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Based on interview, record review, and policy review, the hospital failed to provide written notice to a patient's representative regarding the steps taken to investigate a grievance, and the result of the grievance investigation, for one discharged patient (#26) of two grievance files reviewed. This had the potential to affect all individuals who filed a grievance or complaint. The total hospital census was 21. The Behavioral Health (BHU) census was nine.

Findings included:

1. Review of the hospital's policy titled, "Patient Complaint and Grievance Process," revised 01/2016 showed the following:
- Any patient or family member with a concern, grievance, or complaint would be directed to speak with the BHU Program Director to initiate the complaint/grievance procedure.
- The BHU Program Director would meet with the complainant to discuss and investigate the complaint or grievance. If the complaint was not resolved and involved issues of patient's rights, quality of care, or patient safety, it would be considered a grievance and forwarded to the hospital's Risk Manager.
- A written decision of the grievance would be issued within 30 days to the complainant. This written follow up would contain the name of the hospital, the contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance, and the date of completion.

Review of discharged Patient #26's medical record showed he was admitted to the hospital's BHU on 01/04/22 for inpatient psychiatric care.

Review of the hospital's document titled, "Grievance Process, A Guide for Families," revised 03/13/22, showed that if there were concerns about the care provided at the hospital, contact the BHU Program Director prior to filing a grievance. Patients or families may then call the BHU Patient Advocate to file a grievance.

Review of the hospital's Grievance Form dated 01/27/22 stated that:
- Patient #26's daughter called Staff H, Registered Nurse (RN), Assistant Director of Nursing (ADON), and requested to speak to the BHU Patient Advocate about concerns regarding her father's care while he was a patient on the BHU.
- His daughter was concerned with the drastic decline in Patient #26's health while he was a patient on the BHU, which resulted in a transfer to the hospital's Medical Surgical unit.
- Staff C, RN, BHU Program Director spoke with the family of Patient #26, and told them she would review the patient's medical record.

During an interview on 04/19/22 at 9:00 AM, Staff C, BHU Program Director, stated that there was not a big difference between a complaint and grievance, and that she considered Patient #26's family's concerns a complaint, and no follow up letter was sent to the family.

During an interview on 04/20/22 at 10:00 AM, Staff Q, Patient Advocate, stated that she was involved with grievances and complaints for patients of the BHU, but did not recall Patient #26's grievance.

Based on interview, record review and policy review, the hospital failed to ensure that all nursing staff were properly educated, trained, and demonstrated the proper application of restraints and the safe monitoring of each patient placed in restraints, to include respiratory status, circulatory status, skin integrity, and vital signs. This failure placed all patients admitted to the hospital in need of restraint at increased risk for their safety. The hospital census was 21.

Findings included:

1. Review of the hospital's policy titled, "Restraints," revised 02/12/12, showed that all direct care staff would receive competency based education in the correct application, removal, monitoring, care of the patient, documentation, and first aid training related to the use of restraints. There were no directives to move patients to the Intensive Care Unit (ICU, a unit where critically ill patients are cared for) if they were placed in restraints.

Review of the hospital's untitled document dated 04/21/22, showed that the hospital had hired 22 nursing staff members since June 2021 who had not received hands on training in restraint application or removal.

Review of personnel records showed that three of the four medical-surgical unit nurses: Staff E, Licensed Practical Nurse (LPN); Staff U, Registered Nurse (RN); and Staff AA, RN; did not have restraint training or restraint first aid education documented.

During an interview on 04/19/22 at 10:30 AM, Staff U, RN, stated that the only restraints used on the medical-surgical unit would be soft wrist restraints. They would be applied, then the patient would be moved to the ICU. She had not had a restraint class nor had she demonstrated proper application.

During an interview on 04/18/2022 at 3:15 PM, Staff E, LPN, stated that she did not receive restraint training. She stated that patients on the medical-surgical unit that required restraints, would be moved to the ICU.

During an interview on 04/19/22 at 9:55 AM, Staff F, RN, stated that she did not receive restraint training.

During an interview on 04/20/22 at 9:00 AM, Staff MM, Nursing Administration Secretary, stated that staff were to review video related to restraint application, although personnel files did not contain a transcript of the education classes that were completed, and added that there was no hands-on restraint training provided in over 22 months.

