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Based on observation, interview, and record review, the facility failed to ensure, for four of six sampled incapacitated patients (persons with underlying medical condition or disability which could affect thinking, reasoning, and/or memory; Patients 35, 36, 37, and 15), the Conditions of Services (COS, admission and medical services agreement which included notice of patient rights when admitted to the facility) were provided to Patients 35, 36, 37, and 15's responsible party (RP).

This failure resulted in Patients 35, 36, 37, and 15's RPs not receiving the COS information when the patients were admitted to the facility and had the potential for the RPs to not be aware of the patients' rights.

Findings:

1. During a concurrent observation and interview on April 9, 2021, at 2:40 p.m., conducted with Charge Nurse (CN) 1, Patient 35 was observed lying in bed, awake, and alert. When talked to and asked questions, Patient 35 was observed to smile and answered with "yes" or "no."

CN 1 stated Patient 35 was not conversant and would just smile and would only say "yes" or "no."

During a review of Patient 35's record on April 9, 2021, the "History and Physical" indicated Patient 35 was admitted to the facility on April 4, 2021, with a chief complaint of altered mental status.

Patient 35's "Face Sheet (a record of patient's information)" indicated the patient had an RP listed for emergency contact.

The COS form indicated, "...I certify that I have read the foregoing and received a copy thereof. I am the patient, the patient's legal representative, or am otherwise duly authorized by the patient to sign the above its terms on his/her behalf...Signature of Patient/Parent/Guardian: Pt (Patient 35) unable to sign due to medical condition...Date: 4-4-21 (April 4, 2021)..."

There was no documented evidence the COS information was provided to Patient 35's RP.

2. During a concurrent observation on April 9, 2021, at 3:55 p.m., conducted with Charge Nurse (CN) 2, Patient 36 was observed lying in bed, non-responsive, and was intubated (a breathing tube inserted through the mouth and into the airway to help with the patient's breathing).

During a review of Patient 36's record on April 9, 2021, the "History and Physical" indicated Patient 36 was admitted to the facility on April 3, 2021, with a chief complaint of altered mental status.

The COS form indicated, "...I certify that I have read the foregoing and received a copy thereof. I am the patient, the patient's legal representative, or am otherwise duly authorized by the patient to sign the above its terms on his/her behalf...Signature of Patient/Parent/Guardian: Pt (Patient 36) unable to sign due to medical condition...Date: 4/3/21 (April 3, 2021) at 2:15 a.m..."

The "Progress Note," dated April 3, 2021, at 9:58 p.m., indicated, "...Social Worker able to find family members...At this time family wants (name of Patient 36's family member) to be the emergency contact...Social worker made aware of these changes and states 'I will change the facesheet accordingly'..."

There was no documented evidence the COS information was provided to Patient 36's RP.

3. During an observation on April 9, 2021, at 4:05 p.m., conducted with Charge Nurse (CN) 2, Patient 37 was observed lying in bed, non-responsive, and was intubated (a breathing tube inserted through the mouth and into the airway to help with the patient's breathing).

During a review of Patient 37's record on April 9, 2021, the "History and Physical" indicated Patient 37 was admitted to the facility on April 1, 2021, with a chief complaint of altered mental status and was involved in a motor vehicle collision.

Patient 37's "Face Sheet" indicated the patient had an RP listed for emergency contact.

The COS form indicated, "...I certify that I have read the foregoing and received a copy thereof. I am the patient, the patient's legal representative, or am otherwise duly authorized by the patient to sign the above its terms on his/her behalf...Signature of Patient/Parent/Guardian: Pt (Patient 37) unable to sign due to medical condition...Date: 04-01-21 (April 1, 2021)..."

There was no documented evidence the COS information was provided to Patient 37's RP.

During an interview on April 9, 2021, at 3:17 p.m., with the Director of Admitting (DOA), the DOA stated when a patient was admitted to the facility, the staff from the admitting department would provide the COS information to the patient.

The DOA stated when a patient was incapacitated and the patient had Durable Power of Attorney for healthcare (DPOA - a document of naming someone to make a decision for a person's health if the person became incapacitated), the DPOA would receive the COS information on behalf of the patient.

The DOA stated the admitting department would not give the information of COS to the patient's RP, unless the patient's RP was the DPOA.



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4. During a concurrent observation and interview, on April 11, 2021, at 9:50 a.m., conducted with Registered Nurse (RN) 1, Patient 15 was observed lying in bed, awake, and nonverbal. RN 1 stated Patient 15 was not able to follow commands or respond to questions.

Patient 15's record was reviewed on April 11, 2021. Patient 15 was admitted to the facility on April 8, 2021, for altered level of consciousness.

Patient 15's "Face Sheet" indicated Patient 15's RP was listed as his emergency contact.

The COS form indicated, "...I certify that I have read the foregoing and received a copy thereof. I am the patient, the patient's legal representative, or am otherwise duly authorized by the patient to sign the above its terms on his/her behalf...Signature of Patient/Parent/Guardian: Pt (Patient 15) is unable to sign due to medical condition...Date: 4/8/21 (April 8, 2021)...Time: 13:33 (1:33 p.m.)..."

There was no documented evidence the COS information was provided to Patient 15's RP.

During a review of the facility's policy and procedure (P&P) titled, "Condition of Services," on April 10, 2020, at 12:15 p.m., conducted with the Chief Nursing Officer (CNO), the P&P did not indicate how the facility would provide the COS information for the patients that were incapacitated and did not have a DPOA.

In a concurrent interview, the CNO stated the facility did not have a process on how to provide the COS information for the patients that were incapacitated and did not have a DPOA. The CNO stated the process should be added to the P&P.

