HospitalInspections.org

Based on observations, interviews, review of medical records and incident documentation for 10 of 11 patients who received hospital services (Patients 1, 2, 3, 4, 5, 6, 8, 9, 10 and 11), review of medical record documentation for Patient 7, review of grievance documentation for 9 of 13 patients selected from the grievance log (Patients 13, 14, 15, 18, 19, 20, 21, 22 and 23), review of hospital P&Ps, and review of other documentation, it was determined that the governing body failed to ensure the provision of safe and appropriate care to patients in the hospital that complied with the Conditions of Participation.

The findings identified during the survey reflect the hospital's limited capacity to provide safe and adequate care and services and represent a Condition-level deficiency of CFR 482.12, CoP: Governing Body.

Findings include:

1. Refer to the findings cited under Tag A115, CFR 482.13 - CoP Patient's Rights.

2. Refer to the findings cited under Tag A263, CFR 482.21 - CoP Quality Assessment and Performance Improvement.

3. Refer to the findings cited under Tag A385, CFR 482.23 - CoP Nursing Services.

Based on observations, interviews, review of medical records and incident documentation for 10 of 11 patients who received hospital services (Patients 1, 2, 3, 4, 5, 6, 8, 9, 10 and 11), review of medical record documentation for Patient 7, review of grievance documentation for 9 of 13 patients selected from the grievance log (Patients 13, 14, 15, 18, 19, 20, 21, 22 and 23), review of hospital P&Ps, and review of other documentation, it was determined that the hospital failed to fully develop and implement P&Ps that ensured patients' rights were recognized, protected and promoted in the following areas:
* The hospital failed to develop and enforce P&Ps to ensure Patient 10 received care in a safe setting and was appropriately assessed and supervised and prevented from injuries as follows:
- The patient was recovering from a stroke and had cognitive impairment, confusion, impulsivity and upper extremity weakness. Staff gave the patient a cup of hot water, left the patient unsupervised, and the patient spilled the hot water and sustained extensive full thickness burns with blisters, and pain. The hospital failed to develop and enforce P&Ps to ensure the patient was appropriately assessed, supervised, and prevented from being burned; and staff failed to provide the patient wound care in accordance with physician orders and WOCN recommendations, and the burn wounds developed increased slough.
- The patient fell from his/her wheelchair, got his/her arm stuck in the buckled wheelchair seatbelt after exhibiting agitation and repeatedly requesting the seatbelt be removed, and staff failed to assess the patient and intervene to prevent this from occurring.
- The patient fell another time, complained of head pain, required a head CT, and staff failed to assess the patient for injuries and check vital signs in accordance with hospital P&Ps.
- The hospital failed to conduct clear, complete and thorough investigations of these incidents, and follow up actions to ensure they did not recur.
* The hospital failed to conduct clear, complete and thorough investigations of patient incidents and follow up actions, including those of potential or actual abuse and neglect that involved potential or actual harm, for the following additional patients. Incidents included:
- Patient 1 who was burned with cautery equipment during a surgical procedure.
- Patient 11 who was burned on a stove in the RIO unit therapy kitchen.
- Patients 2, 3, 4, 5, 6, 8 and 9 who experienced skin tears, abrasions, hospital acquired pressure ulcers, other skin conditions, and repeated falls.
* The hospital failed to ensure Medicare beneficiaries were provided the IM notice.
* The hospital failed to ensure patients' or patient representatives' right to be fully informed of the patient's health status.
* The hospital failed to provide written notice of follow-up investigation and resolution to patient grievances that contained the required elements in accordance with hospital P&Ps.

The findings identified during the survey reflect the hospital's limited capacity to provide safe and adequate care and services and represent a Condition-level deficiency of CFR 482.13, CoP: Patient Rights.

Findings include:

1. Refer to the findings cited at Tag A117, CFR 482.13(a)(1) - Standard: Patient Rights: Notice of Rights. Those findings reflect the hospital's failure to ensure Medicare beneficiaries were provided the IM notice.

2. Refer to the findings cited at Tag A131, CFR 482.13(b)(2) - Standard: Patient Rights: Informed Consent. Those findings reflect the hospital's failure to ensure patients' or patient representatives' right to be fully informed of the patient's health status in accordance with hospital P&Ps.

3. Refer to the findings cited at Tag A123, CFR 482.13(a)(2)(iii) - Patient Rights: Standard: Notice of Grievance Decision. Those findings reflect the hospital's failure to provide written notice of follow-up investigation and resolution that contained the required elements in accordance with hospital P&Ps.

