Findings: The surveyor observed, while accompanied by the VP of Risk & Quality, Supervisor Facility Management, and Maintenance Tech 3, during the hours of the survey from 3:30 PM to 7:30 PM on 05/29/18 that there were the following issues: 1) Based on observation, there was construction activity in the sleep suites. However, there is no application number on file with Texas Health and Human Services Commission. Please note the following requirement from the Hospital Licensing Rules: (C) Minor remodeling or alterations. All remodeling or alterations which do not involve alterations to load bearing members or partitions, change functional operation, affect fire safety (e.g. modifications to the fire, smoke, and corridor walls), add or subtract beds or services for which the hospital is licensed, and do not involve changes listed in subparagraph (B) of this paragraph, shall be submitted for approval without submitting contract documents. Such approval shall be requested in writing with a brief description of the proposed changes in accordance with º133.167(f)(3) of this title. - HLR 2007, 133.161 (a)(2)(C).
Findings: The surveyor observed, while accompanied by the VP of Risk & Quality, Supervisor Facility Management, and Maintenance Tech 3, during the hours of the survey from 3:30 PM to 7:30 PM on 05/29/18 that there were the following issues: 1) Based on observation in the Mechanical Room near Building E, there was direct contact between copper pipe and stainless steel hanger without the use of insulator which promotes bimetallic electrolyte action. This item was observed as corrected by the Life Safety Code Surveyor.
Findings: The surveyor observed, while accompanied by the VP of Risk & Quality, Supervisor Facility Management, and Maintenance Tech 3, during the hours of the survey from 3:30 PM to 7:30 PM on 05/29/18 that there were the following issues: 1) Based on observation, there was a large piece of equipment being temporarily stored in the emergency electrical room that prevented access to the ATS panels. It is important for maintenance staff to make a conscious effort to be vigilant and proactive in regards to physical environment safety. This item was observed as corrected by the Life Safety Code Surveyor.
Findings: The surveyor observed, while accompanied by the VP of Risk & Quality, Supervisor Facility Management, and Maintenance Tech 3, during the hours of the survey from 3:30 PM to 7:30 PM on 05/29/18 that there were the following issues: 1) Based on review of the records, there was gap in the maintenance and testing of hospital-grade receptacles at patient bed locations and in patient care areas. No records were available to review for the year 2016 and 2017.
Based on records review and interviews, it was determined that the hospital nursing staff failed to assess one of one patient (Patient #1) according to his ongoing needs. Patient #1 was admitted to the hospital's Psychiatric Emergency Services (PES) on 01/16/15. On 01/19/15 at 07:32 Patient #1 was punched in the face by another patient and fell on the floor, bleeding from the mouth. The patient was dazed and needed assistance from staff twice to prevent a fall. Nursing staff did not notify the physician that the patient was unable to eat a regular breakfast and required a basin and towel for continuous bleeding from his mouth until shortly before lunch. There was no evidence of reassessment of Patient #1's neurological status after the initial assessment. A day after the incident, Patient #1 requested discharge against medical advice and sought treatment at a medical hospital. Oral and Maxillofacial Surgery was consulted, Morphine pain management was provided, and Patient #1 underwent surgery to repair his twice broken jaw and teeth. Cross refer to A -395
Based on records review and interviews, nursing staff failed to supervise and evaluate the care for one of one patient (Patient # 1) who was struck in the face by another patient on 01/19/15 at 07:32 in that: 1) Nursing did not report to the physician that Patient #1 was unable to eat a regular breakfast and required a basin and a towel for continuous bleeding from his mouth, 2) There was no evidence that nursing staff reassessed Patient #1 for neurological changes after an initial assessment at the time of incident, 3) An ice pack was not applied until approximately 23.5 hours after the incident, and 4) A clinical consult and x-ray examination were not ordered until 25 hours after the initial incident. The patient left the psychiatric hospital against medical advice to seek treatment at a medical hospital, received intravenous Morphine pain treatment and underwent surgery for a twice broken jaw and tooth repair. Findings included: 1) Patient #1's Psychiatric Evaluation dated 01/16/15, at 13:34, noted that the patient was admitted to the hospital's Psychiatric Emergency Services (PES) for diagnoses including Psychosis and Cannabis Abuse. Employee #10 stated during an interview on 01/23/15. at 16:45, that Patient #1 was bleeding after he was punched in the face. A puddle of bright red blood in front of Patient #1 was noted and required housekeeping services. Patient #1 was unable to eat regular breakfast foods and Employee #10 brought him yogurt and jello. Employee #7 stated during an interview on 01/23/15, at 18:00, he observed the incident and thought Patient #1's jaw was broken from the intensity and sound of the punch...blood came out like after a tooth is being pulled. Employee #7 provided the patient with a towel and a basin which had blood in it until shortly before lunch. 2) Emergency patient record dated 01/19/15, at 07:40, by Employee #13 noted ... assisted to restroom after spitting up bright red blood...was assisted to the floor x 2 [twice]...MD...instructed to take vital signs and observe Pt [Patient #1] closely for any neurological changes. Emergency patient record dated 01/19/15, at 07:40, by Employee #10 reflected Patient #1 was hit in the mouth/jaw by another pt [patient]. Began bleeding, bleeding able to be controlled...VS [vital signs] taken and stable. Neuro checks WDP [within defined parameter]...no further orders received...will continue to monitor. There was no evidence of further evaluation of Patient #1's neurological status. Employee Physician #6 stated on 01/23/15 at 15:40 that she went into the bathroom with Patient #1 after the incident. Two nurses cleaned the patient up. The physician tried to get him [Patient #1] to open his mouth but he was in shock. The physician told the nurses to asses the patient later and notify the physician of any problems. The physician did not hear back from the nurses. The physician saw Patient #1 later eating a roll and jelly and concluded that nothing was wrong with his jaw. 3) Physician orders dated 01/20/15, at 06:55, noted an order for ice pack to Patient #1's swollen jaw. This was approximately 23.5 hours after the incident was witnessed by nursing staff. Emergency patient record dated 01/20/15, at 09:11, by Employee #14 noted ...ice pack application to shoulder and jaw in the morning. On 01/23/15 at 16:45 Employee #10 (RN) said that she had offered an ice pack to Patient #1 after the incident, but he refused. There was no documentation of this in the medical record. 