Based on interview and record review the hospital failed to ensure the right of the patient to receive, at the time of admission, information about the hospital's patient rights policy(ies) including the mechanism for the initiation, review, and when possible, resolution of patient complaints concerning the quality of care; in that, 9 of 9 patient (Patient #1, #2, #3, #4, #5, #6, #7, #8, and #9) records did not document patient receipt of patient rights including the mechanism for the initiation, review, and when possible, resolution of patient complaints concerning the quality of care. Findings included Patient #1's, #2's, #3's, #4's, #5's, #6's, #7's, #8's, and #9's records did not document patient receipt of patient rights including the mechanism for the initiation, review, and when possible, resolution of patient complaints concerning the quality of care. During an interview on 2/01/17 at 3:00 PM, Personnel #2 was informed of the above findings. Personnel #2 confirmed the findings. Personnel #2 stated, They used to have it on the consent for treatment form. It is not there. The facility's 11/20/15 Complaint/Grievance Process required, The patient/patient representative shall be informed of whom to contact to file a complaint/grievance in the facility...additionally, information - telephone number and address - shall be provided in regards to lodging a complaint with the State hospital licensure agency...
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review and interview, the facility failed to ensure an RN (registered nurse) supervised and evaluated the nursing care for each patient according to the patient's needs, in that; Patient #3 had an unknown, unsupervised, elopement outside the hospital on [DATE] and there was no RN patient assessment documented upon his return. Findings included There was no documented RN reassessment after the return of Patient #3 on 3/03/16 after his unknown, unsupervised, elopement outside the hospital. During an interview on 2/02/17 at 12:27 PM, Personnel #3 was asked for the patient's reassessment by the RN after his return from the elopement on 3/03/16. Personnel #3 stated she did not find one. Personnel #3 was asked if there should have been a reassessment. Personnel #3 stated, Absolutely.
Based on record review and interview, the hospital failed to ensure the patient right to recieve a written notice of the decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion in the resolution of submitted grievances was provided, at a minimum, in that, 5 of 9 reviewed (Patient #2, #3, #4, #5, and #7) grievances did not document initial hospital letters (within 7 days) or resolution hospital letters (14 - 30 days) that contained the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion in the resolution of submitted grievances to the complainant. Findings included Patient #2's, #3's, #4's, #5's, and #7's grievance did not document timely initial hospital letters or resolution hospital letters to the complainant. Patient #2's/daughter's grievance on 2/24/16 documented an initial hospital letter after the 7 day timeframe on 3/09/16 and no resolution letter. Patient #3's 4/13/16 complaint submitted after his 3/03/16 discharge and did not document a timely initial or resolution letter. Patient #4's 8/16/16 grievance was received after his 8/10/16 discharge and did not document a timely initial or resolution letter. Patient #5's 9/13/16 grievance did not document a timely initial or resolution letter and remained unresolved at the time of survey. Patient #7's/friend's grievance was received after his discharge and did not document a timely initial or resolution letter. There was an address on file for both the patient and the friend. During an interview on 2/02/17 at 9:25 AM, Personnel #5 was informed of the above findings. Personnel #5 confirmed the findings and stated, Not many letters to patients. Most of our contact is verbal. Personnel #5 was asked to review the policy stated below. Personnel #4 read the policy and agreed it was correct. The facility's 11/20/15 Complaint/Grievance Process required, A patient grievance is defines as a written or verbal complaint when the verbal complaint is not resolved at the time of the complaint by staff present...regarding the patient's care, abuse, neglect, issues related to the hospital's compliance with the CMS Hospital (Conditions for Coverage) CoP's...postponed for later resolution...referred to other staff for later resolution...requires investigation and/or further actions for resolution...The Hospital Quality Improvement Committee ensures the patient is provided written notice of its decision regarding a complaint/grievance within seven (7) days of the Hospital's receipt...notice shall contain the following: Hospital contact person...steps...to investigate the grievance...results...Date of completion...investigation will be initiated within 72 hour...The CEO or Senior Leader Designee, is responsible for finalizing and sending a resolution letter...initial letter shall be sent no later than 7 days from notification...The resolution response letter shall be mailed...goal of 14 business days and no longer that 1 month...
