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Based on review of hospital policies and procedures, hospital documents, medical records, observations, and staff interviews, it was determined that the hospital failed to comply with protecting and promoting each patient's rights as evidenced by the hospital's failure to:

Findings include:

The Condition level deficiency is the result of the standard deficiencies found under the Conditions of Patient Right in the following tags:

A-0144: Failure to ensure building modifications were approved.

A-0164: Failure to document alternative interventions that were initiated and the results of the use of those alternatives prior to the use of restraint for five (5) patients. (Patient #4, #8, #11, #13, #15)

A-0168: Failure to ensure physician orders were in place for two (2) patients in restraints. (Patients #4, #15).

A-0174: Failure to ensure patients placed in restraints had documentation on attempts for release for five (5) patients in restraints. (Patient #4, #8, #11, #13, #15)

A-0179: Failure to ensure that five (5) patients placed in restraints had with a face-to-face examinations by providers

A-188: Failure to ensure five (5) patients placed in restraints had documentation for the continued need/use of restraints in the medical record. (Patient #4, #8, #11, #13, #15)

A-0353: Failure to ensure medical staff:
1. Evaluated/Assessed patients with a face-to-face evaluation after initiation or before renewal of restraints.
2. Document the required need for continuation of restraints in progress note documentation.

The cumulative effect of these systemic problems resulted in the hospital being ineffective with promoting and protecting the rights of each patient and failure to meet the requirements of the Condition of Participation for Patient Rights.

Based on review of policies and procedures, hospital documents, medical records and interviews, it was determined the hospital failed to ensure the each individual patient's medical record was maintained and complete as demonstrated by the following Standard level citations:

A-0353: Failure to ensure Medical Staff:
1. Evaluated/Assessed patients with a face-to-face evaluation after initiation or before renewal of restraints.
2. Document the required need for continuation of restraints in progress note documentation.
3. Authenticated telephone/verbal orders within the required timeframe.
4. Authenticated physician orders with a signature, time and date.
5. Authenticated progress notes within the required timeframe.
6. Documented daily progress notes on one (1) patient.

A-0449: Failure to ensure Medical Staff documented daily progress notes for one (1) patient.

A-0450: Failure to ensure Medical Staff progress note entries in eleven (11) patient medical records were completed, dated, legible, and authenticated.

A-0454: Failure to ensure medical providers orders were dated, legible and authenticated for seven (7) patients. (Patient #9, #10, #11, #13,#14, #15, #23)

A-0467: Failure to ensure a discharge order was documented in the medical record for one (1) patient.

A-0468: Failure to ensure a discharge summary was documented in the medical record for one (1) patient.

The cumulative effect of these systemic problems resulted in the hospital not ensuring medical records were maintained and complete, leading to a failure to meet the requirements of the Condition of Participation for Medical Records.

Based on review of policies and procedures, hospital documents, medical records, and staff interviews, it was determined the hospital failed to have a discharge planning process in effect that applies to all patients as evidenced by the following Standard level deficiencies:

A-0800: Failure to ensure 12 of 27 patients had a discharge plan documented in the medical record. (Patients #1, 2, 8, 12, 17, 19, 20, 21, 22, 24, 25, 27).

A-0808: Failure to ensure the patient or patient representative were included in the discharge planning of 12 out of 27 patients. (Patients #1, 2, 8, 12, 17, 19, 20, 21, 22, 24, 25, 27

The cumulative effect of these systemic deficient practices resulted in the failure of the hospital to meet the requirements for the Condition of Participation for Discharge Planning.

Based on review of the facility's state licensing file, observation and staff interview, it was determined the Administrator failed to notify and obtain approval from the Department regarding a substantial modification to the second floor patient care area and installation of a new HVAC (heating, ventilation, air conditioning) system. This deficient practice poses a risk to the health and safety of patients if renovations are not approved that might lead to an unsafe environment for patients.

Cross Reference A-0115

Findings include:

Review of the facility's state licensing file revealed an email correspondence dated May 14, 2020 from the facility stating: : "...I wanted to provide to you notification in regards to the temporary closure of the 2nd floor rooms in our hospital related to a decrease in our daily census. I would anticipate re-opening this space in the very near future as our census increases, and we will be sure to provide appropriate notification prior to this occurring. Our Maintenance staff is currently assessing the AC units on the second floor space during this time. If any replacements are required, we will again provide notification and adhere to all infection prevention, life safety and environment of care regulations. No construction is scheduled now or in the near future in any of our occupied space...."

Further review of the facility's state licensing file revealed no additional documentation from the facility regarding the reopening of the second floor patient care area and the repair/installation of a new HVAC system.

While on tour of the facility on 06/12/2023, surveyors observed the second floor consisted of multiple offices, a conference room, a rehabilitiation treatment room, 13 patient care rooms, 2 medication supply rooms, a dirty supply room and a staff lounge. Further observation revealed 10 out of the 13 patient care rooms were occupied by patients.

Employee #3 confirmed during an interview on 06/12/2023 that the facility had started utilizing the second floor patient rooms in March, 2023. Employee #3 confirmed that the facility had recently replaced the HVAC system. Employee #3 confirmed that the facility had not notified the Department that the facility was reopening the second floor patient care area.

Employee #4 confirmed during an interview on 06/14/2023 that the facility had replaced the HVAC system and renovated the second floor patient care area without notifying the Department.

Based on a review of policies and procedures, medical records and interview, it was determined the administrator failed to ensure that hospital personnel and medical staff followed the approved policies and procedures for restraints by documenting the alternative interventions that were initiated and the results of the use of those alternatives prior to the use of restraint for five (5) patients. (Patient #4, #8, #11, #13, #15)

This deficient practice poses a risk to the patient of injury, deteriorating skin conditions, harm to patients for being restrained for extended amounts of time without release or attempts at release and / or loss of autonomy.

Cross Reference -A0115

Repeat deficiency Event #WYR611 9/17/2020

Findings include:

Policy titled, "Patient Rights and Responsibilities", revealed: "...A patient is not subjected to: Restraint, if not necessary to prevent imminent harm to self or others or as allowed under R9-10-225...."

Policy titled, "Restraints", revealed: "...Patients have the right to be free from restraints...Restraints are only used when they are therapeutically necessary and ordered by the physician for the safety of patients and others...Restraints are not used as a means of coercion, discipline, convenience, or staff retaliation...The hospital uses the least restrictive form of restraint that protects the physical safety of the patient, staff or others...The hospital discontinues the use of restraint at the earliest possible time, regardless of the scheduled expiration of the order...Patient Monitoring: type and location of the restraining device(s) shall be documented within an hour of placement and every two (2) hours thereafter...Rationale for restraint (observed condition or behavior) shall be assessed on an ongoing basis and documented every two (2) hours...Alternatives to and less restrictive forms of restraint considered by the caregiver shall be documented every two (2) hours...Other monitoring activities shall be performed at least every two (2) hours, or more frequently if indicated by the condition or behavior of the patient. During monitoring the patient shall be assessed for: signs of any injury associated with the use of restraint, nutrition and hydration needs, circulation, range of motion, hygiene and elimination, physical and psychological status and comfort, readiness for discontinuation or temporary removal from restraint...."

