Based on interview and record review, the hospital failed to ensure staff documented observations three times an hour, as required per hospital policy, of 2 (#3, #4) of 5 (#1, #2, #3, #4, #5) sampled patients who were restrained for non-violent behaviors. The nursing staff also failed to document 2 hour nursing assessments, as required per hospital policy, in the patient's medical record for 1 (#4) of 5 (#1, #2, #3, #4, #5) sampled patients with restraints. Findings: Review of the hospital's policy titled Restraint and Seclusion Utilization revealed the following in part: 5. Order for restraint and seclusion 5A. Order for restraint with non-violent or non-self-destructive behavior a. Duration of order for restraint must not exceed 24 hours for the initial order and must specify clinical justification for the restraint or seclusion, the date and time ordered, the duration of use, the type of restraint to be used and behavior-based criteria for release. 7. Monitoring the patient in restraint or seclusion b. An RN will assess the patient at least every two (2) hours d. A trained staff member monitors each patient in restraint and seclusion at least three (3) times and 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. Patient #3 Review of Patient #3's medical record revealed he had a physician's order for non-violent restraints on 04/26/21 at 3:34 p.m. A review of Patient #3's restraint documentation on 04/27/2021 at 10:47 a.m. revealed there had not been observations documented since 8:45 a.m. (2 hours). In an interview on 04/27/21 at 10:57 a.m. with S6RN, she said she should assess patients in non-violent restraints every 15 minutes or at least 3 times an hour. She verified she had not documented an assessment since 8:45 a.m. on her restraint rounding sheet. Patient #4 Review of Patient #4's medical record revealed a physician's order for restraints on 04/26/2021 at 12:28 p.m. for attempts to remove device, non-violent soft bilateral upper extremities. Review of Patient #4's medical record revealed nursing staff failed to document three safety checks an hour on 04/24/2021 from 3:15 p.m. to 6:45 p.m. (3 1/2 hours). Review of Patient #4's electronic medical record revealed nursing staff failed to document 2-hour nurse assessments of non-violent restraints on 04/24/2021 from 4:00 p.m. to 8:00 p.m. (4 hours). In an interview on 04/27/2021 at 3:30 p.m. with S4RN, she stated according to review of Patient #4's medical records, nursing staff did not complete documentation on 15-minute safety checks and 2-hour nursing assessments of patient #4 while in non-violent restraints on 04/24/2021.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review the hospital failed to ensure a registered nurse supervised and evaluated the care of each patient. This deficient practice is evidenced by the nursing staff: 1. failing to accurately assess wounds for 2 (#2, #3) of 4 (#2, #3, #5, #R2) patients sampled with wounds; and 2. failing to measure and photograph pressure sores routinely to determine if treatment interventions were effective for 2 (#2, #3) of 4 (#2, #3, #5, #R2) patients sampled with wounds; and 3. failing to assess pressure ulcers each shift as per hospital policy for 2 (#2, #3) of 4 (#2, #3, #5, #R2) patients sampled with wounds. Findings: Review of the hospital's policy titled Pressure Injuries revealed in part: Documentation: 1. Wound care should be documented on admission and with each shift assessment. Review of the hospital's policy titled Photograph Documentation of Skin Breakdown revealed in part: 2. The nurse manager or wound care nurse will photograph pressure ulcers, unstageable, Stage 2, SDTI, Stage 3 and Stage 4 on admission, once a week, change in level of care and at the time of discharge. The photos will be taken utilizing the NE1 can stage wound assessment tool. Guidelines 7. Use NE1 can stage wound assessment tool (which promotes consistent assessment, staging, measurement, and documentation of wounds). 1. Failing to accurately assess wounds. Patient #3 Review of Patient #3's medical record revealed he was a current patient that had been admitted on [DATE] at 12:08 p.m. with diagnosis including Edema Lower Extremities and Altered Mental Status. Review of Patient #3's medical record revealed the only daily descriptions of wounds during nursing assessments were of the sacrum, bruising to the arms, a wound to the back. and 1 assessment of a wound to the buttock. Review of Patient #3's skin assessments revealed the following inconsistent skin/wound assessments of the sacrum: 04/15/2021 Posterior Sacrum Stage 3 pressure sore, black tan eschar. 