**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, document review, and staff interview, the facility failed to ensure that notification was made to LRCA (Local [DIAGNOSES REDACTED] Control Authority) following patients presenting with animal bites to the emergency department. This was not in compliance with facility policy. Findings included: Facility policy Management of Patients with Animal Bites Presenting to the Emergency Department stated, in part, For patients presenting to the Emergency Department with animal bite(s): 1. Triage assessment should include 1.1 Circumstances of the incident; 1.2 History and status of the animal regarding identification and immunization status; 1.3 Description of the wound(s); 1.4 History of the patient's tetanus immunization. 2. For animal bites occurring within Austin City Limits, notify the City of Austin-Police Department-411 3. For animal bites occurring outside the city limits notify the Sheriff's Department for the county in which it occurred. A review of medical records for patient #18 and #20 during the investigation was missing documentation in the emergency medical record that notification was made to the proper authorities as per facility policy regarding animal bites. The quality control manager verified that there was no existing paper log or other documentation stating notification had been made in 2 of 2 emergency room records reviewed for animal bites.
Based on a review of documents and interviews, the facility failed to ensure that the hospital ' s discharge planning process must require regular re-evaluation of the patient ' s condition to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes. Findings included: Facility policy entitled, Discharge Planning stated in part, 1. PURPOSE: To identify process .for initiating Discharge Planning that meets each patient's needs and to assure all patients are discharged to the appropriate level of care at the appropriate time. The Discharge Planning assessment done on admission includes the physical, emotional, medical, social, spiritual and financial needs of the patient and family as well as any identified equipment needs and post discharge needs.. 7. Ongoing Case Management Responsibilities are: + Ongoing communication with the Interdisciplinary Team Coordinating the discharge plan with other team members + Communicating the discharge plan and progress toward completion of plan + Acting as a resource to other team members, patient/family members and physicians + Obtaining necessary authorization from third party payors for any ongoing patient care needs 8. The Case Management Team promotes awareness of available resources through education and dissemination of information to patients and families. In addition the Case Management/Social Services has on a file names and numbers of agencies, resources, and advocacy groups. Any referrals made will be documented in the Case Management/Social Services documentation system. Review of the medical record for Patient #1 revealed the following: * Physician note on 08/14/20 stated in part, ...b/c of multiple fxs, will get APS involved ... * Case management note on 08/18/20 at 1147 stated in part, SW discussed pt's case with attending physician. concern regarding pt's rib fractures as well as L3 fracture. SW called APS and filed report with [name]#5424 (Report ID#: 161). SW will continue to follow. * Case management note on 08/18/20 at 0322 stated in part, SW received call from pts APS caseworker [name and phone number]. [Name] stated pt is familiar to him and stated he would like to come by the hospital to lay eyes on the pt tomorrow morning. sw will continue to follow. * Case management note on 08/19/20 at 0129 stated in part. ...MD did not want to send patient back to group home until APS did safety eval. APS is involved. * Case management note on 08/19/20 at 0234 stated, sw called and left voicemail with APS caseworker [name] requesting call back. SW will continue to follow. * Case management note on 08/21/20 at 1053 stated, sw notified HH liaison of pt' s discharge order. sw provided charge RN with RN's phone number for report and group home manager's number for transport. SW to remain available as needed. * Physician note on 08/20/20 stated in part, ...b/c of multiple fxs, pending APS/SW/CM to do safety check ... * The Discharge Summary on 08/21/20 stated in part, - b/c of multiple fxs, pending APS/SW/CM to do safety check at the time of dc. facility aware. Based on documentation in the medical record, the patient's physician wanted Adult Protective Services (APS) to follow up regarding the patient's fractures in order to ensure discharge was to a safe environment. Based on documentation in the medical record, the social worker contacted APS, however there is no documentation that the safety check was completed prior to discharge per physician direction. The safety check and follow up regarding the fractures before discharging the patient to another facility represents a change in condition that created changes to the patient discharge plan, however APS findings or whether the safety check was completed prior to discharge was not documented. It cannot be established the safety check was completed prior to discharge to ensure patient was discharged to a safe environment. In interview on 04/20/21 staff members #1 and 2 verified the above findings.