Hospital document titled, "Critical Care Daily Flowsheet" revealed a documentation section titled Restraints. The Restraint section has across the top of the section boxes for time every hour starting at 0700 through 0600. The side of the Restraint section lists boxes of criteria to be documented: Type of restraint; Meets restraint documentation criteria* see specific documentation; (check mark symbol) equals alternative method used; release q 2 HR (every 2 hours) for ROM (range of motion)& skin integrity; (check mark symbol) equals restraint safety; behavioral patient. The bottom of the Restraint section there is box which includes : Restraint Documentation: Monitoring and Cares must be completed at least every 2 hours; Removal From: (check mark symbol ) equals restraint removed; (check mark symbol) equals ROM done; Safety: (check mark symbol) equals patient safety checks done...Alternative Methods (legend): 1. Close observation; 2. Wedge pillow-Positioning Devices; 3. Mitts (untied) Non-Bulky; 4. Self release seat belt; 5. Self release torso belt; 6. Bed alarm; 7. Personal alarm; 8. Placed in wheelchair at nurse station; 9. side rails X___; Type of Restraint (legend): A. ankle; B. waist belt; LE. lower extremity; V. vest restraint; 1X: 1:1 observation; S: soft; UE: upper extremity; M: mitt bulky; W: wrist; SR: siderails X 4. A box was also at the bottom of the restraint sections that states: * Document need for restraint; * Document alternative methods attempted; * Document Pt. and family education; * Document pulse status Q 2 hrs.; * Document repositioning; * Document nutrition, fluids, and toileting. Medical Surgical has a specific designated Daily Care Flowsheet with a similar section for Restraint documentation.

1. Review of the medical records revealed:

-Patient #4 was admitted to the facility on 05/31/2023 to the ICU. Review of Patient #4 Critical Care Daily Flowsheet dated 06/11/2023, 06/12/2023, 06/13/2023 revealed check marks under the alternate methods used. Review of Patient #4 nursing progress notes dated 06/11/2023, 06/12/2023, 06/13/2023 revealed no documentation regarding the types of alternative methods utilized before restraints or the patient response to the alternative interventions.
-Patient #8 was admitted to the facility on 06/11/2023. Review of Patient #8 Critical Care Daily Flowsheet dated
06/11/2023, 06/12/2023, 06/13/2023 revealed check marks under the alternate methods used. Review of Patient #8 nursing progress note revealed no documentation regarding the type of alternative method used or patient response to the alternative interventions.
-Patient #11 was admitted to the facility on 04/29/2023. Review of the daily care flowsheet revealed Patient #11 was in restraints on 05/21/2023, 05/22/2023, 05/23/2023, 05/24/2023, 05/26/2023, 06/08/2023, 06/09/2023, 06/10/2023, 06/11/2023, 06/12/2023, 06/13/2023. Review of the nursing progress note revealed no documentation regarding the type of alternate method and patient response to the alternative interventions.
-Patient #13 was admitted to the facility on 05/02/2023. Review of Patient #13 daily care flowsheet revealed Patient #13 was in restraints 05/06/2023 through 05/14/2023, 05/17/2023 through 05/19/2023, 05/21/2023 through 05/26/2023, 05/31/2023 through 06/01/2023, 06/08/2023 through 06/10/203, 06/12/2023 through 06/13/2023. Review of the daily care flowsheet revealed no documentation was present on the restraint section regarding alternate methods used for the entire 24 hour period on 06/12/2023. Review of Patient #13 nursing progress note revealed no documentation present for the dates Patient #13 was in restraints regarding the type of alternate methods or patient response to the alternative interventions.
-Patient #15 was admitted was admitted to the facility on 11/26/2022 and discharged on 02/14/2023. Review of Patient #15 daily care flowsheet revealed Patient #15 was in restraints on 01/27/2023, 01/28/2023, 01/30/2023, 02/01/2023. Review of the nursing progress notes for Patient #15 revealed no documentation regarding the alternate methods attempted or the patient reaction to the interventions attempted.

Employee # 9 confirmed during an interview on 06/13/2023 that the required restraint documentation was not present for Patients #4, #8, #11, #13, and #15.

Based on a review of policies and procedures, medical records and interview, it was determined the Hospital allowed patients to be placed in restraints without physician orders for two (2) patients in restraints. (Patients #4, #15) This deficient practice poses a risk to the health and safety of patients if patients are restrained unnecessarily or for inappropriate lengths of time.

Cross Reference A-0115

Repeat deficiency Event #WYR611 9/17/2020

Findings include:

Policy titled, "Restraints", revealed: "...Patients have the right to be free from restraints...Restraints are only used when they are therapeutically necessary and ordered by the physician for the safety of patients and others...The hospital discontinues the use of restraint at the earliest possible time, regardless of the scheduled expiration of the order...Standing or PRN orders for restraints are not valid...A physician's order is valid until the next calendar day...Discontinuation of Restraint: Restraint shall be discontinued when the registered nurse or physician assesses that the behavior or condition that was the basis for the restraint order is resolved, or the criteria for discontinuing the restraint has been met regardless of the duration of the enabling order. If a restraint has been discontinued greater than 2 hours and is reapplied, a new physician order must be obtained...."

Hospital document titled, " KPC Promise Hospital Medical Staff Rules and Regulations", revealed: "...The use of mechanical restraints shall require clinical justification and shall be used only to prevent a patient from injuring himself or others or to prevent serious disruption of the therapeutic environment. Mechanical restraints shall not be used as a means of punishment or for staff convenience. Restraint orders shall be renewed every twenty-four hours and a face-to-face evaluation is required prior to renewal... Each written order for a mechanical restraint shall be time limited. PRN orders shall not be used to authorize the use of restraints...."

Review of the medical records revealed:

-Patient #4 was in restraints on 06/13/2023. Review of the physician orders revealed a restraint order was written on 06/10/2023 at 1500 expiring on 06/11/2023 at 1500. Further review of the physician orders revealed no evidence of restraint orders written after 06/10/2023 at 1500.
-Patient #15 was in restraints on 01/27/2023 at 0030 through 01/28/2023 at 1600, 01/30/2023 at 0100 until 0900, 02/01/2023 at 2200 through 02/02/2023 at 0600. Review of the physician orders revealed restraint orders were written on 01/27/2023 at 0100, on 01/30/2023 at 0140 and 01/31/2023 with no time documented. Review of Patient #15 restraint record revealed Patient #15 was in restraints without a provider order on 01/28/2023 from 0030 until 1600. Patient #15 was in restraints without a provider order from 02/01/2023 at 2200 until 02/02/2023 at 0600.

Employee #9 confirmed during an interview on 06/13/2023 that a physician order is required to place a patient in restraints.

Based on a review of policies and procedures, medical records and interview, it was determined the administrator allowed patients to remain in restraints with no attempts for release for five (5) patients in restraints. (Patient #4, #8, #11, #13, #15) This deficient practice poses a risk to the health and safety of patients if patients are not restrained with the least restrictive device and environment.

Cross Reference A-0115

Repeat deficiency Event #WYP611 9/17/2020

Findings include:

Policy titled, "Patient Rights and Responsibilities", revealed: "...A patient is not subjected to: Restraint, if not necessary to prevent imminent harm to self or others or as allowed under R9-10-225...."