Based on observation, interview and record review the Hospital failed to ensure the Director of Dietary supervised and maintained the dietary department in a responsible manner in that 1) Cleanliness issues were observed in the retail and kitchen production areas, 2) Lack of labeling of food items in the kitchen retail and production areas was observed. Findings included: 1) Cleanliness issues were observed in the retail and kitchen production areas. On 04/17/13 from 08:35 AM to 10:05 AM observation rounds were conducted in the dietary department with Personnel #4 and Personnel #10. a) Kitchen Retail area: The dining area built in cabinets had two cabinet doors with split/exposed particle board. The cabinet doors were not sanitizable. A high-chair sitting in the dining area had brown stains on the front of the chair and on the foot rest. The fork dispenser in the dining area was observed with brown stains and needed cleaning. Behind the serving line the metal counter contained two soup dispensers (not in use at the time of this observation). The counter was soiled with a white substance smeared on the surface of the counter. Behind the serving line on a lower metal shelf was a plastic bin which contained 9 small individual containers of cereal. The interior/exterior surface of the bin was soiled/dirty and had a collection of debris inside the bin. The metal shelf was soiled with debris scattered on the surface. A second plastic bin had a large plastic bag of individually wrapped candy. The plastic bag was torn, soiled with brown stains. The interior/exterior surface of the bin was soiled with a collection of debris. A large green bowl was observed on top of a shelf on the serving line. The interior surface of the bowl was soiled and contained unwrapped pieces of candy. Behind the serving line on the counter was a clipboard with food temperatures. The clipboard was soiled/dirty with brown stains and smears on the plastic and metal surface of the clipboard. A step stool was observed on the floor next to the wall. The step stool was soiled with debris and dirt. On top of the step stool was a plastic bag with Styrofoam food containers available for use. A three shelf roller cart behind the serving line was soiled with debris. The second shelf of the cart had a red container of sanitizer solution for cleaning. A plastic bag of bagels and a loaf of raisin bread was stored next to the solution. The floors, walls and baseboards, behind the serving line were soiled with debris. The door leading into the kitchen was soiled and dirty. b) Kitchen Production area: The dietary ice maker lid gasket was torn and peeling away from the interior surface of the lid. The exterior surface of the filter had a collection of dust and required cleaning. The inpatient tray lid rack shelf' (holds lids for trays) was soiled and littered with debris. The exterior surface of the wall next to walk-in refrigerator and freezer had peeling paint and the surface was not sanitizable. A metal work station contained 5 drawers for storage. Two of the five drawers had debris in the drawer and the interior lip of the drawer was stained with a brown substance. Clean pots and pans were stored on a large three shelf rack. Eight large pans were stacked wet on top of each other. Personnel #10 stated the pans should not have been put away wet. Five plastic bins contained, rice, flour, powdered sugar and cornmeal. The lids of the bins were greasy, soiled with brown particles. The exterior surface of the bins were soiled and needed cleaning. A food weight scale was soiled with debris. The exterior surface of the scale was rusted. Two bags of ziti pasta and one bag of bowtie pasta was observed on top of the garbage disposal. Personnel #10 stated food items were not supposed to be on top of the disposal. The two compartment sink had soiled items which included a soiled cloth, spoon and a bucket of sanitizer solution. On the ledge connected to the two compartment sink was a large metal bowl with olives and tomatoes and an opened can of artichoke hearts. Personnel #10 was asked if the above area was a designated food preparation area. Personnel #10 stated No. Personnel #10 informed the staff to discard the pasta and the food items. Personnel #10 verified and acknowledged all the above surveyor observations. 