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on a review of facility documentation and staff interviews, the facility failed to ensure nursing staff provided services to each patient as needed, as prescribed or according to hospital policy as physician orders were not carried out, nursing assessments were incomplete and services provided were not accurately documented or performed for 10 of 10 patients. Findings were: Facility policy entitled Safe Patient Management Program, last reviewed 12/18/20, included the following: PURPOSE: This policy is to provide guidelines for the safe lifting, transferring, repositioning and moving of patients. DEFINITIONS: ... Patient handling activities include: - Repositioning in bed ... Facility policy entitled Guidelines for Skin and Wound Care, effective date 4/13/2012, included the following: 1. All patients are assessed for potential or actual skin breakdown upon admission and every shift as appropriate. Information from assessment will be entered into Meditech wound screen ... 2. All patients will receive therapeutic interventions aimed at maintaining or restoring the integrity of their skin according to the Nursing assessment. These interventions will be documented in Meditech. GUIDELINES 1. The Braden Scale is one assessment tool used to help provide information for the caregiver, and to identify the risk of skin integrity alteration ... 5. Patients at intermediate or high risk (below 18) will have interventions instituted based on the nursing assessment. All patients scoring 12 or less on the Braden scale should be placed on a low air-flow bed or surface ... Review of Reference #: PC-262 attached to the above policy revealed the following: All patients: All patients have a complete skin assessment on admit, a Braden scale is assigned, and skin condition is documented in Meditech, with photos of any alteration as per policy. A complete skin reassessment is completed at least q shift, and documented in Meditech ... [If Braden score < 18, intact skin, add ...Interventions for at risk patients as listed in policy, including: Monitor mobility, turning, ROM (range of motion) schedule as appropriate...Monitor bony prominences for evidence of skin breakdown, float heels while in bed or chair ... A review of the medical record of Patient #1 revealed she was admitted on [DATE] at 7:05 a.m. via the hospital emergency department. The emergency provider report read as follows: ... Patient is a [AGE]-year-old female with history of mental retardation, gastroparesis (a disease in which the stomach cannot empty itself in the normal manner), dysphagia (swallowing difficulties), seizure disorder, and anxiety who presents with a G-tube (a tube placed into the stomach through the abdominal wall) that was pulled out today ... A history and physical examination performed on 11/14/19 at 9:42 a.m. included the physician note: ...Turn frequently ... In addition, a physician's order on 11/14/19 at 9:42 a.m. read as follows: ...Weigh patient daily ... Patient #1 was eventually discharged from South Austin Medical Center on 11/20/20. She was repeatedly documented by nursing staff to have been a bedbound patient requiring a 2-person assist for activities of daily living. Nursing progress notes and/or assessments which addressed the repositioning/turning of Patient #1 were as follows: 11/14/19 9:18 p.m. - ...Activity: Turn, bedrest... 11/15/19 7:49 p.m. - ...Activity: Turn, bedrest ... 11/15/19 10:55 p.m. - ...Activity: Turn, bedrest ... 11/19/19 9:28 a.m. - Nursing - Turned patient per Q2 turns. The entries above were the only nursing notes which addressed whether or not the patient was turned during her inpatient stay from 11/14/20 through 11/20/20. The note on 11/19/19 identified the patient was turned every 2 hours. The frequency or time of repositioning was not noted at all in the three assessments made on 11/14/19 and 11/15/19. Thus, it is unclear how often the patient was turned, if at all. In an interview with Staff #1 & 2, Director of Quality and Quality Manager, respectively, during review of the patient record, they stated that checking turn on the patient assessment indicated the patient had been repositioned during the shift. When asked how often and when, they stated they did not know. In addition, despite the physician's order on 11/14/19 for daily weights, there were only two documented patient weights in the record of Patient #1: one on 11/15/19 and one on 11/19/19. The order was in effect for the entire patient stay. Review of additional patient medical records (Patients #2-10) revealed each of these patients had a deep tissue injury. The skin alteration assessment for each of these patients was inconsistently performed and/or documented throughout their inpatient stays. For example, Patient #2 had an abrasion on his anterior upper back, a bruise on his right lower arm, a stage 2 pressure injury on his coccyx area, excoriation bilaterally on his groin, and pressure injuries bilaterally on his buttocks. For Patient #1, there was no