4) On 01/20/15 at 08:27 a clinical consult was ordered because the patient had been punched in the mouth. On 01/20/15, at 08:30, an x-ray examination was ordered to rule out a fracture and Ibuprofen 800 mg (milligram) was ordered three times daily for mild pain. Employee Physician #6 stated on 01/23/15, at 15:40, that on 01/20/15, Patient #1's jaw was swollen and x-rays were ordered. Physician Psych Disposition dated 01/20/15, at 06:43, noted that Patient #1 ...wants to go home...it appears pt's [Patient #1's] speech is affected by getting hit in the face yesterday... Patient #1 left against medical advice on 01/20/15 at 12:12. Medical Hospital A's Patient Admission Registration dated 01/21/15, at 10:32, noted that Patient #1 was admitted to Emergency Services. Computer tomography scan dated 01/21/15, at 11:39, noted ...two fractures are identified within the mandible [jaw bone]...fracture through the angle of the left mandible extending through the tooth socket of the posterior molar...contralateral fracture is demonstrated through the body of the right mandible, also through a tooth socket. Patient #1 was transferred via EMS provider to Medical Hospital B for treatment of Mandible Fracture and Blunt Trauma. Medical Hospital B Emergency Department (ED) Provider Notes dated 01/21/15, at 16:44, noted a chief complaint of Facial Injury after being punched in the face while at Green Oaks Hospital... Medical Hospital B Oral and Maxillofacial Surgery Consult Note dated 01/21/15, at 22:33, noted Patient #1...will likely have operative surgery tomorrow. Medical Hospital B Medication Administration dated 01/21/15, at 18:08, noted Morphine was ordered at 4 mg (milligram) doses to be administered intravenously for pain. Patient #1 received Morphine seven times during his 25 hour stay at Medical Hospital B. Medical Hospital B Procedure Summary dated 01/22/15, at 13:53, noted Patient #1 underwent an approximately four hour procedure to repair the broken jaw. Employee #4 at Green Oaks Hospital stated on 01/23/15, at 15:30, that hospital administration had been unaware that Patient #1's jaw was broken until the morning of 01/23/15 when it received notification of the patient status by outpatient clinic staff.
Based on interview and record review, the Governing Body failed to ensure 1 of 10 patients (Patient #1's) discharge plan was appropriate to meet his medical needs in that, (Patient #1) had a compression fracture to the spine, fractured bilateral feet, a fractured wrist of his dominant hand, and was non-weight bearing (NWB). The hospital failed to identify and/or address (Patient #1's) medical needs upon discharge and the discharge placement was appropriate. (Patient #1) was discharged to a boarding home where his medical needs and NWB status could not be ensured, supported or maintained. Findings Included: (Patient #1), with multiple fractures was discharged to a boarding home and was to care for himself medically. The boarding home, that (Patient #1) was discharged to, was not wheelchair accessible and could not meet (Patient #1's) medical needs. (Patient #1's) NWB status was not identified and/or addressed by Hospital A during hospitalization and prior to discharge. (Cross refer to A395 and A800)
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the Governing Body failed to ensure 1 of 10 patients (Patient #1's) discharge plan was appropriate to meet his medical needs in that, (Patient #1) had a compression fracture to the spine, fractured bilateral feet, a fractured wrist of his dominant hand, and was non-weight bearing (NWB). (Patient #1), with multiple fractures, was discharged to a boarding home and was to care for himself medically. The boarding home that (Patient #1) was discharged to was not wheelchair accessible and could not meet (Patient #1's) medical needs. (Patient #1) was then taken to a second temporary boarding home, by the transport van driver, on the night of 07/17/14. (Patient #1's) NWB status was not identified during the hospital stay and/or addressed by Hospital A prior to discharge. Findings Included: Hospital B's physician note for (Patient #1), electronically signed 06/27/14 at 0950, reflected [AGE] year old suicide attempt...jumped from a second story...had an extension cord wrapped around his neck which broke during the jump...brought to ED (emergency department) intubated...positive for high level of Tylenol and cocaine...opiates screen positive, acetaminophen...urine cocaine screen positive... Hospital's B's Discharge Summary dated 07/10/14, timed at 1318, reflected Right distal radius and ulnar styloid process fracture, T12 (thoracic) compression fracture, bilateral calcaneal fractures, tylenol overdose...chronic problems...previous suicide attempts, substance abuse ...underwent evaluation by Orthopedic's and Spine...to psych hospital for further evaluation then will require rehabilitation facility...non-weight bearing all extremities... Hospital B's Discharge Instructions dated 07/03/14, for (Patient #1) reflected, Bilateral Calcaneal fractures, right radius ulnar styloid, process fracture, T12 (thoracic) compression fracture, non-weight bearing, transfer to wheelchair...transfer to Hospital A (psychiatric hospital) ...Dr...in 2 weeks call for appointment...do not change dressing, do not get wet, do not submerge in water... It was noted that the above discharge instructions were also found in (Patient #1's) medical record for Hospital A. Hospital A's 7/03/14, Inpatient Physician's admitting orders for (Patient #1) dated 07/03/14, and initial treatment plan timed at 2030, reflected Axis ...depression...Axis III...status post fall from height in suicide attempt...admit to level one...special precautions...suicide, fall, monitoring level...close observation... . Hospital A's Internal Medicine History and Physical dated 07/04/14, timed 0710, reflected Bilateral ankle fracture, right wrist fracture and T12 compression fracture...cleared from (medical hospital)...gait deferred, tandem walking deferred and pathological reflexes deferred ...place on lovenox, pain control... Hospital A's Discharge Instructions dated 07/17/14, timed at 1539, reflected Your activity resume as tolerated... (Patient #1) was discharged to a boarding home. The discharge instructions did not address his medical issues which included (Patient #1's) non-weight bearing status. On 07/24/14, at 1230, SW (Social Worker) Personnel #6 was interviewed. SW Personnel #6 stated that (Patient #1) was discharged to a boarding home but she did not know he was supposed to be non-weight bearing. On 07/24/14, at 1240, RN Personnel #7 was interviewed. RN #7 stated he did