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Based on the onsite complaint investigation, completed February 5, 2019, the facility failed to comply with the regulations set forth for Life Safety, therefore, deficiencies were cited under Life Safety Code tags K232, K353, K355, K372, and K711. See survey event ID #6HRR21 for full details of the cited deficiencies.

Based on interviews and document review, the facility failed to ensure patients who were placed in physical restraints were monitored and assessed, per facility policy, to ensure their physical and emotional safety in 1 of 4 restraint records reviewed (Patient #8).

Findings include:

Facility Policy

The Physical Restraints (Violent and Non-Violent Behavior) and Seclusion policy read, this policy applied to ensure restraints were used safely, for the shortest possible time, and discontinued at the earliest opportunity. Physicians, nurses and other members of the health care team were expected to work collaboratively to achieve the goal of making restraint use an uncommon event.

Physical restraint devices included hand mittens or mitts. Mittens, whether tied down or not, were considered restraints when the patient's hand or fingers are immobilized. For non-violent behavior restraints, ongoing safety checks and monitoring occurred at least every two hours by the patient's clinical team of the patient's response to the restraint, including any condition changes. Visually observe the patient at least every two hours for safety needs. All documentation of patient status should be in real time.

1. The facility failed to ensure staff conducted required safety checks every two hours while a patient was in mitt restraints.

a. Review of Patient #8's History and Physical, dated 10/18/18, showed the patient was admitted to the hospital for rehabilitation after a stroke and for weaning from a ventilator.

b. Review of Patient #8's restraint documentation showed non-violent mitten restraints were applied to the patient's left and right hands on 10/27/18 at 3:30 p.m. The registered nurse documented the patient was at risk of injuring herself, disturbing monitoring equipment or treatment, had a lack of safety awareness, and the patient's behavior was not redirectable.

Review of Restraint Monitoring (Non-Violent, Non-Self Destructive Behavior) for 10/27/18 - 10/31/18 revealed Patient #8 remained in mitten restraints until 10/31/18 when the restraints were removed. Further review revealed Registered Nurse (RN) #10 documented a safety check of Patient #8 on 10/29/18 at 12:32 p.m. Her next safety check was documented at 3:02 p.m., which was two hours and 27 minutes later. This was in contrast to facility policy which required a safety check and assessment at least every two hours.

c. Review of Patient #8's restraint documentation showed non-violent mitten restraints were reapplied to both of the patient's hands on 11/1/18 at 7:00 a.m. for the same reasons. Review of the Restraint Monitoring forms for 11/1/18 - 11/7/18 revealed Patient #8 remained in mitten restraints until 11/7/18 when the restraints were removed. Further review revealed RN #10 documented a safety check of Patient #8 on 11/1/18 at 3:00 p.m. Her next safety check was documented at 5:43 p.m., which was two hours and 43 minutes later.

Similarly, on 11/2/18, a safety check was documented at 9:03 a.m. The next safety check was documented at 11:43 a.m., which was two hours and 40 minutes later. Later on 11/2/18, a safety check was documented at 5:20 p.m.; the next was documented at 8:00 p.m., which also was two hours and 40 minutes later.

On 11/22/18, a similar two hour and 44 minute gap was documented, and on 12/31/18, a two hour and 25 minute gap was documented. In addition, most documented entries were not made in real time; therefore, it was not possible to determine whether these other safety checks consistently met the two hour requirement.

d. An interview was conducted with RN #10 on 2/05/19 at 4:23 p.m. RN #10 stated she was expected to assess all patients with non-violent restraints at least every two hours, and referred to the items listed on the Restraint Monitoring form, including the patient's mental status, skin integrity, and mobility as important aspects of that assessment. RN #10 stated this was important to ensure the patients didn't hurt themselves worse.

RN #10 reviewed the Restraint Monitoring documentation for Patient #8 and confirmed she had documented restraint assessments for the patient on 11/1/18, 11/2/18, and 11/22/18. RN#10 stated she did not specifically recall why her assessments were late on those days but expected she was busy with another patient. RN #10 stated she documented the specific time she assessed the patient so the times she recorded were accurate.

e. An interview was conducted on 2/5/19 at 4:50 p.m. with the nurse educator (RN #16) who stated when a patient was placed in non-violent restraints, a reassessment of the patient was expected every two hours. This included evaluating the patient's circulation, sensitivity, readiness for release, fluid status, and toileting needs. RN #16 stated it was not acceptable to assess the patient late; the reassessments were required at least every two hours. He stated this specific requirement was in place "for a reason."