documentation of nursing assessment of his wounds on the 11/1/19 day or night shift despite the nurses having documented that a skin alteration existed and assessment was required. There were multiple other shifts with similar issues. As another example, Patient #3 was documented as requiring extensive 2-person assist for activities. She was inpatient at the hospital from 8/31/19 through 9/16/19. Her skin assessments were performed only on the night shifts of 9/3/19 and 9/12/19, and on the day shifts of 9/6/19 and 9/16/19, despite evidence that skin assessments were required throughout her stay. As far as repositioning patient #3, on the 9/10/19 night shift, there was no documented evidence the patient was repositioned. There was also no documented evidence on the night shifts of 9/11/19, 9/12/19 and on both the day and night shifts on 9/14/19. On both shifts of 9/9/19, 9/13/19, 9/15/-9/16/19, as well as the day shifts of 9/10/19, 9/11/19, 9/12/19, the patient record included only turn as evidence the patient had been repositioned. It was unclear whether the patient had been repositioned every two hours, or on another schedule, or only once during the shift. There was no notation of the time of repositioning. Thus, it was unclear Patient #3 was actually repositioned on those shifts. In an interview with Staff #1 & 2, Director of Quality and Quality Manager, respectively, during review of the patient records in the offices housing the two individuals, they stated that checking turn on the patient assessment indicated the patient had been repositioned during the shift. When asked how often and when, they stated they did not know. A tour of the nursing unit called Third Floor Central with the Director of Quality and the Quality Manager, as well as the third floor nursing manager on the afternoon of 3/3/20 revealed no findings of note. The unit charge nurse stated Patient #12 was a total care patient, meaning he needed assistance for activities of daily living. In an interview with Patient #12 stated he was only repositioned when he asked the staff to do it.
Based on review of facility documents, review of medical records and staff interview, the facility failed to ensure the patient or his or her representative had the right to make informed decisions regarding his or her care. Findings included: Facility policy titled Informed Consent and Informed Decision-Making stated in part, Purpose: To clarify the procedure for obtaining and documenting the informed consent to be obtained prior to medical treatment and procedures ... Guidelines Informed Decision-Making: ...In order to give informed consent, the patient or his/her surrogate decision-maker must have a basis upon which to exercise judgment concerning the recommended treatment or procedure ... before consent can be obtained, a patient or his/her surrogate decision-maker must be given enough information to understand the nature of the treatment to be performed, the risks and benefits of the recommended treatment, and alternatives to the recommended ... The information need not be exhaustive, but must be correct and disclose those factors that could influence a reasonable person in making a decision to give or withhold consent ... The physician performing the procedure or administering the medical treatment at issue is responsible for advising the patient or the patient's surrogate decision-maker about the recommended treatment or procedure, and answering any questions, so that an informed decision can be made ... The physician should document in the patient's medical record that the informed consent was obtained including the recommended treatment or procedure, its risks, benefits, and alternative treatments. ...It must be obtained before the procedure is performed, and before any preoperative medications, sedatives, tranquilizers, or narcotics have been administered. Review of the medical record for patient #1 revealed a consent for computed tomography guided celiac block dated 5/15/18 at 7:00 am signed by a designee for patient #1. This consent stated in part, I (we) realize that common to surgical, medical, and/or diagnostic procedures is the potential for infection, blood clots in veins and lungs, hemorrhage, allergic reactions and even death ... SEE ADDITIONAL RISKS (as noted by physician order): [this was left blank] The procedure began on 5/15/18 at 1:13 pm and ended on 2:19 pm with an anesthesia end time of 2:40 pm. Physician orders dated 5/15/18 at 2:18 pm stated in part, 1. Consent ... 2. Risks. Temporary pain or soreness at injection sites, infections, bleeding, spinal block, epidural block, pneumothorax, damage to adjacent organs, injection into adjacent blood vessels or organs resulting in organ damage or death The procedure note dictated on 5/15/18 at 3:26 pm stated in part, After the procedure, risks, [sic] and benefits were discussed with the patient and the patient's family and all questions answered, informed consent was obtained. With the documentation provided, it is unknown if the patient and/or the patient's family were informed of all the risks and benefits prior to the procedure. The above was confirmed in an interview with staff #1 on the afternoon of 9/11/18.