Policy titled, "Restraints", revealed: "...Patients have the right to be free from restraints...Restraints are only used when they are therapeutically necessary and ordered by the physician for the safety of patients and others...Restraints are not used as a means of coercion, discipline, convenience, or staff retaliation...The hospital uses the least restrictive form of restraint that protects the physical safety of the patient, staff or others...The hospital discontinues the use of restraint at the earliest possible time, regardless of the scheduled expiration of the order...Discontinuation of Restraint: Restraint shall be discontinued when the registered nurse or physician assesses that the behavior or condition that was the basis for the restraint order is resolved, or the criteria for discontinuing the restraint has been met regardless of the duration of the enabling order. If a restraint has been discontinued greater than 2 hours and is reapplied, a new physician order must be obtained...."

Review of the medical records revealed:

-Patient #4 had no documentation of attempts to release from restraints by either nursing or medical staff in the medical record.
-Patient #8 had no documentation of attempts to release from restraints by either nursing or medical staff in the medical record.
-Patient #11 had no documentation of attempts to release from restraints by either nursing or medical staff in the medical record.
-Patient #13 had no documentation of attempts to release from restraints by either nursing or medical staff in the medical record.
-Patient #15 had no documentation of attempts to release from restraints by either nursing or medical staff in the medical record.

Employee #9 confirmed during an interview on 06/13/2023 that there was no documentation present in the medical records regarding attempts to release patients from restraints.

Based on review of policies and procedures, hospital documents, medical records and staff interviews, it was determined the administrator failed to ensure that five (5) patients placed in restraints had with a face-to-face examinations by providers . (Patient #4, #8, #11, #13, #15) This deficient practice poses a risk to the health and safety of patients if patients are placed in restraints unnecessarily or inappropriately.

Cross Reference A-0115

Repeat deficiency Event #WYP611 9/17/2020

Findings include:

Policy titled, "Restraints", revealed: "...Patients have the right to be free from restraints...Restraints are only used when they are therapeutically necessary and ordered by the physician for the safety of patients and others...Monitoring the physical and psychological well-being of the patient who is restrained, including but not limited to, respiratory and circulatory status, skin integrity, vital signs, and any special requirements specified by hospital policy associated with the 1-hour face-to-face evaluation...."

Hospital document titled, " KPC Promise Hospital Medical Staff Rules and Regulations", revealed: "...The use of mechanical restraints shall require clinical justification and shall be used only to prevent a patient from injuring himself or others or to prevent serious disruption of the therapeutic environment. Mechanical restraints shall not be used as a means of punishment or for staff convenience. Restraint orders shall be renewed every twenty-four hours and a face-to-face evaluation is required prior to renewal... Each written order for a mechanical restraint shall be time limited. PRN orders shall not be used to authorize the use of restraints...."

Review of the medical records revealed:

-Patient #4 had no documentation present in the daily provider notes of face-to-face assessments/evaluations prior to the initiation or renewal of restraint orders.
-Patient #8 had no documentation present in the daily provider notes of face-to-face assessments/evaluations prior to the initiation or renewal of restraint orders.
-Patient #11 had no documentation present in the daily provider notes of face-to-face assessments/evaluations prior to the initiation or renewal of restraint orders.
-Patient #13 had no documentation present in the daily provider notes of face-to-face assessments/evaluations prior to the initiation or renewal of restraint orders.
-Patient #15 had no documentation present in the daily provider notes of face-to-face assessments/evaluations prior to the initiation or renewal of restraint orders.

Employee #9 confirmed during an interview on 06/13/2023 that a face-to-face evaluation should be performed by the medical provider for patients placed in restraints.

Based on review of policies and procedures, hospital documents, medical records and staff interviews, it was determined the administrator failed to ensure five (5) patients placed in restraints had documentation for the continued need/use of restraints in the medical record. (Patient #4, #8, #11, #13, #15) This deficient practice poses a risk to the patient of injury, deteriorating skin conditions, harm to patients for being restrained for extended amounts of time without release or attempts at release and / or loss of autonomy.

Cross Reference A-0115

Repeat deficiency Event WYP611 9/17/2020

Findings include:

Policy titled, "Restraints", revealed: "...Patient Monitoring: type and location of the restraining device(s) shall be documented within an hour of placement and every two (2) hours thereafter...Rationale for restraint (observed condition or behavior) shall be assessed on an ongoing basis and documented every two (2) hours...Monitoring the physical and psychological well-being of the patient who is restrained, including but not limited to, respiratory and circulatory status, skin integrity, vital signs, and any special requirements specified by hospital policy associated with the 1-hour face-to-face evaluation...."

Hospital document titled, " KPC Promise Hospital Medical Staff Rules and Regulations", revealed: "...The use of mechanical restraints shall require clinical justification and shall be used only to prevent a patient from injuring himself or others or to prevent serious disruption of the therapeutic environment. Mechanical restraints shall not be used as a means of punishment or for staff convenience. Restraint orders shall be renewed every twenty-four hours and a face-to-face evaluation is required prior to renewal... Each written order for a mechanical restraint shall be time limited. PRN orders shall not be used to authorize the use of restraints...."

Review of the medical records revealed:
-Patient #4 had no documentation present in daily provider progress notes or nursing documentation indicating the need or rationale for continued use of restraints.
-Patient #8 had no documentation present in daily provider progress notes or nursing documentation indicating the need or rationale for continued use of restraints.
-Patient #11 had no documentation present in daily provider progress notes or nursing documentation indicating the need or rationale for continued use of restraints.
-Patient #13 had no documentation present in daily provider progress notes or nursing documentation indicating the need or rationale for continued use of restraints.
-Patient #15 had no documentation present in daily provider progress notes or nursing documentation indicating the need or rationale for continued use of restraints.

Employee # 9 confirmed during an interview on 06/13/2023 that the required restraint documentation was not present for Patients #4, #8, #11, #13, and #15.

Based on review of hospital polices/procedures, medical staff bylaws, medical staff rules and regulations, medical records and staff interviews, it was determined the administrator failed to ensure medical staff:

1. Evaluated/Assessed patients with a face-to-face evaluation after initiation or before renewal of restraints.
2. Document the required need for continuation of restraints in progress note documentation.
3. Authenticated telephone/verbal orders within the required timeframe.
4. Authenticated physician orders with a signature, time and date.
5. Authenticated progress notes within the required timeframe.
6. Documented daily progress notes on one (1) patient.

These deficient practices pose a risk to the health and safety of patients if medical staff do not follow the hospital's rules and regulations when providing patient care.