During an interview on 04/20/22 at 6:30 PM, Staff HH, Director of Nursing, stated that all nursing, including the aides, should have received restraint training. She stated that anyone hired after June 2021 would not have had hands on training. The staff would have viewed specific slide shows and signed off on a roster that they had done so. There would not have been a way to validate their ability to apply or remove the restraints, and the hospital did not have a designated trainer. Employee education transcripts/files would be maintained by human resources, but the hospital did not have any type of computer training available to the staff.



45415

Based on observation, interview, record review and policy review, the hospital failed to ensure that:
- The Behavioral Health Unit (BHU) was provided full time nursing care oversight. (A-386)
- The Behavioral Health Unit (BHU) staff followed the Fall Risk Intervention Policy and the General Safety Policy when caring for nine fall risk patients (#6, #7, #11, #13, #35, #36, #38, #39, and #40) of nine patients observed on fall risk precautions. (A-395)
- Nursing staff were trained and educated in telemetry (remote observation of a person's heart rhythm, using signals that are transmitted from the patient to a computer screen). (A-397)
- There was a designated staff member assigned to monitor the telemetry screen at all times. (A-397)
- Cardiac rhythm strips were interpreted, to include measurements of the QR, PR, and R to R intervals (widening or shortening of the measurement, or changes in the rhythm can indicate changes in the hearts activity), dates, and initials per the hospital's telemetry policy. (A-397)
- Nursing staff were evaluated for proficiency in telemetry, prior to being assigned to monitor five current patients (#16, #20, #32, #33 and #34) on telemetry. (A-397)
- Untrained staff (unit secretary) were not utilized for monitoring the telemetry patients. (A-397)
- Staff administered medications according to the hospital's medication administration policy for one current patient (#14) and six discharged patients (#21, #22, #23, #24, #25, and #31). (A-405)

These failures resulted in a systemic failure and non-compliance with 482.23 Condition of Participation: Nursing Services. The hospital census was 21.

The severity and cumulative effect of these practices had the potential to place all patients on telemetry at risk for their health and safety, also known as Immediate Jeopardy (IJ).

On 04/20/22, the survey team informed the hospital of the IJ, the hospital staff created educational tools, began educating all nursing staff and implemented interventions to protect the patients.

As of 04/21/22, at the time of the survey exit, the hospital had provided an immediate action plan sufficient to remove the IJ by implementing the following:
- A text message was sent to all House Supervisors instructing that all telemetry patients would be assigned to nurses who have completed the basic arrhythmia competency (ability to assess changes in the heart's rhythm).
- A signature confirmation of the memo would be placed at the House Supervisor's desk to sign prior to their next working shift.
- A list of nurses who were competent to monitor telemetry, would be left at the House Supervisor's desk along with the daily staffing sheets.
- Staff HH, Director of Nursing (DON), will monitor telemetry staffing every shift until 100% of nursing staff were deemed competent as demonstrated by a score of 90% on the basic arrhythmia test.
- All nursing staff would be educated on the telemetry policy and the documentation of telemetry strip interpretation.
- The House Supervisor would be in charge of monitoring the central telemetry monitor. If the House Supervisor had to step away from the telemetry monitor, a qualified individual would be assigned to monitor the telemetry unit. The House Supervisor may delegate a qualified individual to monitor telemetry at all times.


39562

Based on interview and record review, the hospital failed to ensure full-time nursing oversight was provided to the Behavioral Health Unit (BHU). This failure could impact the nursing care provided to all patients of the BHU. The BHU census was nine.

Findings included:

1. Review of the hospital document titled, "Organizational Chart," dated 01/20/22, showed the BHU was under the direction of Staff HH, the Director of Nursing (DON).

Review of the hospital document titled, "Personnel Action Form," dated 12/26/21, showed that Staff HH was a full time employee with the title of DON effective 12/26/20.

Review of an organization chart for the hospital's contracted BHU service, dated 01/01/22, showed Staff C, the Program Director/Nurse Manager, reported to Staff PP, Vice President of Operations (VPO) and to the Senior VP of Clinical Practice (SVP) of the BHU contracted service. The BHU's organizational chart did not show any collaboration with the hospital's nursing department, or any oversight provided by the DON.