not know (Patient #1) was supposed to be NWB (non-weight bearing). RN Personnel #7 stated (Patient #1) had ace wraps on his feet, a soft padded cast on his wrist and a corset on his thorax. RN Personnel #7 stated (Patient #1) would propel himself with feet and his free arm. RN Personnel #7 stated he reviewed (Patient #1's) medical record and could find nothing in the medical record that indicated (Patient #1) was supposed to be non-weight bearing. On 07/30/14, at 0914, Non-Hospital Staff #26 was interviewed by telephone. Non-Hospital Staff #26 stated he picked up (Patient #1) when (Patient #1) was discharged from Hospital A on 07/17/14. He stated that (Patient #1) was in a wheelchair with ace wraps to his bilateral feet, cast on his right hand/arm and he wore a chest corset. Non-Hospital Staff #26 stated he did not know (Patient #1) was supposed to be non-weight bearing and was not informed by Hospital A that (Patient #1) had special needs. Non Hospital Staff #26 stated the boarding home he took (Patient #1) to was not wheelchair accessible. He stated he found a boarding room that accepted (Patient #1) on an emergency basis for the night. Non-Hospital Staff #26 stated (Patient #1) did have to bear weight and he was in pain. Non-Hospital Staff #26 stated he picked (Patient#1) up the next morning (07/18/14) and took him to a medical hospital for complaints of pain. Non-Hospital Staff #26 stated Hospital A did not communicate (Patient #1's) medical status and/or needs. The policy and procedure entitled, Continuum of Care/Discharge Planning and Referral Social Work Services with a review dated of 12/11 reflected, To provide discharge planning in order to ensure continuity of care...discharge planning begins at admission and continues to be evaluated as necessary...assessing the likelihood that the patient will need post-hospital services and assessing the patient's capacity for self-care or the care received in the environment...physical and psychiatric needs... Hospital A's undated Bylaws of the Medical Staff reflected, The purpose and responsibilities of the Medical Staff are...to provide patients with the quality of care that is commensurate with acceptable standards and available community resources...
Based on interview and record review, Hospital A's nursing services failed to initiate and/or follow Hospital B's discharge instructions for 1 of 10 patients (Patient #1) in that, (Patient #1) had a compression fracture to the spine, fractured bilateral feet and a fractured wrist of his dominant hand and was non-weight bearing (NWB). Hospital A's RN's (registered nurses) failed to identify and/or evaluate (Patient #1's) non-weight bearing status. Findings Included: (Patient #1), with multiple fractures, was discharged to a boarding home and was to care for himself medically. (Patient #1's) NWB status was not identified during the hospital stay and/or evaluated by nursing services. (cross refer to A395)
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interviews and record review, Hospital A failed to initiate and/or follow the discharge instructions from Hospital B for 1 of 10 patients (Patient #1). (Patient #1) had a compression fracture to the spine, fractured bilateral feet and a fractured wrist of his dominant hand and was non-weight bearing (NWB). Hospital A's RN's (registered nurses) failed to identify and/or evaluate (Patient #1's) non-weight bearing status. Findings Included: Hospital B's physician note for (Patient #1), electronically signed 06/27/14, at 0950, reflected [AGE] year old suicide attempt...jumped from a second story...had an extension cord wrapped around his neck which broke during the jump...brought to ED (emergency department) intubated...positive for high level of Tylenol and cocaine...opiates screen positive, acetaminophen...urine cocaine screen positive... Hospital's B's Discharge Summary dated 07/10/14, timed at 1318, reflected Right distal radius and ulnar styloid process fracture, T12 (thoracic) compression fracture, bilateral calcaneal fractures, tylenol overdose...chronic problems...previous suicide attempts, substance abuse...underwent evaluation by Orthopedic's and Spine...to psych hospital for further evaluation then will require rehabilitation facility...non-weight bearing all extremities... Hospital B's Discharge Instructions dated 07/03/14, for (Patient #1) reflected Bilateral Calcaneal fractures, right radius ulnar styloid, process fracture, T12 compression fracture, non-weight bearing, transfer to wheelchair...transfer to Hospital A (psychiatric hospital) ...Dr...in 2 weeks call for appointment...do not change dressing, do not get wet, do not submerge in water... It was noted the above discharge instructions were also found in (Patient #1's) medical record for Hospital A. Hospital A's 7/03/14, Inpatient Physician's admitting orders for (Patient #1) dated 07/03/14, and initial treatment plan timed at 2030, reflected Axis...depression...Axis III...status post fall from height in suicide attempt...admit to level one...special precautions...suicide, fall, monitoring level...close observation... It was noted no orders and/or documentation was found which addressed (Patient #1's) non-weight bearing status. Hospital A's Internal Medicine History and Physical dated 07/04/14, timed 0710, reflected Bilateral ankle fracture, right wrist fracture and T12 compression fracture...cleared from (medical hospital)...gait deferred, tandem walking deferred and pathological reflexes deferred ...place on lovenox, pain control... Hospital A's initial hospital assessment (physician's) dated 07/04/14, timed at 1030, reflected Depression, Multiple Orthopedic Injuries, Status Post Tylenol OD (overdose) requiring intubation...opiates, heroin times three months... Hospital A's physician's orders dated 07/04/14 through 07/17/14, revealed no physician orders which addressed (Patient #1's) non-weight bearing status during his inpatient stay. Hospital A's nursing notes dated 07/04/14 through 07/17/14, revealed no nursing notes which addressed (Patient #1's) non-weight bearing status. On 07/24/14, at 1240, RN Personnel #7 was interviewed. RN #7 stated he did not know (Patient #1) was supposed to be NWB (non-weight bearing). RN Personnel #7 stated (Patient #1) had ace wraps on his feet, a soft padded cast on his wrist and a corset on his thorax. RN Personnel #7 stated (Patient #1) would propel himself with feet and his free arm. RN Personnel #7 stated he reviewed (Patient #1's) medical record and could find nothing in the medical record that indicated (Patient #1) was supposed to be non-weight bearing. The policy and procedure entitled, Continum of Care/Discharge Planning and Referral Social Work Services with a review date of 12/11 reflected, Assessing the likelihood that the patient will need post-hospital services and assessing the patient's capacity for self-care or the care received in the environment...physical and psychiatric needs...