4. Refer to the findings cited at Tag A144, CFR 482.13(c)(2) - Standard: Patient Rights: Care in Safe Setting. Those findings reflect the hospital's failure to ensure patients' rights to receive care in a safe setting.

5. Refer to the findings cited at Tag A145, CFR 482.13(c)(3) - Standard: Patient Rights: Free from Abuse/Harassment. Those findings reflect the hospital's failure to ensure investigations and follow up actions to incidents of potential abuse and neglect with actual or potential harm, were conducted and were timely, clear, and complete to prevent recurrence.

Based on interview, review of documentation in 4 of 4 of medical records for the IM notice to Medicare beneficiaries (Patients 3, 5, 6 and 7), and review of hospital P&Ps, it was determined that the hospital failed to fully develop and implement P&Ps that ensured patients' rights were recognized, protected and promoted as follows:
* The IM form in use was not the standardized, approved and un-altered IM form.
* Inpatient Medicare beneficiaries or their representatives were not provided the IM as required by CFR 489.27(a) and CFR 405.1205; and IM notice documentation was unclear and incomplete.

The CMS Interpretive Guideline for this requirement at CFR 482.13(a)(1) reflects:
* " ... each Medicare beneficiary who is an inpatient (or his/her representative) must be provided the standardized notice, "An Important Message from Medicare" (IM), within 2 days of admission."
* "The IM is a standardized, OMB-approved form and cannot be altered from its original format. The IM is to be signed and dated by the patient to acknowledge receipt ..."
* "Furthermore, 42 CFR 405.1205(c) requires that hospitals present a copy of the signed IM in advance of the patient's discharge, but not more than two calendar days before the patient's discharge."

Findings include:

1. a. Review of the P&P titled "Important Message From Medicare," dated as last reviewed "08/18" reflected:
* "Hospitals are required to deliver the Important Message from Medicare (IM), CMS-R-193 to all Medicare beneficiaries ... who are hospital inpatients. The IM informs hospitalized inpatient beneficiaries of their hospital discharge appeal rights ... " The CMS-R-193 form referenced in the P&P is not the current IM form approved for use.
* "Hospitals must issue the Important Message for Medicare (IM) within two (2) days of admission and must obtain the signature of the beneficiary or his/her representative. Hospitals must also deliver a copy of the signed notice to each beneficiary not more than two (2) days before the day of discharge ... Hospitals must retain a copy of the signed notice."
* The "Initial Notice" section reflected "Hospital personnel must provide the IM at or near admission but no later than 2 calendar days from the day of admission ... "
* The "Follow-up Notice" section reflected "The follow-up IM must be provided as soon as possible prior to discharge, but no more than 2 days before. When a discharge seems likely in 1-2 days, the follow-up notice should be given to the patient, so the patient has ample time to review and act on it. If the follow up notice is delivered on the day of discharge, the patient must be given at least 4 hours prior to discharge to consider their rights. The facility must document delivery of the notice in order to demonstrate compliance with this requirement ... "
* "If the beneficiary refuses to sign the notice, the hospital should note the refusal and date of refusal on the form and this will be considered the date of notice."
* "Hospitals should place a copy of the initial notice in the patient's medical record. Hospitals must document timely delivery of the follow-up copy of the IM in the patient records, when applicable. Hospitals will use the 'Additional Information' section of the IM to document delivery of the follow-up copy. The hospital should also document any attempted contact with beneficiary representatives, including phone calls, messages and subsequent certified mail.

1. b. Review of the P&P titled "Patient Rights and Responsibilities," dated as last reviewed on "11/20" reflected "Legacy provides the 'Important Message from Medicare about Your Rights' to patients in accordance with Medicare guidelines ... "

2. a. The medical record of Patient 3, an 85-year old inpatient Medicare beneficiary, was reviewed and reflected the patient was admitted to the hospital on 09/11/2020 at 1327 and discharged on 09/29/2020. Documentation related to the IM was unclear, incomplete and lacked evidence that the patient or patient representative was issued, signed and dated an un-altered IM form within 2 days of admission; and was presented a copy of the signed IM form in advance of discharge. Examples included:

* The record contained 2 pages of a 3-page "Important Message from Medicare" form that was an altered version of the standardized, approved IM form.
- Page 1 on the form had an electronic "Patient Consent and Acknowledgement (Sign Below)" signature box that was unclearly dated 09/07/2020 at 1558, four days prior to the patient's admission. The signature box was not signed, and instead reflected "Verbal Consent." There was no documentation that described this unclear date, or the reason for a verbal consent, including why the patient or patient representative did not or could not sign the form.
- The space below the signature box reflected a hand written entry that reflected "POA, [name] verbal consent 9/10/20 [at] 1417." This entry on the form was unclearly dated one day prior to admission, and there was no documentation that described this unclear date, or the reason for a verbal consent, including why the patient or patient representative did not or could not sign the form.
* The "Documents" section in the medical record reflected the "E-IM for Medicare" form was "Given/Mailed" and received by hospital staff on 09/12/2020. However, it was unclear if the form was "given" or "mailed," and it was unclear who it was "given" or "mailed" to.