Review of the BHU contracted service's annual evaluation titled, "Annual Review for Staff C," dated 01/20/22 showed that Staff PP, VP of Operations of the contracted service completed the annual review, not the hospital's DON.

During an interview on 04/20/22 at 12:25 PM, Staff HH, DON, stated that she was not aware that the organizational chart showed the BHU was under her direction. She stated that they operated independently, did not report to her and she did no evaluations of the staff.

Based on observation, interview, record review, and policy review, the hospital failed to ensure that the Behavioral Health Unit (BHU) staff followed the Fall Risk Intervention Policy and the General Safety Policy when caring for nine fall risk patients (#6, #7, #11, #13, #35, #36, #38, #39, and #40) of nine patients observed on fall risk precautions. These failures had the potential to affect the quality of care and endanger the safety of all patients admitted to the hospital. The total hospital census was 21. The BHU census was nine.

Findings included:

1. Review of the BHU's policy titled, "Falls Policy, Edmonson," revised 07/2018, showed that fall prevention measures for a patient at risk for falls included placing a fall wristband (a brightly colored wristband to be worn by fall risk patients) on the patient, utilizing a falling star magnet (visual cue for staff to be aware the patient is at risk for falls) on the doorway, and the use of non-slip floor mats when a patient was up in a chair.

Review of the BHU's policy titled, "General Safety," revised 01/2016, showed that all bathrooms should be equipped with emergency call buttons or bells.

Review of BHU Incident Reports from 10/2022 through 04/2022 showed 17 falls had occurred on the BHU.

Review of the hospital's document titled, "BHU Nurses Report Sheet," dated 04/19/22, showed that Patients #6, #7, #11, #13, #35, #36, #38, #39, and #40 were fall risks.

Observation on 04/19/22 at 9:00 AM, showed that there were no falling star magnets on patient room doorways for Patients #6, #7, #11, #13, #35, #36, #38, #39, and #40, who were identified as fall risk patients.

Observation on 04/20/22 at 9:00 AM, showed that there were no call buttons or bells located in patient bathrooms.

During an interview on 04/19/22 at 9:00 AM, Staff C, BHU Program Director, stated that:
- The BHU did not use falling star magnets, fall wristbands, or non-slip mats when patients were up in a chair.
- There were no call buttons or bells located in the patient bathrooms.
- If a patient needed assistance while in the bathroom, the patient would need to yell out for help.

Based on observation, interview, record review, and policy review, the hospital failed to follow the standard of practice and provide consistent and competent cardiac monitoring by a trained nurse or technician for five patients (#16, #20, #32, #33 and #34) on cardiac telemetry (remote observation of a person's heart rhythm). This failure had the ability to affect all patients on cardiac telemetry, creating the potential for abnormal changes and negative outcomes if the heart rhythm changes were to go unnoticed. The hospital census was 21.

Findings included:

1. Review of the hospital's policy titled, "Telemetry," reviewed 12/31/18, showed:
- Instructions for staff members to correctly apply the cardiac monitor leads (noninvasive monitors of the heart that attach to the patient's chest and record heart rhythm) and manage patients on telemetry.
- Telemetry electrocardiogram (ECG or EKG, test that checks for problems with the electrical activity within the heart) strips should be recorded upon admission, then every four hours at 8:00 AM, 12:00 PM, 4:00 PM, 8:00 PM, 12:00 AM, and 4:00 AM.
- The interpretation of the strip should include QR measurement (a measurement on an EKG tracing that measures the electrical impulse as it travels through the ventricles of the heart), PR interval measurement (an electrical measurement of an EKG tracing that reflects whether impulse condition of the heart from the atria to the ventricles is normal), the R to R interval (a measurement on an EKG tracing that measures the rate of the ventricles impulse) regularity, and to identify the rhythm (a tracing that identifies the origination of the heart's electrical impulse [a tracing that helps to identify and treat cardiac issues]).

Review of the hospital's undated document titled, "Medical Telemetry Unit," provided by the hospital as a job description for Registered Nurses (RNs) and Licensed Practical Nurses (LPNs), showed the following expectations for staff:
- To provide high quality care.
- To adhere to and follow organizational policies to provide safe patient care.
- To complete a basic telemetry class (a class in which the focus is on rhythm identification and how to measure elements for interpretation of the EKG).

