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Based on the hospital policies/procedures, Patient Identifier (PI) #11's medical record documentation, and interviews, staff members failed to follow the hospital policy relative to recording the behaviors, complaints, and actions taken with PI #11's family member in November 2009.
On 11/18/2010, an emergency room staff member reportedly observed PI #11's family member using hospital equipment to suction PI #11. When emergency staff intervened, the family member stated he/she [family member] had to suction PI #11 because emergency room staff members were not doing their job.
Emergency room staff members aware of the family member's behavior and statements failed to document this incident in PI #11's medical record or on an incident / occurrence report.
This deficient practice effected PI #11, one of twelve sampled patients.
Findings Include:

3. Facility Policy:
The "Plan for the Provision of Patient Care" policy, issued 7/25/2009 and last reviewed on 8/4/2009. includes:
"...Risk Management shall be notified immediately of any significant occurrences to patients, visitors, volunteers, or personnel, which have the potential for serious harm ...Resolution and appeal processes of patient complaints, are accessed through Risk Management.
SECURITY ...shall provide a secure and safe environment that allows patients, visitors, staff ...to deliver or receive services with minimal threats against their personal safety and property..."

The "Sentinel Event Policy" revised 5/6/09 and issued on 11/2/09 includes:
"...PURPOSE: To establish guidelines to ensure the identification and reporting of sentinel events and near misses and to performance of root cause analyses as part of the hospital ' s quality assurance and quality improvement processes.
...Definitions:
...A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof ...
(Near Miss) The phrase "or the risk thereof" includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome.
...Good Catch: refers to an incident with process variations that did could have resulted in the occurrence of a sentinel event, but which a stop in the process prevented the event from happening.
...PROCEDURE:
...Upon recognition of circumstances that appear to meet the definition of a sentinel event or good catch ...medical and hospital staff shall be responsible for report them to the Quality Director and their immediate supervisor.
...The Quality Director or designee shall initiate an investigation of the circumstances within 72 hours of knowledge of the event.
...The Risk manager shall assist medical and hospital staff in conducting immediate mitigation of circumstances, including prevention of further harm and disclosure of information to the patient and/or family ...Patient and their families, as appropriate, shall be informed of unanticipated outcomes of care, treatment, and services that meet the definition of a sentinel event as defined in...this policy..."

2. Documentation in Patient Identifier PI #11's closed medical record noted this patient arrived by ambulance on 11/18/2009 at 12:11 p.m., and was subsequently admitted to the hospital. PI #11's diagnoses include: Cardiac Disease, Congestive heart failure (CHF), Cardiovascular accident (CVA), Stage IV Sacral Decubitus (present at the time of 11/18/09 admission), Insulin dependant diabetes, Urinary Tract Infection, and PEG tube insertion.

On 11/18/2009, the emergency department physician noted PI #11 arrived from a local nursing home "...nonresponsive...bleeding from PEG tube..." and noted the patient was on "Hospice" at the nursing home.

PI # 11 had no documented respiratory distress or congestion noted by the emergency physician or the emergency room nurses on 11/18/2009,

A security activity report notation, dated 11/18/2009, includes: "...treatment area [emergency room]...female were in the room she were sucking cold out of her mother mouth she did not have authority to do what she were doing in room...talking to her she pull a tape player out of her pocket...escort her from the ER..."

The 11/24/2009 Discharge Summary noted PI #11"...was seen in the ER [emergency room] from the nursing home with reports of bleeding from the PEG tube. There was gross blood able to be gotten from out of the PEG tube in the ER. GI [gastrointestinal] and Surgery saw her [PI #11]. She did have a 4-6 cm abscess in her abdominal wall ...performed I&D [incision and drainage] of the abscess ... has ... chronic pyuria..." PI #11 was transferred by ambulance to another local nursing home on 11/24/09.

