120 was released from other handcuff.

In an interview on 04/20/17, staff members # #A35, 36, and 42 confirmed that the [Security Company Name] Security-Patient Restraint form was stored in the security office of this facility. The form is not part of the patient medical record. The above incidents of restraint were not documented in the medical records, therefore there was no documentation of patient's behavior and the intervention use in the above patients' medical records.

The above findings were confirmed in an interview on 04/20/17 with staff members #A34 and A37.

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

Based on a review of documentation and interview the facility failed to ensure that for restraint episodes, the patient medical record included: Alternatives or other less restrictive interventions attempted (as applicable).

Findings included:

Facility based policy entitled, PC 210 Restraints stated in part,

12. Documentation Requirements:

The medical record contains documentation of:

a. Assessment for risk for restraint

b. Restraint alternatives employed

c. Determination of effectiveness/ineffectiveness of restraint alternatives...

There were multiple documented uses of restraints at the Del Sol campus. Review of sample of Code Strongs recorded for the Emergency Department for the month of March and April 2017 revealed several documented restraints and/or the handcuffing of patients which were not documented in medical records. The Daily Security Supervisor Pass Down reports documented the following:

* On 03/18/17 the form documented the following, ER #36 right handcuff applied @1145 due to punching & throwing food at the wall.

* On 03/23/17 at 7:08 PM the following was documented, EDO Pt tried eloping from the ER and attempted to tackle to the ground [security officer]. [Security officer] tried to restrain the PT but was sprayed with mace by PT. Subject was then restrained and taken into custody by the [police department].

* On 04/12/17 the form documented the following, 1540 Code Strong ER #36 pt became combative while trying to elope and was restrained.

Review of [Security Company Name] Security-Patient Restraint forms revealed the following:

* Patient #A14 was restrained on 04/15/17 at 1200 the form stated, @ 1200 hrs EPPD brought pt into ER being very verbally abusive. Pt was cuffed by off duty EPPD [name] X 2. @ 1330 cuffs off due to pt sleeping.

04/15/17-1855 [name] applied restraints. Pt spitting at security. Constantly calling [staff member #A41] 'N' word. Trying to tip bed over. Shackles and spit mask put on pt.

04/15/17 1945 [staff name] checking restraints

04/15/17 2010-as per charge RN [name] all restraints were removed at 2010 by off duty [name].

* Patient #A15 was restrained on 4/19/17 at 3:00 pm, the form stated in part, At 3:00 pm patient right hand was placed under restraint, because [sic] patient #A15 was combative to staff. Restraints applied by EPPD.

* Patient #A16 was restrained on 3/31/17 the form stated in part, Pt. [patient] was brought in by EPPD [El Paso Police Department] restrained (hands and feet) due to him being uncompliant and combative. Pt. is also under the influence of an unknown substance. RN [staff# 38] approved of pt's hands and feet [4-point restraints] to be restrained to the bed. At 4:39 pm. In 15-minute intervals, staff #A39 stated, 4-point restraints checking okay starting at 5:00 pm until 8:30 pm. No monitoring was documented until midnight on 4/1/17. Staff #A38 documented 4-points restraints Cok [checking okay] in hour intervals starting at 12:00 am until 6:00 am. No monitoring was documented after 6:00 am. There was no documentation for release of restraints.

* Patient #A17 was restrained on 04/14/17 at 2300 the form stated, Patient who is [AGE] years old was restrained (2 x) due to being aggressive. Pt. continued try to remove his I.V. As mother's permission handcuff restraints were applied.

04/15/17 pt @ 0100 was placed with one handcuff.

04/15/17 pt @ 0120 was released from other handcuff.

In an interview on 04/20/17, staff members # #A35, 36, and 42 confirmed that the [Security Company Name] Security-Patient Restraint form was stored in the security office of this facility. The form is not part of the patient medical record. The above incidents of restraint were not documented in the medical records, therefore there was no documentation of alternatives or other less restrictive interventions attempted in the above patients' medical records.

The above findings were confirmed in an interview on 04/20/17 with staff members #A34 and A37.

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

Based on a review of documentation and interview the facility failed to ensure that for restraint episodes, the patient medical record included: The patient's condition or symptom(s) that warranted the use of the restraint or seclusion.

Findings included:

Facility based policy entitled, PC 210 Restraints stated in part,

7. Monitoring the Patient in Restraints

a. Patients are assessed by an RN immediately after restraints are applied to assure safe application of the restraint.

b. An RN will assess the patient at least every 2 hours. The assessment will include:

1) Signs of injury associated with restraint, including circulation of affected extremities

2) Respiratory and cardiac status

3) Psychological status including level of distress or agitation, mental status and cognitive functioning

4) Needs for range of motion, exercise of limbs and systematic release of restrained limbs are being met

5) Hydration/nutritional needs are being met

6) Hygiene, toileting/elimination needs are being met

7) The patient's rights, dignity, and safety are maintained

8) Patient's understanding of reasons for restraint and criteria for release from restraint

9) Consideration of less restrictive alternatives to restraint

c. More frequent monitoring and notification of the ordering physician or LIP occurs when:

1) Patient's medical and emotional needs and health status change

2) The type and design of the device or intervention poses increased risk

3) The level of patient agitation/distress at being placed in restraint as evidenced by an escalation of behavior

4) Evidence of injury related to use of restraint

d. A trained staff member monitors each patient in restraint at least 3 times an hour for safety, and to confirm that the patient's rights and dignity are maintained. This check will be documented in either electronic record or on paper and may be recorded at the end of the shift.

e. Monitoring is based on the individual needs of the patient. Variables of the patient's condition, cognitive status, risks associated with the chosen intervention may require more frequent evaluations.

f. For patients under continuous audio, video or in-person observation, care is rendered in real time, but documentation that safety, rights, and dignity were maintained for the defined period of time may be entered at end of the shift.

g. Any change in physical or psychological response will be reported to the RN. The RN will determine if medical intervention is required or if criteria for release have been met...

There were multiple documented uses of restraints at the Del Sol campus. Review of sample of Code Strongs recorded for the Emergency Department for the month of March and April 2017 revealed several documented restraints and/or the handcuffing of patients which were not documented in medical records. The Daily Security Supervisor Pass Down reports documented the following:

* On 03/18/17 the form documented the following, ER #36 right handcuff applied @1145 due to punching & throwing food at the wall.

* On 03/23/17 at 7:08 PM the following was documented, EDO Pt tried eloping from the ER and attempted to tackle to the ground [security officer]. [Security officer] tried to restrain the PT but was sprayed with mace by PT. Subject was then restrained and taken into custody by the [police department].

* On 04/12/17 the form documented the following, 1540 Code Strong ER #36 pt became combative while trying to elope and was restrained.

Review of [Security Company Name] Security-Patient Restraint forms revealed the following:

* Patient #A14 was restrained on 04/15/17 at 1200 the form stated, @ 1200 hrs EPPD brought pt into ER being very verbally abusive. Pt was cuffed by off duty EPPD [name] X 2. @ 1330 cuffs off due to pt sleeping.

04/15/17-1855 [name] applied restraints. Pt spitting at security. Constantly calling [staff member #A41] 'N' word. Trying to tip bed over. Shackles and spit mask put on pt.

04/15/17 1945 [staff name] checking restraints

04/15/17 2010-as per charge RN [name] all restraints were removed at 2010 by off duty [name].

* Patient #A15 was restrained on 4/19/17 at 3:00 pm, the form stated in part, At 3:00 pm patient right hand was placed under restraint, because [sic] patient #A15 was combative to staff. Restraints applied by EPPD.

* Patient #A16 was restrained on 3/31/17 the form stated in part, Pt. [patient] was brought in by EPPD [El Paso Police Department] restrained (hands and feet) due to him being uncompliant and combative. Pt. is also under the influence of an unknown substance. RN [staff# 38] approved of pt's hands and feet [4-point restraints] to be restrained to the bed. At 4:39 pm. In 15-minute intervals, staff #A39 stated, 4-point restraints checking okay starting at 5:00 pm until 8:30 pm. No monitoring was documented until midnight on 4/1/17. Staff #A38 documented 4-points restraints Cok [checking okay] in hour intervals starting at 12:00 am until 6:00 am. No monitoring was documented after 6:00 am. There was no documentation for release of restraints.

* Patient #A17 was restrained on 04/14/17 at 2300 the form stated, Patient who is [AGE] years old was restrained (2 x) due to being aggressive. Pt. continued try to remove his I.V. As mother's permission handcuff restraints were applied.

04/15/17 pt @ 0100 was placed with one handcuff.

04/15/17 pt @ 0120 was released from other handcuff.

In an interview on 04/20/17, staff members # #A35, 36, and 42 confirmed that the [Security Company Name] Security-Patient Restraint form was stored in the security office of this facility. The form is not part of the patient medical record. The above incidents of restraint were not documented in the medical records, therefore there was no documentation of the patient's condition or symptom(s) that warranted the use of the restraint or seclusion in the above patients' medical records.

The above findings were confirmed in an interview on 04/20/17 with staff members #A34 and A37.

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

Based on a review of documentation and interview the facility failed to ensure that for restraint episodes, the patient medical record included: The patient's response to the intervention(s) used, including the rationale for continued use of the intervention.

Findings included:

There were multiple documented uses of restraints at the Del Sol campus. Review of sample of Code Strongs recorded for the Emergency Department for the month of March and April 2017 revealed several documented restraints and/or the handcuffing of patients which were not documented in medical records. The Daily Security Supervisor Pass Down reports documented the following:

* On 03/18/17 the form documented the following, ER #36 right handcuff applied @1145 due to punching & throwing food at the wall.

* On 03/23/17 at 7:08 PM the following was documented, EDO Pt tried eloping from the ER and attempted to tackle to the ground [security officer]. [Security officer] tried to restrain the PT but was sprayed with mace by PT. Subject was then restrained and taken into custody by the [police department].

* On 04/12/17 the form documented the following, 1540 Code Strong ER #36 pt became combative while trying to elope and was restrained.

Review of [Security Company Name] Security-Patient Restraint forms revealed the following:

* Patient #A14 was restrained on 04/15/17 at 1200 the form stated, @ 1200 hrs EPPD brought pt into ER being very verbally abusive. Pt was cuffed by off duty EPPD [name] X 2. @ 1330 cuffs off due to pt sleeping.

04/15/17-1855 [name] applied restraints. Pt spitting at security. Constantly calling [staff member #A41] 'N' word. Trying to tip bed over. Shackles and spit mask put on pt.

04/15/17 1945 [staff name] checking restraints

04/15/17 2010-as per charge RN [name] all restraints were removed at 2010 by off duty [name].

* Patient #A15 was restrained on 4/19/17 at 3:00 pm, the form stated in part, At 3:00 pm patient right hand was placed under restraint, because [sic] patient #A15 was combative to staff. Restraints applied by EPPD.

* Patient #A16 was restrained on 3/31/17 the form stated in part, Pt. [patient] was brought in by EPPD [El Paso Police Department] restrained (hands and feet) due to him being uncompliant and combative. Pt. is also under the influence of an unknown substance. RN [staff# 38] approved of pt's hands and feet [4-point restraints] to be restrained to the bed. At 4:39 pm. In 15-minute intervals, staff #A39 stated, 4-point restraints checking okay starting at 5:00 pm until 8:30 pm. No monitoring was documented until midnight on 4/1/17. Staff #A38 documented 4-points restraints Cok [checking okay] in hour intervals starting at 12:00 am until 6:00 am. No monitoring was documented after 6:00 am. There was no documentation for release of restraints.

* Patient #A17 was restrained on 04/14/17 at 2300 the form stated, Patient who is [AGE] years old was restrained (2 x) due to being aggressive. Pt. continued try to remove his I.V. As mother's permission handcuff restraints were applied.

04/15/17 pt @ 0100 was placed with one handcuff.

04/15/17 pt @ 0120 was released from other handcuff.

In an interview on 04/20/17, staff members # #A35, 36, and 42 confirmed that the [Security Company Name] Security-Patient Restraint form was stored in the security office of this facility. The form is not part of the patient medical record. The above incidents of restraint were not documented in the medical records, therefore there was no documentation of the patient's response to the intervention(s) used, including the rationale for continued use of the intervention in the above patients' medical records.

The above findings were confirmed in an interview on 04/20/17 with staff members #A34 and A37.

Based on a review of documentation and interview, the facility failed to ensure that patients had the right to safe implementation of restraint or seclusion by trained staff.

Findings included:

Facility based policy entitled, PC 210 Restraints stated in part,

6. Application of Restraints

a. Restraints are applied by staff with demonstrated competence in restraint application.

1) Attachment A: Direct Care Staff (non RN) Monitoring and Providing Care to a Patient Restraint Competency

2) Attachment B: RN Competency: Patient Restraint Competency

3) Attachment C: RN Competency: Patient Restraint for Violent or Self Destructive Behavior...

APPENDIX A: TRAINING REQUIREMENTS (Attachments A, B, & C)

A. Direct Care Staff

Staff will demonstrate competency in the application of restraints, implementation of seclusion, monitoring, assessment and providing care for a patient in restraint or seclusion. Training will be provided to all staff designated as having direct patient care responsibilities, including contract or agency personnel. In addition, if hospital security guards or other non-healthcare staff assist direct care staff, when requested in the application of restraint or seclusion, the security guards, or other non-healthcare staff are also expected to be trained and able to demonstrate competency in the safe application of restraint and seclusion.

Training will occur:

1. Before performing restraint application, implementation of seclusion, monitoring, assessment and providing care for a patient in restraint or seclusion,

2. As part of orientation, and

3. On a periodic basis to ensure staff possess requisite knowledge and skills to safely care for restrained or secluded patients.

4. The results of skills and knowledge assessment, new equipment, or QAPI data may indicate a need for targeted training or more frequent or revised training.

B. Staff who conduct the one hour face-to-face evaluation

The purpose of the 1-hour face-to-face evaluation is to complete a comprehensive review of the patient's condition and determine if other factors such as drug or medication interactions, electrolyte imbalances, hypoxia, sepsis etc. are contributing to the patient's violent or self-destructive behavior.

