HospitalInspections.org

Based on document review and interview, the facility failed to ensure a consent for treatment was obtained from the patient or the patient's representative upon admission to the facility for 1 of 10 medical records (MR) reviewed (Patient #1).

Findings include:

1. Review of the policy/procedure Informed Consent (approved 12-18) indicated the following:
2) Standards
a) Types of Consents
(4) General Consents (a) Other medical or related services provided by the Hospital which require a signed General Consent Form, including, but are not limited to the following: Admission to the Hospital
c) Requirements For a Legally Valid Consent Form
(2) A legally valid Consent Form must include each of the following:
(i) The signature of the person responsible for witnessing the signature of the Patient or Representative as appropriate, and their printed name and title; and
(j) The date and time the Consent Form is signed by the Patient or Representative and the designated witness.

2. Review of the MR for Patient #1 lacked documentation indicating a General Consent form was signed by the patient or the patient's representative and witnessed by a facility representative at or after the time of admission.

3. During an interview on 12-11-19 at 1130 hours, the Clinical Information Supervisor A8 and the Manager of Patient Registration A16 confirmed the MR for Patient #1 lacked a General Consent form and no other documentation was available.

Based upon document review and interview, the facility failed to follow its staffing plan and ensure adequate numbers of Registered Nurses were available for all patients admitted to the facility for 1 of 10 medical records (MR) reviewed (Patient # 1).

Findings include:

1. Review of the 2019 Plan for the Provision of Care (approved 8-19) page 31 titled Unit: Progressive Care Unit under the column heading 'Staffing' indicated the following: Staffing is adjusted daily and as needed to meet patient needs..." and lacked additional documentation or reference indicating how the unit would meet the needs of its patients.

2. Review of the policy/procedure Hourly Rounding (approved 7-17) indicated the following: "Nursing staff (RNs PCPs/CNAs and NTs) are responsible for performing Purposeful Hourly Rounding to assess for pain, position, potty, protection, and possessions (5 P's)...Purposeful Hourly Rounding will be performed each hour for each patient on all units from 6am-10pm...Rounding will minimally be done every two hours from 10pm to 6am on all units...PHR consists of...Repositioning patient if unable to do for self (pressure ulcer prevention)..."

3. Review of an untitled and undated administrative staffing grid with the hand-written letters 'PCU' across the top indicated a column on the left side with the heading Number of Patients and rows below populated with numbers of patients ranging from 10 to 28 and across from the number 24 the grid indicated a shift need for 1 charge Nurse, 8 Registered Nurses and two (2) Patient Care Techs (PCTs).

4. Review of administrative documentation titled PCU Daily Assignment dated 10-18-19 indicated eight (8) Registered Nurses (including the charge nurse) and four (4) PCTs were scheduled from 7 p.m. until 7 a.m. and indicated two (2) PCTs were assigned to be 1:1 patient sitters for rooms 3368 and 3386.

5. Review of administrative documentation titled PCU Daily Assignment dated 10-19-19 indicated seven (7) Registered Nurses (including the charge nurse) and two (2) PCTs were scheduled from 7 p.m. until 7 a.m. and indicated the 2 PCTs were assigned to be 1:1 patient sitters for rooms 3368 and 3386.

6. Review of administrative documentation titled PCU Daily Assignment dated 10-20-19 indicated seven (7) Registered Nurses (plus a Registered Nurse at 11 p.m.) and three (3) PCTs were scheduled from 7 p.m. until 7 a.m. and indicated the 3 PCTs were assigned to be 1:1 patient sitters for rooms 3368, 3386 and 3387.

7. Review of the One Week Staffing Pattern Worksheet completed on the PCU Nursing Unit for the 3 week period from 10-6-19 to 10-26-19 indicated on Friday, 10-18-19 the patient census was 28 and indicated at 7 p.m. that 7 Registered Nurses and 2 additional PCTs were working, on 10-19-19 at 7 p.m. that 7 Registered Nurses and no additional PCTs were working, and on 10-20-19 at 7 p.m. that 8 Registered Nurses and no additional PCTs were working.