2) Lack of labeling of food items was noted in the kitchen retail and production areas. a) Kitchen Retail Area: The serving line had 17 bagels and 22 pieces of bread available for consumption. The individual items were not labeled when opened. The refrigerator unit next to the grill contained a metal container of lettuce, tomatoes and onions. The food products were not labeled. Personnel #10 stated the items should be labeled. Personnel #10 stated the items were not consumable due to the items having freezer burn. b) Kitchen Production Area refrigerator: Brussels sprouts, onions and bacon were observed opened and not labeled. Additionally salad bar containers of black olives, green olives, cheese, ham, chicken, lettuce, tomatoes and onions were not labeled when prepared. Personnel #10 verified the above surveyor observations. The Director of Nutritional Services Job Description dated 02/22/13 reflected, Responsible for the storage and preparation of food supplies, maintenance of equipment and proper sanitation of work areas...director ensures proper assembly, service of foods, sanitation and safety of service and utility areas of the department. The policy entitled, Food Storage dated 01/2011 reflected, To ensure safe and sanitary storage of...dry goods and food...chemicals are stored separately from food and dry goods...all items must be dated... The policy entitled, Food safety dated 01/2011 reflected, To prevent the possibility of food borne illness...food is protected against contamination from dust, vermin, unclean utensils, unclean work surfaces...
Based on observation, interview and record review the infection control officer failed to provide a system to identify, report, investigate, control and avoid sources and transmission of infections and communicable diseases in the maintenance of a sanitary hospital environment in that 1) Dusty patient care equipment was found in the hospital's Emergency Department. Clean and contaminated equipment was stored in close proximity. 2) Cleanliness issues were observed in the retail and kitchen production areas, and 3) Equipment ready for patient use was observed on the floor in patient care areas. Findings included: 1) On 04/16/13 between 10:00 AM and 10:39 AM observational rounds were conducted in the hospital's Emergency Department (ED) with Personnel #2, Personnel #5, Personnel #6, and Personnel #7. The crash cart, the EKG machine, and the ortho cart next to the bay area were dusty with white particles. Three plastic bins filled with KY jelly, cotton tip applicators, and tongue depressors in the ED's clean utility room were dusty. Adult briefs and baby diapers were observed in dusty bins. Blood pressure cuffs were observed in three dusty blue bins on top of a gray cart. The environmental storage room had a dust mop next to a white bin with clean wash rags. Personnel #7 stated, The mop is dirty and agreed clean and dirty equipment were stored within close proximity. The triage area had two dusty shelves. A cart underneath the scale had multiple unwrapped baby diapers. Hospital Personnel #2 stated the diapers were supposed to be individually wrapped. Hospital Personnel #5 and Personnel #6 verified and acknowledged all of the above surveyor observations. 2) On 04/17/13 from 08:35 AM to 10:05 AM observation rounds were conducted in the dietary department with Personnel #4 and Personnel #10. Cleanliness issues were observed in the retail and kitchen production areas. a) Kitchen Retail Area: The dining area built in cabinets had two cabinet doors with split/exposed particle board. The cabinet doors were not sanitizable. A high-chair sitting in the dining area had brown stains on the front of the chair and on the foot rest. The fork dispenser in the dining area was observed with brown stains and needed cleaning. Behind the serving line the metal counter contained two soup dispensers (not in use at the time of this observation). The counter was soiled with a white substance smeared on the surface of the counter. Behind the serving line on a lower metal shelf was a plastic bin which contained 9 small individual containers of cereal. The interior/exterior surface of the bin was soiled/dirty and had a collection of debris inside the bin. The metal shelf was soiled with debris scattered on the surface. A second plastic bin had a large plastic bag of individually wrapped candy. The plastic bag was torn, soiled with brown stains. The interior/exterior surface of the bin was soiled with