Training for the RN or PA who conduct the 1-hour face-to-face will include:

1. Application of restraints.

2. Implementation of seclusion.

3. Monitoring, assessment and providing care for a patient in restraint or seclusion, including:

a.The patient's immediate situation

b.The patient's reaction to the intervention

c.The patient's medical and behavioral condition

d. The need to continue or terminate the restraint and seclusion...

Training Content

A. Restraint and Seclusion

All staff, including contract or agency personnel designated as having direct patient care responsibilities, will receive training in identifying patient and staff behaviors, events and environmental factors that may trigger circumstances that require the use of restraint or seclusion. Education and training will be based on the specific needs of the patient populations served. For example, staff who routinely provide care for patients who exhibit violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others (such as an emergency department or on a psychiatric unit) may receive more in-depth training than staff routinely providing medical/surgical care....

C. Least Restrictive Interventions

Staff will be trained on choosing the least restrictive intervention based on the individualized assessment of the patient's medical or behavioral status or condition. Safe patient care requires looking at the patient as an individual and assessing the patient's condition, needs, strengths, weaknesses, and preferences and tailoring interventions to individual patient's needs after weighing factors such as the patient's condition, behaviors, history, and environmental factors.

D. Safe Application

Staff will be trained on the safe application of all types of restraint and seclusion used in this facility including training to recognize and respond to signs of physical and psychological distress (e.g., positional asphyxia).

E. Necessity of Restraint

Staff will be trained and able to demonstrate competency in identification of specific behavioral changes that may indicate that restraint or seclusion is no longer necessary and can be safely discontinued.

F. Monitoring

Staff will be trained and demonstrate competency in monitoring the physical and psychological well-being of a patient who is restrained or secluded. This training will include but will not be limited to: respiratory and circulatory status, skin integrity, vital signs, and any special requirements identified by the facility associated with the one-hour face-to-face evaluation...

Facility based policy entitled, EC 210 Code Strong stated in part,

Security staff is trained in Nonviolent Crisis Intervention, a program that is safe, non-harmful behavior management system designed to help security and staff professionals provide for the best possible care and welfare of disruptive, assaultive, and out-of-control persons, even during their most violent moments.

Any physical intervention is potentially dangerous and should be handled by security or trained personnel in Nonviolent Physical Crisis Intervention procedures.

A. Security, Law Enforcement, or CPI certified personnel will respond to any situations involving an actual or potential risk of violent, harmful, or threatening behavior involving patients, employees, physicians or visitors...

D. If seclusion/restraint is the outcome of the Code Strong, the Restraint and Seclusion policy will be utilized...

CPI PROCESS...

1. The Security Coordinator shall be responsible for assuring the development scheduling, implementation and documentation of comprehensive training program (CPI) for staff that work in high security risk areas.

2. In the following list of units, any clinical department Charge Nurse shall be provided with CPI training. Morning and Evening shifts. The charge nurse will respond only in their designated unit in the event of Code Strong. All other non-clinical units on the list will have designated staff member chosen by the units Directors.

A. Security (All Staff)...

D. Emergency Dept.

The Del Sol campus was only able to provide documentation that the Emergency Department nursing staff received training in De-escalation-A Culture of Safety which staff member #A34 stated was a 1-2 hour course regarding verbal de-escalation. There was no documented training regarding physical restraints. Per facility policy, the charge nurse for each shift should have received this training. Staff members #A28 confirmed that the nursing staff does not receive training at the Del Sol campus to implement physical restraints.

Review of Del Sol security personnel files revealed that only 1 of 6 employees (#A43) had received comprehensive training program regarding physical interventions. This employee received TRAIN instead of CPI per policy. Staff members #A35 and 36 confirmed that all security personnel did not have documented CPI training. The facility was also not able to provide documentation of training regarding physical/mechanical restraints for the contracted off duty police officers that the facility employs.

The above findings were confirmed in an interview on 04/20/17 with staff members #A34, 35, 36, and A37.

Based on observation and review of records, the facility failed to ensure that nursing care was provided for all patients as a patient's abnormal, elevated blood pressure was not reported to the provider as ordered and per nursing standards. This presents a health risk for a patient.

Findings included:

á

Review of the medical record for Patient #B26 at the Del Sol facility revealed a physician order on 3/25/17 at 1318 which stated, Notify provider if temperature is >101 F, heart rate <50 or >100, oxygen saturation <92%, systolic blood pressure < 90 or >170, diastolic blood pressure > 100, respiratory rate < 12 or >28.

On 3/30/17 at 6:25 am and again at 6:37 am, Patient #B26 had a documented blood pressure of 182/104. The blood pressure was documented 182/104 again at 0910 on 3/30/17. There was no documented evidence of physician notification of the elevated blood pressure nor was there documentation of any nursing assessment or intervention addressing the elevated blood pressure. The above findings were confirmed in an interview with Staff #B14 the afternoon of 4/18/17 on the patient care unit.

Review of the Texas Nurse Practice Act 217.11, Standards of Nursing Practice, states, in part,

(1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: (A) Know and conform to the Texas Nursing Practice Act and the board's rules and regulations as well as all federal, state, or local laws, rules or regulations affecting the nurse's current area of nursing practice;

(B) Implement measures to promote a safe environment for clients and others; ...

(D) Accurately and completely report and document:

(i) the client's status including signs and symptoms;

(vi) contacts with other health care team members concerning significant events regarding client's status;

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

Based on record review and staff interview, the facility failed to ensure that properly executed consent forms were completed before patient treatment.

Findings included:

Review of the medical record for Patient #B22 at the Del Sol facility revealed that Patient #B22 (MDS) dated [DATE] and was admitted on [DATE] between 0200 and 0330 and began receiving inpatient treatment. However the Consent to Treatment was not signed by the patient or other patient representative until 4/18/17 at 1050. The above findings were confirmed in an interview with Staff #B14 the afternoon of 4/18/17 on the patient care unit.

Based on observation, interviews, and tour of the kitchen at Las Palmas, it was determined that the facility failed to ensure that food and dietetic services were organized.

Findings were:

The hospital failed to ensure that food and dietetic services organization requirements were met. Tour of the kitchen the afternoon of 4/17/17 revealed the following findings.

Tour of the kitchen on the afternoon of 04/17/2017 revealed the following:

*In the refrigerator, fish, peas, green beans, onions, carrots cheese oil packages were opened and not labeled.

*In the freezer twelve (12) packages of okra and three (3) packages of peas were not labeled.

*Metal food racks in the freezer were dirty with a white substance.

*Milk from a gallon container with no date, spilled on the bottom floor of the refrigerator.

*Dijon Mustard was opened and not labeled.

*Multiple metal baking pans were stacked while wet. When these pans were separated, water dripped onto the floor. When dishes and pans are not air dried, there is potential for bacterial growth.

*40 metal baking pans contained food debris was observed, this indicating inadequate cleaning.

*Ten (10) muffin pans were observed with food debris.

*One pan with a greasy film was observed.

*Three (3) knives observed with food debris, indicating inadequate cleaning.

*Kitchen utensils handles worn out with food debris.

*Black stains were observed on refrigerator, ceiling and wall indicating improper cleaning and maintenance.

*Kitchen workers were observed using cooking utensils for serving food and not using serving utensil.

*Two (2) large rectangular white cutting boards with black stains and other color stains and multiple knife cuts were dirty, indicating inadequate cleaning and potential for bacterial growth.

At 3:35 pm staff #G 2 was observed using the pans with the food debris.

The above findings were confirmed by Director of Food Services on the afternoon of 04/17/2017.

Based on observation and a review of documentation, the hospital failed to maintain a full-time employee to serve as the director of the food and dietetic services that was responsible for the daily management of the dietary services.

Findings were:

During a tour of the dietary area of the Del Sol campus on 4-19-17, the following observations were made:

*A stack of 4 half-pans had been stacked on top of each other while still wet to the touch and with visible water droplets.

*A stack of 3 24-count cupcake pans had been stacked on top of each other while still wet to the touch and with visible water droplets.

*A stack of 5 full-pan covers had been stacked on top of each other while still wet to the touch and with visible water droplets.

*A stack of 4 large sheet pans had been stacked on top of each other while still wet to the touch and with visible water droplets.

Stacking dishes, pans or any other dietary ware while wet allows a breeding ground for bacteria, increasing the possibility of illness among patients and staff.

*2 serving dishes of what appeared to be a tomato-based product were sitting uncovered in the walk-in freezer.

*1 large sheet pan filled with what appeared to be meatballs was sitting uncovered in the walk-in freezer.

*1 large pan filled with what appeared to be cooked chicken breasts was sitting uncovered in the walk-in freezer.

Failing to cover food allows dust and debris to enter the dish, increasing the possibility of illness among patients and staff.

None of the food items in the dry goods pantry had been marked with a date indicating when they had been received into the facility. These items included (but were not limited to) the following:

*3 138-ounce bottles of salsa

*4 1-gallon bottles of vegetable oil

*25 1-pound boxes of corn starch

*6 5-pound bottles of teriyaki glaze

*5 2-quart bottles of low-sodium soy sauce

*3 1-gallon bottles of teriyaki sauce

*2 1-gallon bottles of barbeque sauce

*7 4.5-pound bottles of sweet & sour sauce

*1 8lb,10oz bottle of enchilada sauce

*3 64-ounce bottles of szechuan stir-fry sauce

*3 1-gallon bottles of lite mayonnaise

*4 1-gallon bottles of ranch dressing

*4 1-gallon bottles of coleslaw dressing

*3 large, metal can carts, each containing 30 rows (with each row holding at least 6 #10 cans of soups, vegetables, sauces etc)

Marking food items with the received date allows proper rotation of stock and reduces the possibility of serving stale or unusable food.

*Greater than 30 external shipping boxes were stored in the pantry with the other food items. External shipping boxes carry dirt and other debris (which may contain bacteria and vermin) into the facility.

Facility policy titled Infection Control states, in part:

Policy:

Food & Nutrition Services will prepare and serve wholesome food under sanitary conditions.

Facility policy titled Storage of Prepared Foods states, in part:

Process Standards

...

E. All stored food must be covered, labeled and dated.

Facility policy titled Handling of Cooked Foods states, in part:

2. All food is wrapped or sufficiently covered before placing in refrigerator or warming cabinet.

Facility policy titled Food Storage states, in part:

Policy:

...

B. Stock is rotated so that older items are used first.

1. Products are dated to assure 'First In-First Out' procedure is followed.

...

L. All cooked foods and protein-based salads and desserts are labeled, dated and securely covered.

...

P. All food items stored after opening or preparation should be tightly covered, labeled and dated before storing.

The above was confirmed in an interview with staff #E-40 on the afternoon of 4-19-17.

Based on observation, interview and record review the facility failed to develop a policy and procedures for the use of SwabCaps (disinfecting cap for needle free connectors).

Findings Include:

An observation made on the morning of 4/18/17 in the facility's operating room revealed Staff #G7, RN, administered Versed, a medication for sedation, intravenous (IV) into Patient #G5's IV access port. The access port was covered with a swab cap, a small plastic cap containing a disinfectant. Staff #G7 removed the swab cab but did not wipe the access port with an alcohol wipe. Staff #G5 administered IV medications through Patient #G5's IV access port (4) four additional times without wiping the access port with an alcohol wipe. Staff #G5 replaced the same swab cap each time.

During an interview on 4/18/17 in the facility's operating room, Staff #G3, Surgery Director, stated, The swab cap takes the place of scrubbing the hub...the swab cap is a single use device.

Review of the facility provided Manufacturer's document Reference Guide for SwabCap reflected ...Single use only...

During an interview on 4/19/17, in the administrative conference room, with Staff #G9, Infection Control Director, when asked if the facility has developed a policy and procedure for the use of the Swab Caps, Staff #G9 stated, No....they are single use ...the manufacturer gave an in-service on the use ...we use Lippencott for the procedure....

Review of the facility provided document Lippencott Procedure- IV bolus injection (dated 4/15/17) reflected, ...For administration through an intermittent vascular access device ...if a disinfectant-containing end cap is on the end of the needleless connector, remove it. Perform a vigorous mechanical scrub of the needleless connector for at least 5 seconds using an antiseptic pad...bolus medication...apply a new disinfectant-containing end cap to the needless connector of the venous access device to reduce the risk of vascular catheter-associated infection....

Based on observation and interview, the facility failed to ensure a sanitary environment and practices to avoid sources and transmission of infections and communicable diseases.

Findings included:

During a tour of the Labor and Delivery unit at the Del Sol facility the morning of 4/19/17, the following was observed:

In LDR room 13, there was a reddish-brown drip approximately 1 inch in length which appeared to be dried blood on the stirrup of the labor and delivery bed, which was available for patient use. There were 2 pieces of plastic tape, approximately 1 inch each in the infant bassinet. The mattress pad in the infant bassinet had tears in the vinyl covering which exposed the porous foam beneath the vinyl covering. This porous material cannot be adequately cleaned between patients, and could harbor pathogens. This was confirmed in an interview with Staff #B14 the morning of 4/19/17 during the tour.

In LDR room 8, there was a paper sticker on the inside of the right and the left stirrup of the labor and delivery bed, which was partially adhered, leaving a sticky substance which could not be properly disinfected. The bed was available for patient use. This presents a risk for cross contamination. This was confirmed in an interview with Staff #B14 the morning of 4/19/17 during the tour.

During a tour of the Newborn Nursery at the Del Sol facility, 6 out of 8 mattress pads in the infant bassinets, available for newborn patient use, had tears, punctures, or worn edges in the vinyl covering which exposed the porous foam beneath the vinyl covering. This porous material cannot be adequately cleaned between patients, and could harbor pathogens. One of the pads had an unknown sticky substance adhered to the pad. This was confirmed in an interview with Staff #B19 the morning of 4/19/17 during the tour.

During a tour of the nursery supply room at the Del Sol facility, there was a water stained ceiling tile observed. At the entrance to the nursery patient supply room, there were lockers which were used by the nursery staff for their personal belongings, including purses and other belongings, which presents a risk for cross contamination. The floor in the supply room was in need of cleaning, as there was debris and dust on the floor. There was a fine layer of dust in the bins containing patient supplies.