Based on review of facility documents, review of medical records and staff interview, the facility failed to ensure a post-anesthesia evaluation for proper anesthesia recovery was completed in accordance with State law and with hospital policies and procedures in two of four patients reviewed for anesthesia administration. Findings included: Medical Staff Rules and Regulations stated in part, 2.3.4.3.3. Moderate, Deep, and Anesthesia Levels of Care: ...Each inpatient given an anesthetic by an anesthesiologist or Certified Registered Nurse Anesthetist (CRNA) shall have a post-anesthesia recovery care note written by an anesthesiologist or CRNA within 48 hours after surgery ... This note should include cardiopulmonary status, level of consciousness, complications, and need for follow-up care. Post-anesthesia notes shall be dated and timed. Review of the medical record for patient #1 revealed a procedure dated 5/15/18 with an anesthesia end time of 2:40 pm. The post-anesthesia follow-up report was dated 5/27/18 at 9:12 am; it was not signed within 48 hours after surgery. There was no evidence a post-anesthesia recovery care note was completed by an anesthesiologist. Review of the medical record for patient #2 revealed a procedure dated 9/5/18 with an anesthesia end time of 3:12 pm. The post-anesthesia follow-up report was dated 9/5/18 but was not timed. The above was confirmed in an interview with staff #1 on the afternoon of 9/11/18.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on review of clinical records and staff interview, the facility failed to ensure information relating to drug information were available to the professional staff. Findings included: Review of the Texas Administrative Code (TAC), Title 22, Part 15, Chapter 291, Subchapter D, Rule º291.74(g)(B) stated in part, (i) For the purpose of promoting therapeutic appropriateness, a pharmacist shall evaluate medication orders and patient medication records for: ...(II) rational therapy-contraindications; ...(VIII) Drug-disease interactions. The package insert for haloperidol [the generic name for Haldol] stated in part, Haloperidol is contraindicated in severe toxic central nervous system depression or comatose states from any cause and in individuals who are hypersensitive to this drug or have Parkinson's disease. Review of patient #1's medical record revealed a neurology consult dated 6/4/17 at 11:37 pm that stated in part, ...is consulted to neurology for suspected Parkinson's disease. Patient on exam does have findings consistent with Parkinson's ... Patient #1 was started on medications for Parkinson's and Parkinson's was added as a diagnosis. An order dated 6/6/17 at 2:15 am for haloperidol lactate 5 mg [milligrams]/ml [milliliter] vial stated in part, Instructions and comments ... [DATE] A recent FDA [Food and Drug Administration] alert, along with new labeling, warns health professionals about the possibility of QT prolongation and Torsades de Pointes in patients treated with the antipsychotic drug Haldol ... This comment was about [AGE] years old and had no warning about the contraindication of Parkinson's disease. In an interview with staff #8 on the afternoon of 6/21/17, staff #8 stated, The alert that fired [in the computer system] for this medication talked about QT prolongation, it did not discuss Parkinson's at all ... The diagnosis [for this patient] is still 'acute respiratory distress ...' It's not populating the Parkinson's on the banner that pharmacy sees ... Parkinson's is an absolute contraindication for Haldol. So is IV [intravenous] use, but we still give it. The nursing and pharmacy staff were unaware of the absolute contraindication of Parkinson's with Haldol at the time of administration to patient #1. The above was verified in an interview with the CNO and other administrative staff on the afternoon of 6/21/17.
Based on a review of documentation and an interview with staff, the facility failed to appoint a chief executive officer to be responsible for managing the hospital. Findings were: Patient #1's vital signs were assessed at the following times: - 8:12 pm on 1-22-17 - 10:46 pm on 1-22-17 - 1:00 am on 1-23-17 - 8:04 am on 1-23-17 - 1:40 pm on 1-23-17 Facility policy ED-VS titled Emergency Department Vital Sign Reassessment Guidelines states, in part: Guideline ... 2. Vital sign reassessment will be based on patient acuity level and will be updated with any change in patient acuity status during ED[emergency department] stay: ... b. Level 2: at least every 30 minutes until stable then hourly. Observation sheets were completed during patient #1's stay in the emergency room . Review of the observation sheets reveal a gap in regular observations (to be performed every 15 minutes), as the patient's behavior was documented at 10:45 pm on 1-22-17 and not again until 12:45 pm on 1-23-17. Facility policy PC-245 titled Guidelines for Management of the Patient Under Suicide Precautions states, in part: Procedure ... Suicide Risk Screening and Assessment: ... 2. The Emergency Department (ED) Registered Nurses will only screen patients admitted to the ED with a primary focus/complaint of a behavioral issue(s) and/or, if the RN has any clinical concerns for any patients presenting with risk for self-harm: 3. Any patient that has a 'YES' answer to any of the suicide risk screening questions will be placed on suicide precautions and the RN will assign patient observation monitoring immediately. An LIP (Licensed Independent Practitioner) order will be generated in order to gain further suicide risk assessment by the assigned LIP and determine an ongoing safety observation and monitoring level. Safe environment and patient safety guidelines will be documented and implemented. ... Heightened Observations: Level 1 = Standard Observation - Monitor and observe minimally every 15 minutes. Staff visually observes the patient at least every 15 minutes and monitors their well-being and physical and mental safety. The above was confirmed in an interview with the Quality Director on the afternoon of 4-24-17.