Based on interviews and record review, the hopital failed to ensure 1 of 10 patients (Patient #1's) discharge plan was appropriate to meet his medical needs upon discharge from the hospital as evidenced by: (Patient #1) had a compression fracture to the spine, fractured bilateral feet, a fractured wrist of his dominant hand, and was non-weight bearing (NWB). The hospital failed to identify during the hospital stay and/or address (Patient #1's) medical needs upon discharge. (Patient #1) was discharged to a boarding home where his medical needs and NWB status could not be ensured, supported or maintained. Findings Included: (Patient #1), with multiple fractures, was discharged to a boarding home and was to care for himself medically. The boarding home that (Patient #1) was discharged to was not wheelchair accessible and could not meet (Patient #1's) medical needs. (Patient #1) was then taken to a second temporary boarding home, by the transport van driver, on the night of 07/17/14. (Patient #1) was then picked up the morning of 07/18/14, and taken to an acute care hospital due to complaints of pain. (Patient #1's) NWB status was not identified and/or addressed by Hospital A during the hospital stay and prior to discharge. (Cross refer to A800)
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interviews and record review, Hospital A failed to identify and/or follow discharge instructions from Hospital B for 1 of 10 patients (Patient #1). (Patient #1) had a compression fracture to the spine, fractured bilateral feet and a fractured wrist of his dominant hand and was non-weight bearing (NWB) from a prior suicide attempt. Hospital A's discharge plan did not address (Patient #1's) medical needs which included (Patient #1's) non-weight bearing status. Findings Included: Hospital B's physician note for (Patient #1), electronically signed 06/27/14 at 0950, reflected [AGE] year old suicide attempt...jumped from a second story...had an extension cord wrapped around his neck which broke during the jump...brought to ED (emergency department) intubated...positive for high level of Tylenol and cocaine...opiates screen positive, acetaminophen...urine cocaine screen positive... Hospital's B's Discharge Summary dated 07/10/14, timed at 1318, reflected Right distal radius and ulnar styloid process fracture, T12 (thoracic) compression fracture, bilateral calcaneal fractures, tylenol overdose...chronic problems...previous suicide attempts, substance abuse...underwent evaluation by Orthopedic's and Spine...to psych hospital for further evaluation then will require rehabilitation facility...non-weight bearing all extremities... Hospital B's Discharge Instructions dated 07/03/14, for (Patient #1) reflected Bilateral Calcaneal fractures, right radius ulnar styloid, process fracture, T12 compression fracture, non-weight bearing, transfer to wheelchair...transfer to Hospital A (psychiatric hospital) ...Dr...in 2 weeks call for appointment...do not change dressing, do not get wet, do not submerge in water... It was noted the above discharge instructions were also found in (Patient #1's) medical record for Hospital A. Hospital A's 7/03/14, Inpatient Physician's admitting orders for (Patient #1) dated 07/03/1,4 and initial treatment plan timed at 2030, reflected Axis ...depression...Axis III...status post fall from height in suicide attempt...admit to level one...special precautions...suicide, fall, monitoring level...close observation... It was noted no orders and/or documentation was found which addressed (Patient #1's) non-weight bearing status. Hospital A's Internal Medicine History and Physical dated 07/04/14, timed 0710, reflected Bilateral ankle fracture, right wrist fracture and T12 compression fracture...cleared from (medical hospital)...gait deferred, tandem walking deferred and pathological reflexes deferred ...place on lovenox, pain control... Hospital A's initial hospital assessment (physician's) dated 07/04/14, timed at 1030, reflecte, Depression, Multiple Orthopedic Injuries, Status Post Tylenol OD (overdose) requiring intubation...opiates, heroin times three months... Hospital A's physician's orders dated 07/04/14 through 07/17/14, revealed no physician orders which addressed (Patient #1's) non-weight bearing status during his inpatient stay. Hospital A's nursing notes dated 07/04/14 through 07/17/14, revealed no nursing notes which addressed (Patient #1's) non-weight bearing status. Hospital A's Discharge Instructions dated 07/17/14, timed at 1539, reflected Your activity resume as tolerated... (Patient #1) was discharged to a boarding home. The discharge instructions did not address his medical issues which included (Patient #1's) non-weight bearing status. On 07/24/14, at 1230, SW (Social Worker) Personnel #6 was interviewed. SW Personnel #6 stated (Patient #1) was discharged to a boarding home but she did not know he was supposed to be non-weight bearing. On 07/24/14, at 1240, RN Personnel #7 was interviewed. RN #7 stated he did not know (Patient #1) was supposed to be NWB (non-weight bearing). RN Personnel #7 stated (Patient #1) had ace wraps on his feet, a soft padded cast on his wrist and a corset on his thorax. RN Personnel #7 stated (Patient #1) would propel himself with feet and his free arm. RN Personnel #7 stated he reviewed (Patient #1's) medical record and could find nothing in the medical record that indicated (Patient #1) was supposed to be non-weight bearing. On 07/30/14, at 0914, Non-Hospital Staff #26 was interviewed by telephone. Non-Hospital Staff #26 stated he picked up (Patient #1) when (Patient #1) was discharged from Hospital A on 07/17/14. He stated (Patient #1) was in a wheelchair with ace wraps to his bilateral feet, cast on his right hand/arm and he wore a chest corset. Non-Hospital Staff #26 stated he did not know (Patient #1) was supposed to be non-weight