Based on document review and interviews, the facility failed to ensure a registered nurse provided oversight for an Licensed Practical Nurse (LPN) in one of thirty-one medical records reviewed (Patient #7).

Findings include:

Facility policy:

The Assessment/Re-Assessment-Interdisciplinary Patient Policy read, an LPN may gather clinical data and make clinical observations in between the RN (Registered Nurse) assessments. The clinical data and clinical observations are reported to the RN for evaluation and determination of needed changes in the patient plan of care. An RN directs the nursing care of every patient through delegation and supervision to other nursing and non-nursing personnel.

1. A registered nurse (RN) did not supervise the nursing care provided to Patient #7.

a. Review of Patient #7's medical record revealed on 11/13/18 at 9:47 a.m., Licensed Practical Nurse (LPN) #15 documented a patient care assessment, which included the following observations: neurological, pulmonary, cardiovascular, gastrointestinal, renal/urological, integumantary (skin), musculoskeletal and signs and symptoms of pain.

At 1:42 p.m., LPN #15 documented Patient #7's wound care was completed.

At 6:11 p.m., LPN #15 documented Patient #7's foley catheter (a thin, sterile tube that is inserted into the bladder to drain urine) was removed and the patient tolerated the procedure well.

Patient #7 was discharged home at 6:14 p.m. LPN #15 signed the patient's discharge instructions.

There was no evidence in Patient #7's medical record which showed a registered nurse supervised Patient #7's care on 11/13/18. The last documented RN oversight was at 5:58 a.m., prior to when LPN #15's shift started.

According to LPN #15's job description, signed 1/23/12, the LPN provides nursing care within the scope of licensure for assigned patients, under the direct supervision of a registered nurse.

b. An interview was conducted with LPN #15 on 2/5/19 at 8:40 a.m. LPN #15 stated when she cared for a patient she completed a head to toe assessment and a registered nurse would follow behind her to verify accuracy.

When asked who had oversight of her on 11/13/18, LPN #15 stated RN #19 supervised her that day. She then instructed the surveyor to go to the documentation on 11/13/18 to find the RN oversight documentation.

Upon request, the facility was unable to provide evidence an RN documented oversight for Patient #7's nursing care.

c. On 2/4/18 at 12:05 p.m., RN #17 was interviewed. She stated RNs were to provide oversight of LPNs patient care. She stated at the end of the shift, the process was for the RN to review and sign off in the medical record, the LPN's work.

d. On 2/4/18 at 12:45 p.m., RN #18 was interviewed. She stated LPNs could do routine assessments, but the patient would be seen by the RN during shift. She stated the RN who supervised would cosign and verify the LPN's work each shift.

e. On 2/5/18 at 1:16 p.m., the nurse educator (RN #16) was present for an interview. He explained at the end of each shift, a worklist showed up in the patient's record for the RN to document the oversight of the patient's care. He said because Patient #7 was discharged before the end of the day shift, the worklist was discharged in the computer system before the RN could document the oversight.

f. On 2/5/18 at 4:50 p.m., a subsequent interview was conducted with RN #16. The chief clinical officer (CCO #7) was also present for the interview. RN #16 stated RNs were responsible for a patient's initial assessment conducted upon admission. He stated LPNs could reassess and observe patients and the RN oversight needed to be done according to both disciplines' scope of practice.

Based on interviews and document review, the facility failed to maintain a complete medical record to provide evidence of telemetry monitoring in the medical record during the time of a change in condition in 3 of 3 patients which required cardiopulmonary resuscitation (CPR) to be performed (Patients #28, #30 and #31). Additionally, the facility failed to ensure nursing staff documented repositioning interventions pursuant to physician's orders, plans of care and facility policy in 9 of 14 medical records reviewed for patients who were required to be repositioned every two hours (Patients #1, #5, #8, #10, #17, #19, #21, #22, and #31).