During a tour of the Labor & Delivery Recovery Room at the Del Sol facility the afternoon of 4/18/17, there was a 1.5 inch opened tear in the vinyl covering of one of the recovery beds which exposed the porous foam beneath the vinyl covering. This porous material cannot be adequately cleaned between patients, and could harbor pathogens. The right stirrup and foot rest were in need of cleaning as they were covered with a layer of dust. There was dust on horizontal surfaces, including the window sills in the Recovery Room. This was confirmed in an interview with Staff #B14 the morning of 4/19/17 during the tour.

In an interview the morning of 4/19/17, Staff #B20, Environmental Services Director in the facility conference room, stated that the housekeeping staff are support to report any torn mattresses or pads when they are observed.

During a tour of the Labor and Delivery OR at the Del Sol facility the morning of 4/19/17, the following was observed:

The flooring in the corners of OR 1 were in need of cleaning as there was dirt or a dirty appearance in these areas This room was available for patient use. There were tears in the flooring in the edges of the flooring baseboard and there was a 1/2 hole in the flooring in the center of the OR. This presents a risk for cross contamination.

The floor in the corners of OR 3 were in need of cleaning as there was dirt or a dirty appearance in these areas and there were small tears in the flooring in the edging of the flooring baseboard. This OR was available for patient use.

There were 10 sterile instruments in paper/plastic peel-packs in a plastic bin and approximately 6 sterile instruments in a second plastic bin, available for patient use. These paper/plastic peel packs had been folded and placed in a plastic bin in OR 3. Sterilized instruments should be stored in a manner that preserves the integrity of the packaging material. Folding the paper presents a risk that the paper will be torn or be creased and the sterility compromised. There were also 6 sterilized instruments observed in OR 3 which were observed in the closed position or the clamps were closed; therefore not all surfaces were exposed to the sterilizing agent preventing effective sterilization. It could not be determined that the sterilizing agent penetrated all surfaces to ensure complete sterilization of all surfaces of the instruments. The Centers for Disease Control and Prevention (CDC) article, GUIDELINE FOR DISINFECTION AND STERILIZATION IN HEALTHCARE FACILITIES, 2008, by William A. Rutala, Ph.D., M.P.H., David J. Weber, M.D., M.P.H., and the Healthcare Infection Control Practices Advisory Committee (HICPAC), found at:áhttp://www.cdc.gov/ncidod/dhqp/pdf/guidelines/Disinfection_Nov_2008.pdf, states on page 74 that hinged instruments and instruments that are closed should be opened during the process of sterilization.

This was confirmed in an interview with Staff #B19 the morning of 4/19/17 during the tour at the Del Sol facility.

Based on observation, interview and record review the facility failed to effectively monitor for care in a safe and sanitary environment when,

a.) Patients with intravenous catheters did not have the access hubs cleaned to prevent possible infections for (4) patients. (Patients G5, G7, G18 and D13)

b.) Medications were not administered in the operating room using aseptic techniques.

Findings:

a.) An observation made on the morning of 4/18/17 in the facility's operating room revealed Staff #G7, RN, administered Versed, a medication for sedation, IV into Patient #G5's IV access hub. The access hub was covered with a swab cap, a small plastic cap containing a disinfectant. Staff #G7 removed the swab cab but did not wipe the access port with an alcohol wipe. Staff #G5 administered IV medications through Patient #G5's IV access hub (4) four additional times without wiping the access hub with an alcohol wipe. Staff #G5 replaced the same swab cap each time.

During an interview on 4/18/17 in the facility's operating room, with Staff #G3, the Surgery Director, when asked how the swab cap is to be used, staff #G3 stated, The swab cap takes the place of scrubbing the hub...the swab cap is a single use device....

An observation made on the morning of 4/18/17 on the facility's Intensive Care Unit (ICU) revealed Staff #G10, RN, disconnected Patient #G18's IV tubing from the access hub. Staff #G10 looped and connected the exposed end of the IV tubing line into a secondary access hub on the IV line tubing. Staff #G10 did not wipe the access hub with an alcohol wipe.

An observation made in the afternoon of 4/19/17 in the facility's emergency room (ER) revealed Staff #G13, RN, administered IV fluids through Patient #G14's peripheral IV catheter access hub. Staff #G13, RN, did not wipe the access hub with an alcohol wipe.

During an interview on 4/18/17 on the facility's ER, Staff #G13, RN, stated, I'm supposed to wipe with alcohol... I didn't...

During a tour of the Las Palmas 5 North Unit on 4/19/17 at approximately 11:10 am in the company of Staff # D21, unit director, Staff #D20, RN, was observed hanging an IV piggyback medication for patient #D13. Staff #D20 was about to connect the piggyback tubing to a blue needleless intravenous hub without disinfecting the hub when the surveyor asked Staff #D20 what the procedure was for disinfecting the hub. Staff #D20 stated that the hub should be cleansed with an alcohol wipe. Staff #20 then obtained an alcohol wipe and cleansed the hub before connecting the piggyback tubing. In an interview with Staff #D20 in the hallway outside Patient #D13's room at approximately 11:15 am, Staff #D20 agreed that she was going to connect the piggyback tubing without disinfecting the hub and that the hub should be disinfected before connecting the piggyback tubing.

Review of the facility provided document Lippencott Procedure- IV bolus injection (dated 4/15/17) reflected, ...For administration through an intermittent vascular access device...if a disinfectant-containing end cap is on the end of the needleless connector, remove it. Perform a vigorous mechanical scrub of the needleless connector for at least 5 seconds using an antiseptic pad...bolus medication ...apply a new disinfectant-containing end cap to the needless connector of the venous access device to reduce the risk of vascular catheter-associated infection ....

b.) An observation made on the morning of 4/18/17 in the facility's operating room revealed Staff #G7, RN, removed the dust cap from a Midazolam 5mg (milligram)/5 ml (milliliter) vial. Staff #G7 did not wipe the rubber septum with an alcohol wipe prior to withdrawing the solution.

Review of the facility provided document Multiple Use Vials/Containers (dated 4/2014) reflected, Purpose: ...guidelines for the utilization of multiple use containers in all areas of the Hospital ...Strict aseptic technique must be utilized in withdrawing drugs from injectable multi-use vials. 1. Ensure that rubber stopper is appropriately cleaned and allowed to air dry prior to withdrawing solution....

Based on review of facility documents, observation and interview, the facility failed to provide a safe and sanitary environment as the facility:

A. Failed to ensure staff responsible for the sterilization of supplies had necessary training.

B. Failed to ensure flash sterilizers were used for emergency sterilization only.

C. Failed to maintain a sterilizer log that included contents of each load, biological indicators and chemical indicators.

D. Failed to ensure preventive maintenance of all sterilizers were performed according to policy, using the sterilizer manufacturer's service manual as a reference.

Findings included:

A. Facility based policy entitled, Sterilization (reference #5.16) stated in part,

L. All new staff members will be in-serviced on the proper procedure prior to using the autoclaves.

Facility based policy entitled, Flash Sterilization: Steam Sterilizer Operation (reference #6.5) stated in part,

D. A steam sterilizer indicator strip (or equivalent product) will be placed in each load and verified prior to taking the load into the OR...

P. All Surgical Services personnel responsible for understanding the principles of flash sterilization and the correct method for operating the autoclaves. Documentation of each load must be done by the person actually running the load.

Q. The Surgical Services personnel must verify that all personnel understand the proper method of flash sterilization. All new personnel must be in serviced on the proper [sic] prior to using the autoclaves.

Facility based policy entitled, IC4.8-Cleaning, Disinfection, and Sterilization stated in part,

17. Quality control

a. All staff assigned to reprocess semicritical and critical instruments and equipment will receive comprehensive sterilizer specific training on hire and annually thereafter to ensure that they understand the importance of reprocessing these items...

Review of the personnel records for staff members in the Surgical Services responsible for immediate use sterilization using sterilizers #1 and 2 revealed that these employees only had a competency on immediate use present in their file. There was no documented training on the specific machines used for this sterilization process. Staff member #A18 confirmed to effectively implement and maintain these sterilizers, staff require training specific to the machine model.

Review of the personnel records for staff members in the Surgical Services responsible for sterilization revealed competencies for Sterilization, Steam that were unsigned by an evaluator at the time of the survey on 4/19/17:

*Staff A11, A12, A13, A14, A21, A22, A23, A24 and A25

The above was verified with staff #A18 in an interview on the afternoon of 4/19/17.

B. A statement from the Association for the Advancement of Medical Instrumentation (AAMI), Accreditation Association for Ambulatory Health Care (AAAHC), Association of periOperative Registered Nurses (AORN), Association for Professionals in Infection Control and Epidemiology (APIC), ASC Quality Collaboration, Association of Surgical Technologists (AST), and International Association of Healthcare Central Service Materiel Management (IAHCSMM). Immediate-Use Steam Sterilization. Undated. Found at: , stated in part, Instrument inventories should be sufficient to meet anticipated surgical volume and permit the time to complete all critical elements of reprocessing.

The Centers for Disease Control and Prevention (CC) website article, GUIDELINE FOR DISINFECTION AND STERILIZATION IN HEALTHCARE FACILITIES, 2008, by William A. Rutala, Ph.D., M.P.H., David J. Weber, M.D., M.P.H., and the Healthcare Infection Control Practices Advisory Committee (HICPAC), found at: , stated in part, it [flash sterilization] is not recommended as a routine sterilization method because of the lack of timely biological indicators to monitor performance, absence of protective packaging following sterilization, possibility for contamination of processed items during transportation to the operating rooms, and the sterilization cycle parameters (i.e., time, temperature, pressure) are minimal... Flash sterilization should not be used for reasons of convenience, as an alternative to purchasing additional instrument sets, or to save time.

Facility based policy entitled, IC4.8-Cleaning, Disinfection, and Sterilization stated in part,

11. Flash Sterilization...

b. When necessary, flash sterilization will be used for patient care items that will be used immediately and cannot be packaged, sterilized and stored before use. Category IB. Flash sterilization should never be used for convenience, to save time, or as an alternative to purchasing additional instrument sets...

Review of Del Sol documentation of Immediate Use Steam Sterilization [IUSS] revealed:

*18 items were sterilized in January with the following reasons:

o only one of these - 2 items

o all like items in use - 4 items

o Surgeon/Rep brought in - 1 item

o Per request by MD - 1 item

*10 items were sterilized in February with the following reasons:

o Late arrival by vendor - 1 item

o All like items in use - 2

o Other: needs in case - 1 item

o Other: not enough in reps tray - 1 item

*33 items were sterilized in March with the following reasons:

o Missing from tray - 1 item

o none available - 1 item

o Per request by MD - 4 items

o All like items in use - 9 items

o Surgeon/rep brought in - 2 items

o Late arrival by vendor - 5 items

o Not enough drills - 1 item

o Other with no further explanation - 1 item

o Other: Not enough - 1 item

*14 items were sterilized in April with the following reasons:

o All like items in use - 6 items

o Surgeon/rep brought in - 2 items

o Per request by Dr. - 1 item

In an interview with staff #A18 on 4/18/17 at 4:00 pm, when asked about IUSS, staff #A18 stated, They don't have enough supplies.

C. The Association of Perioperative Registered Nurses (AORN) Journal Vol. 86, Issue 1, p58-72 article, The New Era of Flash Sterilization (2007) by Arlene Carlo, RN, BSN, CPM, FCSP, found at http://www.aornjournal.org/article/S0001-2092(08) -3/pdf, stated in part, Documenting

Records document that the sterilization process is being monitored as it occurs and provide evidence that cycle parameters have been met. Record-keeping is necessary to document essential information such as the reason for flash sterilization. These might include...

In addition,

* the cycle run (ie, date, time, load number)

* load contents (eg, individual instrument, instrument set);

* CI [chemical indicator] and BI [biological indicator] results;

* patient identification; and

* sterilizer operator identification should be documented. The information typically is recorded in a flash sterilization log (Figure 1).

Flash sterilization records allow for traceability of every load of instruments or set that was used for patients, provide an audit trail, and are necessary if there is a recall of items sterilized or if flash sterilization records are subpoenaed for a lawsuit.

Facility based policy entitled, Infection Control/Positive Biological Monitor Results (reference #6.0) stated in part,

D. Initiate recall of all items from affected loads run in the sterilizer up to present date. Use sterilization logbook to make listings of items run in loads.

Review of IUSS documentation revealed no identification of load contents in:

*3 out of 10 loads in February

*6 out of 33 loads in March

*4 out of 14 loads in April

Review of IUSS documentation revealed no identification of which patient instruments of IUSS were used on in:

*2 out of 33 loads in March

*2 out of 14 loads in April

In an interview with Staff #A18 on 4/18/17 at 4:00 pm, when discussing IUSS logs, staff #A18 stated, These are incomplete. Some don't even have patient names.

Review of the Del Sol sterilization documentation of sterilizers #1 and #2 revealed no biological indicators retained.

In an interview with Staff A18 on 4/20/17 at 10:25 am when asked about chemical indicators for the IUSS [immediate use steam sterilization], Staff #A18 stated, These [logs] are incomplete. I don't know why they don't have the indicators there. There's a few where they copy them, they should just attach them here [to the log].

Review of the IUSS log revealed chemical indicators used:

*2 out of 18 times in January

*2 out of 10 times in February

*4 out of 33 times in March

*2 out of 14 times in April

The above was verified in an interview with Staff #A18 on the morning of 4/20/17.

D. Facility operator manual for the Amsco Century Medium Steam Sterilizers stated in part, 7.1 Preventive Maintenance Schedule: Maintenance procedures described in Sections 7 and 9 must be performed regularly at the indicated intervals ...

7.1.1 Clean Chamber Drain Strainer: Important: The chamber drain strainer must be cleaned at least once a day, preferably in the morning before running the first cycle ...

7.1.2 Clean Chamber: Important: The entire chamber should be wiped down and rinsed following any spills or other soiling ...

Important: Chamber must be at room temperature, sterilizer off all night, before washing.