04/16/2021 at 8:00 a.m. Stage 3, eschar 04/17/2021 at 8:00 a.m. Unstageable black eschar 04/18/21 at 7:45 a.m. Unstageable, eschar 04/19/21 at 8:00 a.m. Pre stage 1 pressure ulcer 04/19/21 at 7:43 p.m. Eschar Stage 3 04/19/21 at 8:00 p.m. Stage 2 04/21/21 at 8:00 p.m. Eschar, Stage 3 Further review of the back wound revealed the last assessment documented by the nurse was on 04/26/21 at 8:00 a.m. as a Stage 2 injury. The only documentation of a description by the nurse of the wound to the lower buttock was on 04/26/21 at 8:40 a.m. as a right lower butt unstageable. In an observation beginning at 1:00 p.m. on 04/27/21, S6RN ICU Educator did a skin assessment on Patient #3. The following wounds/injuries were observed: Deep tissue injury on back Red area sacrum 19 cm Stage 4 sacrum 8 cm X 4.5 cm Stage 3 buttock 7 cm X 2.75 cm Stage 3 Left shin Small deep tissue wound outer aspect L foot Deep tissue with fungus Right heel Grade 1 skin tear Right arm 3 cm X 1.25 cm Grade 4 skin tear left arm Review of Patient #3's medical record revealed there was no documentation of an assessment in Patient #3's medical record by the staff nurses of a wound to Patient #3's left shin, outer aspect of the left foot, deep tissue injury right heel or the red area to the sacrum. In an interview on 04/27/2021 at 12:35 p.m. with S5RN, he said a Stage 3 pressure Ulcer is full thickness through the dermis into the muscle layer. He verified it was not possible to go back and forth in a days time between a Stage 3 and Unstagable wound on Patient #3's sacrum. In an interview on 04/27/2021 at 2:03 p.m. with S5RN, he verified all of Patient #3's wounds should have been assessed and documented in the medical record but were not. Patient #2 Review of Patient #2's medical record revealed he had been admitted on [DATE] with diagnosis including seizures, altered mental status, diabetes mellitus, and [DIAGNOSES REDACTED]. Review of Patient #2's medical record revealed the following inconsistent skin/wound assessments: 11/22/20 at 8:00 a.m.- Skin Alteration none 11/22/20- 7:50 p.m.- Skin alteration- Present/exists with no description 11/23/20- 8:00 a.m.- Stage 3 Pressure injury 11/24/20- 8:00 p.m. Stage 3 11/27/20 at 9:15 a.m.- unstageable 11/27/20 at 7:21 p.m. unstageable 12/04/20 8:00 a.m. Skin Alteration: Present/exists 12/05/20- 8:00 p.m. Present/exists 12/06/20 8:00 a.m.- Stage 2 12/07/20 10:18 p.m. Pre Stage 1 with skin intact 12/08/20 8:30 a.m. - Stage 2 12/09/20- 8:15 a.m. Unstageable 12/10/20 8:15 a.m. Stage 3 In an interview on 04/27/20 at 10:25 a.m. with S4RN, she verified Patient #2's skin/wound assessments were not consistent and accurate. In an interview on 04/27/21 at 10:29 a.m. with S5RN, he verified it did not seem possible that a patient's wound could go back and forth from unstageable, to Stage 2 and Stage 3 on a daily basis. 2. Failing to measure and photograph pressure sores routinely to determine if treatment interventions were effective. Patient #3 Review of Patient #3's medical record revealed a pressure ulcer of the sacrum was documented on a skin assessment on 04/15/2021 and remained on 04/27/21 during an observation of a skin assessment of Patient #3. There were 2 photographs and measurements of the pressure ulcer on the sacrum in the medical record but no photographs or measurements of the other wounds observed during the observation including a deep tissue injury on the back, a red area to the sacrum, Stage 3 pressure ulcer to the buttock, a Stage 3 pressure ulcer to the left shin, a small deep tissue wound to the outer aspect of the left foot, a deep tissue with fungus to the right heel, a Grade 1 skin tear to the right arm and a Grade 4 skin tear to the left arm. Patient #2 Review of Patient #2's medical record revealed a pressure ulcer to the sacrum was discovered on 11/23/2020 and remained until discharge on 12/10/2020. Further review revealed there were no measurements of the wound by nursing staff in the medical record. Review also revealed only 1 photograph of the wound was taken at the time of discovery. In an interview on 04/27/21 at 2:03 p.m. with S5RN, he verified there should be photographs in the medical record of all of the wounds and documentation of the size of the wounds. 