There is no emergency room notation, medical record documentation, or incident/occurrence report that records PI #11's family member's behavior, or her (family member) statements about lack of care by emergency room staff, while PI #11 was in the emergency room on 11/18/2009.

3. Interviews:
On 1/27/2010 at 10:50 a.m., the emergency room nurse that assessed PI #11 on 11/18/2009 was interviewed. This nurse recalled observing the family member enter the treatment room, shortly he/she [nurse] finished assessing PI #11. According to this witness, the family member did not ask questions or voice complaints about PI #11's care.

On 1/28/2010 at 09:00 a.m., another emergency room nurse (on duty when PI #11 arrived in the emergency room 11/18/09) was interviewed. This nurse recalled he/she was passing PI #11's room and observed the family member holding a suction catheter and suctioning PI #11's mouth. This nurse entered the room, asked the family member for the suction quipment and explained hospital staff would do this for the patient. This nurse recalled the family member saying she (family member) connected the suction and began suctioning of PI #11 because the hospital emergency room staff were not doing their job. This nurse stated, while talking to the family member she (family member) particially removed and replaced an unidentified object into her (family member's) pocket and stated she (family member) was recording "this." The nurse said the family member did not indicate what was being recorded, or why. After leaving the room, this nurse reportedly informed the emergency room physician of the family member's activities. This witness did not document observing the family member suctioning PI #11, nor the family member's statements about staff not doing their job.

On 1/27/2009 at 2:10 p.m., the emergency room physician that provided care to PI #11 on 11/18/2009 was interviewed. The doctor recalled being informed by a nurse that PI# 11's family member was suctioning the patient. The physician requested security be called and went to talk with the family member. While talking with the family member, this physician reportedly heard a clicking sound and noted the family member repeatedly putting a hand into a jacket pocket. This physician stated she had security called because she (doctor) did not know what was making the clicking sound coming from the family member's pocket.
The physician did not document her conversations or observations with this family member, nor the concern that lead to a request for hospital security intervention.

On 1/27/2010 at 1:20 p.m., the security guard who responded to the emergency room on 11/18/2009 was interviewed. This security staff member recalled talking with and escorting PI #11's family member from the treatment area. This witness recalled PI #11's family member stated she was recording as she (family member) lifted a small square object from her (family member) pocket. The family member did not indicate who or what was being recorded, nor explain why she (family member) felt a need to record in the emergency room. The security officer recalled this family member saying she was going to talk with the administrator, after being escorted from the emergency treatment area. The security staff recalled the family member returned to the emergency department and was allowed back into the the treatment room with PI #11.

On 1/28/2010 at 09:35 a.m., the emergency department's nurse manager recalled being on duty 11/18/2009 and overhearing the doctor request security. The nurse manager did not document the incident or question staff as the emergency room charge nurse reportedly handled the incident.

On 1/28/2010 at 10:30 a.m., the administrator on duty at the time of the 11/18/2009 incident involving PI #11 was interviewed. This administrator recalled PI #11's family member coming to administration and complaining about security asking her (family) to leave PI # 11's treatment room because she (family member) was suctioning the patient. The administrator reportedly told this family member that she (family) could not be treating the patient but she could return to the patient's room. The administrator did not document or direct other staff members to document the family member's behaviors or complaints relative to this event.

Based on interviews and medical record review, hospital staff failed to assure Patient Identifier (PI) #11's plan of care addressed the patient's identified needs and was updated to reflect PI #11's specific medical and nutritional needs.
This deficient practice effected PI #11, one of eleven sampled patients.
Findings Include:

Patient Identifier # 11 was admitted to the hospital on 11/18/2009 with diagnosis that include: Abscessed PEG site, Insulin Dependent Diabetes, Stage IV Sacral Decubitus, Urinary Tract Infection, Multi-Infarct Dementia, Seizures, and history of Cardiac disease that includes Congestive heart failure.