Based on record review and interview the facility failed to follow the facility's Grievance Process when it could not provide evidence of sending written responses to complainant's/patient's grievances. Findings Include: Review of the facility facility's Policy: Patient/Family Complaint and Grievance Process (dated 3/2014) reflected: ...To establish procedures in which conflict/complaint/ grievances are handled in an appropriate and timely manner ... ...definitions Grievance - A patient care complaint not resolved promptly by staff available ... Policy ...To establish a process for prompt resolution of patient complaints/grievances ... ...The Patient Liaison or other designee from the Resolution Committee will provide to the patient/complainant written notice of its decision regarding the substance of each grievance that contains the name of a hospital contact, steps taken to investigate, and the date of completions. This notice will be sent to the complainant/patient as soon as possible after a determination has been made .... Review of the Patient Grievance Reports from 4/2015 to 3/2016 (rolling 12 months) reflected in part ... (2) Patient Care, (2) staff communication, (6) Staff treatment, (3) staff attitude, (2) staff communication and (1) hygiene Grievances.... The facility could not provide evidence of a written resolution communication to the complainants. On 5/2/16 at 4:00 p.m. in the facility conference room, Staff #15, Quality Manager confirmed the finding.
Based on a review of facility documentation and staff interviews, the facility failed to follow regulatory requirements and its own grievance policy by failing to provide the patient or patient representative with written notice of its decision with all required components for 1 of 4 patient grievances reviewed [Patient #1]. Findings were: Despite several verbal and written complaints made on behalf of Patient #1, the facility provided no information to the patient or complainant regarding steps taken on behalf of the patient to investigate these complaints or any results of the investigations. Facility policy #PR-005 entitled Patient/Family Complaint and Grievance Process, effective 3/2014, included the following: Purpose: ... To establish procedures in which conflicts/complaints/grievances are handled in an appropriate and timely manner ... Definitions: Grievance - A patient care complaint not resolved promptly by staff available, or a patient care complaint presented to the hospital post discharge ... 2. Urgent concerns regarding quality of care or premature discharge will be referred to the Director of Quality Management as received ... 5. The Quality Council, as delegated by the Board of Trustees, will be responsible for the effective operation of the complaint/grievance process ... 2. Efforts will be made to complete an investigation and resolve the grievance within ten (10) working days of receipt of the grievance. The Patient Liaison to log, track and route to the appropriate Departments for review ... 4. Department Director(s)/Unit Manager(s)/Supervisor(s) will attempt to take appropriate action to resolve the grievance ... Resolution Committee 1. The Resolution Committee is responsible for the oversight of the complaint/grievance process. Complaints/grievances will be reviewed at the Resolution Committee meeting twice a month ... 2. The Patient Liaison or other designee from the Resolution Committee will provide to the patient/complainant written notice of its decision regarding the substance of each grievance that contains the name of a hospital contact, steps taken to investigate, and the date of completion. This notice will be sent to the complainant/patient as soon as possible after a determination has been made ... A review of email communication to Staff #4, Med-Surg Nursing Director of the 3rd and 4th floors, from Staff #10, Patient Liaison, revealed the following: Sent on 9/4/15 at 4:02 p.m.: [Wife of Patient #1] was very upset about a nurse on the fourth floor whom was in room 462. She was in tears and could hardly talk about it without crying and getting very upset she stated that the nurse was rough and rude with her husband. I provided her with a formal complaint form and assured her that a manager would be getting in touch with her about her concerns. I told her she could turn the form over to the charge nurse in ICU and we would be forwarding it to the appropriate manager. Sent on 9/7/15 at 10:52 a.m.: [Patient #1] is now in room 384 I don't know if they turned in the formal complaint on Friday I asked [RN] if she had one and did not at this point but they may have turned it in to [another individual]. However, [wife of Patient #1] did want to speak to a manager if possible when I last spoke to her on Friday. An email to Staff #10 from Staff #4 on 9/4/15 at 4:06 p.m., included the following: Is she ok with a Tuesday response or should the charge go up there? No further email communication regarding this matter was made available for surveyor review. Staff #4 stated this was all the email communication she had regarding the matter. Patient Complaint Documentation Form A review of a Patient Complaint Documentation Form, ID# , on 10/14/15 included the following: [Wife of Patient #1] - dischg 9/7 - called me and stated: He was in ICU and that was great. 