a collection of debris. A large green bowl was observed on top of a shelf on the serving line. The interior surface of the bowl was soiled and contained unwrapped pieces of candy. Behind the serving line on the counter was a clipboard with food temperatures. The clipboard was soiled/dirty with brown stains and smears on the plastic and metal surface of the clipboard. A step stool was observed on the floor next to the wall. The step stool was soiled with debris and dirt. On top of the step stool was a plastic bag with Styrofoam food containers available for use. A three shelf roller cart behind the serving line was soiled with debris. The second shelf of the cart had a red container of sanitizer solution for cleaning. A plastic bag of bagels and a loaf of raisin bread were stored next to the solution. The floors, walls and baseboards, behind the serving line were soiled with debris. The door leading into the kitchen was soiled and dirty. b) Kitchen Production area: The dietary ice maker lid gasket was torn and peeling away from the interior surface of the lid. The exterior surface of the filter had a collection of dust and required cleaning. The inpatient tray lid rack shelf' (holds lids for trays) was soiled and littered with debris. The exterior surface of the wall next to walk-in refrigerator and freezer had peeling paint and the surface was not sanitizable. A metal work station contained 5 drawers for storage. Two of the five drawers had debris in the drawer and the interior lip of the drawer was stained with a brown substance. Clean pots and pans were stored on a large three shelf rack. Eight large pans were stacked wet on top of each other. Personnel #10 stated the pans should not have been put away wet. Five plastic bins contained, rice, flour, powdered sugar and cornmeal. The lids of the bins were greasy, soiled with brown particles. The exterior surface of the bins were soiled and needed cleaning. A food weight scale was soiled with debris. The exterior surface of the scale was rusted. Two bags of ziti pasta and one bag of bowtie pasta were observed on top of the garbage disposal. Personnel #10 stated food items were not supposed to be on top of the disposal. The two compartment sink had soiled items which included a soiled cloth, spoon and a bucket of sanitizer solution. On the ledge connected to the two compartment sink was a large metal bowl with olives and tomatoes and an opened can of artichoke hearts. Personnel #10 was asked if the above area was a designated food preparation area. Personnel #10 stated No. Personnel #10 informed the staff to discard the pasta and the food items. Personnel #10 verified and acknowledged all the above surveyor observations. The Director of Nutritional Services Job Description dated 02/22/13 reflected, Responsible for the storage and preparation of food supplies, maintenance of equipment and proper sanitation of work areas...director ensures proper assembly, service of foods, sanitation and safety of service and utility areas of the department. The policy entitled, Food Storage dated 01/2011 reflected, To ensure safe and sanitary storage of...dry goods and food...chemicals are stored separately from food and dry goods...all items must be dated... The policy entitled, Food safety dated 01/2011 reflected, To prevent the possibility of food borne illness...food is protected against contamination from dust, vermin, unclean utensils, unclean work surfaces... The policy entitled, Sanitation & Maintenance of Equipment with a review date of 01/2011 reflected, To ensure safe work practices in order to provide uncontaminated products and a safe work environment... 3) Patient #27 was observed on 04/17/13 at 11:59 AM in the hospital's second floor patient care area. A rectangular pink basin with sudsy water was observed on an overhead table. Patient #27 stated he used it for shaving 2-3 hours ago. Sleeves of the sequential compression device (SCD), a device to prevent patients from having blood clots, were on the floor in three patient rooms (Patient #3, Patient #25, and Patient #27) as observed on 04/17/13 between 11:40 AM and 12 noon. Hospital Personnel #11 acknowledged and verified the above findings. Review of Hospital Policy #6001 revisioned on 02/13/13 reflected all equipment should be cleaned with hospital approved disinfectant solution when visibly soiled.