3. Failing to assess patient's pressure ulcers each shift as per hospital policy. Patient #2 Review of Patient #2' medical record revealed a Stage 3 wound to the sacrum was discovered on 11/23/2020 at the 8:00 a.m. assessment. Further review revealed the patients wounds were not assessed on the morning shift on 11/24/2020. The wounds were not assessed on the evening shift on 11/26/2020 and 12/03/2020. Patient #3 Review of Patient #3's medical record revealed a skin assessment on 04/15/2021 that revealed a Posterior Sacrum Stage 3 pressure sore with black and tan eschar. Further review revealed the patients wounds were not assessed on the morning shift on 04/20/2021, 04/21/2021, 04/22/2021, and 04/23/2021. The wounds were not assessed on the evening shift on 04/20/21, 04/23/2021, 04/25/2021 and 04/26/2021. In an interview on 04/27/20 at 10:25 a.m. with S5RN, she verified patient's pressure ulcers should be assessed every shift.
Based on policy review, observation and interview, the Hospital failed to ensure patients had the right to be free from restraints. This deficient practice was evidenced by the hospital failing to follow its Restraint and Seclusion Utilization Policy for 3 of 3 patients observed in their beds with all four of the side rails raised. (Patients R1, R2, R3). Findings: Review of the hospital's Policy #81 titled, Restraint and Seclusion Utilization revealed in part: K - Side rails considered restraint: Using side rails to prevent a patient from voluntarily getting out of bed would be considered a restraint. In short, the patient may have an increased risk for a fall or other injury by attempting to exit the bed with the side rails raised. Observation on 09/10/2019 at 12:12 p.m. revealed Patients R1, R2, and R3 in their beds with all four of the side rails raised. During an interview on 09/10/2019 at 12:15 p.m., S3RN, the nurse assigned to R2, stated Patient R2 did not require all four of the side rails to be in the raised position. During an interview on 09/10/2019 at 12:17 p.m., S2RN, the nurse assigned to R1 stated Patient R1 did not require all four of the side rails to be in the raised position. During an interview on 09/10/2019 at 12:20 p.m., S4RN, the nurse assigned to R3, stated Patient R3 did not require all four of the side rails to be in the raised position.
Based on record review and interview, the hospital failed to ensure the nursing staff developed and kept current, individualize, and comprehensive nursing care plans. This deficient practice was evidenced by failure of the nursing staff to identify interventions and expected outcomes for identified problems for 5 of 5 (Patients #1, #2, #3, #4, #5) sample patients. Findings: Review of the hospital's Policy #303 titled, Evidence Based Clinical Documentation, revealed in part: Plan of Care: A. The Plan of Care is interdisciplinary with each professional involved in the patient's care contributing to the plan by identifying problems, establishing goals and prescribing interventions. D: For each problem added to the Plan of Care, the electronic information system will suggest related interventions. 1. The clinician will review and edit the suggested interventions to meet the patient's needs. Review of Patient's #1, #2, #3, #4, and #5's Plan of Care revealed a problem list with no nursing interventions or expected outcomes. Surveyors requested S5RN provide printed copies of Patient's #1, #2, #3, #4, #5's Plan of Care with the problem list and interventions. After repeated request from the surveyors, the Plan of Care with interventions and expected outcomes were not provided to the surveyor. During an interview on 09/10/2019 at 1:30 p.m., S1 RN acknowledged the Plan of Care did not include interventions to go with the problem sets. S1RN continued to state the interventions are from the MD orders and standards of care from nurse's training. During an interview on 09/10/2019 at 3:45 p.m., S6RN was unable to provide the surveyor with the Plan of Care nursing interventions and expected outcomes within the medical record. During an interview on 09/10/2019 at 3:50 p.m., S2RN was unable to provide the surveyor with the Plan of Care nursing interventions and expected outcomes for Patient #3.
