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Based on interview, and record review, the hospital failed to protect patients ' rights by not ensuring the Registered Nurse (RN) properly assigned the care of one of one (#1) critically ill patient. The RN assigned the care of a critically ill patient to the care of a Licensed Vocational Nurse (LVN) and as a result, patient #1 was abused, harassed and neglected by the LVN.

It was determined this deficient practice created an Immediate Jeopardy situation and placed the patients at risk for injury and death.

During the visit on 06/11/12 through 06/12/12 it was determined the facility had started an in house investigation and had implemented action that alleviated the immediate jeopardy by terminating the LVN. A plan was submitted and accepted with further corrective actions the facility would implement to ensure Patient Rights were honored. Patient Rights remains at the condition level as there was not enough time for the hospital to fully implement the corrective actions and evaluate the effectiveness of those actions to ensure continued compliance.

Findings Included:

Based on interview, and record review, the hospital failed to provide a safe setting for the care of 1 of 1 patients (# 1). Patient #1 who was critically ill presented to the facility ' s emergency room and care was assigned to an LVN by the RN.

Refer to tag A0144

Based on record review and interview the facility failed to protect and prevent the abuse, neglect and harassment of patient #1 by the facility ' s staff (#2). Patient #1, who was critically ill, was repeatedly told by staff #2 to quit faking.

Refer to tag A0145

Based on interview, and record review, the hospital failed to provide a safe setting for the care of 1 of 1 patients ( # 1). Patient #1, who was critically ill presented to the facility ' s emergency room and care was assigned to an LVN(licensed vocational nurse) (#2) by the RN (Registered Nurse) (#1) without full nursing assessment.

A review of the document titled, " ETMC Jacksonville/Rusk ED Triage Sheet, " for patient #1 and completed by RN #1 revealed, the patient presented to the Emergency Room on 05/30/12 at 07:05 with Chief Complaint: " C/O (complained of) syncope (fainting episode) at Rusk today " . BP (blood pressure) 59/30, HR (heart rate) 133. Area for recording weight was left blank. The area for assessing nutrition required checking one of the following: Unintentional wt loss/gain greater 10lbs in past 6 months, Special diet restrictions, N/V/D greater 3 days, Newly diagnosed diabetic or None. The RN checked, None. The Fall assessment required checking one of the following: Unsteady gait, Use of assisted device, Hx (history) of falls in past 12 months or None. The RN checked, None. The primary care of the patient was then assigned to the LVN by the RN. There was no documentation for review in patient #1 ' s chart of the RN re-assessed the patient prior to or after the patient collapsing in the bathroom at 0845.

A review of the document titled, " ED Physician Notes, " for patient #1 revealed, the area for recording the time of arrival had no time recorded but a hand written statement, " on arrival " . The recorded was BP 59/30 and Pulse 133. History of Present Illness: Hand written entry word for word with the exception of the content within the parenthesis ' s, " Pt has been very weak, fatigue, has not been drinking enough fluids or eating regularly for last 2 weeks, non-compliance with meds. Presented with syncope after syncope episode this AM. Woke up very weak, hypotension. P Ox (Oxygen Saturation) none detectable, Prob 2nd to Hypotension. Pt Hx Bipolar. BP at RSH (Rusk State Hospital) 58/38. " Fluid intake: Decreased, Solid intake: Decreased, Weight loss:
9lbs in 9 days. Assoc Signs and Symps: Malaise/ Gen weakness, Orthostatic: Lightheadedness, Urine Output: Decreased. Examination, Skin: Pale, ENT: Dry mucous membranes, Heart: Tachycardia, Lungs: Clear/Diminished.

A review of the document titled " Rusk Emergency Department Nursing Assessment " completed by the LVN, revealed, Arrival to Room Time: 0705, Skin Color: Normal, Breath Sounds: Clear (LVN checked yes), Diminished (LVN checked no), Grips: equal (LVN checked yes), Strong (LVN checked yes), weak (LVN checked no), Musculo/Skeletal: Unsteady Gait (LVN checked no), Steady Gait (LVN checked yes).

A review of an untitled document containing a chronological listing of blood pressures and heart rates revealed, at 0845 AM patient #1 " s BP 75/55, HR 126.