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interviews and records review, it was determined that the Governing Body was not effective in its oversight of the hospital. A) The medical staff failed to adequately supervise and ensure adequate medical treatment for one of one patient (Patient #1) whose pre-hospital diagnosed left heel Stage IV ulcer was untreated during her eight day hospital stay from 11/28/12 to 12/05/12. B) The nursing staff failed to supervise and evaluate the nursing care for one of one patient (Patient #1). Patient #1's left heel wound dressing was not changed during her eight day hospital stay from 11/28/12 to 12/5/12. Patient #1 was discharged without a dressing change to her left heel wound. Findings included: A) Medical staff noted perfusion complications for Patient #1 but did not evaluate or treat her left heel ulcer. Patient #1 left the hospital after an eight day stay without a wound consult or treatment orders for the wound on her left heel. (Cross refer to A0049) B) Patient #1 had a pre-hospital diagnosis of a left heel stage IV pressure ulcer covered with a wound dressing dated 11/26/12. Patient #1 was admitted on [DATE] and discharged on [DATE]. The dressing to the left heel was not changed during Patient #1's eight day hospital stay. (Cross refer to A0144, A0395 and A0397)
Based on interviews and records review, the Governing Body failed to ensure that medical staff provided quality of care for one of one patient (Patient #1). Patient #1 had a pre-hospital stage IV left heel ulcer. There was no treatment provided to Patient #1's left heel ulcer during her eight day hospital stay from 11/28/12 to 12/05/12. Findings included: Long-term Care Nursing Facility Wound Care Physician Progress Notes dated 11/14/12 and 12/12/12 reflected Patient #1 had a left heel stage IV pressure ulcer. Patient #1's Emergency Department Physician examination dated 11/28/12 at 9:31 PM reflected Patient #1's skin to be warm and dry with normal turgor, without lesions or rashes. The clinical impressions dated 11/28/12 at 11:35 PM noted Urinary Tract Infection, Dehydration, Tachycardia, and Leukocytosis. The patient was admitted to the hospital. Physician Admission Orders dated 11/28/12 at 10:15 PM did not include orders for wound care or wound care consultation. The Admission History and Physical document noted Patient #1 had pressured, excoriated areas on her sacrum. The assessment reflected severe peripheral arterial disease of lower extremities without mention of a left heel wound. The Consultation Report dated 11/29/12 at 5:45 PM recommended an IVC filter (inferior vena cava filter) for acute deep vein thrombosis of left lower extremity. The document noted Patient #1 had leg ulcers with known history of peripheral arterial disease and would be treated conservatively. Physician Order Set Post Cath Orders dated 11/30/12 at 4:20 PM noted patient #1 had a left leg DVT (deep vein thrombosis) and had an IVC filter placed (inferior vena cava filter for recurring thrombosis) without mention of her left heel wound. The Medication Reconciliation Orders/Discharge Planning Record dated 12/05/12 at 4:01 PM reflected Patient #1 had blanching to coccyx (lower back) without mention of the left heel wound. Physician Discharge Summary dated 12/05/12 at 3:28 PM reflected Patient #1 had some swelling over her left lower extremity...which...was positive for deep vein thrombosis without mention of a left heel wound. Long-term Care Facility Physicians' Progress notes dated 12/06/12 reflected Patient #1 returned [from the hospital] with dressing[s] that were dated 11/26/12 - wounds were unattended at [the ] hospital. Physician #12 agreed on 01/15/13 at 4:32 PM that when Patient #1 returned to the Long-term Nursing Care Facility, her dressing was dated from before she left for the hospital. The physician denied he was consulted for wound management on Patient #1. Hospital Personnel #10 stated during an interview on 01/16/13 at 10:25 AM she usually did the dressing changes but denied a wound care consult was ordered for Patient #1. QA/Governing Board Minutes dated 12/21/12 did not reflect skin concerns as PI projects for 2013.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interviews and record review, it was determined that hospital personnel failed to protect and promote the right of one of one patient (Patient #1) to receive care in a safe setting. Findings included: Patient #1 was transferred to the hospital on [DATE] with a pre-hospital diagnosed left heel pressure ulcer protected by a wound cover dated 11/26/12. The patient was admitted for an eight day hospital stay and was discharged on [DATE] without a dressing change to her left heel (cross refer to A0144)