8. Review of the MR for Patient #1 indicated on 10-20-19 the patient required total assistance with activity including repositioning and indicated from 10-20-19 at 2359 hours until 10-21-19 at 0700 hours the patient was in a supine position and no MR documentation indicated the patient was repositioned at least every two hours to minimize the potential for skin breakdown.

9. Review of the MR for Patient #1 indicated on 10-21-19 at 1130 hours an order for a Wound Ostomy Continence Consult was entered because a new area of skin breakdown on the patient's coccyx was identified and indicated at 1707 hours the Wound and Ostomy Nurse A12 evaluated the patient and provided recommendations for ongoing care.

10. During an interview on 12-11-19 at 0900 hours, the Manager of Accreditation A2 confirmed the weekend PCT staffing for the night shifts on 10-19-19 and 10-20-19 was less than the indicated levels to meet the needs of its patients.

11. It could not be determined how the facility would adjust staffing to meet the additional needs of patients on the PCU.

Based upon document review and interview, the facility failed to ensure an individualized plan of care was maintained for 1 of 10 medical records (MR) reviewed (Patient #1).

Findings include:

1. Review of the policy/procedure Interprofessional Plan of Care (approved 6-17) indicated the following: "Anytime a patient meets risk criteria, including safety, falls, skin and restraint needs, these must be included as part of the care plan...Individualized interventions to be implemented during the patient's hospitalization, specific to the patient/family needs and cultural aspects of care provision, will be checked."

2. Review of the MR for Patient #1 lacked documentation indicating the nursing care plan was updated on 10-21-19 after skin breakdown was initially identified on the patient's coccyx, the Wound Ostomy Continence team was consulted, and new interventions were implemented including the routine application of zinc barrier paste to the affected area by nursing personnel.

3. On 12-11-19 at 1042 hours, the Clinical Informatics Supervisor A8, the Interim Manager of Progressive Care A9 and the Administrative Director of Critical Care A10 were requested to provide a copy of the nursing care plan for Patient #1 including the 10-21-19 update after the area of skin breakdown was identified and none was provided prior to exit.

4. During an interview on 12-11-19 at 1214 hours, staff A8, A9, A10 and the Clinical Informatics Educator A17 confirmed the MR for Patient #1 lacked documentation indicating it was modified on 10-21-19 after the area of skin breakdown was identified and new interventions were implemented in response.

Based upon document review and interview, the facility failed to follow its policy/procedure and ensure all patients admitted to the facility were evaluated for discharge needs for 1 of 10 medical records (MR) reviewed (Patient #4).

Findings include:

1. Review of the policy/procedure Care Management (approved 6/15/2018) indicated the following:
Procedure:
B. Case Manager or Social Worker: Discharge Planning
1) Performs initial screening for discharge planning at the admission assessment. Admission assessments are completed within 24 hours with the exception of weekends and Holidays.

2. Review of the MR for Patient #4 indicated on 10-17-19 the morbidly obese patient (Body Mass Index = 54.9) with medical diagnoses including obstructive sleep apnea, atrial fibrillation and renal insufficiency was admitted to the facility for an orthopedic procedure and transferred to the Ortho Nursing Unit after surgery. The MR indicated Patient #4 was evaluated by a Case Manager on 10-17-19 and was discharged on 10-21-19 to a skilled nursing facility for ongoing care.

3. Review of the MR for Patient #4 indicated on Friday, 11-15-19 at 1620 hours the patient was transported to the Emergency Department and was admitted to the Renal/Medical Nursing Unit with a diagnosis of Congestive Heart Failure and the Admission Assessment screening for discharge planning lacked documentation the patient was seen by a Case Manager or a Social Worker prior to discharge home on Monday, 11-18-19 at 1438 hours.

4. During an interview on 12-11-19 at 1301 hours, the Manager of Case Management A3 and the Interim Manager of Progressive Care A9 confirmed the MR for Pt#4 lacked documentation indicating the patient was evaluated by a Case Manager for any discharge needs during the 11/15-18/19 hospital stay.