A review of the document titled " Emergency Department Nursing Assessment (continued) " revealed, " @ 0845, To bathroom via W/C (wheelchair) per request, got to bathroom. While transferring from W/C to toilet pt urinated on herself and became unresponsive. Called for help transported to Trauma room @ 0855. CPR started @0905.

An interview with staff #3 at 0945 on 06/11/12 in the Rusk ER ' s break room confirmed the RN, staff #1, that triaged Patient #1 on 05/30/12 at 0705 AM should not have assigned this critical patient to the LVN on duty, staff #2.

An interview with staff #4 at 0945 on 06/11/12 in the Rusk ER ' s break room confirmed the RN, staff #1, that triaged Patient #1 on 05/30/12 at 0705 AM should not have assigned this critical patient to the LVN on duty, staff #2.


An interview with staff #5 at 0945 on 06/11/12 in the Rusk ER ' s break room confirmed the RN, staff #1, that triaged Patient #1 on 05/30/12 at 0705 AM should not have assigned this critical patient to the LVN on duty, staff #2.

Based on record review, the facility failed to protect and prevent the abuse, neglect and harassment of 1 of 1 patients ( #1) by the facility ' s staff (#2). Patient #1, who was critically ill was repeatedly told by staff to quit faking.

Record review of the document titled " PATIENT RIGHTS " revealed, " 2. Have the right to considerate, respectful care at all times and under all circumstances, with the recognition of your personal dignity, which includes consideration of the psychosocial, spiritual and cultural variables that influence the perceptions of illness. "

Review of the document titled " ABUSE, NEGLECT AND/OR HARASSMENT OF PATIENTS " , revealedthe following:

DEFINITIONS:

Abuse: The willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm. pain or mental anguish.

Neglect: Is considered a form of abuse. It is the failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness.

Harassment: Is the willful act of provocation, aggravation, exasperation, irritation, torment, etc. from staff, other patients or visitors.

A review of a written statement by staff #5 revealed the following as written: " On Wednesday May 30th around 0850 Staff #1 and I was sitting at the nurses ' station desk when Staff #8 that was with Patient #1, came around the corner from the patient restroom and asked Staff #1 for a clean gown. When Staff #1 came back to sit at nurses ' station to work on paperwork Staff #2 yelled out, " Staff #1, I am in the restroom and I need some help. " Staff #1 was headed to restroom when Staff #2 yelled out, " Staff #5, Staff #1, anyone I need some help! " I ran to the restroom and saw Staff #2, Staff #8 and Staff #7 in bathroom, patient was lying on the floor and Staff #2 and Staff #8 had one arm under each arm of the patient and the Staff #7 had a hold of both feet. The patient was then lifted into the wheelchair in the bathroom. Staff #2 says she is faking. Staff #8 nods head yes in agreement. I asked if patient does this. Staff #8 nods yes. Patient was limp in wheelchair and hair was covering face. Staff #2 asked me to put her clothes into a bag. I placed urine soiled clothes in a patient belonging bag. Upon returning to the hallway in front of the nurses ' station patient was in wheelchair and was being wheeled to the trauma room. The Dr #9. stated she is in cardiac arrest. "

A review of a written statement by staff #1 revealed the following as written, " at approximately 9 am, there was a shout from the bathroom from Staff #2, that she needed help, that the patient had fallen. At that point, Staff #5, RN, and I went to the bathroom to help. When we got there, there were 3 healthcare workers, the patient,
and a wheelchair in the bathroom. Staff #2 told us that the patient was there to give a
urine sample and had fallen. She also said that " she does this all the time " and I saw the
Staff #8 nod in agreement. They got the patient into the wheelchair while I went to pull an ammonia cap from the med cart. When they got to the doorway of patient ' s room I snapped the cap under pts nose and there was no response. At the same time, the MD was at chair side with stethoscope and called an arrest code. "