Cross Reference A-0115, A-0431

Repeat deficiency Event WYR611 9/17/2020

Findings include:

Hospital document titled, "KPC Promise Hospital Medical Staff Rules and Regulations", last revised May 2023 revealed; "...Daily progress notes shall be entered in the medical record by the attending physician or a designated mid-level provider...Each medical record entry shall conclude with the legible signature of the provider, indicating that provider's professional credential, and shall be dated and timed. Medical records which have illegible or incomplete signatures, including date and time, will be deemed incomplete. All restraints, now and STAT orders must be signed, dated and timed by the practitioner...All orders for treatment shall be in writing, timed, and dated and then signed by the physician...The attending practitioner shall be responsible for the preparation of a complete and legible medical record for each patient...The use of mechanical restraints shall require clinical justification and shall be used only to prevent a patient from injuring himself or others or to prevent serious disruption of the therapeutic environment. Mechanical restraints shall not be used as a means of punishment or for staff convenience. Restraint orders shall be renewed every twenty-four hours and a face-to-face evaluation is required prior to renewal... Each written order for a mechanical restraint shall be time limited. PRN orders shall not be used to authorize the use of restraints...All orders for treatment shall be in writing. A telephone order shall be considered in writing if given to a licensed nurse or licensed personnel as approved by the Medical Staff, functioning within their scope of practice and signed by the responsible practitioner. All telephone orders shall be "read back" to the physician to assure correctness...All orders dictated over the telephone by the practitioner shall be signed by the appropriately authorized persons who dictated with the name of the practitioner. The responsible practitioner shall authenticate such order within 48 hours...The practitioner's order must be written clearly, legibly, and completely. Orders which are illegible or improperly written will not ve carried out until rewritten and understood...."

1. and 2.
Review of medical records revealed the following five (5) patients (Patient #4, #8, #11, #13, #15) were placed in restraints without documentation of a face-to-face evaluation being conducted by a medical provider. Further review of the medical record revealed no documentation for these five (5) patients (Patient #4, #8, #11, #13, #15) for the need for continuation of restraints in the provider progress note:

-Patient #4 was admitted to the facility on 05/31/2023 to the ICU. Patient #4 was in restraints on 06/11/2023, 06/12/2023,and 06/13/202. Review of the provider progress notes revealed no documentation of a face-to-face evaluation being performed before the initiation or renewal of restraints or the need for continuation of restraints.
-Patient #8 was admitted to the facility on 06/11/2023. Patient #8 was in restraints on 06/11/2023, 06/12/2023, and 06/13/2023. Review of the provider progress notes revealed no documentation of a face-to-face evaluation being performed before the initiation or renewal of restraints or the need for continuation of restraints.
-Patient #11 was admitted to the facility on 04/29/2023. Patient #11 was in restraints on 05/21/2023, 05/22/2023, 05/23/2023, 05/24/2023, 05/26/2023, 06/08/2023, 06/09/2023, 06/10/2023, 06/11/2023, 06/12/2023, and 06/13/2023. Review of the provider progress notes revealed no documentation of a face-to-face evaluation being performed before the initiation or renewal of restraints or the need for continuation of restraints.
-Patient #13 was admitted to the facility on 05/02/2023. Patient #13 was in restraints 05/06/2023 through 05/14/2023, 05/17/2023 through 05/19/2023, 05/21/2023 though 05/26/2023, 05/31/2023 through 06/01/2023, 06/08/2023 through 06/10/203, 06/12/2023 though 06/13/2023. Review of the provider progress notes revealed no documentation of a face-to-face evaluation being performed before the initiation or renewal of restraints or the need for continuation of restraints.
-Patient #15 was admitted was admitted to the facility on 11/26/2022 and discharged on 02/14/2023. Patient #15 was in restraints on 01/27/2023, 01/28/2023, 01/30/2023,and 02/01/2023. Review of the provider progress notes revealed no documentation of a face-to-face evaluation being performed before the initiation or renewal of restraints or the need for continuation of restraints.

3. and 4.

Review of medical records revealed the following seven (7) patients had physician orders that had not been properly authenticated:

-Patient #9 (admit 2/1/2021 discharged 2/10/2021) one (1) telephone order not signed off 2/10/2021.
-Patient #10 (admit 11/11/2021 discharged 12/7/2021) one (1) telephone order not signed off 12/5/2021.
-Patient #11 (admit 4/29/2023) one (1) order not dated or timed, six (6) restraint orders without a time 05/21/2023, 05/22/2023, 05/23/2023, 05/24/2023, 05/26/2023.
-Patient #13 (admit 05/02/2023) three (3) telephone order not signed off 05/06/2023, 05/07/2023, 05/08/2023,
four (4) restraint orders without a signature or time 05/09/2023, 05/10/2023, 06/01/2023, 06/10/2023
eight (8) restraint orders without a time 05/14/2023, 05/17/2023, 05/18/2023, 05/19/2023, 05/23/2023, 06/08/2023, 06/09/2023, and 06/12/2023
-Patient #14 (admit 11/23/2022 discharged 12/6/2022) four (4) telephone orders not signed off 11/22/2022,11/26/2022,11/27/2022,11/30/2022.
-Patient #15 (admit 11/26/2022 discharged 02/14/2023) one (1) restraint order without a time 01/31/2023.
-Patient #23 (admit 05/19/2023) two (2) telephone orders not signed off 06/10/2023.


5.

Review of medical records revealed the following eleven (11) patients had incomplete provider notes:

-Patient #11 admitted 4/29/2023 had five (5) progress notes: 6/1/2023, 6/2/2023, 6/5/2023, 6/7/2023, 6/11/2023.
-Patient #12 admitted 6/2/2023 had six (6) progress notes: 6/6/2023, 6/7/2023, 6/8/2023, 6/9/2023, 6/10/2023, 6/11/2023.
-Patient #13 admitted 5/2/2023 had eighteen (18) progress notes: from each day from 5/23/2023 through 5/31/2023 and every day 6/1/2023 through 6/11/2023 except for 6/6/2023 (it was signed).
-Patient #16 admitted 5/26/2023 had nine (9) progress notes: 5/30/2023 through 6/5/2023, 6/7/2023 and 6/10/2023.
-Patient #17 admitted 05/29/2023 had three (3) progress notes: 6/7/2023, 6/8/2023 ,6/10/2023.
-Patient #18 admitted 5/9/2023 had eleven (11) progress notes: 5/29/2023 through 6/7/2023 and 6/10/2023.
-Patient #19 admitted 6/1/2023 had four (4) progress notes: 6/7/2023 through 6/10/2023.
-Patient #20 admitted 5/20/2023 had eighteen (18) progress notes: 5/23/2023 through 5/30/2023, 6/1/2023 through 6/5/2023 and 6/7/2023 through 6/10/2023.
-Patient#21 admitted 5/25/2023 had nine (9) progress notes: 5/29/2023, 5/30/2023, 6/1/2023 through 6/5/2023, 6/7/2023 and 6/10/2023.
-Patient #24 admitted 6/6/2023 had two (2) progress notes: 6/8/2023 and 6/10/2023.
-Patient #25 admitted 6/1/2023 had four (4) progress notes: 6/7/2023 through 06/10/2023.

6.

Review of medical records revealed daily provider progress notes were not documented for one (1) patient. (Patient #25)

-Patient #25 was admitted to the facility on 06/01/2023. Review of the medical record for Patient #25 revealed no medical provider progress notes were documented for 06/02/2023, 06/03/2023, 06/04/2023, 06/05/2023 or 06/06/2023.

Employee #3 confirmed during an interview on 06/14/2023 that patient medical records were incomplete and missing proper medical provider documentation.

Based on review of policies and procedures, nurse staffing assignments, and staff interview, it was determined the administrator failed to ensure that nurse staffing assignments for the Intensive Care Unit were made according to patient acuity guidelines. This deficient practice poses a risk to the health and safety of patients if there is not sufficient staffing to meet the needs of patients and promote patient safety.

