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Based on the interview and record review, the facility failed to provide three patients (P-4, 10 and 18) of five patients reviewed an Important Message from Medicare within 2 days of admission, resulting in patients not being informed of their rights and potential for patients not understanding their Medicare benefits. Findings include:

During initial tour of the facility on 12/10/24 at 1130, random patient's record (P-10) was chosen for a review on Unit 5M. Record revealed that patient was a 76-year-old male admitted to facility on 11/29/24. There was an IM (an Important Message from Medicare) form in the record. Form was dated 12/06/24. No patient's or patient's representative signature was evident on the form. Registered nurse, Staff I, was present during the review and was asked if the form needs to be signed by the patient or a responsible party. Staff I confirmed that the form needs to be signed.

Further record review of a sample of inpatient medical records for Medicare beneficiaries, was conducted on 12/10/24 with Staff I.

P-4's medical record revealed that patient was an 85-yeal-old male admitted to facility on 9/2/24 and discharged on 9/12/24. Record did not contain a signed and dated IM form provided to the patient within 2 days of the admission. Staff I confirmed the above finding.

On 12/11/24 P-18's medical record was reviewed with Program Coordinator of patients' services, Staff EE. Record revealed that patient was a 79-year-old male, admitted to facility on 8/1/24 and discharged on 8/10/24. Record did not contain a signed and dated IM (an Important Message from Medicare) provided to the patient within 2 days of the admission. Staff EE confirmed the above finding.

Facility's "Hospital Coverage Notices for Medicare Inpatients (including Important Message from Medicare)" policy was requested and reviewed. Policy, dated 04/14/20, indicated:

B. Important Message from Medicare (IMFM)
1. The IMFM notice must be given to all beneficiaries in original Medicare fee-for-service program and to those in Medicare Advantage (MA) and other Medicare health plans subject to the MA regulations.

2. The Tenet Hospital must provide the IMFM to the beneficiary:
a) Within two days of admission (this is known as the "admission/initial IMFM"); and
b) Not more than two calendar days before the day of discharge.
4. The Tenet Hospital must obtain the signature of the beneficiary (or his/ her representative) on a copy of the IMFM and Follow-up Notice(s) and must retain the signed copies in the beneficiary's medical record."

Based on observation and record review, the facility failed to maintain and provide a safe and sanitary environment for all patients in the inpatient Behavioral Health Unit resulting in the potential for less-than-optimal outcomes for all 15 patients present on the unit. Findings include:

During a tour of the inpatient behavioral health unit on 12/10/2024 at 1000:

- Six blue blood vacutainer collection tubes with an expiration date 10/31/2024, two packages of electrodes with expiration date 3/25/22, and three individual 22-gauge needles with expiration dates 2/28/2022, 10/31/2021, and 6/30/2022 were observed on the shelf in the patient supply storage room. Nurse Manager Staff H confirmed the presence of the expired supplies at the time of discovery.

- The facility's patient seclusion room was observed to have a bolt and nut missing that attaches the bed to the floor. Rust including sprinkles of rust were present inside and around the slot where the bolt would be located. Additional rust was observed at the base of the flooring along both sides of the bed. Nurse Manager Staff H confirmed the presence of rust at the time of discovery.

According to the facility's policy "Checking Expiration Dates and Stock Rotation," dated 2/22/2022, "Expiration dates stamped with month and year will be removed from the supply station at the first of each month (example 01/06). Products that have expiration dates of month, day, and year, will be removed from the supply station prior to that date (example 01/12/06)."

According to the facility's policy "Patient Rights and Responsibilities," dated 2/10/2022, "Patient Rights" include "Patients will receive the same treatment and consideration as anyone else regardless of age, race, ethnicity, color , religion, culture, language ,martial status, physical or mental disability, sex, socioeconomic status, source of payment, sexual orientation and gender identify or expression" and Patient can expect their dignity as a human being to be recognized and respected."