Based upon review of 1 of 8 Emergency Department medical records (#2), Emergency Department Policies and Procedures, and interviews, the Registered Nurse failed to: 1) follow Policies and Procedures related to conducting a re-assessment of the response and effectiveness of medications administered to patient #2 while in the Emergency Department, and 2) documented on patient #2 ED record the patient's pupils were equal, round, and reactive to light and accomodation when through interview it was found the pupils were not assessed. Findings: 1) Review of the Emergency Department (ED) Medical Record revealed on 08/15/2011, patient #2 presented to the ED with the chief complaint of a head pain after hitting her head on the attic stairs. According to the list of medications ordered by the Nurse Practitioner S14 and ED physician S9, the Registered Nurse (RN) S12 documented Ketorolac Tromethamine (Toradol) 30 mg (milligrams), Ondansetron HCL (Zofran) 4 mg, and Dexamethasone (Decadron) 4 mg were administered Intravenously at 2:00 PM on 08/15/2011. At 3:27 PM, RN S12 documented patient #2 refused Meperidine HCL (Demerol) 25 mg and Ziprasidone Mesylate (Geodon) 20 mg; however, review of the ED record revealed RN S12 failed to document why the patient refused these medications. At 3:54 PM on 08/15/2011, RN S12 documented she administered Ziprasidone Mesylate (Geodon) 20 mg Intramuscular, and at 3:55 PM, administered Tramadol HCL (Ultram) 50 mg by mouth and repeated the Ondansetron HCL (Zofran) 4 mg Intravenously. The patient was then released from the Emergency Department at 3:55 PM, the same time these medications were administered. There failed to be documentation by RN S12 patient #2 was re-assessed after the administration of the Geodon, Ultram and Zofran administered at 3:55 PM on 08/15/11. On 09/21/11, the policy related to assessing the patient after the administration of medications was requested. Emergency Department Director S4 provided the policy titled Intramuscular Injection Medication for review. According to this policy, the RN was to document Documentation: The following should be noted on the patient's chart/electronic medication administration record: 1. Patient's response to medication; and 4. Evaluate and document outcome of PRN (as needed) medications on PRN Effectiveness Intervention. Review of patient #2's Emergency Department Record revealed there failed to be documented evidence Registered Nurse S12 documented the patient's response and the effectiveness of the medications administered Intravenously or Intramuscular. 2) Review of patient #2's ED record revealed RN S12 documented Yes to the patient's pupils being equal, round and reactive to light and accomodation. Interview with RN S12 on 09/21/11 at 9:30 AM, revealed the patient had sunglasses on and refused to remove them because the light hurt her eyes. When questioned if the patient's pupils were assessed as indicated in the ED record, RN S12 replied no.