Findings include:

Hospital policy titled, "Acuity Staffing Process, Nursing", revealed: "...To provide the process for making patien care assignments based upon individual needs of the patients, qualifications, and competencies of the nursing staff...ICU: Maximum acuity score per nurse is 10, which is a nurse ratio of 1:2...."

Review of the Intensive Care Unit nurse staffing assignments from 06/01/2023 through 06/13/2023 revealed ten (10) shifts with at least one (1) nurse assigned three (3) patients with a total acuity over ten (10). The following are the dates and shifts with the nursing assignments:
06/02/2023 day shift census 6 patients; 1 RN with 3 patients with total acuity of 13; 1 RN with 3 patients with total acuity of 13.
06/2/2023 night shift census 6 patients; 1 RN with 3 patients with total acuity of 12; 1 RN with 3 patients with total acuity of 14.
06/03/2023 day shift census 5 patients; 1 RN with 2 patients with total acuity of 8; 1 RN with 3 patients with total acuity of 13.
06/03/2023 night shift census 5 patients; 1 RN with 2 patients with total acuity of 8; 1 RN with 3 patients with total acuity of 13.
06/04/2023 night shift census 5 patients; 1 RN with 3 patients with total acuity of 13; 1 RN with 2 patients with total acuity of 7.
06/07/2023 night shift census 5 patients; 1 RN with 2 patients with total acuity of 8; 1 RN with 3 patients with total acuity of 12.
06/08/2023 night shift census 5 patients; 1 RN with 2 patients with total acuity of 8; 1 RN with 3 patients with total acuity of 12.
06/09/2023 day shift census 5 patients; 1 RN with 2 patients with total acuity of 8; 1 RN with 3 patients with total acuity of 12.
06/09/2023 night shift census 5 patients; 1 RN with 2 patients with total acuity of 8; 1 RN with 3 patients with total acuity of 12.
06/10/2023 day shift census 5 patients; 1 RN with 3 patients with total acuity of 11; 1 RN with 2 patients with total acuity of 9.

Employee #3 confirmed during an interview on 06/14/2023 that the ICU staffing assignments reviewed during the survey did not follow the Staffing Acuity guidelines.

Employee #16 confirmed during an interview on 06/14/2023, after reviewing the staffing assignments reviewed during the survey, that all the patients were ICU status patients and the ICU staffing acuity guidelines had not been followed when the nursing assignments had been made.

Based on review of policies and procedures, medical records and staff interviews, the Department determined the administrator failed to ensure required documentation was completed for five (5) patients in restraints.(Patient #4, #8, #11, #13, #15) This deficient practices poses a risk to the health and safety of patients if patients are kept in restraints unnecessarily and not assessed as required when they are in restraints.

Repeat deficiency Event #WYP611 9/17/2020

Findings include:

Policy titled, "Restraints", revealed: "...Patients have the right to be free from restraints...Restraints are only used when they are therapeutically necessary and ordered by the physician for the safety of patients and others...Restraints are not used as a means of coercion, discipline, convenience, or staff retaliation...The hospital uses the least restrictive form of restraint that protects the physical safety of the patient, staff or others...The hospital discontinues the use of restraint at the earliest possible time, regardless of the scheduled expiration of the order...Standing or PRN orders for restraints are not valid...A physician's order is valid until the next calendar day...Discontinuation of Restraint: Restraint shall be discontinued when the registered nurse or physician assesses that the behavior or condition that was the basis for the restraint order is resolved, or the criteria for discontinuing the restraint has been met regardless of the duration of the enabling order. If a restraint has been discontinued greater than 2 hours and is reapplied, a new physician order must be obtained...The attending physician shall perform m an in-person assessment of the restrained patient at least once every calendar day, at which time restraint shall be either re-ordered or discontinued as indicated...Patient Monitoring: type and location of the restraining device(s) shall be documented within an hour of placement and every two (2) hours thereafter...Rationale for restraint (observed condition or behavior) shall be assessed on an ongoing basis and documented every two (2) hours...Alternatives to and less restrictive forms of restraint considered by the caregiver shall be documented every two (2) hours...Other monitoring activities shall be performed at least every two (2) hours, or more frequently if indicated by the condition or behavior of the patient. During monitoring the patient shall be assessed for: signs of any injury associated with the use of restraint, nutrition and hydration needs, circulation, range of motion, hygiene and elimination, physical and psychological status and comfort, readiness for discontinuation or temporary removal from restraint...Monitoring the physical and psychological well-being of the patient who is restrained, including but not limited to, respiratory and circulatory status, skin integrity, vital signs, and any special requirements specified by hospital policy associated with the 1-hour face-to-face evaluation...."

Hospital document titled, "Critical Care Daily Flowsheet" revealed a documentation section titled Restraints. The Restraint section has across the top of the section boxes for time every hour starting at 0700 through 0600. The side of the Restraint section lists boxes of criteria to be documented: Type of restraint; Meets restraint documentation criteria* see specific documentation; (check mark symbol) equals alternative method used; release q 2 HR (every 2 hours) for ROM (range of motion)& skin integrity; (check mark symbol) equals restraint safety; behavioral patient. The bottom of the Restraint section there is box which includes : Restraint Documentation: Monitoring and Cares must be completed at least every 2 hours; Removal From: (check mark symbol ) equals restraint removed; (check mark symbol) equals ROM done; Safety: (check mark symbol) equals patient safety checks done...Alternative Methods (legend): 1. Close observation; 2. Wedge pillow-Positioning Devices; 3. Mitts (untied) Non-Bulky; 4. Self release seat belt; 5. Self release torso belt; 6. Bed alarm; 7. Personal alarm; 8. Placed in wheelchair at nurse station; 9. side rails X___; Type of Restraint (legend): A. ankle; B. waist belt; LE. lower extremity; V. vest restraint; 1X: 1:1 observation; S: soft; UE: upper extremity; M: mitt bulky; W: wrist; SR: siderails X 4. A box was also at the bottom of the restraint sections that states: * Document need for restraint; * Document alternative methods attempted; * Document Pt. and family education; * Document pulse status Q 2 hrs.; * Document repositioning; * Document nutrition, fluids, and toileting. Medical Surgical has a specific designated Daily Care Flowsheet with a similar section for Restraint documentation.

Review of medical records revealed the following five (5) patients in restraints had no documentation of required documentation:

-Patient #4 was admitted to the facility on 05/31/2023 to the ICU. Review of Patient #4 nursing progress notes dated 06/11/2023, 06/12/2023, 06/13/2023 revealed no documentation regarding the types of alternative methods utilized before restraints or the patient response to the alternative interventions. Further review of the medical record revealed Patient #4 had no documentation of attempts to release from restraints by nursing staff. Further review of the medical record revealed Patient #4 had no nursing documentation indicating the need or rationale for continued use of restraints.Further review of the medical record revealed Patient #4 was in restraints on 06/13/2023 without a physician order in place.

-Patient #8 was admitted to the facility on 06/11/2023. Review of Patient #8 nursing progress note revealed no documentation regarding the type of alternative method used or patient response to the alternative interventions. Further review of the medical record revealed Patient #8 had no documentation of attempts to release from restraints by nursing staff. Further review of the medical record revealed Patient #8 had no nursing documentation indicating the need or rationale for continued use of restraints.