4th floor terrible - nurse told everyone he pulled out IV and just left it there. I told them to never give him more than 1 Tylenol because his heart is too weak and [RN, Staff #5] gave him 2 and he almost didn't wake up. Next night nurse gave him sleeping pill and shot - he was ice cold - nearly died . On the third floor (384) the nurse didn't put up the rail - they didn't give him any help with his food. I took him to the BR (bathroom) and he accidentally pulled the cord but no one came. I put depends on him that I brought from home. The next day he was still in the same ones ...The nurses on 3 just played with their hair and texted and acted bored - didn't look up when I walked up - didn't wait on the pts. Did nothing for him so I took him out AMA. (I asked how he is now) He's doing good - was home 2 days then I took him to HH (he was there 9/9-9/17). That's what you get when you overdose - won't ever come to SAMC again ...Just walk on the 3rd floor some evening and see - no one is doing anything ... If he had died you'd hear a lot more from me. Check on this cause it's bad. She said there was nothing else - just wanted us to know this ... In an interview with Staff #4, Nursing Director, Medical-Surgical 3rd and 4th floors, on the morning of 1/26/16 in a facility office, when asked about whether there had been a complaint that she knew of regarding this patient, she stated, We heard that [the wife of Patient #1] was upset, but by the time we came to address it, they'd left AMA. Another manager did a brief chart review, but then she reported to me that there were no issues. In an interview with Staff #9, Special Projects Director/Patient Liaison, on the morning of 1/26/16 in a facility office, she stated, [The wife of Patient #1] called me directly in October. She was obviously upset about the care and we had a fairly long conversation. I tried to transcribe exactly what she was telling me ...When we got to the end of the conversation, I asked her if there was anything else and she said no, she just wanted us to know about this. She didn't ask for any kind of response or result. And quite frankly, we wouldn't supply the results of any kind of investigation we ever did here to a patient. That's our own internal process. If we send a letter, it's just that we received they're complaint and have followed up with it appropriately. Sometimes I'll send a letter if they've indicated they want one. In an interview with Staff #1, Quality Management, on the morning of 1/26/16, in a facility office, she stated, We don't automatically supply a written response to patient complaints. From what I understood, [the wife of Patient #1] said she just wanted us to know about the issues. Upon review of the documentation of interactions of staff with [the wife of Patient #1] and her complaints, she stated, Yes, this sounds like a grievance and should have had more thorough follow-up. The above findings were again confirmed in an interview with the Quality Manager and other administrative staff on the morning of 1/27/16 in a facility office during the exit conference.
Based on a review of facility documentation and staff interviews, nursing services failed to document on an ongoing basis the hygiene and linen care provided in 2 of 4 patient records reviewed [Patients #1 and #4] per hospital policy and accepted standards of nursing practice. Findings were: Facility policy #PA-002 entitled Patient Assessment and Reassessment, effective 3/2014, included the following: B. For in-patient units, a system assessment is completed by the RN every shift ... PCTs, LVNs may assist in collection of vital signs, height, weight, intake and output, including characteristics ... Medical Surgical Nursing Units: Reassessment - Every shift ... - Patient care needs ... In an interview with Staff #4, Nursing Director, Medical-Surgical 3rd and 4th floors, on the morning of 1/26/16 in a facility office, she stated, I can't find where there's much documentation of patient care [for Patient #1]. There's a stand-alone screen where nurses are supposed to document, where they should document, bath, linen care, and special baths - personal care stuff. I don't really see any of that in this chart. Only one nurse on one shift completed it ... Additional patient records were reviewed on the morning of 1/27/16. Upon review of the medical record of Patient #4, she agreed only one RN consistently documented these items. These findings were again confirmed in an exit interview with the Quality Manager and other administrative staff on the morning of 1/27/16 in a facility office.