Findings include:

Facility Policies:

The Continuous Cardiac Monitoring (Telemetry) policy read, once telemetry was initiated, qualified staff would maintain visual surveillance 24 hours a day. If there were any possible dysrhythmias, a tracing would be printed and the attending or house physician would be notified immediately. A qualified staff member would interpret the strips and a qualified and competent registered nurse (RN) would validate the rhythm strip. A strip would be printed for any patient who was transferred to a higher level of care, experienced a change of condition while on telemetry or whose death was not expected. In the event of a code (notification to other team members the patient needed immediate resuscitation) the patient would remain on telemetry and the monitor technician (tech) or other qualified staff member would initiate recording of the cardiac activity until notified by the RN or physician to discontinue recording. All strips would become a part of the permanent medical record.

The Assessment/ Reassessment policy read, an acute change of condition was a clinically important change from a patient's established and documented baseline.

The Prevention and Treatment of Pressure Ulcers and Non-Pressure Related Wounds policy read, healthy skin care interventions are used to reduce pressure, friction, shear, and are based on the patient's risk level and condition. Pressure ulcer prevention interventions are initiated based on the Braden risk factors identified initially and ongoing. The policy also stated high risk patients are turned at a minimum of every 2 hours. The policy specified in critically ill patients small shifts in position for patients who cannot be turned for medical reasons should be considered. Documentation of repositioning regimes must include the frequency, the position adopted, and the outcome of the repositioning regime.

References:

The Monitor Technician Job Description read, the tech monitored heart rhythm patterns of patients to detect abnormal pattern variances, using telemetry equipment. The tech observed the screen of cardiac monitors and listened for alarms to identify abnormal variations in heart rhythms. The tech maintained accurate records of telemetry patients.

The Clinical Skills Initial Core Competency Checklist for Monitor Technicians read the tech obtained telemetry strips according to the policy and placed telemetry strips in the patient's medical records.

1. The facility failed to provide evidence of telemetry monitoring in the medical record during the time of a change in condition which required CPR to be performed.

a. Review of Patient #31's medical record revealed she had a change in medical condition on 11/14/18 at 9:54 p.m. Patient #31 was pulseless and unresponsive which required CPR to be initiated. She regained consciousness and was transferred to another facility to a higher level of care. Further review of Patient #31's medical record revealed no telemetry strips were located to document the change in medical condition and CPR.

Review of Patient #30's medical record revealed he had a change in medical condition on 11/28/18 at 6:00 p.m. Patient #30 stated he could not breathe, became unresponsive and did not have a pulse which required CPR to be initiated. Patient #30 was transferred to another facility for a higher level of care. Further review of Patient #30's medical record revealed no telemetry strips were located to document the change in medical condition and CPR.

Review of Patient #28's medical record revealed he had a change in medical condition on 4/14/18 in which he was without a pulse and required CPR at 2:56 a.m. He regained a pulse and was transferred to another facility for a higher level of care. Further review of Patient #28's medical record revealed no telemetry strips documenting the change in medical condition which required a code to be called to initiate CPR.

b. On 1/30/19 at 3:51 p.m., an interview with a monitor technician (Tech #2) was conducted. Tech #2 stated she would interpret and then print an abnormal telemetry strip when a patient had a change of condition. Tech #2 stated she would then give the telemetry strip to the patient's primary nurse or the charge nurse to validate the strip. Additionally, she would then place the telemetry strips into the variance monitor log at the nurse's station. At no point did Tech #2 state the telemetry strips which were printed during a patient change of condition would be placed in the medical record.

c. On 1/31/19 at 11:30 a.m., an interview with a monitor technician (Tech #3) was conducted. Tech #3 stated her role as a monitor tech required her to print telemetry strips and interpret them every four hours as well as when there was a cardiac rhythm change or a patient had a change of condition. Tech #3 stated she would let the nurse on the unit know the patient had a change of condition, print the telemetry strip and place the strip in the medical record and make a copy to place in the variance monitor log which was kept at the nurse's station.

d. On 2/4/19 at 9:42 a.m., an interview with Registered Nurse (RN) #4 was conducted. RN #4 stated the monitor tech would print a telemetry strip when a patient had a change of condition, she would then validate the rhythm and she would sign the telemetry strip. RN #4 was unclear as to where the strips went after her validation.