2. Washing the inside of the chamber and shelf assembly (plus any other loading equipment) with a mild detergent solution such as STERIS liquid-Jet or current STERIS equivalent ...

4. Professional cleaning of the chamber on a yearly basis (or as required due to local conditions) is suggested to maintain appearance of the chamber interior. Contact STERIS for information regarding this service.

Facility based policy entitled, Sterilization (reference #5.16) stated in part,

I. Sterilizers are maintained on a quarter basis. Weekly they are also washed with a sterile towel and distilled water...

Facility based policy entitled, Sterilizer Maintenance (reference #6.2) stated in part,

A. The filter screen in steam sterilizers will be checked at the beginning of each day for lint and debris. Gaskets and outsides are wiped down each day with hospital approved disinfectants...

During a tour of the Del Sol campus Surgical Services area on 04/19/17, the sterilizers #1 and 2 used for immediate use sterilization were observed to be Amsco Century models.

In an interview on 04/20/17, staff member #A18 was asked about routine maintenance performed on these sterilizers such as cleaning the drain. Initially, the staff member reported the surgical services staff that utilized the sterilizer stated that these models had fixed drains that did not require checking or cleaning that was done during quarterly preventative maintenance of the machines. Staff member #A18 returned shortly and informed this surveyor they had contacted the manufacturer and the drains are not fixed, this staff member was personally able to pop the drain out with minimal effort.

Staff member #A18 confirmed that staff responsible for maintaining the 2 immediate use sterilizers had not been checking or cleaning the drain, per policy and manufacturer recommendations.

This staff member also confirmed there was no evidence of the machines being cleaned weekly, per policy. The Sterile Processing department maintained a logbook related to cleaning their sterilizers, there was no log book documenting the cleaning of the immediate use sterilizers #1 and 2.

Based on observation, interview and record review the facility failed to provide Surgical Services in an organized manner when,

a.) The facility did not implement a procedure to ensure the sterile processing washers and sterilizers were cleaned and maintained according to the manufacturer's instructions.

b.) The operating room had dust on the horizontal surfaces and equipment was rusting and had areas of chipped paint.

c.) (1) Hemostat was sterilized in the closed position, was available for use and surgical staff did not recognize the hemostat should not be used.

Findings Include:

a.) During an interview on 4/18/17 in the facility's Sterile Processing Department (SPD) Staff #G6, SPD Director when asked what routine maintenance the facility provides of the washers stated, ...we check the drains each day and do verification weekly .... When asked what was done during the weekly verification Staff #G6 stated, I'm not sure. When asked if the facility documents the cleaning of the washers and sterilizers Staff #G6 stated, No. When asked for the washer manual the facility was unable to provide them; they needed to be sent by overnight mail.

On 4/19/17, review of the facility provided washer document reflected ...6.2 Daily Cleaning ...Remove sump debris screen from wash chamber and clean...Remove manifold sliding inlet and inspect for debris. 7. Brush off and rinse under tap water...Reinstall manifold sliding inle....Weekly Cleaning...Clean wash chamber rotary spray arm assembly...Remove locking pin securing each spray arm on rotary spray arm hub. Remove spray arms. D. Use a fine wire to clean sediment from spray jet...Rinse spray arms under running water to clean out sediments f. Reinstall spray arm assembly to the ceiling of wash chamber. 4. Remove spray arms from bottom rotary spray arm assembly as follows....Clean spray arms using a fine wire and running water to clear sediments...Clean rotary spray arm....

b.) Observations made on the morning of 4/18/17 of the facility's operating rooms revealed the following items and conditions that would make the items unable to be thoroughly cleaned:

- Operating Room #9, rust on the metal Stryker cabinet and tape on walls and equipment,

- Operating Room #1, chipped paint and rust on the overhead light and operating bed,

- Operating Room #6, Olympus metal cart with dust on the horizontal surfaces and

- Operating Room storage room, (3) Valley Lab metal carts with chipped paint and rust.

During a tour on 4/18/17, of the facility's operating rooms, Staff #G3, Director of Surgery, confirmed the findings.

c.) An observation made during a tour of the facility's SPD on 4/18/17 revealed a hemostat (a surgical instrument that clamps shut) that had been sterilized in the closed position was available for use.

During an interview on 4/18/17 in the SPD, Staff #G3, Director of Surgery, stated, They must have closed after processing...but the staff would not use them... When asked if the surgical staff was aware not to use them, Staff #G3 approached staff members, showed them the hemostat, and asked them if the instrument was able to be used. (4) Four out of (5) surgical staff, when asked if the closed hemostat should be used, were not able to recognize the instrument might not have been thoroughly sterilized and should not be used.

Based on record review and interview the facility failed to ensure the completeness of medical records when a surgeon did not complete a patient's Medical History and Physical prior to the procedure. (Patient #G5)

Findings include:

An observation made on the morning of 4/18/17 in the facility's operating room #9 revealed Patient #G5's medical history and physical had not been completed prior to the surgery. The Patient #G5 had already been sedated and the medical procedure had started.

During an interview on 4/18/17, in the facility's operating room #9, Staff #G3, Director of Surgery, stated, It should have been filled out prior to the surgery.

Review of the facility provided document Provision of Care (dated 8/09) reflected, ...relevant documents have been assembled prior to the start of the procedure...D. Relevant documents to be reviewed include: 1. H&P that meets the CMS conditions of participation.

An observation on the morning of 4/18/17 in the facility's operating room #8 revealed Staff #G8, MD, completing Patient #G5's history and physical after the completion of the procedure.

Based on record review and interview the facility failed to ensure the completeness of medical records when an abbreviation was used on a Surgical Consent. (Patient G17)

Findings include:

Review of Patient #G5's Disclosure and Consent dated 4/19/17 revealed, ...to treat my condition which has been explained to me...Left UPJ stone obstruction...

During an interview on the morning of 4/20/17, in the Surgical Pre-Operative Unit, Staff #16, Pre-Operative Clinical Coordinator, confirmed UPJ was an abbreviation and stated, ...we don't use abbreviations on consents... that consent was filled out by the floor nurse... we should have caught it...

Review of the facility provided document Ethics, Rights & Responsibilities (dated 7/28/15) reflected, ...All documentation within the consent, both preprinted and handwritten will be completed without the use of abbreviations. All words must be fully written out...

Based on review of clinical records and staff interview, the facility failed to ensure that medical records were completed with 30 calendar days following discharge.

Findings included:

The medical record for Patient #1 was not completed within 30 days as there were physician notes that were signed more than 30 days after written and after Patient #1 was discharged , to include the following:

Clinical Note 11/15/16 0705, not signed by physician until 12/28/16.

Internal Medicine Progress Note 11/16/16 0617, not signed by physician until 12/28/16.

Internal Medicine Progress Note 11/17/16 0618, not signed by physician until 12/28/16.

Internal Medicine Progress Note 11/18/16 0650, not signed by physician until 12/28/16.

Internal Medicine Progress Note 11/19/16 1459, not signed by physician until 12/28/16.

Internal Medicine Progress Note 11/20/16 1545, not signed by physician until 12/28/16.

Internal Medicine Progress Note 11/21/16 1634, not signed by physician until 12/28/16.

Discharge Summary 11/23/16 at 1525, not signed by physician until 12/28/16.

The above findings were confirmed in an interview with Staff #4 the afternoon of 2/7/17 in the administration office.

Based on review of documentation and interview, the facility failed to ensure that a patient was afforded the right to informed consent to treatment and provided their patient rights as there was no documented evidence that patient rights were received or consent to inpatient treatment was provided by the patient or legally authorized representative.

Findings included:

Facility policy, Legal Authority for Consent RI 120.2, stated, in part, 3. In an emergency, consent is implied by law, but such consent exists only during the immediate emergency and is limited to treatment necessary to resolve the emergency.

4. When an adult patient is comatose, incapacitated or otherwise mentally or physically incapable of communication, another adult may consent to the medical treatment for the patient (Consent to Medical Treatment Act (1993).

4.1 In order of priority, the following individuals may consent to treatment of an incapacitated adult patient.

4.1.1 Agent designated by Medical Power of Attorney ...

The medical record for Patient #1 was reviewed. The Conditions of Admission and Consent for Outpatient Care in the medical record for Patient #1, an 8 page document, was not signed by the patient or the legally authorized representative of the patient. The document included:

1. Consent to Treatment ...

9. Medicare Patient Certification and Assignment of Benefit ...

12. Communications About My Healthcare ...

15. Other Acknowledgements, including information about Personal Valuables, Patient Visitation Rights, Records Retention, Patient Self Determination Act (Advance Directives), Notice of Privacy Practices, and Acknowledgement of Notice of Patient Rights and Responsibilities.

The spaces on the form for patient or legally authorized representative initials were left blank, including the acknowledgement of receipt the Notice of Patient Rights and Responsibilities. The form was not dated. The form was left blank/no signature in the space for Patient/Patient Representative Signature. The space for Witness Signature and Title had a hand-written signature (illegible) and the space for Additional Witness Signature and Title: (required for Patients unable to sign without a representative or Patients who refuse to sign) had a hand-written signature (also illegible). The signatures were not dated or timed.

However, Patient #1 did have a Power of Attorney, per the Surgical Consent to Treatment for Patient #1 for surgery on 11/22/16 related to a pelvic ring fracture sustained during a fall on 11/18/16. This consent was signed on 4 separate pages on 11/21/16 at 2000 PM by the daughter of Patient #1, who documented her relationship to the patient with each of the 4 signatures as Daughter/POA.

There was no documented evidence of a Consent to Treatment for Inpatient Care in the medical record for Patient #1 provided to the survey team for the inpatient admission of Patient #1.

There was no documented evidence in the record or provided to the survey team that Patient #1 or the legally authorized representative for Patient #1 was provided with the Conditions of Admission or provided Consent for Treatment. There was no documented evidence in the medical record that Patient #1 or the legally authorized representative for Patient #1 were advised of their Patient Rights.

In an interview with Staff #2 the afternoon of 2/8/17 in the Administration Office, the above findings were confirmed. Staff #2 stated that Patient #1 came in through the ER via EMS and therefore consent was not obtained.

Based on review of documentation and interview, the facility failed to ensure that patients were informed of their rights as there was no documented evidence to show that patient rights documents were received or provided to the patient or legally authorized representative.

Cross refer: CFR 482.13(a)(1) Patient Rights: Notice of Rights

Based on review of documentation and interview, the facility failed to ensure that a patient was afforded the right to informed consent to treatment and provided their patient rights as there was no documented evidence that patient rights were received or consent to inpatient treatment was provided by the patient or legally authorized representative.

Cross refer: CFR 482.13(b)(2) A0131 Patient Rights: Informed Consent

Based on review of documentation and interview, it was determined that the facility failed to provide patient care in a safe setting as the hospital did not supply an adequate number of licensed registered nurses and other personnel to provide nursing care to all patients in accordance with the Staffing Table for 5 South Medical/Surgical Unit. The hospital failed to ensure that nursing care was properly supervised, implemented, and evaluated; failed to ensure that assessments were conducted and documented; failed to verify that patient care equipment was operational. This was not in accordance with facility policy and standards of nursing practice and presents a risk to all patients admitted to the hospital.

Cross refer: CFR 482.13(c)(2) A0144 Patient Rights: Care in Safe Setting

Based on review of documentation and interview, the facility failed to ensure that a patients were informed of their patient rights as there was no documented evidence that patient rights documents were received or provided to the patient or legally authorized representative.

Findings included:

The medical record for Patient #1 was reviewed. The Conditions of Admission and Consent for Outpatient Care in the medical record for Patient #1, an 8 page document, was not signed by the patient or the legally authorized representative of the patient. The document included:

1. Consent to Treatment ...

9. Medicare Patient Certification and Assignment of Benefit ...

12. Communications About My Healthcare ...

15. Other Acknowledgements, including information about Personal Valuables, Patient Visitation Rights, Records Retention, Patient Self Determination Act (Advance Directives), Notice of Privacy Practices, and Acknowledgement of Notice of Patient Rights and Responsibilities.

The spaces on the form for patient or legally authorized representative initials were left blank, including the acknowledgement of receipt the Notice of Patient Rights and Responsibilities. The form was not dated. The form was left blank/no signature in the space for Patient/Patient Representative Signature. The space for Witness Signature and Title had a hand-written signature (illegible) and the space for Additional Witness Signature and Title: (required for Patients unable to sign without a representative or Patients who refuse to sign) had a hand-written signature (also illegible). The signatures were not dated or timed.

However, Patient #1 did have a Power of Attorney, per the Surgical Consent to Treatment for Patient #1 for surgery on 11/22/16 related to a pelvic ring fracture sustained during a fall on 11/18/16. This consent was signed on 4 separate pages on 11/21/16 at 2000 PM by the daughter of Patient #1, who documented her relationship to the patient with each of the 4 signatures as Daughter/POA.

There was no documented evidence in the record or provided to the survey team that Patient #1 or the legally authorized representative for Patient #1 were provided with or advised of their Patient Rights.

In an interview with Staff #2 the afternoon of 2/8/17 in the Administration Office, the above findings were confirmed. Staff #2 stated that Patient #1 came in through the ER via EMS and therefore consent was not obtained, which included providing or advising the patient of their Patient Rights.

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

Based on review of documentation and interview, it was determined that the facility did not always provide patient care in a safe setting as the hospital did not supply an adequate number of licensed registered nurses and other personnel to provide nursing care to all patients in accordance with the Staffing Table for 5 South Medical/Surgical Unit. The hospital failed to ensure that nursing care was properly supervised, implemented, and evaluated, failed to ensure that assessments were conducted and documented and failed to verify that patient care equipment was on and operational. This was not in accordance with facility policy and standards of nursing practice and presents a risk to all patients admitted to the hospital.

Findings included:

Review of the medical record Plan of Care for Patient #1 revealed that she was an [AGE] year old female with a documented High Risk for Falls. Approximately a week before she was admitted to Del Sol hospital on [DATE], Patient #1 had fallen and suffered a wrist fracture.