Review of the hospital's undated document titled, "RN & LPN - Skills List for Nursing Personnel," showed a list of skills and techniques that any nursing staff should be able to demonstrate proficiently prior to performing the tasks independently. One task listed under the cardiac section was "telemetry."

Observation on 04/19/22, from 8:50 AM to 9:10 AM, at the medical-surgical unit nurses station, showed the telemetry monitor with several patients' heart rhythms, with multiple staff members at the desk, but no one directly observed the telemetry monitor.

During an interview on 04/19/22 at 9:55 AM, Staff F, RN, stated that whoever was at the nurses' desk watched the telemetry monitor, including nurses, aides, unit secretaries or house supervisors.

During an interview on 04/19/22 at 10:05 AM, Staff U, RN, stated that everyone at the nurse's desk watched the telemetry monitor, including the unit secretary, house supervisor, or whomever was in the area, and confirmed that no one was designated to monitor the telemetry.

2. Review of Patient #16's medical record showed that he was a 68 year old male with a medical history that included an abnormal heart rhythm. He had an order for telemetry monitoring. There were EKG strips placed in the medical record, but there were no measurements, interpretations, dates, times, or initials present.

Review of Patient #20's medical record showed that she was a 67 year old female with a medical history that included three aortic (the main artery that carries blood from the heart to the body) surgeries. She had an order for telemetry monitoring. There were EKG strips placed in the medical record, but there were no measurements, interpretations, dates, times, or initials present.

Review of Patient #32's medical record showed that she was a 90 year old female with a medical history that included an abnormal heart rhythm. She had an order for telemetry monitoring. There were EKG strips placed in the medical record, but there were no measurements, interpretations, dates, times, or initials present.

Review of Patient #33's medical record showed that he was a 45 year old male admitted after collapsing. He had an order for telemetry monitoring. There were EKG strips placed in the medical record, but there were no measurements, interpretations, dates, times, or initials present.

Review of Patient #34's medical record showed that she was an 85 year old female with a medical history that included a pacemaker (small device that's placed in the chest to help control abnormal heart rhythms). She had an order for telemetry monitoring. There were EKG strips posted to the chart, but there were no measurements, interpretations, dates, times, or initials present.

Review of the hospital's nursing assignment sheet, dated 04/18/22, showed that Staff U, RN, was assigned care of Patients #32 and #34, and Staff E, LPN, was assigned care of Patients #16 and #33.

Review of the hospital's assignment sheet, dated 04/19/22, showed that Staff AA, RN, was assigned care of Patients #16, #20, and # 33 and Staff U, RN, was assigned care of Patient #34.

Review of the undated "RN & LPN - Skills List for Nursing Personnel," for Staff U, RN, showed no evidence of basic telemetry education.

During an interview on 04/19/22 at 10:05 AM, Staff U, RN, stated that she had not taken a telemetry class, nor did she complete any type of rhythm identification test upon hire.

Review of the "RN & LPN - Skills List for Nursing Personnel," dated 10/26/21 for Staff E, LPN, showed no evidence of basic telemetry education.

Review of the "RN & LPN - Skills List for Nursing Personnel," dated 10/26/21 for Staff AA, RN, showed no evidence of basic telemetry education.

During an interview on 04/20/22 at 9:00 AM, Staff MM, Nursing Administrative Secretary, stated that the hospital did not have a nurse educator and that there were no transcripts of telemetry education in the staffs' personnel files.

During an interview on 04/20/22 at 12:30 PM, Staff HH, Director of Nursing (DON), stated that:
- There was not a designated individual to observe the telemetry monitors, and that everyone at the nursing station was responsible.
- Unit secretaries did not have arrhythmia training.
- All of the nurses "should" have a basic understanding of telemetry and be able to identify any abnormalities, although they were not tested to determine proficiency with basic arrhythmia identification.
- She would expect the interpretation of an EKG strips placed in the patients' records to include rhythm identification, measurements, date, and initials.
- The hospital did not have a computer education system, a nurse educator, or the ability to track nursing classes that staff had completed.