Based on observation, interview, and record review, the facility failed to ensure that registered nurses supervised and evaluated the nursing care for 8 patients (P-1, 3, 4, 13 and 14, 15, 16, 17) of 18 patients reviewed for care supervised by registered nurses, resulting in negative outcomes to patients, including potential for harm and preventable physical decline. Findings include:

See Specific Tags:

A-395 Failure to ensure that nursing staff supervise and evaluates patients' care, including ongoing assessments, evaluations and documentations.

A-396 Failure to ensure that nursing staff developed patient centered individualized plan of care that meets patients' needs.

Based on observation, interview, and record review, the facility failed to ensure that registered nurses supervised and evaluated the nursing care for 5 patients (P-1, 3, 4, 13 and 14) of 18 patients reviewed for care supervised by registered nurses, resulting in negative outcomes to patients, including potential for adverse outcomes and preventable physical decline. Findings include:

During initial tour of the facility on 12/10/2024, medical surgical unit (4L) was observed for patient care and environment from 1048 to approximately 1125. During the tour, unit Nurse manager, Staff Y, and clinical nurse coordinator, Staff Z, were interviewed regarding wound management, patients' assessment and repositioning. Staff Y was asked how often nurses do patients' skin assessments. She stated that skin assessments are done every shift (day and night). Staff Z stated that facility had a mobility team that helps staff with repositioning patients who are on every 2 hours repositioning schedule. Nurse added that mobility team coordinates care with nurses on the unit, however it was nurses' (or nursing assistants') responsibility to document the activity. When asked if there were any patients with compromised skin integrity or pressure injuries, Staff Z, provided information for P-13 and P-14.

P-13

On 12/11/2024 at 1035 nurse in care for P-13, Staff CC, was interviewed. She stated that she did not complete patient's shift skin assessment yet, however per report from the night shift nurse, patient had a pressure injury. Staff CC was asked if she does daily skin and wound assessments, care plan updates and education. Nurse stated yes.

Following the interview with Staff CC, at 1040, P-13 was interviewed in his room. Patient was noted sitting in his bed with his legs positioned directly on the bed. No foam positioning devices were observed in the patient's bed. Patient was asked if he needs assistance with repositioning. Patient stated that he can roll from side to side but he needs assistance with prepping the pillow, so he doesn't roll back. When asked if staff repositioned him every 2 hours he said "no". Patient proceeded to share that some nursing staff doesn't come for long periods of time when he calls the call light. P-13 added that day shift nurses are better with providing care, at night though it was difficult to get staff's attention. P-13 was asked if his roommate, P-14 (who was sleeping), was repositioned every 2 hours. P-13 said that "the guy was sleeping all morning, and no one touched him yet".

Record review for P-13 revealed that patient was a 31-year-old male who was admitted to facility on 12/01/24 with chief complaint of chronic generalized pain and testicular swelling. Physician's examination dated 12/1/2024 0814 revealed that P-13 had a past medical history of T7 paraplegia (causes complete paralysis of the hips and legs, loss of bladder and bowel control, and no feeling in the abdominal muscles) secondary to GSW (gun shot wound), neurogenic bladder requiring straight catheterization, and colostomy dependence.
Provider's History and physical assessment for P-13 dated 12/01/2024 1504 revealed: "well healed wounds at the buttocks area with scab formation".

Nursing assessment of P-13 dated 12/02/2024 2100 revealed Braden score of 14 (tool for risk assessment of pressure injury development that range from 6 to 23 with a lower score indicating high risk).
Wound assessment documentation dated 12/03/2024 0900 indicated P-13 had left hip pressure injury stage 3 present on admission. Further review of the nursing documentation revealed no other wounds or skin impairment documentation.
Wound care nurse note dated 12/03/2024 1112 revealed the following wound assessment: resurfaced stage 3 pressure injury, left lateral hip, size 2 x 2 cm (centimeters), full thickness. Under the plan there were instructions "to be completed daily": 4. Assess skin, wound, and all bony prominences every shift and document. 6. Turn and reposition q2 (every 2) hours with assistance of foam wedge, pillows, or turn assist feature on specialty bed and document each shift in Plan of Care and Q2h in Activity & Intervention. 7. Offload heels with use of heel lift boots or pillows placed under patient's calves.