-Patient #11 was admitted to the facility on 04/29/2023. Review of the daily care flowsheet revealed Patient #11 was in restraints on 05/21/2023, 05/22/2023, 05/23/2023, 05/24/2023, 05/26/2023, 06/08/2023, 06/09/2023, 06/10/2023, 06/11/2023, 06/12/2023, 06/13/2023. Review of the nursing progress note revealed no documentation regarding the type of alternate method and patient response to the alternative interventions. Further review of the medical record revealed Patient #11 had no documentation of attempts to release from restraints by nursing staff. Further review of the medical record revealed Patient #11 had no nursing documentation indicating the need or rationale for continued use of restraints.

-Patient #13 was admitted to the facility on 05/02/2023. Review of Patient #13 daily care flowsheet revealed Patient #13 was in restraints 05/06/2023 through 05/14/2023, 05/17/2023 through 05/19/2023, 05/21/2023 through 05/26/2023, 05/31/2023 through 06/01/2023, 06/08/2023 through 06/10/203, 06/12/2023 through 06/13/2023. Review of the daily care flowsheet revealed no documentation was present on the restraint section regarding alternate methods used for the entire 24 hour period on 06/12/2023. Review of Patient #13 nursing progress note revealed no documentation present for the dates Patient #13 was in restraints regarding the type of alternate methods or patient response to the alternative interventions. Further review of the medical record revealed Patient #13 had no documentation of attempts to release from restraints by nursing staff. Further review of the medical record revealed Patient #13 had no nursing documentation indicating the need or rationale for continued use of restraints.

-Patient #15 was admitted was admitted to the facility on 11/26/2022 and discharged on 02/14/2023. Review of Patient #15 daily care flowsheet revealed Patient #15 was in restraints on 01/27/2023, 01/28/2023, 01/30/2023, 02/01/2023. Review of the nursing progress notes for Patient #15 revealed no documentation regarding the alternate methods attempted or the patient reaction to the interventions attempted. Further review of the medical record revealed Patient #15 had no documentation of attempts to release from restraints by nursing staff. Further review of the medical record revealed Patient #15 had no nursing documentation indicating the need or rationale for continued use of restraints. Further review of the medical record revealed Patient #15 was in restraints on 01/27/2023 at 0030 through 01/28/2023 at 1600, 01/30/2023 at 0100 until 0900, 02/01/2023 at 2200 through 02/02/2023 at 0600. Review of the physician orders revealed restraint orders were written on 01/27/2023 at 0100, on 01/30/2023 at 0140 and 01/31/2023 with no time documented. Review of Patient #15 restraint record revealed Patient #15 was in restraints without a provider order on 01/28/2023 from 0030 until 1600. Patient #15 was in restraints without a provider order from 02/01/2023 at 2200 until 02/02/2023 at 0600

Employee #3 confirmed during an interview on 06/14/2023 that patient medical records did not contain the required nursing documentation for patients in restraints.

Based on facility documentation and interview, the Department determined the administrator failed to ensure that Medical Staff documented daily progress notes for one (1) patient (Patient #25). This deficient practice poses a risk to the health and safety of patients when there is no documentation on continuity of care and patient progress or condition.

Cross Reference A-0431

Findings include:

Hospital document titled, "KPC Promise Hospital Medical Staff Rules and Regulations" last revised May 2023, revealed: "...Daily progress notes shall be entered in the medical record by the attending physician or a designated mid-level provider...Each medical record entry shall conclude with the legible signature of the provider, indicating that provider's professional credential, and shall be dated and timed. Medical records which have illegible or incomplete signatures, including date and time, will be deemed incomplete...The attending practitioner shall be responsible for the preparation of a complete and legible medical record for each patient...."

Patient #25 was admitted to the facility on 06/01/2023. Review of the medical record for Patient #25 revealed no medical provider progress notes were documented for 06/02/2023, 06/03/2023, 06/04/2023, 06/05/2023 or 06/06/2023.

In an interview conducted on 06/14/2023, Employee #3 confirmed patient medical records were missing required documentation.

Based on facility documentation and interview, the Department determined the administrator failed to ensure that Medical Staff progress note entries in eleven (11) patient medical records were completed, dated, legible and authenticated, which poses a potential risk to patient health and safety. (Patient #11, #12, #13, #16, #17, #18, #19, #20,#21, #24, #25)

Cross Reference A-0431

Repeat deficiency Event WYP611 09/17/2020

Findings include:

Hospital document titled, "KPC Promise Hospital Medical Staff Rules and Regulations" last revised May 2023 revealed: "...Daily progress notes shall be entered in the medical record by the attending physician or a designated mid-level provider...Each medical record entry shall conclude with the legible signature of the provider, indicating that provider's professional credential, and shall be dated and timed. Medical records which have illegible or incomplete signatures, including date and time, will be deemed incomplete...The attending practitioner shall be responsible for the preparation of a complete and legible medical record for each patient...."

A review of medical records found the following patients provider progress notes with incomplete authentication:

-Patient #11 admitted 4/29/2023 had five (5) progress notes: 6/1/2023, 6/2/2023, 6/5/2023, 6/7/2023, 6/11/2023.
-Patient #12 admitted 6/2/2023 had six (6) progress notes: 6/6/2023, 6/7/2023, 6/8/2023, 6/9/2023, 6/10/2023, 6/11/2023.
-Patient #13 admitted 5/2/2023 had eighteen (18) progress notes: from each day from 5/23/2023 through 5/31/2023 and every day 6/1/2023 through 6/11/2023 except for 6/6/2023 (it was signed).
-Patient #16 admitted 5/26/2023 had nine (9) progress notes: 5/30/2023 through 6/5/2023, 6/7/2023 and 6/10/2023.
-Patient #17 admitted 05/29/2023 had three (3) progress notes: 6/7/2023, 6/8/2023 ,6/10/2023.
-Patient #18 admitted 5/9/2023 had eleven (11) progress notes: 5/29/2023 through 6/7/2023 and 6/10/2023.
-Patient #19 admitted 6/1/2023 had four (4) progress notes: 6/7/2023 through 6/10/2023.
-Patient #20 admitted 5/20/2023 had eighteen (18) progress notes: 5/23/2023 through 5/30/2023, 6/1/2023 through 6/5/2023 and 6/7/2023 through 6/10/2023.
-Patient#21 admitted 5/25/2023 had nine (9) progress notes: 5/29/2023, 5/30/2023, 6/1/2023 through 6/5/2023, 6/7/2023 and 6/10/2023.
-Patient #24 admitted 6/6/2023 had two (2) progress notes: 6/8/2023 and 6/10/2023.
-Patient #25 admitted 6/1/2023 had four (4) progress notes: 6/7/2023 through 06/10/2023.

In an interview conducted on 06/14/2023, Employee #3 confirmed the progress notes had not been authenticated by the medical provider.

Based on facility documentation and interview, the Department determined the administrator failed to medical providers orders were dated, legible and authenticated for seven (7) patients. (Patient #9, #10, #11, #13,#14, #15, #23) This deficient practice poses a risk to the health and safety of patients if patients are provided treatments that have been ordered incorrectly or improperly.