Based on interview and record review, the facility failed to ensure written letters of facility response related to the grievances filed by the complainants for three of five patients (Patients 48, 50, and 52) were provided to the complainants.

In addition, the facility failed to ensure a written letter of acknowledgment of the grievance filed for one patient (Patient 51) was provided to the complainant.

These failures resulted in the complainants to not receive acknowledgement of the filed grievances and not be informed in writing of the grievance resolutions.

Findings:

The "Grievance Log (a record of written or verbal complaint made to the hospital by a patient or the patient's representative [RP], regarding the patient's care)," was reviewed on April 13, 2021, at 10:20 a.m., with the Director of Patient and Family Experience (DPFE) and Interpreter for Patient and Family Experience (IPFE). The "Grievance Log" indicated:

a. On June 8, 2020, Patient 48's RP called the facility and filed a grievance for the patient about the quality of care provided to Patient 48 by the physician and nursing staff in the facility on multiple occasions in the months of May and June 2020. Patient 48's RP's grievance status was "in progress."

On June 8, 2020, a letter from Patient and Family Experience Department (PFED) was sent to Patient 48's RP. The letter indicated, "...We are in the process of reviewing the concerns you expressed to us regarding (name of Patient 48)...I will be providing you with feedback at the conclusion of our review...You will be notified by mail should our investigation require more than 30 business days to ensure a thorough investigation into your concerns is completed..."

In a concurrent interview, the IPFE stated there was no documentation a follow up letter was sent to Patient 48's RP regarding the status of the grievance filed.

b. On July 23, 2020, Patient 50 called the facility and filed a grievance about the physician's and nursing staff's attitude towards the patient when she was in the facility on July 20, 2020. Patient 48's grievance status was "in progress."

On July 23, 2020, a letter from PFED was sent to Patient 50. The letter indicated, "...We are in the process of reviewing the concerns you expressed to us...I will be providing you with feedback at the conclusion of our review...You will be notified by mail should our investigation require more than 30 business days to ensure a thorough investigation into your concerns is completed..."

In a concurrent interview, the IPFE stated there was no documentation a follow up letter was sent to Patient 48's RP regarding the status of the grievance filed.

The DPFE stated if the grievance resolution was not obtained within 30 days, a letter should be sent to the complainant informing of the status of the grievance filed.

c. On October 8, 2020, Patient 52 called the facility and filed a grievance about the nursing staff's attitude, communication, and quality of care provided to the patient on October 7, 2020. Patient 52's grievance status was "closed" on October 30, 2020.

On October 11, 2020, a letter from PFED was sent to Patient 50. The letter indicated, "...We are in the process of reviewing the concerns you expressed to us...I will be providing you with feedback at the conclusion of our review...You will be notified by mail should our investigation require more than 30 business days to ensure a thorough investigation into your concerns is completed..."

In a concurrent interview, the IPFE stated there was no documentation a follow up letter was sent to Patient 48's RP regarding the status of the grievance filed.

The DPFE stated the facility has 30 days to resolve any grievances filed. The DPFE stated the facility should have sent a letter informing the complainants of the grievance resolution.

d. On October 5, 2020, Patient 51's RP called the facility and filed a grievance for the patient about the nursing staff's attitude, communication, quality of care, and the patient's discharge from the Emergency Department on October 2, 2020. Patient 51's grievance status was "in progress."

On November 5, 2020, at 9:37 a.m., the log indicated, "...Corrected status to grievance and referred to Quality for review..."

On November 5, 2020, a letter from PFED was sent to Patient 51's RP. The letter indicated, "...I am writing to let you know the review of your concerns, related to (Patient 51)...is currently in progress...I am inclined to also inform you that an audit of our records identified that I failed to follow our internal procedure to ensure your concerns were responded to in a timely manner...

Your complaint was received and communicated to the appropriate individual on 10/5 (October 5)...

Letter acknowledging receipt of your complaint mailed to you within 7 days; standard not met..."

The DPFE stated the facility should have sent a letter of acknowledgement to the complainant within seven days after the grievance was filed.

During a review of the facility's policy and procedure (P&P) titled, "Patient Complaint/Grievance Process," revised on August 31, 2016, the P&P indicated, "...An acknowledgement letter shall be sent to the complainant to acknowledge receipt of the complaint...a grievance that is considered more serious in nature may take up to 30 days. If resolution cannot be completed within 7 days, a letter will be sent to the complainant explaining additional time is needed to complete the investigation...Upon closure of the grievance, Patient & (and) Family Experience Department will mail a written response to the complainant within thirty (30) business days of the closure of the investigation..."

Based on observation, interview, and record review, the facility failed to ensure, for four of six sampled incapacitated patients (persons with an underlying medical condition or disability which could affect thinking, reasoning, and/or memory; Patients 35, 36, 37, and 15), the information to formulate an Advance Directive (AD, a written document of a person's wishes regarding medical treatment should the person be unable to communicate them to the physician) was provided to the patients' responsible parties (RP).

These failures resulted in the patients'/RPs' right to receive information to formulate an AD to not be exercised.

Findings:

1. During a cocurrent observation and interview, on April 9, 2021, at 2:40 p.m., conducted with Charge Nurse (CN) 1, Patient 35 was observed lying in bed, awake, and alert. When talked to and asked questions, Patient 35 would smile and answered with "yes" or "no".

CN 1 stated Patient 35 was not conversant, would just smile and would only say "yes" or "no."