The 11/18/2009 emergency room record documentation notes PI #11 arrival by ambulance to the emergency department. The emergency room physician note PI #11 was "nonresponsive...bleeding from PEG tube...,"and ...on "Hospice..." prior to admission.

A security activity report, dated 11/18/2009, noted the family member with PI # 11 was in the "...treatment area...sucking cold out of...[PI #11's] mouth...did not have authority to do...pull a tape player out of her [family member's] pocket...escort her [family member] from the ER..."

The dietitian's 11/20/2009 nutritional assessment used an approximate weight, that was 40 pounds under the actual weight noted by nurses on the unit, to calculate PI #11's nutritional needs. The suggestions by the dietitian were not added to the plan of care.

PI #11's plan of care included a list of preprinted problems listed on a form. This form included a "Status" section where staff could check each preprinted problem as an Actual, Potential, or N/A [not applicable].

PI# 11's 11/19/2009 plan of care includes the following selection of problems (as indicated by staff signature):
"Problem: Alteration in skin Integrity R/T [related to] Prolonged Immobility"
"Goal: No break in skin integrity"

Staff failed to indicate if the problems selected was an actual, potential, or not applicable problem or concern.

The "Nursing Diagnosis..." plan of care includes:
"...Potential for anxiety R/T knowledge deficit, separation from SO's [significant others] loss of control, procedure pain, diagnostic results, and/or care after discharge..."
"Goals: Pt [patient] nonresponsive..."
"Goal Met:" is marked "No."

The Nursing Diagnosis for "...Lack of knowledge related to poor recall..."
Goals: "...Family ...[patient] will be able to explain and specific intr. [instructions] Teaching methods utilized consistent with patient preference..."
Goal Met is marked: "Yes"

PI # 11's medical conditions documented on the 11/18/2009 admission included Peg Tube Abscess with active bleeding, Insulin dependent diabetes, Stage IV sacral decubitus, Chronic urinary catheter, and Urinary tract infection. The 11/19/2009 plan of care did not identify these as actual problems or concerns at the time of the patient's admission.

Based on the hospital policies/procedures, Patient Identifier (PI) #11's medical record documentation, and interviews, staff members failed to follow the hospital policy relative to recording the behaviors, complaints, and actions taken with PI #11's family member in November 2009.
On 11/18/2010, an emergency room staff member reportedly observed PI #11's family member using hospital equipment to suction PI #11. When emergency staff intervened, the family member stated he/she [family member] had to suction PI #11 because emergency room staff members were not doing their job.
Emergency room staff members aware of the family member's behavior and statements failed to document this incident in PI #11's medical record or on an incident / occurrence report.
This deficient practice effected PI #11, one of twelve sampled patients.
Findings Include:

3. Facility Policy:
The "Plan for the Provision of Patient Care" policy, issued 7/25/2009 and last reviewed on 8/4/2009. includes:
"...Risk Management shall be notified immediately of any significant occurrences to patients, visitors, volunteers, or personnel, which have the potential for serious harm ...Resolution and appeal processes of patient complaints, are accessed through Risk Management.
SECURITY ...shall provide a secure and safe environment that allows patients, visitors, staff ...to deliver or receive services with minimal threats against their personal safety and property..."

The "Sentinel Event Policy" revised 5/6/09 and issued on 11/2/09 includes:
"...PURPOSE: To establish guidelines to ensure the identification and reporting of sentinel events and near misses and to performance of root cause analyses as part of the hospital ' s quality assurance and quality improvement processes.
...Definitions:
...A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof ...
(Near Miss) The phrase "or the risk thereof" includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome.
...Good Catch: refers to an incident with process variations that did could have resulted in the occurrence of a sentinel event, but which a stop in the process prevented the event from happening.
...PROCEDURE:
...Upon recognition of circumstances that appear to meet the definition of a sentinel event or good catch ...medical and hospital staff shall be responsible for report them to the Quality Director and their immediate supervisor.
...The Quality Director or designee shall initiate an investigation of the circumstances within 72 hours of knowledge of the event.
...The Risk manager shall assist medical and hospital staff in conducting immediate mitigation of circumstances, including prevention of further harm and disclosure of information to the patient and/or family ...Patient and their families, as appropriate, shall be informed of unanticipated outcomes of care, treatment, and services that meet the definition of a sentinel event as defined in...this policy..."