bearing and was not informed by Hospital A that (Patient #1) had special needs. Non Hospital Staff #26 stated the boarding home he took (Patient #1) to was not wheelchair accessible. He stated he found a boarding room that accepted (Patient #1) on an emergency basis for the night. Non-Hospital Staff #26 stated (Patient #1) did have to bear weight and he was in pain. Non-Hospital Staff #26 stated he picked (Patient#1) up the next morning 07/18/14, and took him to an acute care hospital for complaints of pain. Non-Hospital Staff #26 stated Hospital A did not communicate (Patient #1's) medical status and/or needs The policy and procedure entitled, Continuum of Care/Discharge Planning and Referral Social Work Services with a review date of 12/11 reflected, To provide discharge planning in order to ensure continuity of care...discharge planning begins at admission and continues to be evaluated as necessary...assessing the likelihood that the patient will need post-hospital services and assessing the patient's capacity for self-care or the care received in the environment...physical and psychiatric needs...
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, record review and interview, the hospital failed to identify and/or prevent the development of pressure ulcers for 1 of 10 patients (Patient #1) while inpatient. The hospital failed to evaluate and/or accurately document and/or provide treatment for (Patient #1). (Patient #1) was discharged on [DATE] to home. The home health nurse assessed (Patient #1) on 10/22/13 and found a total of four Stage II Pressure Ulcers. One pressure ulcer to the left heel, top of coccyx, buttock and lower back not identified by the hospital and, 2) Although (Patient #10) was noted to have blister on his toes and changes to the vision in his left eye on admission, no interventions were initiated until 38 hours into his inpatient hospital stay. Findings Included: 1) (Patient #1's) initial skin assessment dated [DATE] timed at 1900 reflected, Brain Stimulatory to the right upper chest with a bruise, scratch to the left upper back, scar to the right (outer ankle) and multiple bruises to the right and left (anterior) legs... The PES (Psychiatric Emergency Services) unit physician note dated 10/13/13 timed at 0845 reflected, Female arrives with...police believes someone is trying to sedate her...delusional...thinks husband and son are trying to harm her... The 10/20/13 nurse note timed at 1210 reflected, Patient moved to wheelchair...taken to room...some redness was noted to her bottom...doctor on unit events reported and did see patient... The 10/20/13 nurse reassessment note timed at 2250 reflected, Integumentary Assessment...WDP (within defined parameters) Y (yes)...at 1023 discharged home... No documentation was found which addressed (Patient #1's) altered skin integrity. (Patient #1's) medical record from (Outside Agency A #26) reflected the following: The 10/22/13 Oasis Resumption of Care Assessment reflected, Inpatient discharge from hospital...10/21/13...pressure ulcer onset 10/21/13, low back, heel, buttocks...Stage II...functional limitations bowel and bladder incontinence... The 10/22/13 skin record reflected, Left Heel Stage II 0.5 cm (centimeters) x 0.5 cm...top of coccyx 0.2 cm x 02 cm Stage II...wound three, buttock 1.8 cm x 1.8 cm Stage II and lower back 1.3 cm x 3.1 cm Stage II...no wound care ordered at this time... On 07/17/14 at 1640 Agency A Staff #27 was interviewed. Agency A Staff #27 stated (Patient #1) had no skin issues prior to being admitted to Hospital A. Agency A Staff #27 stated the RN (registered nurse) at Agency A assessed (Patient #1) the day after she was discharged from Hospital A. Agency A Staff #27 stated (Patient #1) acquired multiple pressure ulcers while inpatient at Hospital A. On 07/24/14 at approximately 1045 Personnel #3 was interviewed. Personnel #3 reviewed (Patient #1's) Agency A's resumption of care assessment dated [DATE]. Personnel #3 acknowledged (Patient #1) had pressure ulcers. On 07/24/14 at 1100 Personnel #10 was interviewed. Personnel #10 stated he did not remember anyone contacting and/or notifying him (Patient #1) had any skin problems. 2) (Patient #10) was observed on 07/18/14 at 1219 on the hospital's Adult Unit II requesting help from the surveyor for his left toe. He stated he had received care for the blister on his left toe. He also complained of his left eye being blurry. Upon surveyor notification of nursing staff, (Patient #10) removed his sock and showed Personnel #8 his left toe with a blister. On 07/18/14 at 1219 Personnel #8 reviewed the chart and denied that (Patient #10) had medical intervention for his toe. The Triage documents dated 07/16/14 timed at 2154 note (Patient #10) had asthma, blisters on his toes, and changes to the vision in his left eye. Initial diagnoses noted a medical (Axis III) diagnosis of asthma only. The PES (Psychiatric Emergency Services) Medication Orders dated 07/17/14 timed at 0500 noted (Patient #10) was to...program on the inpatient unit... There were no orders for the patient's blisters or vision changes and no nursing interventions to address (Patient #10's) medical conditions of blisters and/or vision changes. The physician orders dated 07/18/14 timed at 0555 and 1021 did not reflect orders for (Patient #10's) medical conditions. The policy and procedure entitled, Organization-Wide Patient Assessment with a review date of 03/2012 reflected, Each patient is reassessed as necessary based on his/her plan of care or changes in his/her condition...the patient, family and/or significant other and all clinical disciplines collaborate in the process of planning care including discharge planning...the systems/focused physical assessment of patient...patients are reassessed as needed for significant changes in diagnosis, condition, circumstances...