During a review of Patient 35's record on April 9, 2021, the "History and Physical," indicated Patient 35 was admitted to the facility on April 4, 2021, with a chief complaint of altered mental status.

Patient 35's "Face Sheet (a record of patient's information)" indicated the patient had an RP listed for emergency contact.

The COS form indicated, "...Advance Health Care Directive..."

Do you have an Advance Health Care Directive (there was no mark for the answer of yes or no)...

If no Advance Directive, gave a copy of "A Patient's Right to know Brochure" (there was no mark for the answer of yes or no)...

Initials: unable...

I certify that I have read the foregoing and received a copy thereof. I am the patient, the patient's legal representative, or am otherwise duly authorized by the patient to sign the above its terms on his/her behalf...Signature of Patient/Parent/Guardian: Pt (Patient 35) unable to sign due to medical condition...Date: 4-4-21 (April 4, 2021)..."

There was no documented evidence the information to formulate an AD was provided to Patient 35's RP.

2. During an observation on April 9, 2021, at 3:55 p.m., conducted with Charge Nurse (CN) 2, Patient 36 was observed lying in bed, non-responsive, and was intubated (a breathing tube inserted through the mouth and into the airway to help with the patient's breathing).

During a review of Patient 36's record on April 9, 2021, the "History and Physical" indicated Patient 36 was admitted to the facility on April 3, 2021, with a chief complaint of altered mental status.

The COS form indicated, "...Advance Health Care Directive...

Do you have an Advance Health Care Directive (there was no mark for the answer of yes or no)...

If no Advance Directive, gave a copy of "A Patient's Right to know Brochure" (there was no mark for the answer of yes or no)...

Initials: (there was no initials)...

I certify that I have read the foregoing and received a copy thereof. I am the patient, the patient's legal representative, or am otherwise duly authorized by the patient to sign the above its terms on his/her behalf...Signature of Patient/Parent/Guardian: Pt (Patient 36) unable to sign due to medical condition...Date: 4/3/21 (April 3, 2021) at 2:15 a.m..."

The "Progress Note," dated April 3, 2021, at 9:58 p.m., indicated, "...Social Worker able to find family members...At this time family wants (name of Patient 36's family member) to be the emergency contact...Social worker made aware of these changes and states 'I will change the facesheet accordingly'..."

There was no documented evidence the information to formulate an AD was provided to Patient 36's RP.

3. During an observation on April 9, 2021, at 4:05 p.m., conducted with Charge Nurse (CN) 2, Patient 37 was observed lying in bed, non-responsive, and was intubated (a breathing tube inserted through the mouth and into the airway to help with the patient's breathing).

During a review of Patient 37's record on April 9, 2021, the "History and Physical" indicated Patient 37 was admitted to the facility on April 1, 2021, with a chief complaint of altered mental status and was involved in a motor vehicle collision.

Patient 37's "Face Sheet" indicated the patient had an RP listed for emergency contact.

The COS form indicated, "...Advance Health Care Directive...

Do you have an Advance Health Care Directive (there was no mark for the answer of yes or no)...

If no Advance Directive, gave a copy of "A Patient's Right to know Brochure" (there was no mark for the answer of yes or no)...

Initials: (there was no initials)...

I certify that I have read the foregoing and received a copy thereof. I am the patient, the patient's legal representative, or am otherwise duly authorized by the patient to sign the above its terms on his/her behalf...Signature of Patient/Parent/Guardian: Pt (Patient 37) unable to sign due to medical condition...Date: 04-01-21 (April 1, 2021)..."

There was no documented evidence the information to formulate an AD was provide to Patient 37's RP.

During an interview on April 9, 2021, at 3:17 p.m., with the Director of Admitting (DOA), the DOA stated when a patient was admitted to the facility, the staff from the admitting department would provide the COS information, which also addressed the AD.

The DOA stated when a patient was incapacitated and the patient had a Durable Power of Attorney for healthcare (DPOA - a document of naming someone to make a decision for a person's health when the person became incapacitated), the representative indicated on the DPOA would be asked regarding the patient's AD.

When the incapacitated patient did not have an AD, the admitting department would provide the information to formulate an AD to the DPOA representative.

The DOA stated when an incapacitated patient did not have a DPOA, the admitting department would not inquire or give information regarding the patient's AD to the patient's RP.

The DOA stated even if the patient had an RP identified, the information would not be given unless the patient's RP was the DPOA.



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d. During an observation and interview, on April 11, 2021, at 9:50 a.m., conducted with Registered Nurse (RN) 1, Patient 15 was observed lying in bed, awake, and nonverbal. RN 1 stated Patient 15 was not able to follow commands or respond to questions.

Patient 15's record was reviewed on April 11, 2021. Patient 15 was admitted to the facility on April 8, 2021, for altered level of consciousness.

Patient 15's "Face Sheet (a record of patient's information)" indicated Patient 15's RP was listed as his emergency contact.

Patient 15's COS form indicated, "...Do you have an Advance Healthcare Directive? (Yes or No unmarked)...If so, does the hospital have a copy? (Yes or No unmarked)...Copy requested? (Yes or No unmarked)...If no Advance Directive, gave a copy of 'A Patient's Right to Know Brochure' (Yes or No unmarked)...Patient requested and was given an 'Advance Health Directive Form' ? (Yes or No unmarked)...Initials ___ (blank)...

I certify that I have read the foregoing and received a copy thereof. I am the patient, the patient's legal representative, or am otherwise duly authorized by the patient to sign the above its terms on his/her behalf...Signature of Patient/Parent/Guardian: Pt (Patient 15) is unable to sign due to medical condition...Date: 4/8/21 (April 8, 2021)...Time: 13:33 (1:33 p.m.)..."