2. Documentation in Patient Identifier PI #11's closed medical record noted this patient arrived by ambulance on 11/18/2009 at 12:11 p.m., and was subsequently admitted to the hospital. PI #11's diagnoses include: Cardiac Disease, Congestive heart failure (CHF), Cardiovascular accident (CVA), Stage IV Sacral Decubitus (present at the time of 11/18/09 admission), Insulin dependant diabetes, Urinary Tract Infection, and PEG tube insertion.

On 11/18/2009, the emergency department physician noted PI #11 arrived from a local nursing home "...nonresponsive...bleeding from PEG tube..." and noted the patient was on "Hospice" at the nursing home.

PI # 11 had no documented respiratory distress or congestion noted by the emergency physician or the emergency room nurses on 11/18/2009,

A security activity report notation, dated 11/18/2009, includes: "...treatment area [emergency room]...female were in the room she were sucking cold out of her mother mouth she did not have authority to do what she were doing in room...talking to her she pull a tape player out of her pocket...escort her from the ER..."

The 11/24/2009 Discharge Summary noted PI #11"...was seen in the ER [emergency room] from the nursing home with reports of bleeding from the PEG tube. There was gross blood able to be gotten from out of the PEG tube in the ER. GI [gastrointestinal] and Surgery saw her [PI #11]. She did have a 4-6 cm abscess in her abdominal wall ...performed I&D [incision and drainage] of the abscess ... has ... chronic pyuria..." PI #11 was transferred by ambulance to another local nursing home on 11/24/09.

There is no emergency room notation, medical record documentation, or incident/occurrence report that records PI #11's family member's behavior, or her (family member) statements about lack of care by emergency room staff, while PI #11 was in the emergency room on 11/18/2009.

3. Interviews:
On 1/27/2010 at 10:50 a.m., the emergency room nurse that assessed PI #11 on 11/18/2009 was interviewed. This nurse recalled observing the family member enter the treatment room, shortly he/she [nurse] finished assessing PI #11. According to this witness, the family member did not ask questions or voice complaints about PI #11's care.

On 1/28/2010 at 09:00 a.m., another emergency room nurse (on duty when PI #11 arrived in the emergency room 11/18/09) was interviewed. This nurse recalled he/she was passing PI #11's room and observed the family member holding a suction catheter and suctioning PI #11's mouth. This nurse entered the room, asked the family member for the suction quipment and explained hospital staff would do this for the patient. This nurse recalled the family member saying she (family member) connected the suction and began suctioning of PI #11 because the hospital emergency room staff were not doing their job. This nurse stated, while talking to the family member she (family member) particially removed and replaced an unidentified object into her (family member's) pocket and stated she (family member) was recording "this." The nurse said the family member did not indicate what was being recorded, or why. After leaving the room, this nurse reportedly informed the emergency room physician of the family member's activities. This witness did not document observing the family member suctioning PI #11, nor the family member's statements about staff not doing their job.

On 1/27/2009 at 2:10 p.m., the emergency room physician that provided care to PI #11 on 11/18/2009 was interviewed. The doctor recalled being informed by a nurse that PI# 11's family member was suctioning the patient. The physician requested security be called and went to talk with the family member. While talking with the family member, this physician reportedly heard a clicking sound and noted the family member repeatedly putting a hand into a jacket pocket. This physician stated she had security called because she (doctor) did not know what was making the clicking sound coming from the family member's pocket.
The physician did not document her conversations or observations with this family member, nor the concern that lead to a request for hospital security intervention.