Based upon review of 1 of 8 Emergency Department (ED) Records (#2), and interviews, the Registered Nurse failed to follow standards of practice as evidenced by allowing ED patient #2 to hand to her visitor a prescribed medication tablet in order for the patient to consume the medication after being discharged from the ED. Findings: Interview with patient #2 on 09/16/11 at 10:50 AM revealed while in the Emergency Department, Registered Nurse (RN) S12 gave her the medication Ultram in a pill form for pain. Patient #2 stated RN S12 gave her water to take the medication; however, she could not take the medication with water and required a Sprite which she had in the car. According to the patient, she gave the medication to her husband who then placed the medication in his pocket for later consumption. Interview with RN S12 on 09/21/11 at 9:30 AM, revealed when asked about the administration of the Ultram, RN S12 responded she did give patient #2 the Ultram to take by mouth; however, the patient stated she could not take the medication with water and required a soda. RN S12 further stated patient #2 then gave the medication to her husband who placed it in his pocket for later consumption. When asked if she would continue to allow patients to take medications ordered by the ED Physician home with them, RN S6 stated yes. Interview with ED Nursing Director S4 and ED Nursing Manager S7 on 09/21/11 at 9:55 AM revealed when asked about ED patient's being allowed to take medications home with them, S4 responded no, this is not a dispensing hospital and that is not allowed.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on closed medical record and Home Medication Reconciliation policy review and interview with staff, the hospital failed to enure nursing staff followed the policy to have home medications reconciled and ordered by the physician for 1 of 1 sampled patients in a total of 5 (patient #1). Findings: Review of the closed medical record for patient #1 revealed an admission date of [DATE] at 3:30 PM. Review of the admitting physician orders by S3 general surgeon revealed patient will give med (ications) list . Review of the Adult Admission assessment dated [DATE] revealed Home Medication Reconciliation Record was entered at 6:24 PM. Further review of the medical record revealed a computer generated Home Medication Reconciliation dated 6/16/11 that had the medications listed but the record was not signed by the admitting physician. Review of a second Home Medication Reconciliation record that was generated on 6/17/11 revealed it was signed by the admitting general surgeon on 6/20/11, after patient #1 was discharged . Interview on 9/8/11 at 10:40 AM with S2 Medical Director revealed if a patient was not admitted by his/her PCP (primary care physician), the admitting MD writes the orders. When a patient has home medications, this information was given to the nurse to make a list for the MD to sign as orders. S2 stated if there were medications for pain on the list, the MD may want to change them. Interview with S14 RN on 9/9/11 at 9:30 AM revealed if a patient was admitted and brought home medications, these would be sent to the pharmacy to be identified and labeled with a bar code. The patient would then be allowed to have their own medications dispensed by the hospital staff or they can elect to send their own medications home, but provide a list to the nurse of what medications they take at home, so the physician can write an order for the medications as he deemed appropriate during the hospital stay. Interview with S16 RN on 9/9/11 at 9:50 AM revealed if the patient brought home medications, they were taken to the pharmacy for coding and scanning with administration documented. S16 stated if a patient 's Home Medication Reconciliation record was not signed the nurse should call the physician for clarification; if the record was checked and signed, then it was an order. S16 confirmed the Home Medication Reconciliation record for patient #1 was not signed. Interview with S9 Registered Pharmacist on 9/8/11 at 2:10 PM revealed if patients bring home medications, a list was obtained (and entered in computer under Home Medication Reconciliation), reviewed and signed by the physician which now becomes a physician order and was sent to the pharmacy. Review of the Home Medication Reconciliation record for patient #1 dated 6/16/11 with the pharmacist, confirmed the record was not signed by the physician; therefore, it was not an order and would not be filled. S9 stated the responsibility falls on the nurse staff to ensure the physician sees that list and signs it if the home medications were to be continued during the hospital stay. Interview with S15 RN on 9/9/11 at 9:55 AM revealed she worked the 7P-7A shift on 6/14/11 and 6/15/11. S15 stated she did not recall seeing the Home Medication Reconciliation record for patient #1 that night so did not know if it was signed or not. S15 confirmed she performed the 24 hour chart check and did not identify the incomplete Home Medication Reconciliation record. Interview with S13 LPN on 9/9/11 at 10:45 AM revealed she did not recall patient #1 except that she had a draining wound, had orders for dressing changes and was in contact isolation after her surgery. Her wound had been covered prior to surgery. S13 was asked how home medications were addressed and she indicated that home medications were entered into the data base and sent to pharmacy for coding. The home med sheet was on the chart for the physician to reconcile on rounds and order. Interview with S12 RN OB/GYN manager on 9/9/11 at 11:15 AM revealed the policy indicated that the home medication list was entered into the system for the physician to reconcile and then order, usually within 24 hours. S12 also stated the incomplete Home Medication Reconciliation record should have been found during the 24 hour chart check. Interview with S3 General Surgeon, the admitting physician, on 9/9/11 at 9:15 AM confirmed the home medications for patient #1 were not ordered. S3 stated he recalled telling patient #1 to bring her list of home medications but did not address the medications that day. S3 confirmed when he visited on 6/15/11, patient #1 was in surgery (along with her chart), so he thought S4 may have addressed the home medications, but that did not happen. S3 indicated he depended on the nursing staff to have that available on the chart for the physician to review and order.