There was no documented evidence the Advance Healthcare Directive information was provided to Patient 15's RP.

During a review of the facility's policy and procedure (P&P) titled, "Advance Health Care Directives," revised on August 15, 2017, the P&P indicated, "...The hospital will provide written information to eligible patients of an individual's right under the law to make decisions regarding medical care, including the right to accept or refuse treatment and the right to formulate an AD...

Written information should be given to the patient on or before EVERY admission to the hospital...

If a patient is incapacitated at the time of admission, the hospital may give AD information to a family member or surrogate..."

Based on observation, interview, and record review, the facility failed to ensure, for two of three sampled patients (Patients 37 and 38), the patients' care plans addressed the use of restraints (any object or device attached or adjacent to an individual's body that cannot be removed easily and would limit the patient's movement).

This failure resulted in an individualized and patient centered care plan addressing the use of restraints to not be developed and implemented for Patients 37 and 38. This failure had the potential to result in the unnecessary and inappropriate use of restraints for Patients 37 and 38.

Findings:

1. During an observation on April 9, 2021, at 4:05 p.m., conducted with Charge Nurse (CN) 2, Patient 37 was observed lying in bed, non-responsive, and was intubated (a breathing tube inserted through the mouth and into the airway to help with the patient's breathing). Patient 37 was obeserved to have a soft wrist restraint on the right wrist.

During a review of Patient 37's record on April 10, 2021, at 2:45 p.m., conducted with CN 2, the "History and Physical" indicated Patient 37 was admitted to the facility on April 1, 2021, with a chief complaint of altered mental status and was involved in a motor vehicle collision.

There was no documented evidence Patient 37's care plan addressed the use of soft wrist restraints.

In a concurrent interview, CN 2 stated Patient 37's care plan should have included the use of soft wrist restraints.

2. During an observation on April 9, 2021, at 3:45 p.m., conducted with Registered Nurse (RN) 2, Patient 38 was observed lying in bed, asleep, and had bilateral (both sides) soft wrist restraints.

During a review of Patient 38's record on April 10, 2021, at 11:23 a.m., conducted with the Intensive Care Unit Educator (ICUE), the "History and Physical" indicated Patient 38 was admitted to the facility on April 6, 2021, with a chief complaint of assault (a physical attack).

There was no documented evidence Patient 38's care plan addressed the use of soft wrist restraints.

In a concurrent interview, the ICUE stated Patient 38's care plan should have include the use of soft wrist restraints.

During a review of the facility's policy and procedure (P&P) titled, "Initial Patient Assessment and Reassessment," revised on September 15, 2020, the P&P indicated, "...Any change in the patient's condition shall require an immediate reassessment with changes in the plan of care and SBAR tool reflecting the change in condition...

The plan of care will be reviewed regularly in consultation with the patient/significant other/family and care team members, and revised as patient's condition of diagnosis changes..."

Based on interview and record review, the facility failed to ensure the physician's telephone order for physical restraints (any object or device attached or adjacent to an individual's body which cannot be removed easily and would limit the individual's movement) and seclusion (a type of restraint which involved confining a person in a room from which the person cannot exit freely) for one patient (Patient 13) were cosigned and validated by the physician in a timely manner according to facility procedure.

This failure had the potential to result in an inappropriate, unnecessary, and prolonged use of restraints and seclusion.

Findings:

On April 10, 2021, Patient 13's record was reviewed. Patient 13 was admitted to the facility on March 8, 2021, with diagnoses that included psychosis (a serious mental illness) and suicidal behavior.

Patient 13's physician's telephone phone order, dated March 10, 2021, at 2:27 a.m., indicated a Registered Nurse (RN)cdocumented "...Phone with Read Back order...Restraint Type Violent...4 points (the restraint of both arms and both legs)..." The order for 4-point restraints was validated and signed by the physician on March 15, 2021, at 11:01 a.m. (five days later).

Patient 13's physician's telephone order, dated March 10, 2021, at 2:27 a.m., indicated an RN documented "...Phone with Read Back order...Seclude..." The order for seclusion was validated and signed by the physician on March 15, 2021, at 11:01 a.m. (five days later).

During an interview and record review on April 12, 2021, at 11 a.m., conducted with the Director of Mental Health (DMH), the DMH reviewed Patient 13's restraint and seclusion orders from March 10, 2021. The DMH acknowledged the telephone order was cosigned and validated after five days on March 15, 2021.

The DMH stated the expectation was for the physician to cosign orders within 24 hours.

During a review of the facility document titled, "(Name of Facility) RN Face to Face Evaluation," dated April 10, 2021, the document indicated, "...Physician Orders...The physician must sign the order for violent/self-destructive restraints within 24 hours of the original order being placed..."

Based on observation, interview, and record review, the facility failed to ensure the monitoring and reassessment for two of three sampled patients in restraints (Patients 37 and 38) were conducted in accordance with the facility's policy and procedure (P&P).

This failure had the potential to result in an inappropriate, unnecessary, and/or prolonged use of restraints.

Findings:

1. During an observation on April 9, 2021, at 4:05 p.m., conducted with Charge Nurse (CN) 2, Patient 37 was observed lying in bed, non-responsive, and was intubated (a breathing tube inserted through the mouth and into the airway to help with the patient's breathing). Patient 37 was observed to have a soft wrist restraint on the right wrist.

During a review of Patient 37's record on April 10, 2021, at 2:45 p.m., conducted with CN 2, the "History and Physical" indicated Patient 37 was admitted to the facility on April 1, 2021, with a chief complaint of altered mental status and was involved in a motor vehicle collision.