45415

Based on observation, interview, record review and policy review, the hospital failed to ensure staff administered medications according to the hospital's medication administration policy for two current patient (#14 and #16) and six discharged patients (#21, # 22, #23, #24, #25, and #31). These failed practices showed an overall systemic problem and had the potential to cause harm and/or ineffective medication therapy to all patients admitted to the hospital. The hospital census was 21.

Findings included:

1. Review of the hospital's policy titled, "Medication Administration," revised 04/01/13, directed nursing staff to scan the patient's armband to verify identification and to scan each medication prior to administration.

Review of the hospital's policy titled, "Medication Errors," revised 06/21/21, defined a medication error as any preventable event that may cause or lead to inappropriate medication use or patient harm. Types of medication errors would include wrong drug, wrong dose, wrong route, wrong time, wrong reason, and wrong documentation, omission of a dose, or an unordered dose.

Review of multiple hospital documents titled, "Event Report," showed:
- On 01/09/22 at 7:00 PM, a nurse administered an intravenous (IV, in the vein) antibiotic for another patient to Patient #25. The pharmacist listed the safety failure as not scanning the patient's bracelet when administering medications.
- On 01/24/22 at 9:35 AM, Patient #24 received two subcutaneous (under the skin) injections of the same medication. The pharmacist listed the safety failure as the nurse not properly documenting the medication at the time of administration.
- On 01/31/22 at 11:50 PM, Patient #31 received medications ordered for another patient. Two of those medications were seroquel (an anti-psychotic medication used to treat certain mental/mood conditions) and Coreg (a medication that can lower your bl/od pressure and significantly decrease your heart rate). The pharmacist listed the safety failure as the patient's bracelet was not scanned when the medications were administered.
- On 02/01/22, Patient #23 received a repeat dose of a medication because the night nurse failed to document the administration of the medication that she gave. The pharmacist listed the safety failure as not scanning the medication upon administration.
- On 03/02/22 at 1:40 AM, another patient's medication was found at the bedside of Patient #22. The pharmacist listed the lack of scanner use as a safety failure.
- On 03/15/22 at 7:40 PM, Patient #21 received another patient's nonsteroidal anti-inflammatory (NSAID, medication used to relieve pain and reduce inflammation) injection. The pharmacist listed lack of scanner use as a safety failure.

Review of the hospital's document, "Medication Compliance Report," dated 01/01/22 through 04/19/22, showed that there were 128 staff members who were able to administer medications. A total of 53 of those staff members failed to scan a single medication they administered. A total of 60 of those staff members failed to scan a single patient bracelet.

Observation on 04/19/22 at 8:42 AM, showed that Staff U, RN, scanned Patient #14's identification bracelet, she then scanned a paper on her computer on wheels (COW) desktop, and then proceeded to scan the medication that she was administering.

During an interview on 04/19/22 at 8:47 AM, Staff U, RN, stated that when she tried to scan Patient #14's bracelet, it did not work, so she scanned a patient label on her report sheet instead.

During a concurrent observation and interview on 04/19/22 at 9:48 AM, Staff U, RN, entered Patient #14's room to administer her scheduled medications. She scanned the patient's identification bracelet and attempted to scan the medication packages. The scanner accepted the bracelet, but would not scan the medications. Staff U, RN, stated that she had verified the schedule medications prior to entering the patient's room. Since the scanner malfunctioned, she would need to scan the medication packages at the nurses desk with the hardwired computer and scanner located there, after she administerd the medications to the patient. The scanners frequently malfunction, so staff would routinely scan medications at the nurses desk.

Observation on 04/19/22 at 9:15 AM, showed Staff AA, RN, had to use three different computers to scan Patient #16's identification bracelet before she found a scanner that worked.

During an interview on 04/19/22 at 9:15 AM, Patient #16 stated that he was admitted three days ago, and the nurses had never scanned his bracelet before.

During an interview on 04/20/22 at 10:00 AM, Staff GG, Pharmacist, stated that he had voiced his concerns about the scanning rates of the nursing personnel, and was told that the issue was a nursing issue and to remain hands off. He had been told by the previous Director of Nursing (DON) that she would handle it, however there continued to be issues with the scanning of bracelets and medications, inidcating that the problem had not been addressed.

During an interview on 04/20/22 at 12:25 PM, Staff HH, DON, stated that her expectation was that nurses would scan patient identification bracelets and each medication they administer.


45415