Cross Reference A-0431

Repeat deficiency Event #WYP611 09/17/2020

Findings include:

Hospital document titled, "KPC Promise Hospital Medical Staff Rules and Regulations" last revised May 2023, revealed: "...Each medical record entry shall conclude with the legible signature of the provider, indicating that provider's professional credential, and shall be dated and timed. Medical records which have illegible or incomplete signatures, including date and time, will be deemed incomplete. All restraints, now and STAT orders must be signed, dated and timed by the practitioner...All orders for treatment shall be in writing, timed, and dated and then signed by the physician...The attending practitioner shall be responsible for the preparation of a complete and legible medical record for each patient...All orders for treatment shall be in writing. A telephone order shall be considered in writing if given to a licensed nurse or licensed personnel as approved by the Medical Staff, functioning within their scope of practice and signed by the responsible practitioner. All telephone orders shall be "read back" to the physician to assure correctness...All orders dictated over the telephone by the practitioner shall be signed by the appropriately authorized persons who dictated with the name of the practitioner. The responsible practitioner shall authenticate such order within 48 hours...The practitioner's order must be written clearly, legibly, and completely. Orders which are illegible or improperly written will not ve carried out until rewritten and understood...."

A review of medical records revealed the following seven (7) patients had incomplete orders. (Patient #9, #10, #11, #13,#14,#15, #23):

-Patient #9 (admit 2/1/2021 discharged 2/10/2021) one (1) telephone order not signed off 2/10/2021.
-Patient #10 (admit 11/11/2021 discharged 12/7/2021) one (1) telephone order not signed off 12/5/2021.
-Patient #11 (admit 4/29/2023) one (1) order not dated or timed, six (6) restraint orders without a time 05/21/2023, 05/22/2023, 05/23/2023, 05/24/2023, 05/26/2023.
-Patient #13 (admit 05/02/2023) three (3) telephone order not signed off 05/06/2023, 05/07/2023, 05/08/2023,
four (4) restraint orders without a signature or time 05/09/2023, 05/10/2023, 06/01/2023, 06/10/2023
eight (8) restraint orders without a time 05/14/2023, 05/17/2023, 05/18/2023, 05/19/2023, 05/23/2023, 06/08/2023, 06/09/2023, and 06/12/2023
-Patient #14 (admit 11/23/2022 discharged 12/6/2022) four (4) telephone orders not signed off 11/22/2022,11/26/2022,11/27/2022,11/30/2022.
-Patient #15 (admit 11/26/2022 discharged 02/14/2023) one (1) restraint order without a time 01/31/2023.
-Patient #23 (admit 05/19/2023) two (2) telephone orders not signed off 06/10/2023..

In an interview conducted on 06/14/2023, Employee #3 confirmed the orders were incomplete and missing components to be considered a complete medical record.

Based on review of policies and procedures, hospital documents, medical records and staff interviews, it was determined the administrator failed to ensure a discharge order was documented in the medical record for one (1) patient (Patient #26).

Cross Reference A-0431

Findings include:

Policy titled, "Transfers", revealed: "...1. A change in condition resulting in service or care that cannot be provided at KPC Promise Hospital will result in the transfer of a patient ...Emergency Transfer/Hospital to Hospital Transfers ... Obtain a physician order for transfer. The order will define the appropriate level of care required during the transfer .... If the consulting physician is requesting for patient to be transferred, the consulting physician or primary care nurse will obtain an order from the admitting physician to transfer the patient...."

Document titled, " KPC Promise Hospital of Phoenix Medical Staff Rules and Regulations", revealed: "...Whenever physician's responsibilities are transferred to another practitioner/medical group, a note governing the transfer of responsibility shall be entered on the order sheet and progress note of the medical record and will notify the Medical Staff Coordinator...."

Patient #26's medical record review revealed no evidence of a medical provider transfer order.

Employees #3, #7 and #9 each confirmed in separate interviews conducted on 06/14/2023 they were unable to locateorder for the transfer.

Based on review of policies and procedures, hospital documents, medical records and staff interviews, it was determined the administrator failed to ensure a discharge summary was documented in the medical record for one (1) patient (Patient #26).

Cross Reference A-0431

Findings include:

Document titled, " KPC Promise Hospital of Phoenix Medical Staff Rules and Regulations", revealed: "...Whenever physician's responsibilities are transferred to another practitioner/medical group, a note governing the transfer of responsibility shall be entered on the order sheet and progress note of the medical record and will notify the Medical Staff Coordinator. A progress note summarizing the patient's condition and treatment shall be made and the practitioner transferring his responsibility shall personally notify the other practitioner to ensure the acceptance of that responsibility is clearly understood...15. Practitioners shall:...b) Adhere to hospital admitting and discharge policies and procedures/rules and regulations .... 17. In case of urgent need for transfer to another healthcare facility due to an acute medical condition or mental disturbance, the attending physician will make arrangements for immediate transfer to the most appropriate healthcare facility. The physician making the transfer should also provide any medical information necessary for the receiving physician to initiate safe and appropriate treatment. Should the attending physician fail to make such arrangements, the Medical Director or the Chief of Staff may affect the transfer." A portion of the same document titled, " Medical Records " revealed, " 11. A Discharge Summary shall be completed on patients hospitalized. The responsible physician shall sign all summaries. Discharge Summaries must be completed within thirty (30) days of the patient's discharge; however, expiration summaries must be dictated within seventy-two (72) hours. 12. The Discharge Summary shall include:
a) The final diagnosis;
b) Complications and infections (if any);
c) Procedures performed during admissions;
d) A summary of pertinent history, physical findings, laboratory and x-ray results;
e) Reasons for hospitalization;
f) Progress during hospitalization;
g) Functional status at time of discharge;
h) Special instructions, equipment, diet etc.;
i) List of medications;
j) Rehabilitation potential; and
k) Follow-up plan and physician for follow-up care...."

Patient #26's medical record with an admission date of 11/17/2022 revealed, " FACE SHEET ... DISCHARGE DATE: 11/22/2022 TIME: 10:17 ... DISCHARGE TO Disch/Trfr to Critical Acc " . Review of the medical record revealed no provider progress note documenting the rationale for Patient #26 being transfer to another acute care facility. Further review of the medical record revealed no evidence of a nursing progress note regarding the patient's transfer to another acute care facility. Further review revealed no evidence of a discharge plan. Further review revealed no evidence of a discharge order or discharge summary documented by the medical provider. Further review revealed no evidence of a medical provider transfer order.

Employees #3, #7 and #9 each confirmed in separate interviews conducted on 06/14/2023 they were unable to locate a discharge plan and a discharge summary for Patient #26. Furthermore, Employee #3, #7, and #9 were each individually asked to locate evidence of a reason for transfer, location of the transfer, order for the transfer, or any documentation regarding the transfer of this patient, no documentation was provided.

Based on a review of hospital records and interview, the Department determined the hospital failed to have an Infection Preventionist trained in infection control practices and procedures. This deficient practice poses the risk of infectious organisms not being identified, contagions spreading throughout staff and patient populations, the inability to track trends throughout the hospital, and no monitoring of infection control mitigation.