Patient 37's physician's order, dated April 7, 2021, indicated, "...Restraint Type...Soft Limb - Right Wrist..."

The restraint flowsheet record indicated Patient 37's right soft wrist restraint was assessed and monitored on April 7, 2021, at 4 a.m.

Patient 37's right soft wrist restraint was next assessed and monitored on April 8, 2021, at 8 a.m. (28 hours later).

There was no documented evidence Patient 37's right soft wrist restraint was discontinued on April 7 and 8, 2021.

There was no documented evidence Patient 37's use of bilateral soft wrist restraints were assessed and monitored between 4 a.m. on April 7, 2021, and 8 a.m. on April 8, 2021.

In a concurrent interview, CN 2 stated Patient 37's record indicated the patient was in the Operating Room (OR) on April 7, 2021, from 12 p.m. to 3:04 p.m.

CN 2 stated Patient 37's right soft wrist restraint should have been assessed and monitored every two hours before and after going to the OR to ensure patient safety and to evaluate if the patient was still in need of the restraint.

2. During an observation on April 9, 2021, at 3:45 p.m., conducted with Registered Nurse (RN) 2, Patient 38 was observed lying in bed, asleep, and had bilateral (both sides) soft wrist restraints.

During a review of Patient 38's record on April 10, 2021, at 11:23 a.m., conducted with the Intensive Care Unit Educator (ICUE), the "History and Physical" indicated Patient 38 was admitted to the facility on April 6, 2021, with a chief complaint of assault (a physical attack).

The Physician's Order, dated April 8 and 9, 2021, indicated non-violent restraints were intiated for Patient 38.

The restraint flowsheet record indicated Patient 38's bilateral soft wrist restraints were assessed and monitored on April 8, 2021, at 6 p.m.

Patient 38's bilateral soft wrist restraints were next assessed and monitored on April 9, 2021, at 8 a.m. (14 hours later).

There was no documented evidence Patient 38's bilateral soft wrist restraints were discontinued on April 8 and 9, 2021.

There was no documented evidence Patient 38's use of bilateral soft wrist restraints were assessed and monitored between 6 p.m. on April 8, 2021, and 8 a.m. on April 9, 2021.

In a concurrent interview, the ICUE stated Patient 38's bilateral soft wrist restraints should have been assessed and monitored every two hours to ensure patient safety and to evaluate if the patient was still in need of the restraints.

During a review of the facility's policy and procedure (P&P) titled, "Restraint and Seclusion Guidelines," revised on September 15, 2016, the P&P indicated, "...The staff will monitor the patient at intervals not to exceed every (2) hours..."

Based on interview and record review, the facility failed to ensure the recording of deaths associated with the use of restraints were documented in the facility's internal log within seven days of the patients' death for 10 patients (Patients 41, 42, 43, 44, 45, 46, 47, 28, 29, and 30), according to facility policy.

This failure resulted in the facility not meeting the federal regulations for the death reporting requirements associated with the use of restraints. This failure had the potential for these deaths associated with the use of restraints to not be investigated appropriately and timely which may impact the care of patients on restraints.

Findings:

During a review of the facility's death restraint internal log on April 9, 2021, at 2:20 p.m., conducted with the Chief Nursing Officer (CNO), the log indicated the following:

1. Patient 41 who had a two-point soft wrist restraint died on October 7, 2020.

Patient 41's death information was recorded in the log on December 11, 2020 (65 days after the patient's date of death);

2. Patient 42 who had a two-point soft wrist restraint died on October 16, 2020.

Patient 42's death information was recorded in the log on December 11, 2020 (56 days after the patient's date of death);

3. Patient 43 who had on a two-point soft wrist restraint died on October 20, 2020.

Patient 43's death information was recorded in the log on December 11, 2020 (52 days after the patient's date of death);

4. Patient 44 who had on a two-point soft wrist restraint died on November 10, 2020.

Patient 44's death information was recorded in the log on December 11, 2020 (31 days after the patient's date of death);

5. Patient 45 who had on a two-point soft wrist restraint died on November 10, 2020.

Patient 45's death information was recorded in the log on December 11, 2020 (31 days after the patient's date of death);

6. Patient 46 who had a two-point soft wrist restraint died on February 5, 2021.

Patient 46's death information was recorded in the log on March 16, 2021 (39 days after the patient's date of death);

7. Patient 47 who had a two-point soft wrist restraint died on February 10, 2021.

Patient 47's death information was recorded in the log on March 16, 2021 (34 days after the patient's date of death);

8. Patient 28 who had a two-point soft wrist restraint died on February 10, 2021.

Patient 28's death information was recorded in the log on March 16, 2021 (34 days after the patient's date of death);

9. Patient 29 who had on a two-point soft wrist restraint died on March 7, 2021.

Patient 29's death information was recorded in the log on March 16, 2021 (9 days after the patient's date of death); and

10. Patient 30 who had a two-point soft wrist restraint died on March 8, 2021.

Patient 30's death information was recorded in the log on March 16, 2021 (8 days after the patient's date of death).

In a concurrent interview with the CNO, the CNO stated there was a delay in recording the patients' deaths associated with the use of restraints.

The CNO stated it should have been recorded in the internal death restraints log within seven days after the patient died.

During a review of the facility's policy and procedure (P&P) titled, "Restraint and Seclusion Guidelines," revised on September 15, 2016, the P&P indicated, "...Hospitals are no longer required to report deaths to CMS if there was no use of seclusion and the only restraint was 2-point soft wrist restraints....Hospital staff must now record the incident in an internal log or other system...