Based on interview and record review the hospital failed to provide 1) a full-time director of food and dietetic service in that Personnel #6 served as the hospital's Dietary Manager and EVS (environmental services) Director. 2) failed to ensure the Dietary Director maintained the dietary department in a responsible manner in that: a) Cleanliness issues were observed throughout the kitchen, b) Lack of labeling of food items in the kitchen and/or refrigeration units, c) Perishable food item left thawing in standing water in the kitchen, d) Cold food items at the service line were not held at the appropriate temperature. Such practices placed patients, employees, and visitors at risk for acquiring illnesses and infections. Findings Included: 1) Personnel #6's Job Description dated 06/30/14 reflected, Title Director of Nutritional/Environmental Services...this position oversees the overall operations of nutritional/environmental services... On 07/18/14 at approximately 1300 Personnel #1 was interviewed. Personnel #1 stated Personnel #6 was responsible for the environmental services department and the dietary department. 2) On 07/18/14 from 1038 to 1155 during observation rounds in the dietary department with Personnel #1 and Personnel #6 the following was observed: 2 a) Kitchen Cleanliness: The interior surface of the refrigerated unit was soiled with debris and grime on the floor of the unit and the external surface of the unit. Three white bins on wheels were observed under a metal work station. Bin #1, #2, and #3 were soiled with dirt and debris on both the interior and exterior surface of the bins. The plastic lids covering the bins were soiled with grime and debris on both exterior and interior surface. The bins housed flour, rice and sugar. The bins were moved and large amount of dirt and debris was observed on the floor. A single soiled disposable glove was observed on the floor. Behind the oven area/grill a box of cellophane wrap was observed sitting on the ledge behind the oven and grill. A box of foil was observed sitting on the floor. A thick coat of grease/grime and debris was observed behind the units. A large sink was observed filled with water. Floating in the water was a large amount of raw fish. The interior surface of the sink was soiled with a brown substance. Personnel #6 stated the sink was dirty. Personnel #6 stated the sink should be clean before thawing fish out. A large 4 tier shelf unit was observed. One of the shelves had greater than 20 pans stacked wet on top of each other. One of the four shelves was rusted. A large metal work station adjacent to the 4 tier shelf unit was observed. The bottom of the work station was soiled with dirt and debris. A pan of uncovered black eyed peas was sitting on the bottom of the shelf. 2 b) Food items in the kitchen and/or refrigeration units were not labeled: A large metal work station adjacent to the 4 tier shelf unit was observed. A pan of uncovered black eyed peas was sitting on the bottom of the shelf. The pan of peas was not labeled. The refrigerator unit had a opened package of sliced American cheese. The cheese was not labeled when opened. Twelve individually sliced pieces of lemon meringue pie were not labeled when prepared. A container of diced green peppers, ham and chili peppers was not tabled. 3) Perishable food item left thawing in standing water in the kitchen: A large sink was observed filled with water. A large amount of fish were observed floating in standing water. Personnel #6 stated the fish should not be thawed out floating in the water. Personnel #6 stated the fish was going to be used to feed the patients. Personnel #6 stated the fish must be covering the drain. 4 d) Cold food items at the service line were not held at the appropriate temperature. The lunch meal service was in progress at 1130. Personnel #7 was asked for the food temperature log. Personnel #7 stated the food temperatures were not taken prior to starting meal service. The following cold items on the service line were greater than 41 degrees: Pistachio Salad 44 degrees Fahrenheit. Mandarin Oranges 45 degrees Fahrenheit. Macaroni Salad 44 degrees Fahrenheit. Hard Boiled Eggs 44 degrees Fahrenheit. On 07/18/14 at approximately 1155 Personnel #6 stated the above observations and/or findings were not how the kitchen is typically managed. Personnel #6 stated she was responsible for the dietary department. The policy and procedure entitled, Food and Supply Storage with a review date of 06/11 reflected, Food products shall be stored in a safe, sanitary manner...organization and cleaning of the storage areas...all food should be stored in closed containers, clear plastic wrap...all food storage containers must be marked with item name and date...are labeled with tight fitting lids... The policy and procedure entitled, Food Temperature Patient Service Log-Checklist with a review date of 06/11 reflected, Temperatures of hot and cold foods need to be logged...correct temperature for cold food items should be 40 degrees Fahrenheit or below... The policy and procedure entitled. Food Preparation and Service with a review date of 06/11 reflected, Foods will be prepared and serviced in such a manner as to prevent food borne illness and contamination...equipment is cleaned and sanitized...
Based on record review and interview, the facility failed to provide a safe setting during transfer from one setting to another setting for 1 of 1 patient (patient #1). Findings included: 1) Record review included patient #1 was being transferred from the PES (patient emergency services) unit to an adult in-patient unit on 3/14/14. The patient was escorted by a MHT (mental health tech) when the patient was able to jump a fence, onto a roof and then onto a canvas overhang. From the canvas overhang the patient was able to jump to the ground and run down a service road and into the Emergency Services of an acute care hospital located on the same campus as the facility. The acute care hospital notified the facility the patient was in their waiting room. 2) During an interview with the surveyor at 0950 on 6/02/14 the Director of the PES stated the patient was able to leverage his jump by using the door knob on the gate. He stated the patient was not transported in a manner to assure the patient's safety.