On 11/18/16 a nursing shift assessment was completed at 0830 by Staff #13, RN which revealed the following:

Fall Risk Elements: Fall HX (Last 3 Months) ...

Month/Year of Last Fall: [DATE] ...

Fall Risk Comment: HOURLY ROUNDING. CALL BELL AND PERSONAL BELONGINGS WITHIN REACH

High Risk for Falls: Y [Yes]

Fall Precautions Comment: NON SLIP FOOTWEAR

There was no documented evidence that the nurse verified that the bed alarm was on and activated for Patient #1, or that Patient #1 had a yellow wristband or yellow gown per the hospital Fall Precautions Policy.

The morning of 11/18/16, Patient #1 suffered a fall in her patient room resulting in injuries, including left acetabular and inferior pubic rami fractures. The only nursing note documenting the incident by Staff #13, RN on 11/18/16 stated, At 0933 was called into Room 527. Maintenance had found patient on the floor. CNA [Staff #15] and RN [Staff #16] assisted patient back to bed. VS obtained and were WNL, see chart. No complaints of pain noted at this time. Patient had non slip footwear on, bed alarm was in place however did not go off. Informed Dr [Staff #17] at 0945. Around 1015, physical therapist went in to work with patient (sic) and stated that patient had excruiating (sic) pain to left hip upon movement, even when elevating the HOB. [Staff #17] notified once again verbally and requested an xray.

An interview was conducted with Staff #5, Mechanic from Maintenance Department the afternoon of 2/7/17 in the Administration Office. When asked about the incident involving a patient fall on November 18, 2016 on 5 South, Staff #5 stated, I was walking in the hallway, checking the floor, I heard one voice screaming 'help, help.' I think it was afraid. Staff #5 stated, through a translator, The cry for help sounded like she was scared, versus in pain. Staff #5 stated he looked into the patient room through the door from the hall and saw a patient on the floor. He went to the nurse's station and told them the patient was on the floor. The staff got up and responded.

At 1005 on 11/18/16, Staff #14, PT, DPT entered the room of Patient #1 for scheduled physical therapy treatment and assessed Patient #1. Staff #14 determined at that time that Patient #1 was in pain with limited range of motion of the left leg and bruising. Staff #14 notified the nursing staff of the injury to Patient #1 and informed the nursing staff that Patient #1 needed an x-ray to rule out a fracture.

At 1328 on 11/18/16, Staff #14. PT, documented that at 1005, Patient presents in supine and upon arrival into room she indicates she has some pain. She refuses to get OOB [out of bed].

PROM [Passive Range of Motion]: RLE [right lower extremity] WFL [within functional limits]. However LLE [left lower extremity] is extremely painful with all PROM.

Palpation: No TTP [thrombotic[DIAGNOSES REDACTED] purpura tender to palpation] over RLE, but bruising noted and TTP over L knee and hip.

A: Patient demonstrates post fall reported by nursing this morning. She was found by Maintenance on the floor. She exhibits bruising and TTP over L knee and hip. She also indicates pain with bringing HOB [head of bed] up past 70 degrees, flinching towards L LE. Nursing notified that x-ray needs to be ordered to rule out fracture.

CT scan on 11/18/16 at 1:38 pm for Patient #1 revealed Left anterior sacral cortex fracture. Vertical Left obturator ring fracture .... X-ray of Left hip with pelvis on 11/18/16 revealed interval fracture off the medial left acetabulum. There is also irregularity of the left inferior pubic ramus not seen previously ...Impression: Left acetabular and inferior pubic rami fractures.

There was no documented evidence in the medical record of an immediate assessment for evidence of injury after the fall, before Patient #1 was moved, in accordance with facility policy.

There was no medical record entry or nursing assessment documented related to the fall by Staff #16, RN, who was the RN that assisted the patient back to bed from the floor after the fall.

There was no documented evidence of a Post Fall Assessment by nursing for injuries after the fall as required by facility policy.

There was no documented evidence of a neurological assessment conducted by nursing after the fall as required by facility policy.

There was no documented evidence that Patient #1 was wearing a yellow wristband or yellow gown to indicate high risk for falls per policy.

There was no documented evidence of a Fall Risk Assessment conducted on Patient #1 after her fall on 11/18/16 at 0933, as required by facility policy; a Fall Risk Assessment was not conducted until the following shift at 2130.

As stated in the nurses note, the bed alarm did not sound and there was no documented evidence the bed alarm was on and functioning.

Review of the hospital report of the incident revealed that Patient #1 was not wearing a yellow falls precautions wristband or was wearing a yellow gown at the time of the fall, in accordance with facility policy.

A fall risk assessment was also not conducted in accordance with facility policy after Patient #1 returned to her room after a surgical intervention in the OR to repair the fracture on 11/22/16.

On 11/16/16 at 1100, Patient #1 was transferred to a different patient room. A Fall Risk Assessment was not conducted after the move in accordance with facility policy until 2235 on 11/16/16. A medical record entry was made at 1500 on 11/16/16 (4 hours after the patient was moved to the new room) which stated, Fall Risk Precautions, View Only, Default from Fall Risk Assessment.

An interview was conducted the afternoon of 2/7/17 in the administration office with Staff #4. Staff #4 was asked by the survey team about the bed alarm not going off when Patient #1 got out of bed and fell . Staff #4 stated that she had spoken about the bed alarm to Staff #13, RN, the registered nurse assigned to Patient #1 when she fell and was injured. Staff #4 stated that Staff #13 told her that she had been in the room of Patient #1 earlier in the morning, working with her and moving her around on the bed. Staff #13 said that the bed alarm should have gone off during the time she was working with Patient #1, but it didn't occur to Staff #13 at the time that the alarm was not alarming. Per Staff #4, Staff #13 stated that she should have realized that when she was moving Patient #1 around on the bed, the bed alarm should have been going off, but it didn't occur to her until later, after the fall that the bed alarm wasn't working. Staff #4 stated that the bed alarm didn't alarm with the movement earlier in the morning or when Patient #1 got out of bed and fell at 9:33 am.

During the hospitalization of Patient #1 (11/14/16 - 11/23/16), there were only 3 instances of nursing documentation that the bed alarm for Patient #1 was on and verified. This documentation occurred on 11/15/16 at 1919, on 11/16/16 at 1500, on 11/19/16 at 1925.

Review of the medical record for Patient #1 revealed that a Fall Risk Assessment was not conducted each shift in accordance with policy for a patient with a high fall risk. There was no Fall Risk Assessment documented on the following shifts:

11/19/16 - no AM Fall Risk Assessment documented

11/20/16 - no AM Fall Risk Assessment documented

11/21/16 - no AM Fall Risk Assessment documented

11/22/16 - no AM Fall Risk Assessment documented

11/22/16 - no PM Fall Risk Assessment documented

A Fall Risk Assessment is required every shift in accordance with facility policy for a patient designated as a High Risk of Falls. Review of the medical record for Patient #1 revealed no documented evidence in the Fall Risk Assessment required every shift that the nurse verified that the bed alarm was on or activated on the following dates:

11/15/16 at 0910 No statement that the nurse verified the bed alarm was on or activated, only the words, Bed Alarm

11/16/16 at 0910 No statement that the nurse verified the bed alarm was on or activated

11/16/16 at 2100 No statement that the nurse verified the bed alarm was on or activated, only the words, Bed Alarm

11/16/16 at 2235 No statement that the nurse verified the bed alarm was on or activated, only the words, Bed Alarm in place

11/17/16 at 0730 No statement that the nurse verified the bed alarm was on or activated, only the words, Bed Alarm in place

11/17/16 at 2135 No statement that the nurse verified the bed alarm was on or activated, only the words, Bed Alarm in place

11/18/16 at 0830 No statement that the nurse verified the bed alarm was on or activated

11/18/16 at 0933 Patient #1 fell and bed alarm did not alarm

11/18/16 at 2130 No statement that the nurse verified the bed alarm was on or activated

11/19/16 at 2100 No statement that the nurse verified the bed alarm was on or activated

11/20/16 at 2155 No statement that the nurse verified the bed alarm was on or activated

11/21/16 at 2130 No statement that the nurse verified the bed alarm was on or activated

11/23/16 at 0800 No statement that the nurse verified the bed alarm was on or activated

There were 7 text nursing notes during the hospitalization of Patient #1 (11/14/16 - 11/23/16) which stated Bed alarm in place; however there was no statement that the nurse verified that the bed alarm was on or activated. (11/18/16 at 0632, 11/18/16 at 1900, 11/18/16 at 2055, 11/19/16 at 0639, 11/20/16 at 0612, 11/20/16 at 1900, 11/23/16 at 0830).

Review of the medical records for 9 current patients the afternoon of 2/7/17 that were admitted to the 5 South unit of Vista Del Sol Medical Center revealed the following:

+ Patient #2 revealed no statement the bed alarm was on or activated for 02/02/17.

+ Patient #5 revealed no statement the bed alarm was on or activated for 02/06/17.

+ Patient #6 revealed no statement the bed alarm was on or activated for 02/05/17.

+ Patient #7 revealed no statement the bed alarm was on or activated for 01/31/17.

+ Patient #9 revealed no statement the bed alarm was on or activated for 02/06/17.

In an interview on the afternoon of 2/7/17 at the 5 South nurses station, the clinical coordinator, Staff #10, confirmed the findings.

Review of the medical record for Patient #1 on 11/18/16 at 0830 revealed the assessing nurse documented, N [No] to the fall risk assessment indicator, Pt has 3 or more meds in drug classes known to be indicator of fall risk. Patient #1 was taking Clonazepam, Enalapril and Gabapentin routinely, all of which are labeled in the hospital electronic eMAR system, **CAUTION: MEDICATION ASSOCIATED WITH FALLS**. Patient #1 was also taking Morphine for her wrist fracture pain. 7 out of 11 shifts where fall risk assessments were documented had an incorrect response to the question regarding 3 or more medications, as below.

11/16/16 at 0910 documented N [No] for 3 or more medications

11/16/16 at 2100 documented N [No] for 3 or more medications

11/16/16 at 2235 documented N [No] for 3 or more medications

11/17/16 at 0730 documented N [No] for 3 or more medications

11/18/16 at 0830 documented N [No] for 3 or more medications

11/18/16 at 2130 documented N [No] for 3 or more medications

11/23/16 at 0800 documented N [No] for 3 or more medications

The Unit Activity Report for Patient #1 provided to the survey team revealed a Detailed record of all activities per Unit/Team in date order. This report included a timed report of every nurse or nurse assistant entering and exiting the room of Patient #1 between 11/17/16 and 11/23/16. Patient #1, a high risk for falls, would require rounding every hour, according to hospital policy. Review of the Unit Activity Report revealed that nursing staff did not make rounds every hour in accordance with facility policy for Patient #1 at least 24 times between 11/17/16 and 11/23/16.

11/17/16

No rounds between 1:39 am and 3:07 am

No rounds between 3:33 am and 4:38 am

No rounds between 7:13 pm and 9:15 pm

11/18/16

No rounds between 4:53 am and 6:20 am

No rounds between 6:24 am and 8:24 am

11/19/16

No rounds between 4:18 pm and 5:39 pm

No rounds between 7:35 pm and 9:12 pm

11/20/16

No rounds between 1:03 pm and 2:19 pm

No rounds between 8:13 pm and 9:54 pm

11/21/16

No rounds between 00:16 am and 2:11 am

No rounds between 2:11 am and 3:20 am

No rounds between 4:04 am and 5:10 am

No rounds between 5:18 am and 6:48 am

No rounds between 4:13 pm and 5:24 pm

11/22/16

No rounds between 00:45 am and 3:43 am

No rounds between 3:53 am and 5:16 am

No rounds between 3:20 pm and 5:20 pm

11/23/16 - returned from OR at 2309 on 11/22/16

No rounds between 00:53 am and 3:34 pm

No rounds between 3:36 am and 5:30 am

No rounds between 5:45 am and 7:21 am

No rounds between 8:53 am and 11:39 am

No rounds between 1:57 pm and 3:14 pm

No rounds between 7:56 pm and 9:28 pm

No rounds between 9:49 pm and 11:06 pm

In an interview with Staff #2 the afternoon of 2/7/17 in the Administration Office, she stated that rounds are not made every hour during the night shift. Review of the document provided to the survey team entitled, In-Patient Hourly Rounding Log revealed a form used on the unit to track hourly rounding. The form had a line for every hour until 10 pm-12am, 12-2 am, 2-4 am, and 4-6 am. Staff #2 stated that the form was not a part of the medical record and was thrown away after each shift.

The personnel folder was reviewed for Staff #13, RN, who was the Registered Nurse assigned to Patient #1 on 11/18/16 when she sustained a fall resulting in injury. Review of the personnel record revealed a Position Description and Competency Evaluation, Annual Evaluation Effective Date May 2016. The Annual Evaluation, signed by Staff #13 on 6/16/16 documented a specific goal which stated, State specific steps with deadline dates to accomplish goals ...3. Check bed/wheelchair alarms during hourly rounding (7/1/16). 2016 Mandatory Fair Requirement Record dated 5/31/16 revealed Fall Prevention training for Staff #13 (completed before the annual evaluation). The In-service Record document dated November 29 -30, 2016 revealed Staff #13 attended a Power Point presentation dated 5/25/16 and 5/26/16 that included a section on preventing falls. There was no documented follow-up on the 6/16/16 goal for Staff #13 to check bed/wheelchair alarms during hourly rounding with a due date of 7/1/16. Staff #13 was and continues to be licensed as an RN in the state of Texas. All other required training, including CPR certifications were current on 11/18/16 and as of 2/7/17. The above was confirmed in an interview the afternoon of 2/7/17 with Staff #2 in the Administration Office.

Review of facility policy PC 237_Patient Fall Prevention stated, in part, PURPOSE: To identify patients at risk for falls, to assess fall potential, and to provide a maximum level of patient protection and safety without compromising mobility and functional independence. POLICY: Upon admission, patients are assured of assessment of their risk for falls; manipulation of the environment to prevent falls, and appropriate management of those who experience a fall. Most falls do not lead to serious injury; however, moderate to severe injuries reduce mobility and independence and increase the risk for premature death ...Of all fall-related fractures, hip fractures are the most serious and lead to the greatest number of health problems and death. Patients who fall once during their outpatient stay are more likely to fall again, increasing the risk for more injury.