The log entry must be made no later than seven days after the date of death of the patient..."

Based on observation, interview, and record review, the facility failed to ensure the interdisciplinary plan of care was developed and updated for two patients (Patients 22 and 37).

This failure resulted in Patients 22 and 37 not having an individualized and patient centered care plan and had the potential for the necessary care to meet the needs of the patients to not be provided.

Findings:

1. During a review of Patient 22's record on April 11, 2021, at 9:44 a.m., conducted with the Nurse Manager (NM), the "Progress Notes," dated April 6, 2021, indicated Patient 22 was admitted to the facility on April 5, 2021.

Further review of the notes indicated, "...Assessment/Plan...HTN (hypertension - high blood pressure [a blood pressure reading of above 140/90]) continue hydralazine (a medication use for HTN) as needed...."

Patient 22's Medication Administration Record indicated hydralazine was administered to the patient on:

- April 7, 2021, at 1:12 a.m.;

- April 8, 2021, at 3:59 a.m.; and

- April 9, 2021 at 4:10 a.m. and 9:47 p.m.

There was no documented evidence Patient 22's plan of care addressed the patient's HTN.

In a concurrent interview with the NM, the NM stated Patient 22 had issues with HTN and was administered several doses of hydralazine to control the patient's high blood pressure.

The NM stated Patient 22's plan of care should have been updated to include HTN.

2. During an observation on April 9, 2021, at 4:05 p.m., conducted with Charge Nurse (CN) 2, Patient 37 was observed lying in bed, non-responsive, and was intubated (a breathing tube inserted through the mouth and into the airway to help with the patient's breathing). Patient 37 had bilateral (both sides) chest tubes (a flexible tube placed into the chest to drain blood, fluid, or air from around the lungs).

During a review of Patient 37's record on April 10, 2021, at 2:45 p.m., conducted with CN 2, the "History and Physical (H&P)" indicated Patient 37 was admitted to the facility on April 1, 2021, with a chief complaint of altered mental status and was involved in a motor vehicle collision.

Further review of the H&P indicated, "...Chest...bilateral chest tubes were placed...

Assessment/Plan...Respiratory failure...

Airway not secured. Emergency department...intubated the patient successfully..."

There was no documented evidence Patient 37's plan of care addressed the patient's respiratory failure or airway issues.

In a concurrent interview with CN 2, CN 2 stated Patient 37's plan of care should have addressed the patient's intubation and the need for bilateral chest tubes.

During a review of the facility's policy and procedure (P&P) titled, "Initial Patient Assessment and Reassessment," revised on September 15, 2020, the P&P indicated, "...Upon completion of the initial admission assessment...plan of care will be developed in consultation with the patient/significant other/family and care team members...

Any change in the patient's condition shall require an immediate reassessment with changes in the plan of care and SBAR tool reflecting the change in condition...

The plan of care will be reviewed regularly in consultation with the patient/significant other/family and care team members, and revised as patient's condition of diagnosis changes..."

Based on observation, interview, and record review, the facility failed to ensure medications were administered according to physician's orders and in accordance with the facility's policy and procedure (P&P) for four patients (Patients 37, 26, 22, and 13) when:

1. The doses of norepinephrine (medication used to treat low blood pressure) and Fentanyl (medication used for pain) for Patient 37 were not titrated (the dose of a medication may be increased or decreased in response to patient condition and therapeutic goal) as ordered by the physician;

2. There was no documented evidence Patient 26's blood pressure (BP) was taken prior to the administration of hydralazine (medication used for high BP [reading of above 140/90]) according to the parameters ordered by the physician for Patient 26.

In addition, there was no documented evidence Patient 26's BP was reassessed after the administration of hydralazine according to facility's P&P to indicate if the medication was effective ;

3. There was no documented evidence Patient 22's BP was reassessed after the administration of hydralazine according to facility's P&P to indicate if the medication was effective; and

4. Patient 13's physician's telephone order received for chemical restraints (medication given to primarily control a person's behavior) was not signed and validated timely.

These failures had the potential to result in medication errors that may lead to patients' harm or death.

Findings:

1. During an observation on April 9, 2021, at 4:05 p.m., conducted with Charge Nurse (CN) 2, Patient 37 was observed lying in bed, non-responsive, and was intubated (a breathing tube was inserted through the mouth and into the airway to help with the patient's breathing). Patient 37 was observed to have bilateral (both sides) chest tubes (flexible tube placed into the chest to drain blood, fluid, or air from around the lungs).

Further observation showed Patient 37 had multiple intravenous (IV, through the vein) medication infusing including norepinephrine and Fentanyl.

During a review of Patient 37's record on April 10, 2021, at 2:45 p.m., conducted with CN 2, the "History and Physical" indicated Patient 37 was admitted to the facility on April 1, 2021, with a chief complaint of altered mental status and was involved in a motor vehicle collision.

1a. Patient 37's physician's order indicated, "...Norepinephrine IV...8 mg (milligram, unit of measurement)...titrate per protocol...Start Date: 04/01/21 (April 1, 2021), at 10:59 (a.m.)..."

The "Norepinephrine (Levophed) Protocol," last revised on November 2017, indicated, "...Titrate to keep: MAP (mean arterial pressure, the average pressure in a patient's arteries during one heart cycle) greater than or equal to 65 mmHg (millimeter of mercury, unit of measurement)...

For cardiogenic shock (a serious condition when the heart cannot pump enough blood and oxygen to the brain, kidneys, and vital organs): Increase drip by 0.05 mcg/kg/min (microgram per kilogram pre minute) every 5 (five) min until target MAP is obtained...