e. On 2/4/19 at 9:00 a.m., an interview with Charge RN (RN) #5 was conducted. RN #5 stated when a patient had a change in their telemetry, the strip was placed in the medical record. However, RN #5 stated when a patient received CPR, the strip was not consistently placed in the medical record. RN #5 stated he had never read a policy stating the telemetry strip should be placed in the medical record to document the change of condition.

f. On 2/4/19 at 12:18 p.m., an interview with the nurse manager (Manager #6) was conducted. Manager #6 stated when a patient had a cardiac rhythm change, the monitor tech would print and measure the telemetry strip which showed the change of condition. The tech would then hand the telemetry strips to the patient's primary RN and the charge RN. Manager #6 further stated when a patient experienced a code, the strip would be printed out for that event as well. Manager #6 stated he thought the telemetry strip should be in the medical record, but would have to review the policy.

Manager #6 then read the Continuous Cardiac Monitoring (Telemetry) policy. Manager #6 stated the rhythm strip which documented a medical change of condition should be in the patient's medical record. Manager #6 reviewed the medical records of Patients #28 and #31 and verified the telemetry strips for their codes were not in the medical record.

g. On 2/5/19 at 11:15 a.m., an interview with the director of quality (Director #8) was conducted. Director #8 stated staff should place telemetry strips documenting a change in condition or CPR in the medical record to show the care which was provided. Review of quality review documents, of code blue events for Patients #28, #30 and #31 revealed telemetry strips for Patients #30 and #31 were stapled to the code blue review documents and were not a part of the medical record. No telemetry strips were found documenting the code for Patient #28.

h. On 2/5/19 at 5:20 p.m., an interview with the chief clinical officer (CCO #7) was conducted. CCO #7 stated staff should print telemetry strips when a patient had a change of condition and place the telemetry strips in the medical record. CCO #7 stated it was important for telemetry strips to be in the medical record to have an accurate picture of the patient's visit and care which was performed.





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2. Nursing staff did not ensure patients were repositioned every two hours.

a. Record review was conducted for Patient #19 who arrived to the facility on 8/31/18. According to the History and Physical, dated 8/31/18, the reason for admission was for ventilator management and continued care for traumatic brain injury.

On 8/31/18 at 7:10 p.m., an initial skin assessment was documented. The note read, the patient's sensory perception was completely limited, he was bedfast, completely immobile and had potential problems for friction and shear. The assessment rated the patient as a high risk for pressure ulcers according to the Braden Scale used for the assessment.

On 8/31/18 at 10:00 p.m., Patient #19's physician ordered the patient to be repositioned every two hours.

Review of the patient's repositioning nursing notes, revealed a lack of documented evidence the nursing staff repositioned every two hours as ordered and per policy. As example, on 9/7/18, there was no documented evidence Patient #19 was repositioned in his bed from 5:30 a.m. until 3:07 p.m., which was a nine hour and 37 minute time frame.

On 9/8/18, there was no documentation Patient #19 was repositioned in his bed from 6:00 a.m. until 6:42 p.m., which was a twelve hour and 42 minute time frame.

On 9/16/18 there was no documented evidence Patient #19 was repositioned every two hours, from 9:36 p.m. until 9/17/18 at 2:20 a.m., which was a four hour and 56 minute time frame.

In addition, an additional seven periods extending greater than three hours between repositioning, were identified from 9/3/18 through 9/19/18 (9/3, 9/5, 9/9, 9/10, 9/12, 9/13 and 9/14) .

The examples were in contrast to the policy Prevention and Treatment of Pressure Ulcers and Non-Pressure Related Wounds that stated high risk patients were turned at a minimum of every 2 hours as well as in contrast to physician orders.

b. Record review revealed Patient #31 was admitted on 10/16/18. According to the History and Physical, dated 10/16/18, Patient #31 was admitted for ventilator management, tracheostomy (breathing tube) care, hemodialysis and rehabilitation after a prolonged hospital stay. Additionally, Patient #31 was a quadriplegic.

According to the Physical Therapy Initial Evaluation, dated 10/17/18 at 9:05 a.m., Patient #31 required restorative therapy to prevent contractures due to her quadriplegia and was dependent with all mobility.

On 10/16/18 at 5:34 p.m., the nursing initial skin assessment, revealed she had a slightly limited sensory perception was bedfast and completely immobile with potential problems with friction and shear.