Nursing wound assessments documentation review revealed missing assessments on 12/06/2024- night shift and 12/07/2024- day shift. Also, no repositioning every 2 hours were documented on 12/04/2024 (from 12/03/2024 at 1700 to 12/05/2024 at 0700).

Provider's orders review revealed order for heel lift boots, dated 12/03/2024 at 0903. There was also a provider's order for "Reposition patient" dated 12/03/2024 at 0903. Order details indicated: "Q 15 min -1 hour if in chair or wheelchair and unable to shift weight independently. Turn q2 (every 2) hours when patient is in bed. Head of bed not greater than 30 degrees if tolerated. Avoid side-lying on trochanter. 30-degree side lying position produces lower interface pressures. Use pillows or foam positioning devices. Provide foam positioning wedge to maintain body position. Protect bony prominences and heels." Further, there was an order for "Suspend heels off bed" dated 12/03/2024 at 0903.

P-14

On 12/11/2024 at 1020 P-14 was observed sleeping in bed. Patient was positioned on his back with a pillow lying next to his right hip and another pillow tucked under his left hip. No foam positioning devices were observed in the patient's bed. Patients' heels were positioned directly on the bed. No protective boots were noted on patient's feet.

Following this observation, at 1025, P-14's nurse in care, Staff BB, was interviewed regarding patient's status. He stated that patient had multiple pressure injuries. He was provided a specialty bed to relieve the pressure. When asked if nurse did his assessments yet, he stated that patient had been sleeping all morning and nurse did not want to disturb him.

Medical record for P-14 was reviewed and revealed that patient was a 44-year-old male admitted to facility on 11/29/2024 with complaint of abdominal pain and leakage around SPT (suprapubic urinary catheter) site. Patient had a past medical history of T6 paraplegia following gunshot wound, neurogenic bladder with SPT, left hip osteomyelitis (infection in a bone) and recurrent UTIs (urinary tract infection).
Nursing wound assessment documentation dated 11/30/2024 0700 revealed the following wound documentation: coccyx pressure ulcer, stage 3 present on admission, hip right lateral pressure ulcer stage 3 present on admission, hip left lateral pressure ulcer stage 3 present on admission, buttock left pressure ulcer stage 3 present on admission.

Wound care nurse note dated 12/03/2024 1039 revealed: "healing stage 4 pressure injury to Sacro coccyx, 2cm x 1cm x 1cm (length x width x depth); healing stage 4 pressure injury to right hip, 3cm x 8cm; healing stage 4 pressure injury to left hip, 3cm x 2cm; healing stage 4 pressure injury to left ischium, 1.5cm x 1cm x 1cm. Healed pressure injuries present to bilateral heels." Under the plan there were instructions "to be completed daily": 4. Assess skin, wound, and all bony prominences every shift and document. 6. Turn and reposition q2 hours with assistance of foam wedge, pillows, or Turn Assist feature on specialty bed and document each shift in Plan of Care and Q2h in Activity & Intervention. 7. Offload heels with use of heel lift boots or pillows placed under pt's calves.

Nursing wound assessments documentation review revealed missing assessments on 12/01/2024 for day and night shift, on 12/02/2024 for night shift, on 12/03/2024 for night shift, on 12/04/2024 for day shift, on 12/07/2024 for day shift.

Facility's wound care nurse, Staff K, was interviewed on 12/11/2024 at 1130. She was asked if her expectations were that facility staff nurses follow her wound care recommendations and skin deterioration preventive measures. Staff K stated yes.