Based on a review of documentation and interview, it was determined that the facility failed to ensure the right of patients to the confidentiality of his or her clinical record. Findings were: ? Patient Kardex forms were received at Department of State Health Services (DSHS)via fax for 5 out of 7 patient medical records reviewed (Patients #1, 2, 3, 5, and 6). The Kardex form included the following personal health information: the patient medical record number, birth date, admitted , primary diagnosis, medical history, hospitals/surgery history, allergies, and diet order. ? SBAR (Situation, Behavior, Assessment, and Re-Assessment)Fax Reports were received at DSHS via fax for 2 out of 7 patient medical records reviewed (Patients # 4 and 7. The SBAR Fax Report included the following personal health information: patient name, age, sex, weight, height, chief complaint, admitting doctor, admission diagnosis, vital signs, allergies, medical history, medications administered in the emergency room , physical assessment information and other information. ? Several pages of handwritten SBAR (Situation, Behavior, Assessment, and Re-Assessment) notes were received at DSHS on 6 out of 7 patient medical records reviewed (patients # 1, 2, 3, 4, 5, and 6). The handwritten SBAR notes contained personal health information including input and output measurements, labs, and orders. Facility policy & procedure titled Health Information Management stated in part Paper Documents Containing PHI A. Facilities must ensure that reasonable safeguards are in place to protect paper documents containing PHI: 1. to the extent feasible: i. PHI should be removed from high visibility areas, even if those areas are not open to the public, and ii. PHI should be maintained in a confidential manner in order to prevent workforce members and others that do not have a need to know from accessing such PHI. iii. Documents must not be left unattended in areas accessible to the public (e.g. , charts may not be left unattended on a counter that is open to the public). iv. Access to areas containing PHI must be limited to authorized personnel. 2. Documents containing PHI must be disposed of securely (e.g., place PHI in shred bins not regular trash cans or recycle bins that will not be shredded). The facility must eliminate unnecessary regular trash cans. Facility Document titled Patient Rights stated in part, Confidentiality of your health care information/medical records and communication, written or oral, between you and your healthcare providers except as otherwise provided for by law or contracts with your third party payer. The issues regarding the right to confidentiality of clinical records was confirmed in an interview with the Director of Quality Management on the afternoon of 7/16/12.
Based on observation and a review of documentation, the governing body failed to be responsible for all services furnished in the hospital. Findings were: Review of facility policy CC-015 titled, Discharge of the Patient from the Hospital states, in part, Once the physician ' s order for discharge is received, the patient ' s nurse or his/her designee will: ...13. Accompany or call for a volunteer to accompany the patient to the vehicle of transportation. 14. Assist the patient to transfer to the vehicle as needed. During the review of the clinical record for patient #1, documentation reveals that the discharge instructions, as well as warnings and medication instructions were provided and reviewed with the patient. Documentation states, The patient was discharged home and unaccompanied at time of discharge. The patient left the Emergency Department ambulatory. The above was confirmed in an interview with the Director of Quality Outcomes Management on the afternoon of 4-2-12 in the facility conference room.
Based on review of the clinical record and interview with staff, it was determined that the nursing care and nursing staff assignments were not appropriate to meet the patients needs: Findings were: On admission on 1-14-2010, patient's skin was documented as having no breakdown. On 1-26-2010, nursing progress notes documented there was a potential for Stage 2 pressure ulcer. On 1-27-2010, the wound care nurse was asked to see the patient regarding a sacral ulcer, which measures 3 cm x 1.5 cm, covered with yellow slough. Nursing provided care for the pressure ulcer until the patient was discharged to the nursing home. Interview with the Chief Nursing Officer and Quality Manager confirmed the above findings on 5-23-2011 in the conference room.
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