Based on review of Patient Grievance Policy and interview with staff, the hospital failed to provide written response to a grievance filed with the hospital. Findings: Interview on 9/8/11 at 9:15 AM with S12 RN OB/GYN manager revealed she was responsible for investigating complaints that were voiced while a patient was still hospitalized . S12 stated she immediately met with the complainant for more details and discussed the allegations. Afterwards, S12 speaks with the nurse staff or with PCT (patient care technician) responsible for the individual patient 's care for information relevant to the allegation. If at all possible, S12 indicated the allegation was resolved at the time, but if the patient was discharged , the investigation continued and a follow up letter was sent to the complainant. Interview with S5 CNO on 9/9/11 at 9:00 AM revealed she was not made aware of patient #1's verbal complaint upon discharge until well after patient #1's discharge on 6/17/11. Patient #1 submitted a written grievance dated 7/11/2011 and a second investigation was launched. There was also a written grievance submitted to the hospital by patient #1's mother that addressed the same issues. This letter was forwarded to Health Standards, Joint Commission, and the Board of Medical Examiners; receipt of this letter by Health Standards was verified by stamp-7/11/11. S5 revealed the hospital staff met on 7/13/11 to review the letters received 7/11/11 and realized S12 did not thoroughly investigate the allegations and document the findings in real time. S12 was reprimanded for not thoroughly investigating patient #1's complaint. S12 stated she typed her conversations with the staff on her computer with nursing staff on 7/19/11 and printed them for surveyor review. Interview with S12 RN OB/GYN manager on 9/9/11 at 11:15 AM revealed she recalled speaking with patient #1 on 6/17/2011, the day of her discharge. S12 stated patient #1 informed her of her dissatisfaction with her care regarding not receiving her routine home medications, not seeing the surgeon before discharge and not being sure of how to care for her surgical site after discharge. S12 stated hospital staff contacted the surgeon and S4 immediately visited patient #1 and explained how to care for the wound. S12 stated even though she visited with patient #1 every morning, she did not recall patient #1 making any other allegations about her care. S12 also indicated she provided a written follow up letter apologizing to patient #1 that her expectations were not met, that the hospital did strive to provide excellent care, and that she further educated the nursing staff of hospital expectations to provide that care. A copy of the follow up letter dated 6/22/2011 was provided to the survey team for review. The letter failed to address the results of the investigation. Review of the Patient/Family Grievance/ Complaint Management Policy effective 10/94, reviewed 2/2010 and revised 2/2011 revealed When a patient/family complains to a direct caregiver regarding care, the immediate supervisor in charge of the department/patient care unit should be notified without delay and every effort made, at that time, to promptly resolve the issue to the patient ' s satisfaction. When the complaint cannot be immediately resolved to the patient's /family's satisfaction, a grievance should be entered into the Risk Management Module using the Meditech Occurrence Reporting System. A Grievance/complaint form should be used during Meditech downtime. The grievance is then entered into the Risk Management Module by the Unit Manager or Department Director when the downtime is complete . Further review revealed the hospital will contact the patient/family within 72 hours to acknowledge that the grievance/complaint has been received with concern, even if the investigations are not complete,and agrees to send a follow-up letter for all grievances; Most grievances should be resolved and a follow up letter sent within seven working days. Occasionally, a grievance is complicated and may require an extensive investivation. IF the grievan ce will not be resolved, or if the investigation is not or will not be completed within seven days, the complainant should be followed u with a written response within 21 days. On 9/8/11 at 2:30 PM, interview with S17, Risk Manager, revealed when the Joint Commission received the letters from patient #1 and her mother, the Joint Commission notified the hospital and the hospital responded to them about the progress of their investigation. S17 stated information of the investigation was provided to Joint Commission. Review of the Joint Commission letter dated 8/30/11 revealed based on review of your organization's response to incident number ... the Joint Commission will take no further action at this time . S17 was questioned if a written response was sent to patient #1's mother and she said there was no written response to the second written grievance since the hospital considered all of this as one complaint. S17 confirmed the policy was not followed.
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