Facility's "Pressure injuries: Prevention and Care" policy was requested and reviewed. Policy 2PC 5202, dated 8/10/21, revealed:
A. An RN assesses each patient admitted to [facility] inpatient unit for risk pressure injury risk using the Braden scale.
1. Braden scale score of less or equal 18 or low subscale scores indicates that the patient is at risk for pressure injury development. Interventions targeting risk areas are implemented to prevent and manage pressure injuries.
2. Patients with actual or healed pressure injuries are considered high risk.
C. RN responsibilities:
1. Provide assessment, planning, documentation and evaluation of skin, pressure injuries, and wound care with shift assessment. Pressure injuries are measured on admission, every Monday, upon development or deterioration.
2. Assess the patient's risk using the Braden scale.
3. Reposition patient to 30-degree side lying position ensuring sacrum/ coccyx and heels are offloaded at least every two hours while in bed, unless contraindicated.
11. Consult the APRN/CWOCN (wound care) for stage 3, stage 4, unstageable, deep tissue pressure injuries, or mucosal membrane pressure injuries."

P-3

P-3 was admitted to the facility on 12/09/2023 with a pressure wound described as "unstageable (with slough/or eschar) pressure injury to coccyx...Measurements dated 12/11/2023 at 2000 were 12 X 6.5cm (centimeters). Wound care nurse was not consulted until 01/04/2024 (26 days after admission). Wound care nurse note dated 01/04/2024 at 1316 revealed "patient has unstageable pressure injury that evolved from deep tissue pressure injury, present on admission. Location: Coccyx, length x width: 13cm x 11cm, depth: full thickness. Wound bed color/necrotic tissue (%): 90% black/yellow and 10% dull pink wound bed."

Nursing documentation on 01/08/2024, the day prior to discharge, noted P-3's wound had increased in size to 15 X 9.5cm.

P-4

P-4's medical record was reviewed and revealed that patient was an 85-year-old male admitted to facility on 09/02/2024 at 1521 with chief complaint of back pain post fall a week prior. Patient was diagnosed with vertebral compression fractures and unstable T10 fracture.

There were the following providers' orders:

1) MRI- Request dated 9/2/2024 1840, order status: Discontinued on 9/3/2024 1013 (not completed).
2) MRI- Request dated 9/3/2024 1013, order status: Discontinued on 9/4/2024 0717 (not completed).
3) MRI- Request dated 9/4/2024 0716. Order status- completed (P-4 had an MRI test on 9/4/2024).
4) Nothing By Mouth (procedure, NPO-nothing by mouth, except for medications) dated 9/2/2024 1845, order status: Discontinued on 9/6/2024 0815.
5) Diet order- cardiac, dated 9/4/24 1950.

Further record review with Program Coordinator of patients' services, Staff EE, revealed the following documentation.
On 9/2/24 and 9/3/24 no oral intake was documented for entire day for P-4.
On 9/4/24 patient had an MRI test. At 2000 there was a documentation of 75% of dinner consumed by P-4.
On 9/5/24 there was a documentation of graham crackers consumed at 0000 and 0300. At 2000- apple juice x 2 and graham crackers were documented.
On 9/7/24, 9/8/24 and 9/9/24- there was no documentation of any food consumed by P-4.

On 9/10/24 patient had a surgery for his thoracic compression fracture (T10 and L3 kyphoplasty). There was a documentation of 50% breakfast consumed at 0800 and "all lunch" at 1200 (noon).

On 9/11/24 and 9/12/24- there was no documentation of any food consumed by P-4.
Patient was discharged home on 9/12/24 at 1726.
Staff EE confirmed the findings.

On 12/11/24 at 1330 Chief Nursing Officer, Staff B, was interviewed. She was asked if her expectations were that registered nurses and clinical staff were following facility's procedures and policies. Staff B stated "yes".