Based on record review and interview, the hospital failed to ensure 1 of 1 patient (Patient #1) received care in a safe setting and was protected from harm. Patient #1 was hit by a staff member (Personnel #12). Findings Included: 1) The facility video at 0032 on 01/03/12 included Patient #1 jumping up from his chair and striking at the staff member #12. The staff member's back was to the camera, he pulled his arm back and swung at the patient's head. At 0032 the nurse assessed the patient and noted he had a bloody nose. The patient was placed on 1:1 precautions and placed in the quiet room. A nursing assessment of the patient at 0500 included the patient had bruising around his left eye. 2) In an interview with the surveyor at 14:00 PM on 02/28/12 the CNO/COO and the Director of Psychiatric Emergency Services stated Employee #12 was involuntarily terminated after hitting the patient.
Based on record review and interview, the hospital failed to ensure 2 of 3 patients (Patient #2 and #3) received care in a safe setting in that each of the patients were hit by a peer (Patient #1 and Patient #4) on two separate occasions. Findings Included: 1) Patient #2's medical record included that she was asleep in her room on 11/14/11 when Patient #1 came into the room and hit her in the face. The 11/14/11 nursing note timed at 14:40 PM reflected, sitting in the nurse's station and heard a scream from patient's room. A mental health technician and material management staff were in the room on each side of (Patient #1), and (Patient #2) was crawling down the bed. The patient had less than 1 cc (cubic centimeters) of blood going down the right side of her face...approximately one inch scratch was cleaned with saline...Band-Aid was placed on it..at 14:51 PM the physician assistant assessed the patient for a broken nose with no additional injuries noted.. 2) Patient #3's medical record included that on 10/20/11 he had been verbally abusive and threatening in PES (psychiatric emergency services). Patient #4 got out of his chair and hit Patient #3 in the face. The medical record reflected, on 10/20/11 at 07:26 AM Patient #3 was disruptive, agitated, cursing at staff and peers on the unit. He attempted to start fights...at 12:07 PM he was administered Ativan, Benadryl and Haldol for aggression and agitation...at 13:37 PM the patient was in his wheelchair cursing at other patients and threatening to beat up staff and peers...he threw a bottle of water at a staff member...a peer (Patient #4) got out of his chair and hit (Patient #3). (Patient #3) was sent to the medical hospital...to close the laceration over the eye... In an interview with the surveyor at 14:00 PM on 02/08/12 the CNO/COO (Employee #1) confirmed that patients #2 and #3 were hit by other patients.
Based on review of records and interview with staff, the facility failed to ensure that a registered nurse supervised and evaluated the nursing care for 1 of 1 patient whose record was reviewed, as Patient #1 fell and fractured left arm. The Registered Nurse failed to reassess Patient#1 after the fall, as per hospital policy. Findings were: The facility policy entitled, Falls: Prevention Guidelines stated, I. Purpose: To provide for identification and ongoing assessment of patients who are at risk of falling during hospitalization . To establish minimal safety interventions to be implemented for the at-risk patient. To provide for communication of pertinent information about patient's fall risk status. To establish interventions to be followed in the event that a fall occurs. Further review of this policy stated, IV. Procedure: A.2. All inpatients and PES patients will be assessed on admission by a Registered Nurse to identify those who are at risk for falling using the fall risk assessment tool. All patients will be reassessed each day, when the patient's condition changes, or immediately after a fall. G. In the event a patient does fall, the Registered Nurse will: 1. Assess patient and record assessment findings in the Post Fall assessment toll. Assessment Elements Include: a) VS b) Neurological Assessment c) Motor Strength d) Musculoskeletal e) Skin Integrity f) Pain. The Registered Nurse failed to reassess Patient#1 after the fall. An in-person interview was conducted with the Chief Nursing Officer and the Quality Director, on 7/28/2011 in a facility office. The facility did not provide to the surveyors, at the time of the investigation, documentation in the patient medical record where the Registered Nurse reassessed the patient after the fall. The above was confirmed.
Based on review of records and interview with staff, the facility failed to track indicators, including adverse patient events, for 1 of 1 patient whose record was reviewed. Patient #1 fell and fractured left arm and this event was not reported per hospital policy. Findings were: The facility policy entitled, Occurrence Reporting stated, I. Policy: It is the policy of Green Oaks to (1) formally report all occurrences through Meditech Notification Program (2) restrict the circulation of occurrence reports to internal administrative channels only as described in this policy and (3) to promote a culture of non-punitive error reporting. III. Definitions stated, A1. Occurrence- any happening out of the ordinary course of treatment which results in a potential for injury, or actual injury or damage to the following: patient ... Further review of this policy stated, IV. Procedures: C. Reporting Patient, Visitor, Occurrences, 1a. When a patient is involved in an occurrence which may result in injury or complaint, the staff in charge of the involved department must see that the information is relayed to the appropriate health care personnel. 1b. The Occurrence Report should be filled out as soon as possible after occurrence, reviewed by the Department Director or designee and the Risk Manager as soon as possible. The Occurrence report will be maintained by the Risk Manager. There was no Incident Report on file for Patient #1's fall, which happened in the quiet room on 7/09/2011, and therefore, no follow-up to facilitate changes to improve patient safety. An in-person interview was conducted with the Chief Nursing Officer and the Quality Director, on 7/28/2011 in a facility office. The facility did not provide to the surveyors at the time of the investigation a copy of the Incident Report. The above was confirmed.