For septic shock (a life-threatening condition caused by severe localized or systemic-wide infection): Increase drip by 0.02 mcg/kg/min every 5 min until target MAP is obtained..."

Patient 37's "Titration Flowsheet," dated April 1, 2021, indicated the following :

- Patient 37's MAP was 68 mmHg at 11 a.m.

- At 11:21 a.m., norepinephrine was initiated at 0.01 mcg/kg/min.

- At 11:25 a.m., the norepinephrine dose was increased to 0.02 mcg/kg/min.

There was no documented evidence of Patient 37's MAP was reassessed prior to increasing the norepinephrine dose;

- At 11:30 a.m., the norepinephrine dose was increased to 0.04 mcg/kg/min.

There was no documented evidence of Patient 37's MAP was reassessed prior to increasing the norepinephrine dose;

- At 11:45 a.m., the norepinephrine dose was increased to 0.06 mcg/kg/min (15 minutes after the last titrated dose).

There was no documented evidence of Patient 37's MAP was reassessed increasing the norepinephrine;

- At 12 p.m., the norepinephrine dose was increased to 0.08 mcg/kg/min (15 minutes after the last titrated dose).

Patient 37's MAP was 88 mmHg (the MAP goal per protocol was 65 mmHg);

- At 12:13 p.m., the norepinephrine dose was increased to 0.1 mcg/kg/min (13 minutes after the last titration dose).

There was no documented evidence of Patient 37's MAP was reassessed to increasing the norepinephrine dose;

- At 12:30 p.m., the norepinephrine dose was increased to 0.2 mcg/kg/min (17 minutes after the last titration dose).

There was no documented evidence of Patient 37's MAP was reassessed prior to increasing the norepinephrine dose;

- At 12:45 p.m., the norepinephrine dose was increased to 0.3 mcg/kg/min (15 minutes after the last titration dose).

There was no documented evidence of Patient 37's MAP was reassessed prior to increasing the norepinephrine dose;

- At 3:09 p.m., the norepinephrine dose was increased to 0.5 mcg/kg/min (1 hour and 55 minutes after the last titrated dose).

Patient 37's last MAP was 88 mmHg (the MAP goal per protocol was 65 mmHg or above) at 3 p.m.;

- At 4:36 p.m., the norepinephrine dose was increased to 0.55 mcg/kg/min (1 hour and 27 minutes after the last titrated dose).

Patient 37's last MAP was 81 mmHg (the MAP goal per protocol was 65 mmHg) at 4 p.m.;

- At 5:36 p.m., the norepinephrine dose was increased to 0.6 mcg/kg/min (one hour after the last titrated dose).

Patient 37's last MAP was 95 mmHg (the MAP goal per protocol was 65 mmHg) at 5 p.m.;

- At 6 p.m., the norepinephrine dose was increased to 0.7 mcg/kg/min (24 minutes after the last titrated dose).

Patient 37's last MAP was 97 mmHg (the MAP goal per protocol was 65 mmHg) at 6 p.m.; and

- At 6:30 p.m., the norepinephrine dose was increased to 0.75 mcg/kg/min (30 minutes after the last titrated dose).

There was no documented evidence of Patient 37's MAP was reassessed prior to increasing the norepinephrine dose.

In a concurrent interview, CN 2 stated Patient 37's norepinephrine dose titration was not in accordance with the protocol.

CN 2 stated the nurses should have followed the "Norepinephrine Protocol" as ordered by the physician for Patient 37.

1b. Patient 37's physician's order indicated, "...Fentanyl 2,500 mcg (microgram - unit of measurement)...Titrate per protocol...Start Date: 04/01/21 (April 1, 2021), at 10:01 a.m..."

The "Fentanyl Drip Protocol," last revised on November 2020, indicated, "...Initiate infusion: 50 mcg/hr (hour)...

Titrate to keep: CPOT (Critical Care Pain Observation Tool, tool designed to assess the pain of critically ill patients who were incapable of reporting pain) less than 2...

Titration: increase or decrease in increment of 25 mcg/hr every 30 minutes..."

Patient 37's "Titration Flowsheet," dated April 1, 2021, indicated the following :

- At 11:59 a.m., Fentanyl was infused at 50 mcg/hr.

Patient 37's CPOT score was 0 at 12 p.m.;

- At 12:59 p.m., the Fentanyl dose was increased to 100 mcg/hr (increased by 50 mcg/hr, one hour later).

There was no documented evidence Patient 37's CPOT was reassessed prior to increasing the Fentanyl dose;

- At 1:59 p.m., the Fentanyl dose was increased to 150 mcg/hr (increased by 50 mcg/hr, one hour later).

Patient 37's CPOT score was 0 at 2 p.m.; and

- At 2:59 p.m., the Fentanyl dose was increased to 200 mcg/hr (increased by 50 mcg/hr, one hour later).

There was no documented evidence Patient 37's CPOT was reassessed prior to increasing the Fentanyl dose.

In a concurrent interview, CN 2 stated Patient 37's Fentanyl dose titration was not in accordance with the protocol.

CN 2 stated the nurses should have followed the Fentanyl Drip Protocol as ordered by the physician for Patient 37.

During a review of the facility's P&P titled, "Medication Orders," last reviewed on August 2017, the P&P indicated, "...Medical Staff approved drug administration protocols may be used by the physician if available...Once a drug protocol is approved, the physician may write the drug and 'per protocol.' The nurse will then use the protocol to guide administration..."