Facility's "Patient assessment and Documentation" policy was requested and reviewed. Policy 2 PC 201 dated 2/23/22, revealed:
B. The RN (registered nurse) documents patient information in the electronic medical record (EMR) except when such documentation is outside the scope of existing electronic forms or during system downtime when downtime procedures will be followed.
C. The RN documents admission and on-going and focused assessments, patient/ family teaching, plan of care, interventions and patient response in the medical record. The RN documents all pertinent patient data, including but not limited to designated required fields.
D. The RN is responsible for patient assessment, data interpretation, determination of patient needs, establishment of nursing intervention priorities, and evaluating effectiveness of the plan of care.
G. The RN may delegate data collection tasks to other nursing team members.
H. RNs verify all data documented and co-sign documentation of selected data collected by Licensed Practical Nurses, Student Nurses Associates, Nurse Associates, Patient Care Associates, Constant Observers, Mental Health Techs, and ED Techs."



50585


P-1

On 10/16/2024 at 2000 (day of admission), the nurse documentation revealed that P-1 had a Braden score (scaled used to determine risk for patients developing pressure injuries) of 13. According to the facility's policy "Pressure Injury, Prevention and Care," dated 8/10/2021, "Braden Scale score of
The nursing note on 10/17/2024 at 2000 revealed that P-1 had a pressure injury classified as Stage I on the sacrum present on admission and the medical record revealed there were no other pressure injuries present.

Five days later, the nurses note on 10/22/2024 at 2300 revealed the sacrum pressure injury was classified as Stage II. P-1 had additional pressure injuries identified on 10/24/2024 (right heel that measured 3 cm x 2 cm) and on 10/29/2024 at 1000 (Stage II pressure ulcer on the left buttock).

According to P-1's medical record, the facility staff did not reposition P-1 at the following dates and times: 10/18/2024 at 0700 0900, 1300 1500, 1700, and 1900 and on 10/19/2024 at 1800, 2000, 2200 and on 10/20/2024 at 0200, 0400, 0600, 2000, 2200.

Based on interview and record review, the facility failed to develop care plans for 3 of 3 patients in isolation (P-15, P-16, P-17) and failed to initiate a care plan timely for 1 of 1 patient with a high risk for developing pressure injuries (P-1), resulting in a potential risk for the transmission of infection and less than optimal outcomes. Findings include:

On 12/11/24, assisted by RN Staff G, 3 medical records were reviewed of patients selected from unit 5M (P-15, P-16, P-17) revealed all 3 patients were admitted with a known history of Candida Auris (C. Auris). All 3 records had an order for contact isolation, but none of the 3 records had a care plan open addressing infection risk. None of the 3 records contained documentation that isolation was implemented or maintained. Only 1 of the 3 records (P -15) contained patient/family education documentation on C. Auris. Staff G confirmed the findings during chart review, and confirmed the education on C. Auris should have been charted.

On 12/11/24 at approximately 1330, an interview with CNO Staff B revealed that it is her expectation that staff follow policy and procedures of the hospital.

On 12/11/24 record review of policy titled, "Nursing Plan of Care" dated 3/16/22, revealed: "Objective: To document the plan of care required to meet the admitted patient's needs through the episode of care ... The RN collaborates with the patient, family ... to formulate the Plan of Care ... The RN individualizes ...plans of care to be reflective of the patient's condition ...The RN is responsible for reviewing, evaluating, and documenting the progress toward established plan of care goals and updates the plan of care accordingly ...every 12 hours".


50585

P-1

On 10/16/2024 at 2000 (day of admission), the nurse documentation revealed that P-1 had a Braden score (scaled used to determine risk for patients developing pressure injuries) of 13. According to the facility's policy "Pressure Injury, Prevention and Care," dated 8/10/2021, "Braden Scale score of
The nursing note on 10/17/2024 at 2000 revealed that P-1 had a pressure injury classified as Stage I on the sacrum present on admission and the medical record revealed there were no other pressure injuries present. Five days later, the nurses note on 10/22/2024 at 2300 revealed the sacrum pressure injury was classified as Stage II. P-1 had additional pressure injuries identified on 10/24/2024 (right heel that measured 3 cm x 2 cm) and on 10/29/2024 at 1000 (Stage II pressure ulcer on the left buttock).

P-1's nursing plan of care for integumentary (body's outside layer e.g., skin) impaired tissue was not initiated until 10/23/2024.