On 10/17/18 at 12:24 a.m., the patient's nurse documented a skin assessment which indicated the patient was at high risk.

Review of the patient's repositioning nursing notes, revealed a lack of documentation that the patient was repositioned every two hours according to policy. As example, on 10/16/18, there was no documented evidence Patient #31 was repositioned in her bed from 9:32 p.m. until 10/17/18 at 3:02 a.m., which was a five hour and 30 minute time frame.

On 10/17/18, there was no documented evidence of Patient #31 was repositioned in her bed from 3:02 a.m. until 10/17/18 at 3:30 p.m., which was a twelve hour and 28 minute time frame.

In addition to the above, an additional sixteen periods extending greater than three hours were identified from 10/16/18 through 11/14/18.

c. Review of Patient #10's medical record showed, the patient was admitted to the facility on 12/14/18. According to the History and Physical, dated 12/14/18, the patient was transferred to the facility for antibiotic therapy, wound care management and rehabilitation involving physical and occupational therapy. The note further read, the patient had always been bed ridden and subsequently developed sacral right gluteal wounds.

On 12/14/18 at 5:33 p.m., the patient's registered nurse (RN) documented a skin assessment which indicated the patient's skin was moist, the patient was bedfast and his mobility was very limited. The nurse documented the patient was a high risk.

On 12/14/18 at 5:50 p.m., the patient's RN added an intervention to the patient's plan of care. The patient was to be repositioned every two hours.

Review of the Patient #10's repositioning nursing notes revealed a three hour and 11 minute gap between documented turns on 12/22/18. At 12:21 a.m., nursing staff documented the patient was placed in a supine (lying facing upward) position. The next documented reposition was not until 3:32 a.m.

On 12/26/18, from 8:35 a.m., until 1:09 p.m., there was no evidence nursing staff repositioned the patient during the four hour 34 minute period. This was in contrast to policy and the patient's plan of care.

Further review of Patients #1, #5, #8, #17, #21 and #22 records revealed similar findings with the lack of repositioning every two hours according to policy and physician order.

d. An interview was conducted with the wound care nurse (RN #11) on 2/5/19 at 10:27 a.m. RN #11 stated turning and repositioning patients every two hours was best practice for injury prevention. Furthermore, she explained the longer a person was in one position, the skin could be pinched between the surface and the body weight which could cause a pressure injury to the skin. RN #11 explained position and repositioning documentation was completed within the daily nursing cares.

e. An interview was conducted with RN #9 on 2/5/19 at 9:15 a.m. RN #9 stated all patients had an order for repositioning upon admission. She further explained the patients were repositioned every two hours or as specified by the physician's orders. RN #9 stated she was not aware of limitations to staff availability to reposition patients every two hours as ordered.

RN #9 stated repositioning was important to prevent skin breakdown. She said, if the patient refused, the refusal would be documented in the patient's medical record and the patient would be educated.

Based on interviews and document review, the facility failed to provide patient specific discharge instructions and teaching for post-hospital care to the patient's caregiver in 1 of 2 patients discharged home (Patient #7).

Findings Include:

Facility policy:

The Discharge Planning policy read, Patient and/or Patient's Representative, must be assessed for capability of post-discharge self-care and, as needed will involve family/friends/support person in providing more information to ensure patient safety is a major priority. Nurses will ensure that all necessary patient teaching had occurred. Nurses will also document discharge related activities in the medical record, including discharge instructions given.

1. The facility failed to ensure Patient #7's caregiver (her daughter) was given discharge instructions and required teaching to meet the patient's wound care needs.

a. Review of Patient #7's medical record revealed the patient was admitted to the facility on 10/15/18. According to the patient's History and Physical, dated 10/15/18, the patient was admitted from an acute care hospital after she was treated for a rapidly evolving diabetic wound in the perianal buttock area. The patient was referred to the facility for admission due to the patient's poor diabetic control, inability to sit and extensive perianal wound.

b. On 10/16/18 at 3:52 p.m., Case Manager (CM) #20 documented a patient assessment. She documented the patient lived with family and her family were able to help her if needed. CM #20 documented Patient #7 used a home healthcare agency in the past.