The Falls Prevention Program Includes ...2. Basic safety considerations/interventions for all patient. 3. Screening to identify patients at risk for falls or injury. 4. Use of recommended interventions for patients assessed at Risk. 5. Post-fall management, documentation and follow-up.

PROCEDURE:

GENERAL ...C. Patient at a high risk for falls will be identified with a YELLOW wristband and YELLOW socks. D. Patients that have one or more of the following criteria (confused, impulsive or history of falls) will be identified with a YELLOW gown in addition to the YELLOW wristband and YELLOW socks. E. Hourly rounding will be performed on all patients.

RISK ASSESSMENT:

A. A Fall evaluation is defined as an assessment that includes the following: a history of all circumstances, medications, acute or chronic medical problems, and mobility levels; an examination of vision, gait and balance, and lower extremity joint function; an examination of basic neurological function, including mental status, muscle strength; and assessment of basic cardiovascular status including heart rate and rhythm, and blood pressure ...

D. A Fall Risk Assessment will be completed in Meditech as part of the Nursing Admission Assessment and every shift ...

E. All adult and geriatric patients on the nursing units will have a fall risk assessment performed on:

1. Admission

2. Once a shift

3. Transfer (be receiving unit)

4. After receiving IV sedation

5. A change of condition or LOC

6. Change in medications that may contribute to falls risk

7. After any surgical intervention/procedure and

8. After any fall ...

E. The fall assessment will determine whether a fall risk exists for the patient, and if so, whether it is low, moderate, or high risk. Based on the assessment, fall precautions will be initiated and documented.

a. Score of 0-8 = Low Risk

b. Score >9 = High Risk

Interventions and Preventive Strategies

A. Implement the following interventions according to the Fall Risk Assessment scores.

1. Low Risk Intervention Score of 0-8 ...

Hourly rounds using the 4-P's - Pain, Potty, Positioning, and Possessions

Call Bell within reach; room is free of clutter, nightlight it on; bed is in the lowest position and locked; and all personal items are within reach ...

Both side bedrails are up X2 ...

Evaluate medication regime: Medication categories determined to potentiate risk of falls include narcotics, sedatives, tranquilizers, psychotropic's, cardiovascular, diuretics, anticonvulsives, laxatives, and antidepressants.

2. High Risk Interventions (Score at or greater than 9)

Implement all intervention for Low Risk

Alert: Apply yellow armband

Bed Alarm on bed ...

Provide non-slip footwear

Assist: Mobility

Assist: ADL

Review of facility policy PC 237_Patient Fall Prevention stated, in part,

POST-FALL-WHENEVER A FALL OCCURS

1. Assess immediately for evidence of injury before moving the patient.

2. Post Fall Assessment. The physician, family/legal representative, manager, and nursing supervisor are notified.

3. The nurse documents the fall data and all persons notified in the Nursing Notes ...

DOCUMENTATION: ...

2. Complete a Post Fall Assessment and re-evaluate the Plan of Care and adjust interventions accordingly. Follow-up should consist of implementing and documenting the following in the nurses notes:

Vitals: Blood pressure, Pulse, Respirations

Neurological: Level of consciousness, Headache, Glascow Coma Score, Pupils (size/reaction) (If medicated with narcotics or sedatives in the last 12 hrs, consider that head injury may be masked because of medications)

Motor Strength: Arms and legs, Bilateral hand grasp

Musculoskeletal: Bilateral Upper & lower Extremities, Gait, ROM & Muscle tone

Skin Integrity: Skin intact & location, Bruising/contusions (location), Laceration/abrasions (location), Lines/tubes intact

Pain: Location, level, radiates to ...

Facility policy, PC 201_Assessment/Reassessment stated, in part, 2. Focused assessment (Shift Reassessment) ...For all patients reassessment is at specified, regular intervals which may be related to: ...f. Risk for falling when appropriate and action taken to reduce risk.

NURSING ...9 ...The patient's health status will determine the frequency of assessment; however, an R.N. will perform a reassessment to include an update of the Plan of Care in at least the following situations ...

a. Prior to, upon arrival, and discharge from special procedures (i.e. Endo, OR, Cath lab) area.

b. Any time there is a significant change in the patient's condition ...

e. When the patient is transferred from one unit to another unit ...

i. Focused re-assessment, at least, once a shift.

Review of the Texas Nurse Practice Act 217.11, Standards of Nursing Practice, states, in part,

(1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: (A) Know and conform to the Texas Nursing Practice Act and the board's rules and regulations as well as all federal, state, or local laws, rules or regulations affecting the nurse's current area of nursing practice;

(B) Implement measures to promote a safe environment for clients and others; ...

(D) Accurately and completely report and document:

(i) the client's status including signs and symptoms;

(ii) nursing care rendered; ...

(v) client response(s); and

(vi) contacts with other health care team members concerning significant events regarding client's status;

The above findings were confirmed in an interview the afternoon of 2/7/16 with Staff #2 in the Administration Office.

Based on review of documentation and interview, the nursing service did not supply an adequate number of licensed registered nurses and other personnel to provide nursing care to all patients in accordance with the Staffing Table for 5 South Medical/Surgical Unit. This deficient practice had the likelihood to cause harm to all patients admitted to 5 South.

Cross refer: CFR 482.23(b) A0392 Staffing and Delivery of Care

Based on document review, observation, and interviews, the hospital failed to ensure that nursing care was properly supervised, implemented, and evaluated, failed to ensure that assessments were conducted and documented and failed to verify that patient care equipment was on and operational. This was not in accordance with facility policy and standards of nursing practice and presents a risk to all patients admitted to the hospital.

Cross refer: CFR 482.23(b)(3) A0395 RN Supervision of Nursing Care

Based on review of documentation and interview, the nursing service did not ensure adequate number of licensed registered nurses and other personnel to provide nursing care to all patients in accordance with the Staffing Table for 5 South Medical/Surgical Unit. This deficient practice had the likelihood to cause harm to all patients admitted to 5 South.

Findings included:

Review of the medical record for Patient #1 on 5 South revealed that Patient #1 suffered a fall resulting in injuries. The only nursing note documenting the incident by Staff #13, RN on 11/18/16 stated, At 0933 was called into Room 527. Maintenance had found patient on the floor. CNA [Staff #15] and RN [Staff #16] assisted patient back to bed. VS obtained and were WNL, see chart. No complaints of pain noted at this time. Patient had non slip footwear on, bed alarm was in place however did not go off. Informed Dr [Staff #17] at 0945. Around 1015, physical therapist went in to work with patinet (sic) and stated that patient had excruiating (sic) pain to left hip upon movement, even when elevating the HOB. [Staff #17] notified once again verbally and requested an xray.

CT scan on 11/18/16 at 1:38 pm for Patient #1 revealed Left anterior sacral cortex fracture. Vertical Left obturator ring fracture .... X-ray of Left hip with pelvis on 11/18/16 revealed interval fracture off the medial left acetabulum. There is also irregularity of the left inferior pubic ramus not seen previously ...Impression: Left acetabular and inferior pubic rami fractures.

Review of the actual staffing for the day shift on 5 South for 11/18/16 revealed 1 Charge Nurse, 3 RNs, and 2 Nurse Assistants for 23 patients. The unit was short 1 RN and 1 nurse assistant per the Staffing Table.

Review of the actual staffing for the day shift for 2/5/17 revealed 1 Charge Nurse, 3 RNs, and 3.5 Nursing Assistants with a census of 20 patients. The unit was short 1 RN per the Staffing Table.

Review of the actual staffing for the day shift for 2/6/17 revealed 1 Charge Nurse, 3 RNs, and 2 Nursing Assistants with a census of 21 patients. The unit was short 1 RN per the Staffing Table.

Review of the actual staffing for the day shift for 2/7/17 revealed 1 Charge Nurse, 3 RNs, and 2 Nursing Assistants with a census of 20 patients. The unit was short 1 RN per the Staffing Table.

Review of the Staffing Table for 5 South Medical/Surgical Unit provided to the survey team on 2/7/16 in the Administrative Office revealed the following:

For a census of 20 patients:

1 Charge Nurse, 4 RNs, and 2 Nurse Assistants for the 7-3 pm day shift;

1 Charge Nurse, 4 RNs, and 2 Nurse Assistants for the 3-7 pm evening shift.

For a census of 21 patients:

1 Charge Nurse, 4 RNs, and 2 Nurse Assistants for the 7-3 pm day shift;

1 Charge Nurse, 4 RNs, and 2 Nurse Assistants for the 3-7 pm evening shift.

For a census of 23 patients:

1 Charge Nurse, 4 RNs, and 3 Nurse Assistants for the 7-3 pm day shift;

1 Charge Nurse, 4 RNs, and 2 Nurse Assistants for the 3-7 pm evening shift.

'The above findings were confirmed in an interview the afternoon of 2/7/17 with Staff #2 in the Administrative Office.

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

Based on document review, observation, and interviews, the hospital failed to;

1. ensure that nursing care was properly supervised, implemented, and evaluated;

2. ensure that assessments were conducted and documented; and

3. verify that patient care equipment was on and operational.

These practices were not in accordance with facility policy and standards of nursing practice and presents a risk to all patients admitted to the hospital.

Findings included:

Review of the medical record Plan of Care for Patient #1 revealed that she was an [AGE] year old female with a documented High Risk for Falls. Approximately a week before she was admitted to Del Sol hospital on [DATE], Patient #1 had fallen and suffered a wrist fracture.

On 11/18/16 a nursing shift assessment was completed at 0830 by Staff #13, RN which revealed the following:

Fall Risk Elements: Fall HX (Last 3 Months) ...

Month/Year of Last Fall: [DATE] ...

Fall Risk Comment: HOURLY ROUNDING. CALL BELL AND PERSONAL BELONGINGS WITHIN REACH

High Risk for Falls: Y [Yes]

Fall Precautions Comment: NON SLIP FOOTWEAR

There was no documented evidence that the nurse verified that the bed alarm was on and activated for Patient #1, or that Patient #1 had a yellow wristband or yellow gown per the hospital Fall Precautions Policy.

The morning of 11/18/16, Patient #1 suffered a fall in her patient room resulting in injuries, including left acetabular and inferior pubic rami fractures. The only nursing note documenting the incident by Staff #13, RN on 11/18/16 stated, At 0933 was called into Room 527. Maintenance had found patient on the floor. CNA [Staff #15] and RN [Staff #16] assisted patient back to bed. VS obtained and were WNL, see chart. No complaints of pain noted at this time. Patient had non slip footwear on, bed alarm was in place however did not go off. Informed Dr [Staff #17] at 0945. Around 1015, physical therapist went in to work with patinet (sic) and stated that patient had excruiating (sic) pain to left hip upon movement, even when elevating the HOB. [Staff #17] notified once again verbally and requested an xray.

An interview was conducted with Staff #5, Mechanic from Maintenance Department the afternoon of 2/717 in the Administration Office. When asked about the incident involving a patient fall on November 18, 2016 on 5 South, Staff #5 stated, I was walking in the hallway, checking the floor, I heard one voice screaming 'help, help.' I think it was afraid. Staff #5 stated, through a translator, The cry for help sounded like she was scared, versus in pain. Staff #5 stated he looked into the patient room through the door from the hall and saw a patient on the floor. He went to the nurse's station and told them the patient was on the floor. The staff got up and responded.

At 1005 on 11/18/16, Staff #14, PT, DPT entered the room of Patient #1 for scheduled physical therapy treatment and assessed Patient #1. Staff #14 determined at that time that Patient #1 was in pain with limited range of motion of the left leg and bruising. Staff #14 notified the nursing staff of the injury to Patient #1 and informed the nursing staff that Patient #1 needed an x-ray to rule out a fracture.

At 1328 on 11/18/16, Staff #14. PT, documented that at 1005, Patient presents in supine and upon arrival into room she indicates she has some pain. She refuses to get OOB [out of bed]. PROM [Passive Range of Motion]: RLE [right lower extremity] WFL [within functional limits]. However LLE [left lower extremity] is extremely painful with all PROM. Palpation: No TTP [thrombotic[DIAGNOSES REDACTED] purpura tender to palpation] over RLE, but bruising noted and TTP over L knee and hip. A: Patient demonstrates post fall reported by nursing this morning. She was found by Maintenance on the floor. She exhibits bruising and TTP over L knee and hip. She also indicates pain with bringing HOB [head of bed] up past 70 degrees, flinching towards L LE. Nursing notified that x-ray needs to be ordered to rule out fracture.

CT scan on 11/18/16 at 1:38 pm for Patient #1 revealed Left anterior sacral cortex fracture. Vertical Left obturator ring fracture .... X-ray of Left hip with pelvis on 11/18/16 revealed interval fracture off the medial left acetabulum. There is also irregularity of the left inferior pubic ramus not seen previously ...Impression: Left acetabular and inferior pubic rami fractures.

There was no documented evidence in the medical record of an immediate assessment for evidence of injury after the fall, before Patient #1 was moved, in accordance with facility policy.

There was no medical record entry or nursing assessment documented related to the fall by Staff #16, RN, who was the RN that assisted the patient back to bed from the floor after the fall.

There was no documented evidence of a Post Fall Assessment by nursing for injuries after the fall as required by facility policy.

There was no documented evidence of a neurological assessment conducted by nursing after the fall as required by facility policy.

There was no documented evidence that Patient #1 was wearing a yellow wristband or yellow gown to indicate high risk for falls per policy.

There was no documented evidence of a Fall Risk Assessment conducted on Patient #1 after her fall on 11/18/16 at 0933, as required by facility policy; a Fall Risk Assessment was not conducted until the following shift at 2130.

As stated in the nurses note, the bed alarm did not sound and there was no documented evidence the bed alarm was on and functioning.

Review of the hospital report of the incident revealed that Patient #1 was not wearing a yellow falls precautions wristband or was wearing a yellow gown at the time of the fall, in accordance with facility policy.