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, nursing staff failed to provide care in a safe setting for one of one patient (Patients #1) as evidenced by Patient #1's left heel wound dressing was not changed during her eight day hospital stay from 11/28/12 to 12/05/12. Findings included: Long-term Care Nursing Facility Wound Care Physician Progress Notes dated 11/14/12 and 12/12/12 reflected Patient #1 had a left heel stage IV pressure ulcer. Patient #1's Emergency Department Physician examination dated 11/28/12 at 9:31 PM reflected Patient #1's skin to be warm and dry with normal turgor, without lesions or rashes. The clinical impressions dated 11/28/12 at 11:35 PM noted Urinary Tract Infection, Dehydration, Tachycardia, and Leukocytosis. The patient was admitted to a medical bed. Physician Admission Orders dated 11/28/12 at 10:15 PM did not reflect orders for dressing changes. The Nursing Admission assessment dated [DATE] at 1:39 AM reflected skin concerns on Patient #1's right shoulder and left heel which was further described as multiple bruises, skin tear to [the] right shoulder [and] right heel injury which nursing staff was unable to visualize due to drsg (dressing) in place. Nursing skin assessment reflected a right heel wound with dressing. The electronic Care Trends - Integumentary flow sheet dated 11/29/12 at 1:39 AM noted Patient #1 had a wound dressing on her right heel. Flow sheets dated 11/29/12 at 12:54 PM, 11/30/12, and 12/01/12 did not mention wounds or dressings on the patient's feet or heels. Flow sheets dated 12/03/12 at 12:27 PM and 11 PM, 12/04/12 at 1:48 PM, and 12/05/12 at 11:17 AM reflected a right heel reddened, warm pressure area. The Medication Reconciliation Orders/Discharge Planning Record dated 12/05/12 at 4:01 PM reflected Patient #1 had blanching to coccyx (lower back). Long-term Care Facility Physicians' Progress notes dated 12/06/12 reflected Patient #1 returned [from the hospital] with dressing[s] that were dated 11/26/12 - wounds were unattended at [the ] hospital. Long-term Nursing Care Facility Staff #3 stated on 01/15/13 at 11:32 AM that he and Physician #12 examined Patient #1 upon returning to the nursing facility after her hospitalization . The patient had a dressing to her left heel which was initialed by the Long-term Care Facility's nursing staff and dated two days prior to Patient #1's hospital admission. Physician #12 agreed on 01/15/13 at 4:32 PM that when Patient #1 returned to the Long-term Nursing Care Facility, her dressing was dated from before she left for the hospital. Hospital Personnel #10 stated during an interview on 01/16/13 at 10:25 AM she usually did the dressing changes but denied a wound care consult was ordered for Patient #1. Hospital Personnel #10 stated being unaware of any skin issues for Patient #1. Hospital Employee #11 stated during an interview on 01/16/13 at 11:30 AM she had noticed that computerized documentation stated Patient #1 had a wound to her right foot. Instead, Hospital Employee #11 took the wrapping off Patient #1's left foot. The dressing was at least a couple of days old and dated a few days back because she did not recognize the initials on it. It did not look like something PT (Physical Therapy) does. Employee #11 stated she put the same dressing back on Patient #1's left foot and planned to receive further care instructions from another nurse. Employee #11 stated, I know I needed to follow up on it but I did not do it. Hospital Personnel #1 was interviewed on 01/16/13 at 12:40 PM. She denied any dressing changes were documented on Patient #1. Policy RI.120 Patient Rights and Responsibilities approved by the Medical Executive Committee on 10/15/12 reflected the Right to Care and Services 2.2.7 that...each patient has the right to receive individualized, planned and appropriate care, treatment...based on both an interdisciplinary evaluation of his/her needs and the severity of his/her disease, condition...and on goals, actions and interventions as collaboratively designed and agreed upon by the physicians, nursing staff and other health care providers...