The review of a written statement by staff #7 revealed the following as written, " On Wed. morning, May 30,2012, I was in my xray office and heard Staff #2, hollering for help in the bathroom. I ran to the bathroom where she was. She said the patient was having a seizure and she needed help. when I got to the bathroom, I saw Staff #2 at the door, the patient in the floor in front of the wheelchair and a Staff #8 in the corner. Staff #2 said help me pick her up and put her in the wheelchair. I got her legs and Staff #2 got the top and we put her back in the wheelchair. At that time, Staff #1 and Staff #5 came to assist. I went to wash my hands, and went and got housekeeping to come clean up the bathroom. Next thing I heard was lab and xray needed to come to assist the code in the trauma room. It was the patient I saw in the bathroom.
In response to your question was there any comments in the bathroom. Yes, there were. I heard Staff #2 say that the patient was faking a seizure because she didn ' t want to give a urine sample. I believe Staff #1 asked if it was a seizure and I looked up and the aid from the state hospital shook her head yes as if it was normal for that patient to do something like this. "

A review of a written statement by staff #8(Psychiatric Nursing Assistant from the state hospital) revealed the following, " On 05/30/12 I was at the ER with patient #1. We arrived at approx, 7AM or earlier. The patient had been sent out because of dehydration and she had not eaten in days. While we were there the patient was talking. The patient ' s blood pressure was not stable and kind of low. Patient #1 asked for a glass of water. The patient consumed a large Styrofoam cup of water. The patient then began to belch, I asked her if she was ok. The patient stated no, I think I need to throw up. At that time I went and contacted the nurse " staff #2 " LVN. The nurse (#2) came in and asked patient #1 if she drank the water too fast. Patient #1 stated she guessed that she did. The nurse(#2) then told her to get up and pee in a cup because they needed a urine sample. Patient #1 advised that she could do it. She got up and fell back onto the bed and stated she was too weak. The nurse(#2) then advised that she would get her a wheelchair. The nurse (#2 )returned with the wheelchair and the patient was lying in the bed and stated that she was too weak to get in the wheelchair and the nurse (#2) said, come on and get in the wheelchair. Patient #1 got to the side of the bed and the nurse (#2) assisted her in getting into the wheelchair. The nurse(#2) then asked me to get the urine cup and to follow them. So we get to the restroom and nurse (#2) told patient #1 to get on the toilet. The patient appeared very weak and when asked to get on the toilet. The patient then strained to get on the toilet and in the process of getting on the toilet the patient collapsed. When Patient #1 fell the nurse (#2) kept telling her to get up. Patient #1 was on the floor moaning, the nurse (#2) continued to tell the patient to get up and stated that she knew she was faking. The nurse(#2) then stated that she had been working at this for 17 yrs and she knew faking when she sees it. The nurse(#2) then rolled patient #1 over, the nurse(#2) then realized that patient #1 had urinated all over herself and the floor. The nurse(#2) then continued to tell her to get up. She then requested from me to assist her in getting the patient into the chair. At this time the patient was still moaning. The nurse (#2) then asked me to go and get a hospital gown for patient #1 because she was wet. I then went and acquired a gown. I then returned to patient #1 and the nurse (#2). Upon my return patient #1 was still on the floor and the nurse had removed her clothes. When the nurse lifted the patient ' s arm to put her gown on the patient exhaled air in a loud manner. The nurse (#2) then stated " oh you are alright now " . The nurse (#2)then requested that I assist her in placing the patient in the wheelchair. We were unable to get the patient into the wheelchair. The nurse (#2) then contacted the other nurses. Two to three nurses came over and one stated " Oh my God she ' s out of it " That ' s when Staff #2 said " oh no she ' s alright. " The nurses got her into the chair and she was wheeled to a room. At that time, one of the nurses attempted to revive the patient with some smelling salt. However the patient did not respond. A doctor then came in and was examining her and applied a stethoscope and stated that the patient had gone into cardiac arrest. "

Based on record review and interview the facility failed to ensure the registered nurse properly assess and assigned the care of 1 of 1 (#1) critically ill patients and supervise the care of the patient once assigned. Patient #1 presented to the facility ' s emergency room, critically ill. The care of the patient was assigned to a Licensed Vocational Nurse.

It was determined this deficient practice created an Immediate Jeopardy situation and placed the patients at risk for injury and death.

During the visit on 06/11/12 through 06/12/12 it was determined the facility had started an in house investigation and had implemented action that alleviated the immediate jeopardy by terminating the LVN. A plan was submitted and accepted with further corrective actions the facility would implement to ensure the facility continued compliance. Nursing Services remains at the condition level as there was not enough time for the hospital to fully implement the corrective actions and evaluate the effectiveness of those action to ensure continued compliance.