A fall risk assessment was also not conducted in accordance with facility policy after Patient #1 returned to her room after a surgical intervention in the OR to repair the fracture on 11/22/16.

On 11/16/16 at 1100, Patient #1 was transferred to a different patient room. A Fall Risk Assessment was not conducted after the move in accordance with facility policy until 2235 on 11/16/16. A medical record entry was made at 1500 on 11/16/16 (4 hours after the patient was moved to the new room) which stated, Fall Risk Precautions, View Only, Default from Fall Risk Assessment.

An interview was conducted the afternoon of 2/7/17 in the administration office with Staff #4. Staff #4 was asked by the survey team about the bed alarm not going off when Patient #1 got out of bed and fell . Staff #4 stated that she had spoken about the bed alarm to Staff #13, RN, the registered nurse assigned to Patient #1 when she fell and was injured. Staff #4 stated that Staff #13 told her that she had been in the room of Patient #1 earlier in the morning, working with her and moving her around on the bed. Staff #13 said that the bed alarm should have gone off during the time she was working with Patient #1, but it didn't occur to Staff #13 at the time that the alarm was not alarming. Per Staff #4, Staff #13 stated that she should have realized that when she was moving Patient #1 around on the bed, the bed alarm should have been going off, but it didn't occur to her until later, after the fall that the bed alarm wasn't working. Staff #4 stated that the bed alarm didn't alarm with the movement earlier in the morning or when Patient #1 got out of bed and fell at 9:33 am.

During the hospitalization of Patient #1 (11/14/16 - 11/23/16), there were only 3 instances of nursing documentation that the bed alarm for Patient #1 was on and verified. This documentation occurred on 11/15/16 at 1919, on 11/16/16 at 1500, on 11/19/16 at 1925.

Review of the medical record for Patient #1 revealed that a Fall Risk Assessment was not conducted each shift in accordance with policy for a patient with a high fall risk. There was no Fall Risk Assessment documented on the following shifts:

11/19/16 - no AM Fall Risk Assessment documented

11/20/16 - no AM Fall Risk Assessment documented

11/21/16 - no AM Fall Risk Assessment documented

11/22/16 - no AM Fall Risk Assessment documented

11/22/16 - no PM Fall Risk Assessment documented

A Fall Risk Assessment is required every shift in accordance with facility policy for a patient designated as a High Risk of Falls. Review of the medical record for Patient #1 revealed no documented evidence in the Fall Risk Assessment required every shift that the nurse verified that the bed alarm was on or activated on the following dates:

11/15/16 at 0910 No statement that the nurse verified the bed alarm was on or activated, only the words, Bed Alarm

11/16/16 at 0910 No statement that the nurse verified the bed alarm was on or activated

11/16/16 at 2100 No statement that the nurse verified the bed alarm was on or activated, only the words, Bed Alarm

11/16/16 at 2235 No statement that the nurse verified the bed alarm was on or activated, only the words, Bed Alarm in place

11/17/16 at 0730 No statement that the nurse verified the bed alarm was on or activated, only the words, Bed Alarm in place

11/17/16 at 2135 No statement that the nurse verified the bed alarm was on or activated, only the words, Bed Alarm in place

11/18/16 at 0830 No statement that the nurse verified the bed alarm was on or activated

11/18/16 at 0933 Patient #1 fell and bed alarm did not alarm

11/18/16 at 2130 No statement that the nurse verified the bed alarm was on or activated

11/19/16 at 2100 No statement that the nurse verified the bed alarm was on or activated

11/20/16 at 2155 No statement that the nurse verified the bed alarm was on or activated

11/21/16 at 2130 No statement that the nurse verified the bed alarm was on or activated

11/23/16 at 0800 No statement that the nurse verified the bed alarm was on or activated

There were 7 text nursing notes during the hospitalization of Patient #1 (11/14/16 - 11/23/16) which stated Bed alarm in place; however there was no statement that the nurse verified that the bed alarm was on or activated. (11/18/16 at 0632, 11/18/16 at 1900, 11/18/16 at 2055, 11/19/16 at 0639, 11/20/16 at 0612, 11/20/16 at 1900, 11/23/16 at 0830).

Review of the medical records for 9 current patients the afternoon of 2/7/17 that were admitted to the 5 South unit of Vista Del Sol Medical Center revealed the following:

+ Patient #2 revealed no statement the bed alarm was on or activated for 02/02/17.

+ Patient #5 revealed no statement the bed alarm was on or activated for 02/06/17.

+ Patient #6 revealed no statement the bed alarm was on or activated for 02/05/17.

+ Patient #7 revealed no statement the bed alarm was on or activated for 01/31/17.

+ Patient #9 revealed no statement the bed alarm was on or activated for 02/06/17.

In an interview on the afternoon of 2/7/17 at the 5 South nurses station, the clinical coordinator, Staff #10, confirmed the findings.

Review of the medical record for Patient #1 on 11/18/16 at 0830 revealed the assessing nurse documented, N [No] to the fall risk assessment indicator, Pt has 3 or more meds in drug classes known to be indicator of fall risk. Patient #1 was taking Clonazepam, Enalapril and Gabapentin routinely, all of which are labeled in the hospital electronic eMAR system, **CAUTION: MEDICATION ASSOCIATED WITH FALLS**. Patient #1 was also taking Morphine for her wrist fracture pain. 7 out of 11 shifts where fall risk assessments were documented had an incorrect response to the question regarding 3 or more medications, as below.

11/16/16 at 0910 documented N [No] for 3 or more medications

11/16/16 at 2100 documented N [No] for 3 or more medications

11/16/16 at 2235 documented N [No] for 3 or more medications

11/17/16 at 0730 documented N [No] for 3 or more medications

11/18/16 at 0830 documented N [No] for 3 or more medications

11/18/16 at 2130 documented N [No] for 3 or more medications

11/23/16 at 0800 documented N [No] for 3 or more medications

The Unit Activity Report for Patient #1 provided to the survey team revealed a Detailed record of all activities per Unit/Team in date order. This report included a timed report of every nurse or nurse assistant entering and exiting the room of Patient #1 between 11/17/16 and 11/23/16. Patient #1, a high risk for falls, would require rounding every hour, according to hospital policy. Review of the Unit Activity Report revealed that nursing staff did not make rounds every hour in accordance with facility policy for Patient #1 at least 24 times between 11/17/16 and 11/23/16.

11/17/16

No rounds between 1:39 am and 3:07 am

No rounds between 3:33 am and 4:38 am

No rounds between 7:13 pm and 9:15 pm

11/18/16

No rounds between 4:53 am and 6:20 am

No rounds between 6:24 am and 8:24 am

11/19/16

No rounds between 4:18 pm and 5:39 pm

No rounds between 7:35 pm and 9:12 pm

11/20/16

No rounds between 1:03 pm and 2:19 pm

No rounds between 8:13 pm and 9:54 pm

11/21/16

No rounds between 00:16 am and 2:11 am

No rounds between 2:11 am and 3:20 am

No rounds between 4:04 am and 5:10 am

No rounds between 5:18 am and 6:48 am

No rounds between 4:13 pm and 5:24 pm

11/22/16

No rounds between 00:45 am and 3:43 am

No rounds between 3:53 am and 5:16 am

No rounds between 3:20 pm and 5:20 pm

11/23/16 - returned from OR at 2309 on 11/22/16

No rounds between 00:53 am and 3:34 pm

No rounds between 3:36 am and 5:30 am

No rounds between 5:45 am and 7:21 am

No rounds between 8:53 am and 11:39 am

No rounds between 1:57 pm and 3:14 pm

No rounds between 7:56 pm and 9:28 pm

No rounds between 9:49 pm and 11:06 pm

In an interview with Staff #2 the afternoon of 2/7/17 in the Administration Office, she stated that rounds are not made every hour during the night shift. Review of the document provided to the survey team entitled, In-Patient Hourly Rounding Log revealed a form used on the unit to track hourly rounding. The form had a line for every hour until 10 pm-12am, 12-2 am, 2-4 am, and 4-6 am. Staff #2 stated that the form was not a part of the medical record and was thrown away after each shift.

The personnel folder was reviewed for Staff #13, RN, who was the Registered Nurse assigned to Patient #1 on 11/18/16 when she sustained a fall resulting in injury. Review of the personnel record revealed a Position Description and Competency Evaluation, Annual Evaluation Effective Date May 2016. The Annual Evaluation, signed by Staff #13 on 6/16/16 documented a specific goal which stated, State specific steps with deadline dates to accomplish goals ...3. Check bed/wheelchair alarms during hourly rounding (7/1/16). 2016 Mandatory Fair Requirement Record dated 5/31/16 revealed Fall Prevention training for Staff #13 (completed before the annual evaluation). The In-service Record document dated November 29 -30, 2016 revealed Staff #13 attended a Power Point presentation dated 5/25/16 and 5/26/16 that included a section on preventing falls. There was no documented follow-up on the 6/16/16 goal for Staff #13 to check bed/wheelchair alarms during hourly rounding with a due date of 7/1/16. Staff #13 was and continues to be licensed as an RN in the state of Texas. All other required training, including CPR certifications were current on 11/18/16 and as of 2/7/17. The above was confirmed in an interview the afternoon of 2/7/17 with Staff #2 in the Administration Office.

Review of facility policy PC 237_Patient Fall Prevention stated, in part, PURPOSE: To identify patients at risk for falls, to assess fall potential, and to provide a maximum level of patient protection and safety without compromising mobility and functional independence. POLICY: Upon admission, patients are assured of assessment of their risk for falls; manipulation of the environment to prevent falls, and appropriate management of those who experience a fall. Most falls do not lead to serious injury; however, moderate to severe injuries reduce mobility and independence and increase the risk for premature death ...Of all fall-related fractures, hip fractures are the most serious and lead to the greatest number of health problems and death. Patients who fall once during their outpatient stay are more likely to fall again, increasing the risk for more injury.

The Falls Prevention Program Includes ...2. Basic safety considerations/interventions for all patient. 3. Screening to identify patients at risk for falls or injury. 4. Use of recommended interventions for patients assessed at Risk. 5. Post-fall management, documentation and follow-up.

PROCEDURE:

GENERAL ...C. Patient at a high risk for falls will be identified with a YELLOW wristband and YELLOW socks. D. Patients that have one or more of the following criteria (confused, impulsive or history of falls) will be identified with a YELLOW gown in addition to the YELLOW wristband and YELLOW socks. E. Hourly rounding will be performed on all patients.

RISK ASSESSMENT:

A. A Fall evaluation is defined as an assessment that includes the following: a history of all circumstances, medications, acute or chronic medical problems, and mobility levels; an examination of vision, gait and balance, and lower extremity joint function; an examination of basic neurological function, including mental status, muscle strength; and assessment of basic cardiovascular status including heart rate and rhythm, and blood pressure ...

D. A Fall Risk Assessment will be completed in Meditech as part of the Nursing Admission Assessment and every shift ...

E. All adult and geriatric patients on the nursing units will have a fall risk assessment performed on:

1. Admission

2. Once a shift

3. Transfer (be receiving unit)

4. After receiving IV sedation

5. A change of condition or LOC

6. Change in medications that may contribute to falls risk

7. After any surgical intervention/procedure and

8. After any fall ...

E. The fall assessment will determine whether a fall risk exists for the patient, and if so, whether it is low, moderate, or high risk. Based on the assessment, fall precautions will be initiated and documented.

a. Score of 0-8 = Low Risk

b. Score >9 = High Risk

Interventions and Preventive Strategies

A. Implement the following interventions according to the Fall Risk Assessment scores.

1. Low Risk Intervention Score of 0-8 ...

Hourly rounds using the 4-P's - Pain, Potty, Positioning, and Possessions

Call Bell within reach; room is free of clutter, nightlight it on; bed is in the lowest position and locked; and all personal items are within reach ...

Both side bedrails are up X2 ...

Evaluate medication regime: Medication categories determined to potentiate risk of falls include narcotics, sedatives, tranquilizers, psychotropic's, cardiovascular, diuretics, anticonvulsives, laxatives, and antidepressants.

2. High Risk Interventions (Score at or greater than 9)

Implement all intervention for Low Risk

Alert: Apply yellow armband

Bed Alarm on bed ...

Provide non-slip footwear

Assist: Mobility

Assist: ADL

Review of facility policy PC 237_Patient Fall Prevention stated, in part,

POST-FALL-WHENEVER A FALL OCCURS

1. Assess immediately for evidence of injury before moving the patient.

2. Post Fall Assessment. The physician, family/legal representative, manager, and nursing supervisor are notified.

3. The nurse documents the fall data and all persons notified in the Nursing Notes ...

DOCUMENTATION: ...

2. Complete a Post Fall Assessment and re-evaluate the Plan of Care and adjust interventions accordingly. Follow-up should consist of implementing and documenting the following in the nurses notes:

Vitals: Blood pressure, Pulse, Respirations

Neurological: Level of consciousness, Headache, Glascow Coma Score, Pupils (size/reaction) (If medicated with narcotics or sedatives in the last 12 hrs, consider that head injury may be masked because of medications)

Motor Strength: Arms and legs, Bilateral hand grasp

Musculoskeletal: Bilateral Upper & lower Extremities, Gait, ROM & Muscle tone

Skin Integrity: Skin intact & location, Bruising/contusions (location), Laceration/abrasions (location), Lines/tubes intact

Pain: Location, level, radiates to ...

Facility policy, PC 201_Assessment/Reassessment stated, in part, 2. Focused assessment (Shift Reassessment) ...For all patients reassessment is at specified, regular intervals which may be related to: ...f. Risk for falling when appropriate and action taken to reduce risk.

NURSING ...9 ...The patient's health status will determine the frequency of assessment; however, an R.N. will perform a reassessment to include an update of the Plan of Care in at least the following situations ...

a. Prior to, upon arrival, and discharge from special procedures (i.e. Endo, OR, Cath lab) area.

b. Any time there is a significant change in the patient's condition ...

e. When the patient is transferred from one unit to another unit ...

i. Focused re-assessment, at least, once a shift.