On 1/27/2010 at 1:20 p.m., the security guard who responded to the emergency room on 11/18/2009 was interviewed. This security staff member recalled talking with and escorting PI #11's family member from the treatment area. This witness recalled PI #11's family member stated she was recording as she (family member) lifted a small square object from her (family member) pocket. The family member did not indicate who or what was being recorded, nor explain why she (family member) felt a need to record in the emergency room. The security officer recalled this family member saying she was going to talk with the administrator, after being escorted from the emergency treatment area. The security staff recalled the family member returned to the emergency department and was allowed back into the the treatment room with PI #11.

On 1/28/2010 at 09:35 a.m., the emergency department's nurse manager recalled being on duty 11/18/2009 and overhearing the doctor request security. The nurse manager did not document the incident or question staff as the emergency room charge nurse reportedly handled the incident.

On 1/28/2010 at 10:30 a.m., the administrator on duty at the time of the 11/18/2009 incident involving PI #11 was interviewed. This administrator recalled PI #11's family member coming to administration and complaining about security asking her (family) to leave PI # 11's treatment room because she (family member) was suctioning the patient. The administrator reportedly told this family member that she (family) could not be treating the patient but she could return to the patient's room. The administrator did not document or direct other staff members to document the family member's behaviors or complaints relative to this event.

Based on interviews and medical record review, hospital staff failed to assure Patient Identifier (PI) #11's plan of care addressed the patient's identified needs and was updated to reflect PI #11's specific medical and nutritional needs.
This deficient practice effected PI #11, one of eleven sampled patients.
Findings Include:

Patient Identifier # 11 was admitted to the hospital on 11/18/2009 with diagnosis that include: Abscessed PEG site, Insulin Dependent Diabetes, Stage IV Sacral Decubitus, Urinary Tract Infection, Multi-Infarct Dementia, Seizures, and history of Cardiac disease that includes Congestive heart failure.

The 11/18/2009 emergency room record documentation notes PI #11 arrival by ambulance to the emergency department. The emergency room physician note PI #11 was "nonresponsive...bleeding from PEG tube...,"and ...on "Hospice..." prior to admission.

A security activity report, dated 11/18/2009, noted the family member with PI # 11 was in the "...treatment area...sucking cold out of...[PI #11's] mouth...did not have authority to do...pull a tape player out of her [family member's] pocket...escort her [family member] from the ER..."

The dietitian's 11/20/2009 nutritional assessment used an approximate weight, that was 40 pounds under the actual weight noted by nurses on the unit, to calculate PI #11's nutritional needs. The suggestions by the dietitian were not added to the plan of care.

PI #11's plan of care included a list of preprinted problems listed on a form. This form included a "Status" section where staff could check each preprinted problem as an Actual, Potential, or N/A [not applicable].

PI# 11's 11/19/2009 plan of care includes the following selection of problems (as indicated by staff signature):
"Problem: Alteration in skin Integrity R/T [related to] Prolonged Immobility"
"Goal: No break in skin integrity"

Staff failed to indicate if the problems selected was an actual, potential, or not applicable problem or concern.

The "Nursing Diagnosis..." plan of care includes:
"...Potential for anxiety R/T knowledge deficit, separation from SO's [significant others] loss of control, procedure pain, diagnostic results, and/or care after discharge..."
"Goals: Pt [patient] nonresponsive..."
"Goal Met:" is marked "No."

The Nursing Diagnosis for "...Lack of knowledge related to poor recall..."
Goals: "...Family ...[patient] will be able to explain and specific intr. [instructions] Teaching methods utilized consistent with patient preference..."
Goal Met is marked: "Yes"

PI # 11's medical conditions documented on the 11/18/2009 admission included Peg Tube Abscess with active bleeding, Insulin dependent diabetes, Stage IV sacral decubitus, Chronic urinary catheter, and Urinary tract infection. The 11/19/2009 plan of care did not identify these as actual problems or concerns at the time of the patient's admission.