Based on review of records and interview with staff, the facility failed to track indicators, including adverse patient events, for 1 of 1 patient whose record was reviewed. Patient #1 fell and fractured left arm and this event was not reported per hospital policy. Findings were: The facility policy entitled, Occurrence Reporting stated, I. Policy: It is the policy of Green Oaks to (1) formally report all occurrences through Meditech Notification Program (2) restrict the circulation of occurrence reports to internal administrative channels only as described in this policy and (3) to promote a culture of non-punitive error reporting. III. Definitions stated, A1. Occurrence- any happening out of the ordinary course of treatment which results in a potential for injury, or actual injury or damage to the following: patient ... Further review of this policy stated, IV. Procedures: C. Reporting Patient, Visitor, Occurrences, 1a. When a patient is involved in an occurrence which may result in injury or complaint, the staff in charge of the involved department must see that the information is relayed to the appropriate health care personnel. 1b. The Occurrence Report should be filled out as soon as possible after occurrence, reviewed by the Department Director or designee and the Risk Manager as soon as possible. The Occurrence report will be maintained by the Risk Manager. There was no Incident Report on file for Patient #1's fall, which happened in the quiet room on 7/09/2011, and therefore, no follow-up to facilitate changes to improve patient safety. An in-person interview was conducted with the Chief Nursing Officer and the Quality Director, on 7/28/2011 in a facility office. The facility did not provide to the surveyors at the time of the investigation a copy of the Incident Report. The above was confirmed.
Based on observation, interview, and record review, the facility failed to provide furnishings that did not present a safety hazard to one of one patient (Patient #1) that had a history of suicidal ideation and recent previous suicide attempts. The patient was able to tie a sheet to the handle on her bed, drape the sheet across the bed and hang herself. Findings included: 1) Record review for Patient #1 included that she had 4 suicide attempts during the current year. Her psychiatric assessment included that she intended to hang herself that day. 2) During a tour of the inpatient unit that Patient #1 was admitted to, and a tour of her room, the facility had beds with handles 8 inches off the floor that were to be used for restraint application. 3) In an interview with the surveyor on 05/18/11 at 2:00 PM the CNO/COO (Personnel #1) was asked how the patient had hung herself. The CNO/COO explained that the patient's bed was in the corner of the room with the head against one wall and one side of the bed against a wall. She stated the patient tied the sheet on one of the handles on the long side of the bed, draped the sheet across the bed, tied the sheet around her neck and covered her head to her chest with a blanket. The CNO was asked if this bed presented a safety hazard to this patient. She confirmed that it did. Facility: Patient Rights Policy reflected: Basic Rights for All Patients...3. You have the right to a clean and humane environment in which you are protected from harm...
Based on record review and interview, the facility did not assure that the inpatient nurse followed the facility policy of completing a nursing assessment within 8 hours of admission for 1 of 1 patient (Patient #1) after admission to the inpatient unit. Findings included: 1) The medical record for Patient #1 included that the patient was admitted to the PES (Psychiatric Emergency Services) unit on 04/16/11. She was admitted to the inpatient unit at 12:15 AM on 04/17/11. 2) The inpatient nursing assessment completed by Personnel #2 was started at 11:37 AM and completed at 11:40 AM on 04/17/11. 3) In an interview with the surveyor on 06/06/11 at 1:45 PM the CNO/COO (Personnel #1)was asked approximately how long the nursing assessment should have taken to complete. She stated 20-30 minutes. She was asked how the nurse had completed the assessment in 3 minutes and completed the assessment before the patient arrived on the unit. She stated the nurse had copied the assessment of the PES unit nurse from the electronic record. Facility Policy: Organization Wide Patient Assessment reflected: 2. i. The admission assessment will be completed by the RN as soon as possible upon arrival to the nursing unit, but within 8 hours of admission for the inpatient, and patient in the Psychiatric Emergency Services (PES)...
Based on record review and interview, the Director of Psychiatric Nursing (Personnel # 1) failed to assure that nursing staff followed the facility policy for transcribing and verifying physician ordered medications to the pharmacy, in that Patient #1 received medications that were not ordered for her. Findings included: 1) Review of the medical record for Patient #1 included that she received Geodon on 04/16/11 at 6:53 PM, Seroquel at 9:37 PM and Dilantin at 9:39 PM. On 04/17/11 she received Geodon at 8:39 AM and 3:44 PM, Seroquel 100 mg at 9:00 AM and 300 mg at 8:51 PM, and Dilantin at 8:38 AM and 8:52 PM. There were no orders for these medications. 2) In an interview with the surveyor on 06/06/11 at 1:30 PM the CNO/COO (Personnel #1) was asked if there were other medication orders. She stated there were not. She was asked how Patient #1 received medications that were not ordered for her. She stated that the nurse transcribed the physician medication order and sent it to the pharmacy. The nurse failed to follow the facility policy in that she did not verify that the pharmacy filled the medication order correctly. The medications appeared on the patient's electronic list of medications and nursing staff administered the medications from that list. Facility Policy: Processing of Medication Orders/Medication Administration reflected: Order Process Guideline...5. The nurse is responsible for making sure that all medication orders are transcribed appropriately by pharmacy on all shifts...7. The nurse will ensure that all medications are processed correctly...
Based on interview, the facility failed to protect the privacy of 1 of 1 patient (Patient #3) whose diagnosis was repeated by a staff member in the facility lobby. Findings included: In an interview on 05/18/11 at 10:30 AM Personnel #2 stated the receptionist admitted to repeating to Patient #3's fiancee/wife that the facility would accept the patient's HIV medication. This was said loud enough so that others in the lobby, including the patients friends who did not know of the patient's illness, heard his diagnosis. The employee was informed that she had failed to protect the patient's privacy.
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