Review of the Texas Nurse Practice Act 217.11, Standards of Nursing Practice, states, in part,

(1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: (A) Know and conform to the Texas Nursing Practice Act and the board's rules and regulations as well as all federal, state, or local laws, rules or regulations affecting the nurse's current area of nursing practice;

(B) Implement measures to promote a safe environment for clients and others; ...

(D) Accurately and completely report and document:

(i) the client's status including signs and symptoms;

(ii) nursing care rendered; ...

(v) client response(s); and

(vi) contacts with other health care team members concerning significant events regarding client's status;

The above findings were confirmed in an interview the afternoon of 2/7/16 with Staff #2 in the Administration Office.

Based on a review of facility policies and staff interviews, the hospital failed to implement and enforce its own policy related to the resolution of patient grievances in 1 of 5 patient grievances reviewed (Patient #1).

Findings were:

Facility policy #RI 146 entitled Patient Grievance and Complaint Management, approval date 2/16, included the following:

DEFINITIONS:...

A Patient Grievance is a written or verbal complaint (when the verbal complaint about patient care is not resolved at the time of the complaint by staff present) by a patient, or the patient's representative, regarding the patient's care, abuse or neglect, issues related to compliance with the CMS Conditions of Participation (CoP), or a Medicare beneficiary billing complaint related to rights and limitations provided by 42 CFR 489...A verbal complaint is a grievance if it cannot be resolved at the time of the complaint by staff present, if it is postponed for later resolution, if it is referred to other staff for later resolution, if requires investigation, and/or if it requires further actions for resolution...

POLICY...

A Patient or Non-Patient Notification should be initiated for all concerns/complaints/grievances requiring further follow-up and forwarded to the following:...

2. Quality Management - shall be responsible for any quality of care issues...

5. Facility Privacy Officer (FPO) shall be responsible for overseeing the investigation and resolution of grievances related to the Health Insurance Portability and Accountability Act (HIPAA)...

Patient #1 visited the hospital emergency department on 4/12/16. After leaving, she realized she had been given the discharge instructions of Patient #2, another patient with a similar name. She believed she'd received inappropriate care as a result. Patient #1 contacted the facility by telephone on 4/13/16 to express her concerns. These concerns included several issues related to the care she had received.

In a group interview with the administrative director of quality, administrative director for critical care, and the emergency department director, Staff #1, 4 and 5 respectively, on the morning of 1/3/17 in a facility administrative meeting room, Staff #4 stated, I talked to [Patient #1] on the phone when she called to complain...I remember she said she didn't feel she'd had the right care. But I passed her on to [Staff #12, ED physician] and he said the care had been correct. He told her that on the phone...We didn't consider this a grievance because [Staff #12] looked at it and said the care given was appropriate. We were just looking at this as a HIPAA violation.

In an interview with Staff #1, Administrative Director of Quality, on the morning of 1/3/17 in a facility meeting room, she stated, I didn't know anything about this, so we don't have any kind of investigation into the problem or any kind of follow-up grievance communication to share. I'm not sure what happened here, but this is the first I've heard of it. I don't think we'd normally call this a grievance.

In an interview with Staff #3, Facility Privacy Official, on the morning of 1/3/17 in a facility meeting room, she was asked whether Patient #2 had been contacted regarding Patient #1 receiving discharge instructions in her name. Staff #3 stated Ethics & Compliance wasn't contacted about this incident. Typically - and unfortunately this case was a fall-out - we have a process for reporting that we follow in these types of cases. Our process is set up for reporting even at this late point. Our own policies weren't followed here. What should have happened is that they would let me know so that I can do all of that reporting. We'd also retrieve the information back or ask for confirmation that it was appropriately disposed of.

During an interview with Staff #6, Risk Manager, on the afternoon of 1/3/17, she was asked about grievances and the facility's process of dealing with them. She stated, The process is that during a patient stay, a complaint is dealt with by the unit director personally. It's after they're discharged that we get involved in a complaint. We'll get notified either by phone, letter or in person, but it's not a grievance unless the complaint is made after discharge. While they're here, it's handled by the unit director...We didn't know anything about this complaint.

The above findings were confirmed in an interview with the administrative director of quality, the director of nursing and the interim director of quality on the afternoon of 1/3/17 in a facility administrative meeting room.

Based on a review of facility policies and staff interviews, the hospital failed to implement and enforce its own policy related to protected health information (PHI) and the confidentiality of patient records for 1 of 3 patient records reviewed in which a breach of confidentiality had occurred (Patients #1).

Findings were:

Corporate policy reference #IP.PRI.011 entitled Information Protection, effective date 9/23/2013, included the following:

PURPOSE: To facilitate compliance with the Health Information Technology for Economic and Clinical Health Act (HITECH) component of the American Recovery and Reinvestment Act of 2009 (ARRA) breach notification of unsecured protected health information (PHI) requirements and any and all Federal regulations and interpretive guidelines promulgated thereunder...

POLICY: Any Company-affiliated facility in the case of a breach of unsecured PHI, must notify the patient or their personal representative without unreasonable delay and in no case later than 60 days of discovering the breach.

A breach is considered discovered as of the first day on which the breach is known by the business associate and/or facility...

Corporate policy reference #IP.PRI.012 entitled Information Protection, effective date 9/23/2013, included the following:

PURPOSE: To facilitate compliance with the Health Insurance Portability and Accountability Act (HIPAA) Standards for Privacy of Individually Identifiable Health Information (Privacy Standards), 45 CFR Parts 160 and 164, the Health Information Technology for Economic and Clinical Health Act (HITECH) component of the American Recovery and Reinvestment Act of 2009 (ARRA0, and any and all other Federal regulations and interpretive guidelines promulgated thereunder. To establish guidelines for protecting and safeguarding protected health information (PHI)...

POLICY:...The facility must identify and utilize appropriate administrative, physical, and technical safeguards in order to protect PHI from inappropriate and/or unauthorized access, use and/or disclosures...This policy addresses oral and paper-based PHI...

Paper Documents Containing PHI...

4. Facilities must have a process in place to verify documents are for the correct patient prior to providing the documents to the recipient (e.g., verify recipient and content prior to giving discharge papers to an individual)...

Corporate policy reference #IP.PRI.013 entitled Information Protection, effective date 9/23/2013, included the following:

POLICY: In order to protect PHI when inappropriate or unauthorized access, use and/or disclosure of PHI occur, the facility must take immediate, reasonable steps to mitigate the situation. The facility must review the administrative, physical, and technical safeguards in place to help ensure PHI is protected from further inappropriate and/or unauthorized access, use and/or disclosure...

Paper Documents Containing PHI

In the event documents containing PHI are accessed, used, and/or disclosed inappropriately or without authorization, the following mitigation efforts must be taken, as applicable:

A. If the incorrect PHI is given to a patient or the incorrect patient receives PHI, the facility must make attempts to retrieve the PHI or request that the PHI be destroyed. Documentation supporting the attempts to retrieve the PHI and supporting the mitigation attempts...must be included as part of the facility's investigation documentation...

Patient #1 visited the hospital emergency department on 4/12/16. After leaving, she realized she had been given the discharge instructions of Patient #2, another patient with a similar name. She believed she'd received inappropriate care as a result. Patient #1 contacted the facility by telephone on 4/13/16 to express her concerns.

In a group interview with the administrative director of quality, administrative director for critical care, and the emergency department director, Staff #1, 4 and 5 respectively, on the morning of 1/3/17 in a facility meeting room, Staff #4 stated, I talked to [Patient #1] on the phone when she called to complain...I remember she said she didn't feel she'd had the right care. But I passed her on to [Staff #12, ED physician] and he said the care had been correct. He told her that on the phone...We didn't consider this a grievance because [Staff #12] looked at it and said the care given was appropriate. We were just looking at this as a HIPAA violation.

In an interview with Staff #3, Facility Privacy Official, on the morning of 1/3/17 in a facility meeting room, she was asked whether Patient #2 had been contacted regarding Patient #1 receiving discharge instructions in her name. Staff #3 stated Ethics & Compliance wasn't contacted about this incident. Typically - and unfortunately this case was a fall-out - we have a process for reporting that we follow in these types of cases. Our process is set up for reporting even at this late point. Our own policies weren't followed here. What should have happened is that they would let me know so that I can do all of that reporting. We'd also retrieve the information back or ask for confirmation that it was appropriately disposed of.

The above findings were confirmed in an interview with the administrative director of quality, the director of nursing and the interim director of quality on the afternoon of 1/3/17 in a facility administrative meeting room.

Based on a review of documentation and interview, it was determined the facility failed to ensure discharge planning included a list of (HHAs or) SNFs that are available to the patient, that are participating in the Medicare program, and (that serve the geographic area (as defined by the HHA) in which the patient resides, or ) in the case of a SNF, in the geographic area requested by the patient. The facility also failed to document in the patient's medical record that the list was presented to the patient or to the individual acting on the patient's behalf.

Findings included:

Facility based policy entitled Discharge Planning, stated in part, The discharge planning process provides for timely and appropriate identification of discharge planning needs for patients/family, and facilitates a smooth transition through an interdisciplinary team approach. Discharge planning at Las Palmas Del Sol Healthcare is a direct service provided to patients to ensure their right to free access to assistance with discharge needs. Las Palmas Del Sol Health care endeavors to ensure continuous quality of care in the post-discharge phase. The Discharge Planning assessment done on admission includes the physical, emotional, medical, social, spiritual, and financial needs of the patient and family as well as any identified equipment needs and post discharge needs.

Responsibilities:

C. Case Management Team: Comprised of Case Managers and Social Workers. Participate in interdisciplinary team meetings, high risk screenings, and assist with coordinating complex discharge plans and alternate placements....

* 1. Case Management Team works closely with the patient and family to coordinate the appropriate resources for the discharge plan and post-acute care incorporating the needs of the patient and family, medical necessity, financial capabilities, and available community resources...

* 4. Social Worker assists patients, families, or guardians with psycho-social and financial issues, which impact continuity of care. Participate in interdisciplinary team meetings and facilitate placements and alternate levels of care along the continuum, including: adult foster care, home health, hospice support groups, rehabilitation, long term facilities.

The CHOICE LETTER, when completed, is part of the patient medical records, it was signed by Patient #1 on 04/21/2015, it states in part: Your physician has recommended the following services after you leave the hospital. Out of seven options, Skilled Nursing- VHHCC is hand written and Inpatient Rehabilitation- DSMC (hand written). Also, stated in part: You have the right to select who provides and where you receive these services. It is your choice. If you need more information before making this decision, please ask our Case Management staff to assist and provide you with alternatives. If you require Home Health, a Skilled Nursing Facility, or Hospice, a list will be provided. The list will include those facilities/agencies that participate in the Medicare program and serve the geographic areas that you request or in which you reside. Managed Care patients will be given a list of providers that are in their plan network.

Five out of 10 medical records reviewed (Patients #1, 2, 3, 4, and 5) did not have documentation that the patient/family were provided with a list of Home Health, Skilled Nursing Facilities or Hospice, during discharge planning or prior to discharge from the hospital.

In an interview on 5/28/15, staff member # 3, the Director of Case Management confirmed the above findings.

Based on grievance log review, policy review, and staff interview the facility failed to follow their own policy in regard to providing the patient's representative written notice of the hospital decision on a grievance brought by the patient's representative.

The findings include:

Review of document titled Patient Guest Relations/Patient Complaints 1st QTR 2014 contained the following information: Date: January 17, 2014; Complaint: Daughter was not satisfied with the way the patient was transferred to ICU; Action: Addressed; Referred: Janlyn.

Facility policy titled Patient Grievance and Complaint Management, effective date 11/27/12, states, in part In resolution of the grievance, a written notice of the 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 results of the grievance investigation, and the date of completion. A grievance is considered resolved when the patient and/or patient's representative is satisfied with the actions taken on their behalf. A grievance/complaint log will be maintained by Risk Management Department (Patient Guest Relations-Del Sol only). The documentation in the log will include the date of complaint, location, summary of issue, how the issue was addressed, date resolved, and response to complainant, and the individual responding to the grievance.

Interview with the director of risk management, nurse director of the nursing unit, and assistant chief nursing officer on 4/29/14 and 5/1/14 confirmed the above findings and as of this date no written notification has been sent to the complainant per hospital policy on complaint resolution.

Based on medical record review, policy review, and staff interview, data in the patient medical record contained information written by different staff members under the authentication of a single staff member.

The findings include:

Review of medical record for patient #1 on 4/30/14 revealed the 0800 entry on the patient by staff #5 entered at 2127 had data from assessments done on the patient throughout the day on 4/30/14 and contained inaccurate data for the period staff #5 was documenting at 0800. These include lung assessments for the patient, ventilator settings for the patient, and orientation and responsiveness of the patient even though at 0800 the patient was on oxygen per nasal cannula and was not on the ventilator.

Facility policy titled Assessment/Reassessment states, in part All assessments/reassessments are documented in the patient's medical record. The medical record serves as a mechanism for communication and addresses the patient's care/treatment needs, response to treatment, and continued care requirements as appropriate.

Interview with the assistant chief nursing officer on 4/30/14 and 5/1/14 confirmed the above findings and she confirmed the charting for 0800 by staff #5 contained data for the ventilator settings and the patient was not on a ventilator at 0800 while a patient on the medical floor.

Failure to document nursing assessments on a patient in a timely manner delays the communication of patient information and the continuity of care for the patient.

Based on medical record review, policy review, and staff interview the facility failed to ensure they had physician orders for the administration of oxygen therapy.

The findings include:

Review of medical record for patient #1on 4/29/14 revealed there were no admitting orders for oxygen therapy for the patient and no orders for maintenance of an oxygen saturation level for the patient receiving oxygen therapy.

Facility policy Oxygen Therapy Protocol states, in part Oxygen should be considered as a drug and therefore requires an order from a physician or physician's assistant. Oxygen should be prescribed to achieve a target saturation range. Those who administer oxygen will monitor the patient and keep within the target saturation range, unless specific guidelines have been set by physician.

Interview with the assistant chief nursing officer confirmed there was no order for oxygen administration in the patient medical record and the patient was on oxygen therapy since admission to the facility.