Findings Included:

Based on record review and interview the facility failed to ensure the registered nurse supervised the care and assessed the patient after collapsing onto the floor.
Refer to Tag A0395


Based on interview, and record review, the hospital failed to ensure the register nurse assessed and properly assigned a critical patient.
Refer to Tag A0397

Based on record review and interview the facility failed to ensure the registered nurse supervised the care and assessed 1 of 1 (#1) patients after collapsing onto the floor.

Record review of a document titled " ETMC Jacksonville/Rusk ED Triage Sheet " for patient #1 and completed by RN #1 revealed, the patient presented to the Emergency Room on 05/30/12 at 07:05 with Chief Complaint: " C/O (complained of) syncope (fainting episode) at Rusk today " . BP (blood pressure) 59/30, HR (heart rate) 133. Area for recording weight was left blank. The area for assessing nutrition required checking one of the following: Unintentional wt loss/gain greater 10lbs in past 6 months, Special diet restrictions, N/V/D greater 3 days, Newly diagnosed diabetic or None. The RN checked, None. The Fall assessment required checking one of the following: Unsteady gait, Use of assisted device, Hx (history) of falls in past 12 months or None. The RN checked, None. The primary care of the patient was then assigned to the LVN (licensed vocational nurse) by the RN. There was no documentation for review in patient #1 ' s chart of the RN re-assessed the patient prior to or after the patient collapsing in the bathroom at 0845.

A review of the " Vocational Nurse Scope of Practice Under Rule 217.11, " revealed,
Licensed Vocational Nurse:
(1) Clarification of Practice Parameters Directed practice under the supervision of a registered nurse, advanced practice registered nurse, physician assistant, physician, dentist, or podiatrist. (Independent practice not permitted).

(2) Provider of Care:
(a)Assist in the determination of predictable healthcare needs of clients within structured healthcare settings who are experiencing common, well-defined health problems with predictable outcomes.

(4) Member of a Profession:
(a) Assume accountability and responsibility for the quality of nursing care provided to clients.
(b) Act as a client advocate to maintain a safe environment for clients.
(c) Demonstrate behaviors that promote development of positive outcomes in relation to the practice of vocational nursing.

Registered Nurse:
(2) Provider of Care:
(a) Determine the predictable or unpredictable health status and health needs of clients (individual and family) through interpretation of health data and preventive health practice in collaboration with clients and interdisciplinary health care team members.

(b) Utilize a systematic approach to provide individualized, goal-directed nursing care by:
i. performing comprehensive nursing assessments regarding the health status of the client(s);
vi. evaluate client's (individual and family) responses and outcomes to therapeutic interventions; and
vii. utilize a critical thinking approach to analyze clinical data and current literature as a basis for decision making in nursing practice.

(3) Coordinator of Care:
Make assignments to licensed staff (LVNs, RNs) and delegate to unlicensed staff
in compliance with current Board of Nursing rules in both structured and unstructured health settings for clients with predictable as well as unpredictable health needs.

(4) Member of a Profession:
(a) Assume accountability and responsibility for the quality of nursing care provided to clients.
(b) Act as a client advocate to maintain a safe environment for clients.
(c) Serve as a healthcare advocate in monitoring and promoting quality of health care and services for client; and
(d) Participate in activities and act as a leader in promoting best practices within professional nursing.

An interview with staff #3 at 0945 on 06/11/12 in the Rusk ER ' s break room confirmed the RN (staff #1) should have re-assessed once the patient collapsed in the bathroom floor.

An interview with staff #4 at 0945 on 06/11/12 in the Rusk ER ' s break room confirmed the RN (staff #1) should have re-assessed once the patient collapsed in the bathroom floor.

An interview with staff #5 at 0945 on 06/11/12 in the Rusk ER ' s break room confirmed the RN (staff #1) should have re-assessed once the patient collapsed in the bathroom floor.

Based on interview, and record review, the hospital failed to ensure the register nurse assessed and properly assigned the care of 1 of 1 (#1) critical patients.