On 11/12/18 at 2:20 p.m., CM #20 documented she met with the patient, on 11/9/18, regarding discharge. The patient stated she felt ready to go home and wanted to leave. CM #20 also documented the patient stated she and her family could care for her wounds. CM #20 advised patient that the safest discharge would be to have home healthcare with wound care assistance.

CM #20 documented a second note on 11/12/18 at 2:28 p.m. She documented she met with the patient and discussed treatment progression. CM #20 noted she would speak with the wound nurse and set a plan for discharge.

c. On 11/9/18 at 2:31 p.m., two telephone orders were entered by RN #11 for Physician #22.

The first order was for wound care instructions for Patient #7's right perineum (the area between the anus and the vulva). The instructions read for the patient's wound to be cleansed with normal saline wound cleanser and then pat dry. Then, a barrier cream was to be applied. The order indicated the wound care to be done every other day.

The second order was for wound care instructions for the patient's left perineum. The instructions read for the patient's wound to be cleansed with normal saline wound cleanser and pat dry; then apply peri-wound skin barrier. The order further read for the dead space to be filled with collagen and covered with a folded 4 x 4 gauze. The dressing should be secured with medipore tape.

Patient #7 was discharged home on 11/13/18.

d. Review of Patient #7's discharge instructions, dated 11/13/18, revealed the patient was discharged home without home healthcare. The patient's nurse (Licensed Practical Nurse, LPN #15) documented the patient did have wound care/dressing changes at the time of discharge. However, there was no evidence on the discharge instructions signed by Patient #7 which indicated the details of the wound care and if family was educated on how to provide the wound care.

e. Review of the Discharge Summary, dated 11/13/18, revealed Physician #22 documented Patient #7 would be discharged home after Wound Care had educated the family member regarding daily wound care.

Review of the Patient/Family Education Plans, showed no evidence Patient #7's family member (daughter) was educated, prior to discharge, on the wound care instructions ordered 11/9/18.

f. On 2/4/18 at 1:56 p.m., an interview was conducted with Patient #7's case manager (CM #20) and CM #21. A review of Patient #7's medical record was conducted.

CM #20 stated she remembered the patient. She stated the patient did not go home with home health because the patient did not have any Medicaid at the point of discharge. She stated Patient #7's Medicaid had been cancelled and the facility assisted with the reapplication process. CM #20 stated the patient insisted on going home and would not wait for Medicaid reinstatement.

CM #20 said the patient felt her and her family could care for the wounds. However, she advised the patient the safest discharge would be to have home healthcare for the wound care. CM #20 reported the patient originally needed home health because of her wound. She wanted to make sure someone followed up with the patient and made sure her wound continued to heal without infection. She stated the patient was diabetic. CM #20 stated the patient was provided three weeks of wound care supplies at discharge which was documented in her notes. When asked who was going to perform the patient's wound care. She stated the patient's daughter.

e. On 2/5/18 at 8:40 a.m., an interview was conducted with LPN #15 who provided Patient #7 her discharge instructions on 11/13/18.

When asked about Patient #7, LPN #15 reviewed a copy of the patient's discharge instructions, signed by the LPN. She stated she did not remember the patient. LPN #15 was asked what wound care instructions were given to the patient; she stated if the wound care team was here that day, they would give the patient the instructions. If not, she would review the instructions at the time of discharge. She stated the family "probably" was educated.

f. On 2/5/19 at 1:10 p.m., and interview was conducted with the chief clinical officer (CCO #7) and the wound care nurse (RN #11). RN #11 stated Patient #7 was capable of rolling in bed by herself and reaching her perineum area. She stated she taught her to apply the cream to the wound with gauze. RN #11 stated she believed the patient did the last dressing change with her while they were sorting through wound care products. RN #11 stated she did not remember if she talked with the patient's daughter. She said she did not feel the patient needed any home healthcare.

CCO #7 stated wound care instructions and verification of ability to perform dressing changes independently were done, so the patient was able to maintain the wound care themselves when they go home.

Review of the education plan documented by RN #11, on 11/9/18, showed she did educate Patient #7 on wound care instructions on 11/7/18 at 3:00 p.m. However, there was no evidence in her documentation, the patient was able to demonstrate competency with the dressing change. RN #11 documented the patient required additional training and reinforcement.