2. During a review of Patient 26's record on April 11, 2021, at 11:10 a.m., conducted with the Chief Nursing Officer (CNO), the "History and Physical" indicated Patient 26 was admitted to the facility on April 7, 2021, with a chief complaint of possible stroke (condition which occur when the blood supply to part of the brain was interrupted, preventing the brain tissue from getting oxygen and nutrients).

Patient 26's "Physician's Order," dated April 9, 2021, indicated to give hydralazine 10 mg (milligram, unit of measurement) IV (Intravenous, through the veins) push every four hours as needed (PRN) for hypertension (high BP).

Patient 26's "Medication Administration Record" indicated the following:

- On April 10, 2021, at 4:14 p.m., hydralazine was administered for BP of 171/84 mmHg (millimeter of mercury).

Patient 26's BP reassessment was checked at 7:40 p.m. (3 hours and 26 minutes after the hydralazine was given); and

- On April 11, 2021, at 12:35 a.m., hydralazine was administered.

There was no documented evidence Patient 26's BP was assessed prior to the administration of hydralazine.

In a concurrent interview, the CNO stated Patient 26's BP should have been assessed prior to administration of the PRN medication (Hydralazine) as indicated per the physician's order.

The CNO stated when giving PRN medication, a follow up evaluation of the patient should be conducted within 30 minutes to one hour after the medication was administered, to assess if the medication was effective.

The CNO stated Patient 26's BP should have been reassessed 30 minutes to one-hour after administration of the Hydralazine.

During a review of the facility's P&P titled, "Medication Orders," last reviewed in August 2017, the P&P indicated, "...As Needed (PRN) orders are orders acted on based on the occurrence of a specific indication or symptom...Nursing will utilize the indication to ensure the correct medication is administered per the patient's symptoms and order..."

During a review of the facility's P&P titled, "Nursing Guideline for Medication Prescription and Administration," last reviewed in December 2020, the P&P indicated, "...Follow up: Reassess patient in 1 (one) hour for effectiveness of treatment..."

3. During a review of Patient 22's record on April 11, 2021 at 9:44 a.m., conducted with the Nurse Manager (NM), the "Progress Notes," dated April 6, 2021, indicated Patient 22 was admitted to the facility on April 5, 2021.

Further review of the notes indicated, "...Assessment/Plan...HTN (hypertension) continue Hydralazine (a medication used for HTN) as needed...."

Patient 22's "Physician's Order," dated April 5, 2021, indicated to give hydralazine 10 mg IV push every four hours as needed for hypertension.

Patient 22's "Medication Administration Record" indicated the following:

- On April 7, 2021, at 1:12 a.m., hydralazine was administered for a BP of 163/77 mmHg.

Patient 22's BP was reassessed on April 7, 2021, at 4:11 a.m. (2 hours and 59 minutes after the administration of hydralazine);

- On April 8, 2021, at 3:59 a.m., hydralazine was administered for a BP of 169/80 mmHg.

Patient 22's BP was reassessed on April 8, 2021, at 8:32 a.m. (4 hours and 21 minutes after the administration of hydralazine);

- On April 9, 2021, at 4:10 a.m., hydralazine was administered for a BP of 168/80 mmHg.

Patient 22's BP was reassessed on April 9, 2021, at 8:49 a.m. (4 hours and 39 minutes after the administration of hydralazine); and

- On April 9, 2021, at 9:47 p.m., hydralazine was administered for a BP of 161/77 mmHg.

Patient 22's BP was reassessed on April 10, 2021, at 12:14 a.m. (2 hours and 27 minutes after administration of hydralazine).

In a concurrent interview, the NM stated when giving PRN medication, a follow up evaluation of the patient should be conducted within 30 minutes to one hour after the medication was administered to know if the medication was effective.

Patient 22's record as reviewed with the CNO on April 11, 2021, at 2:40 p.m. During a concurrent interview, the CNO stated Patient 22's BP should have been reassessed 30 minutes to one-hour after administration of the Hydralazine.

During a review of the facility's P&P titled, "Nursing Guideline for Medication Prescription and Administration," last reviewed in December 2020, the P&P indicated, "...Follow up: Reassess patient in 1 (one) hour for effectiveness of treatment..."



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4. On April 10, 2021, Patient 13's record was reviewed. Patient 13 was admitted to the facility on March 8, 2021, with diagnoses that included psychosis (a mental disorder) and suicidal behavior.

Patient 13's physician's telephone orders, dated March 10, 2021, at 1:26 a.m., indicated a Registered Nurse (RN) entered the following:

-"...lorazapam (medication used to treat anxiety disorders)...2 mg (milligrams - unit of measurement)...IM (intramuscular) injection...once...";

-"...haloperidol (medication used to treat mental disorders, including psychosis)...5 mg...IM injection...once..."; and

-"...diphenhydramine (medication used to treat allergy symptoms and induce sleep)...50 mg...IM injection...once..."

The physician's telephone orders for lorazapam, haloperidol, and diphenhydramine were validated and signed by the physician on March 15, 2021, at 11:01 a.m. (five days later).

During an interview on April 11, 2021, at 8:50 a.m., conducted with the Chief Nursing Officer (CNO), the CNO stated physician's telephone orders for medication should be validated and cosigned within 48 hours per facility policy and procedure.

During a review of the facility's P&P titled, "Medication Orders," last reviewed in August 2017, the P&P indicated, "...To establish a policy for safely ordering and transcribing medication orders...telephone and verbal orders will be kept to a minimum as outlined in the Medical Staff Rules and Regulations...The prescriber shall countersign the order within 48 hours either on paper or electronically..."