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interviews and record review it was determined the hospital failed to provide nursing service supervised by a registered nurse to one of one patient (Patient #1) whose left heel wound dressing was not changed during her eight day hospital stay from 11/28/12 to 12/05/12. Findings included: Patient #1 was admitted to the hospital with a left heel pressure ulcer dressed with a wound cover dated 11/26/12. During her eight day hospitalized from [DATE] to 12/05/12 Patient #1's wound was documented to be on her right foot. Patient #1 was discharged without a dressing change to her left heel wound (cross refer to A0395 and A0397)
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, hospital nursing staff failed to supervise and evaluate the nursing care for one of one patient (Patient #1). Patient #1's left heel wound dressing was not changed during her eight day hospital stay from 11/28/12 to 12/05/12. Findings included: Long-term Care Nursing Facility Wound Care Physician Progress Notes dated 11/14/12 and 12/12/12 reflected Patient #1 had a left heel stage IV pressure ulcer. Patient #1's Emergency Department Physician examination dated 11/28/12 at 9:31 PM reflected Patient #1's skin to be warm and dry with normal turgor, without lesions or rashes. The clinical impressions dated 11/28/12 at 11:35 PM noted Urinary Tract Infection, Dehydration, Tachycardia, and Leukocytosis. The patient was admitted to a medical bed. The Nursing Admission assessment dated [DATE] at 1:39 AM reflected skin concerns on Patient #1's right shoulder and left heel which was further described as multiple bruises, skin tear to [the] right shoulder [and] right heel injury which nursing staff was unable to visualize due to drsg (dressing) in place. Nursing skin assessment reflected a right heel wound with dressing. The electronic Care Trends - Integumentary flow sheet dated 11/29/12 at 1:39 AM noted Patient #1 had a wound dressing on her right heel. Flow sheets dated 11/29/12 at 12:54 PM, 11/30/12, and 12/01/12 did not mention wounds or dressings on the patient's feet or heels. Flow sheets dated 12/03/12 at 12:27 PM and 11 PM, 12/04/12 at 1:48 PM, and 12/05/12 at 11:17 AM reflected a right heel reddened, warm pressure area. Long-term Care Facility Physicians' Progress notes dated 12/06/12 reflected Patient #1 returned [from the hospital] with dressing[s] that were dated 11/26/12 - wounds were unattended at [the ] hospital. Long-term Nursing Care Facility Staff #3 stated on 01/15/13 at 11:32 AM that he and Physician #12 examined Patient #1 upon her return to the nursing facility after her hospitalization . The patient had a dressing to her left heel which was initialed by the long-term facility's nursing staff and dated two days prior to Patient #1's hospital admission. Physician #12 agreed on 01/15/13 at 4:32 PM that when Patient #1 returned to the Long-term Nursing Care Facility, her dressing was dated from before she left for the hospital. Hospital Personnel #2 stated on 01/16/13 at 11:03 AM that during an educational meeting the day before one of the nurses stated she took the dressing off Patient #1, then reapplied the previously dated and initialed, used dressing back on the wound. Hospital Personnel #2 identified the nurse as a Hospital Personnel #11, a new LVN (Licensed Vocational Nurse). Hospital Employee #11 stated during an interview on 01/16/13 at 11:30 AM she had noticed that computerized documentation stated Patient #1 had a wound to her right foot. Instead, Hospital Employee #11 took the wrapping off Patient #1's left foot. The dressing was at least a couple of days old and dated a few days back because she did not recognize the initials on it. It did not look like something PT (Physical Therapy) does. Employee #11 stated she put the same dressing back on Patient #1's left foot and planned to request further care instruction from another nurse. Employee #11 stated, I know I needed to follow up on it but I did not do it. Employee #11 stated she was recently hired and was just taken off her preceptorship. Hospital Personnel #1 was interviewed on 01/16/13 at 12:40 PM. She denied any dressing changes were documented on Patient #1. Policy PC.103 titled Assessment and Reassessment of the Patient dated with Board Approval on 05/17/10 reflected the Implementation Method 3.1.2.2.1 The Registered Nurse is responsible for the assessment and coordination of patient care.