Record review of a document titled " ETMC Jacksonville/Rusk ED Triage Sheet " for patient #1 and completed by RN #1 revealed, the patient presented to the Emergency Room on 05/30/12 at 07:05 with Chief Complaint: " C/O (complained of) syncope (fainting episode) at Rusk today " . BP (blood pressure) 59/30, HR (heart rate) 133. Area for recording weight was left blank. The area for assessing nutrition required checking one of the following: Unintentional wt loss/gain greater 10lbs in past 6 months, Special diet restrictions, N/V/D greater 3 days, Newly diagnosed diabetic or None. The RN checked, None. The Fall assessment required checking one of the following: Unsteady gait, Use of assisted device, Hx (history) of falls in past 12 months or None. The RN checked, None. The primary care of the patient was then assigned to the LVN (licensed vocational nurse) by the RN. There was no documentation for review in patient #1 ' s chart of the RN re-assessed the patient prior to or after the patient collapsing in the bathroom at 0845.

A review of the document titled " ED Physician Notes " for patient #1 on 06/11/12 at 11:00 AM revealed, Time: (hand written) on arrival, BP 59/30, Pulse 133. History of Present Illness: Hand written entry word for word with the exception of the content within the parenthesis ' s, " Pt has been very weak, fatigue, has not been drinking enough fluids or eating regularly for last 2 weeks none compliance with meds Presented with syncope after syncope episode this AM Woke up very weak, hypotension P Ox (Oxygen Saturation) none detectable Prob 2nd to Hypotension. Pt Hx Bipolar BP at RSH (Rusk State Hospital) 58/38. " Fluid intake: Decreased, Solid intake: Decreased, Weight loss:
9 lbs in 9 days. Assoc. Signs and Symptoms: Malaise/ Gen weakness, Orthostatic: Lightheadedness, Urine Output: Decreased. Examination, Skin: Pale, ENT: Dry mucous membranes, Heart: Tachycardia, Lungs: Clear/Diminished.

A review of the document titled " Rusk Emergency Department Nursing Assessment " completed by the LVN(Staff #2), revealed, Arrival to Room Time: 0705, Skin Color: Normal, Breath Sounds: Clear (LVN checked yes), Diminished (LVN checked no), Grips: equal (LVN checked yes), Strong (LVN checked yes), weak (LVN checked no), Musculo/Skeletal: Unsteady Gait (LVN checked no), Steady Gait (LVN checked yes).

Review of the RN #1 ' s Triage and the assessment completed by the LVN (Staff #2) was not comparable to the Evaluation done by the Physician.

Multiple requests were made to Staff #3, Staff #4 and Staff #5 on 06/11/12 to review the facility ' s policy as they relate to the RN assigning patients to the LVN. No policies were made available to the surveyor.

Review of " 15.27, The Licensed Vocational Nurse Scope of Practice, " revealed, " The setting in which the LVN provides nursing care should have well defined policies, procedures, and guidelines, in which assistance and support are available from an appropriate clinical supervisor. "

A review of an untitled document containing a chronological listing of blood pressures and heart rates revealed, at 0845 AM patient #1 ' s BP was 75/55, HR was 126.

A review of the document titled " Emergency Department Nursing Assessment (continued) " revealed, " @ 0845 To bathroom via W/C (wheelchair) per request, got to bathroom. While transferring from W/C to toilet pt urinated on herself and became unresponsive. Called for help transported to Trauma room @ 0855. CPR started @0905.

Staff #1 failed to supervise Staff #2 and provide clinical direction for the care of crtitcally
ill patient #1.

An interview with staff #3 at 0945 on 06/11/12 in the Rusk ER ' s break room confirmed the RN, staff #1, triaged Patient #1 on 05/30/12 at 0705 AM and should not have assigned this critical patient to the LVN on duty, staff #2.

An interview with staff #4 at 0945 on 06/11/12 in the Rusk ER ' s break room confirmed the RN, staff #1, triaged Patient #1 on 05/30/12 at 0705 AM and should not have assigned this critical patient to the LVN on duty, staff #2.


An interview with staff #5 at 0945 on 06/11/12 in the Rusk ER ' s break room confirmed the RN, staff #1, triaged Patient #1 on 05/30/12 at 0705 AM and should not have assigned this critical patient to the LVN on duty, staff #2.