Findings include:

Hospital document titled, "Infection Prevention Plan 2023", revealed: "...The Infection Prevention Committee is responsible for oversight and recommendations for prevention, identification and control of infections within KPC Promise Hospital. The Infection Prevention Committee is composed of physician, Chief Clinical Officer, Infection Control Coordinator, Respiratory Manager, Director of Quality Improvement/Risk Management, Director of Pharmacy and Director of Nursing...The Infection Control Coordinator has the authority to develop and implement a system for surveillance and prevention of infections, identifying, reporting, and analyzing clusters of infections, outbreaks, sentinel events, emerging pathogens, and special studies or reports...The Infection Control Coordinator develops a system for identifying, reporting and analyzing the incidence and causes of healthcare acquired infections...Monitors patient admissions and placement...Identifies when a patient is transferred or referred with a healthcare acquired infection that was not known at the time of transfer or referral...Provides or oversees infection prevention education...Reports state mandated reportable diseases and coordinates with the public health department and other appropriate government and regulatory agencies for the reporting, investigation, and prevention of infections...."

Review of the hospital Organizational Chart revealed the Infection Preventionist/Infection Control Coordinator position was vacant.

Employee #1 and #3 confirmed during an interview on 06/13/2023 that the facility did not have an Infection Preventionist. Employee #1 confirmed that the Infection Control Coordinator had quit earlier in the month and the position was vacant.

Based on review of policies and procedures, medical records and staff interviews, it was determined the administrator failed to ensure 12 of 27 patients had a discharge plan documented in the medical record. (Patients #1, 2, 8, 12, 17, 19, 20, 21, 22, 24, 25, 27).This deficient practice poses a risk to the health and safety of patients when continuity of care is not ensured post discharge.

Cross Reference A-0799

Findings include:

Hospital policy titled, "Discharge Planning and Interdisciplinary Process", revealed: "...Discharge planning starts during the pre-admission phase of the assessment process...All patients will have an IAA Social Services/Case Management started upon admission to facilitate a safe and coordinated discharge to the appropriate post acute provider and community resources...The case manager/social worker will work with the patient and family, members f the patients's healthcare team, and the payor to formulate a safe and coordinated discharge plan...The patient's discharge plan and goals identified during the pre-admission phase will be assessed on admission and adjusted to meet the discharge needs of the patient and family...The interdisciplinary team discharge plan will include the expected discharge disposition, anticipated length of stay, prognosis for achieving long term goals, identification of obstacles to overcome and a continuing plan of action to safely discharge the patient...."

Review of 27 medical records revealed 12 patients had no documented discharge in place.

Patient #1 was admitted on 06/03/2023. Review of Patient #1 medical record revealed no documentation of a discharge plan in place.

Patient #2 was admitted on 05/18/2023. Review of Patient #2 medical record revealed no documentation of a discharge plan in place.

Patient #8 was admitted to the facility on 06/11/2023. Review of Patient #8 medical record revealed no documentation of a discharge plan in place.

Patient #12 was admitted to the facility on 06/02/2023. Review of Patient #12 medical record revealed no documentation a discharge plan in place..

Patient #17 was admitted to the facility on 05/29/2023. Review of Patient #17 medical record revealed no documentation of a discharge plan in place.

Patient #19 was admitted to the facility on 06/01/2023. Review of Patient #19 medical record revealed no documentation of a discharge plan in place.

Patient #20 was admitted to the facility on 05/20/2023. Review of Patient #20 medical record revealed no documentation of a discharge plan in place.

Patient #21 was admitted to the facility on 05/25/2023. Review of Patient #21 medical record revealed no documentation of a discharge plan in place.

Patient #24 was admitted to the facility on 06/06/2023. Review of Patient #24 medical record revealed no documentation of a discharge plan in place.

Patient #25 was admitted to the facility on 06/01/2023. Review of Patient #25 medical record revealed no documentation of a discharge plan in place.

Patient #27 was admitted to the facility on 11/17/2022 and discharged on 11/22/2022. Review of Patient #8 medical record revealed no documentation of a discharge plan in place.

Employee #9 confirmed during an interview on 06/13/2023 that every patient should have a discharge plan in place which should be initiated at time of admission.

Based on review of policies and procedures, medical records and staff interviews, the Department determined that the administrator failed to ensure the patient or patient representative were included in the discharge planning of 12 out of 27 patients. (Patients #1, 2, 8, 12, 17, 19, 20, 21, 22, 24, 25, 27).This deficient practice poses a risk to the health and safety of patients when patients and patient representatives are not aware of the discharge plan to meet the needs and wishes of patients.

Cross Reference A-0799

Findings include:

Hospital policy titled, "Discharge Planning and Interdisciplinary Process", revealed: "...Discharge planning starts during the pre-admission phase of the assessment process...All patients will have an IAA Social Services/Case Management started upon admission to facilitate a safe and coordinated discharge to the appropriate post acute provider and community resources...The case manager/social worker will work with the patient and family, members f the patients's healthcare team, and the payor to formulate a safe and coordinated discharge plan...The patient's discharge planning needs will be reassessed. The reassessment will include the patient, family and the interdisciplinary team....The case manager/social worker will work with the patient and family to ensure there is participation in the discharge planning process and the patient and family agree with the discharge plan and goals...."

Review of 27 medical records revealed 12 patients had no evidence of documentation regarding involvement of the patient or patient representative with the patient's discharge plan.

Patient #1 was admitted on 06/03/2023. Review of Patient #1 medical record revealed no documentation of patient or family involvement in the discharge process.

Patient #2 was admitted on 05/18/2023. Review of Patient #2 medical record revealed no documentation of patient or family involvement in the discharge process.

Patient #8 was admitted to the facility on 06/11/2023. Review of Patient #8 medical record revealed no documentation of patient or family involvement in the discharge process.

Patient #12 was admitted to the facility on 06/02/2023. Review of Patient #12 medical record revealed no documentation that the patient or family were involved in the patient's discharge plan.

Patient #17 was admitted to the facility on 05/29/2023. Review of Patient #17 medical record revealed no documentation that the patient or family were involved in the patient's discharge plan.

Patient #19 was admitted to the facility on 06/01/2023. Review of Patient #19 medical record revealed no documentation of patient or family involvement with the discharge planning process.

Patient #20 was admitted to the facility on 05/20/2023. Review of Patient #20 medical record revealed no documentation of patient or family involvement with the discharge planning process.

Patient #21 was admitted to the facility on 05/25/2023. Review of Patient #21 medical record revealed no documentation of patient or family involvement with the discharge planning process.

Patient #24 was admitted to the facility on 06/06/2023. Review of Patient #24 medical record revealed no documentation of patient or family involvement with the discharge planning process.

Patient #25 was admitted to the facility on 06/01/2023. Review of Patient #25 medical record revealed no documentation of patient or family involvement with the discharge planning process.

Patient #27 was admitted to the facility on 11/17/2022 and discharged on 11/22/2022. Review of Patient #8 interdisciplinary care plan revealed no documentation of patient or family involvement with the patient's discharge plan.

Employee #9 confirmed during an interview on 06/13/2023 that patients or the patient's representative should be involved in all parts of the patient's care plan including discharge planning and it should be documented in the medical record.