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, hospital nursing staff failed to assign nursing care of one of one patient (Patient #1) in accordance with the patient's needs and the specialized qualifications and competence of the nursing staff available in that an LVN (Licensed Vocational Nurse) (Hospital Personnel #11) visualized Patient #1's left heel wound, re-applied the used dressing, and did not request further care instructions from an RN. After an eight day hospital stay from 11/28/12 to 12/05/12, Patient #1 was discharged without dressing change of her left heel wound. Findings included: Long-term Care Nursing Facility Wound Care Physician Progress Notes dated 11/14/12 and 12/12/12 reflected Patient #1 had a left heel stage IV pressure ulcer. Patient #1's Emergency Department Physician examination dated 11/28/12 at 9:31 PM reflected Patient #1's skin to be warm and dry with normal turgor, without lesions or rashes. The clinical impressions dated 11/28/12 at 11:35 PM noted Urinary Tract Infection, Dehydration, Tachycardia, and Leukocytosis. The patient was admitted to a medical bed. The Nursing Admission assessment dated [DATE] at 1:39 AM reflected skin concerns on Patient #1's right shoulder and left heel which was further described as multiple bruises, skin tear to [the] right shoulder [and] right heel injury which nursing staff was unable to visualize due to drsg (dressing) in place. Nursing skin assessment reflected a right heel wound with dressing. The electronic Care Trends - Integumentary flow sheet dated 11/29/12 at 1:39 AM noted Patient #1 had a wound dressing on her right heel. Flow sheets dated 11/29/12 at 12:54 PM, 11/30/12, and 12/01/12 did not mention wounds or dressings on the patient's feet or heels. Flow sheets dated 12/03/12 at 12:27 PM and 11 PM, 12/04/12 at 1:48 PM, and 12/05/12 at 11:17 AM reflected a right heel reddened, warm pressure area. Long-term Care Facility Physicians' Progress notes dated 12/06/12 reflected Patient #1 returned [from the hospital] with dressing[s] that were dated 11/26/12 - wounds were unattended at [the ] hospital. Long-term Nursing Care Facility Staff #3 stated on 01/15/13 at 11:32 AM that he and Physician #12 examined Patient #1 upon her return to the nursing facility after her hospitalization . The patient had a dressing to her left heel which was initialed by the long-term facility's nursing staff and dated two days prior to Patient #1's hospital admission. Physician #12 agreed on 01/15/13 at 4:32 PM that when Patient #1 returned to the Long-term Nursing Care Facility, her dressing was dated from before she left for the hospital. Hospital Personnel #2 stated on 01/16/13 at 11:03 AM that during an educational meeting the day before one of the nurses stated she took the dressing off Patient #1, then reapplied the previously dated and initialed, used dressing. Hospital Personnel #2 identified the nurse as Hospital Personnel #11, a new LVN (Licensed Vocational Nurse). Hospital Employee #11 stated during an interview on 01/16/13 at 11:30 AM she had noticed that computerized documentation stated Patient #1 had a wound to her right foot. Instead, Hospital Employee #11 took the wrapping off Patient #1's left foot. The dressing was at least a couple of days old and dated a few days back because she did not recognize the initials on it. It did not look like something PT (Physical Therapy) does. Employee #11 stated she put the same dressing back on Patient #1's left foot and planned to request further care instruction from another nurse. Employee #11 stated, I know I needed to follow up on it but I did not do it. Employee #11 stated she was recently hired and was just taken off her preceptorship. Hospital Personnel #1 was interviewed on 01/16/13 at 12:40 PM. She denied any dressing changes were documented on Patient #1. Policy PC.103 titled Assessment and Reassessment of the Patient dated with Board Approval on 05/17/10 reflected the Implementation Method 3.1.2.2.1 The Registered Nurse is responsible for the assessment and coordination of patient care.
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