* The record contained another "Important Message from Medicare" form that was also an altered version of the IM form.
- Page 1 on the form had an electronic "Patient Consent and Acknowledgement (Sign Below)" signature box that was blank. An undated, un-authored handwritten entry next to the box reflected "Patient unable to sign." A handwritten entry below the signature box reflected "Issued via phone with patient's [family member], [name, phone number] on Monday, 9/28/20 [at] 11:10 am." There was no documentation that described the reason the patient was "unable to sign" the form. There was no documentation that described the reason the form was "issued via phone" to a family member.
* Social Worker notes dated 09/28/2020 at 1126 unclearly reflected "Required Notices: IMM - Complete." There was no further information that described what that meant.
* The "Documents" section in the medical record unclearly reflected "Second IM for Medicare Second IMM, 9/28/2020 ... [Status] Received ... [Received By] [name, Transcription] ... [Received On] 09/29/2020 ... [Expires On] 09/30/2020."
The documentation was unclear and lacked evidence that reflected the patient or patient representative was provided a signed copy of an un-altered, approved version of the IM form within 2 calendar days of discharge.

2. b. Similar findings were identified during review of medical records for the following inpatient Medicare beneficiaries:
* Patient 5, a 67-year old admitted to the hospital on 10/02/2020 and discharged on 10/26/2020.
* Patient 6, an 83-year old admitted to the hospital on 10/28/2020 and discharged on 11/12/2020.
* Patient 7, a 69-year old admitted to the hospital on 10/29/2020 and discharged on 11/13/2020.
Documentation in the medical records of Patients 5, 6, and 7 related to the IM notice was unclear, incomplete and lacked evidence that the patient or patient representative was issued, signed and dated an un-altered IM form within 2 days of admission; and was presented a copy of the signed IM form in advance of discharge as required by this CFR.

3. During an interview and review of the medical records of Patients 3, 5, 6, and 7 with the CI-1, RIO NM, ACC and other hospital staff on 02/23/2021 at 1600 and 03/01/2021 at 1425, they confirmed the IM documentation was unclear and incomplete. The ACC confirmed the IM form in the medical records was altered and was not the approved, standardized version of the IM form.



















44104

Based on interview, review of grievance documentation for 9 of 13 patients selected from the grievance log (Patients 13, 14, 15, 18, 19, 20, 21, 22 and 23), and review of hospital P&Ps, it was determined that the hospital failed to fully implement P&Ps that ensured patients' rights were recognized, protected and promoted as follows:
* Responses to and investigations of patient complaints and grievances were not timely or complete; and a written grievance notice that contained the required elements including the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion was not provided to each patient/patient representative who filed a complaint or grievance with the hospital, in accordance with hospital P&Ps.

Findings included:

1. The policy and procedure titled "Managing Patient's Complaints and Grievances" dated last revised "12/20" was reviewed. It stipulated:
* "A grievance is a statement of concern, communicated by a patient or the patient's representative ... about patient care that does not meet the definition of a complaint. Grievances should be documented in the incident reporting system by the person to whom the grievance was reported. Examples of Grievances include ... A complaint that cannot be resolved at the time of the complaint by the staff present ... When the patient or the patient's representative requests that his or her statement of concern be handled as a formal grievance ... Lost patient belongings that cannot be found prior to discharge ... When the patient requests a response from the hospital ... Any written statement of concern communicated by a patient or the patient's representative to the hospital or clinic, regarding patient care ... Any verbal or written statement of concern alleging the failure of the hospital to comply with one or more of the CMS Conditions of Participation (COPs) or other CMS requirement ... Statements of concern that are expressed after the patient leaves the hospital, unless it is a post-hospital verbal communication regarding patient care that would routinely have been resolved by staff present if the communication had occurred during the stay/visit ... Examples include: A call to seek clarification of post-discharge instructions or assistance ... verbal complaints about housekeeping or the quality of food ... "
* "Managing Grievances ... Grievances are investigated and managed by the affected Unit, Department or Service Manager or Director. It is advisable to partner with a Patient Relations Specialist to assure compliance with timeframes, the content of the mandatory response letter and documentation of the grievance."
* "Timelines: Grievances will be investigated and managed within a reasonable time period determined by the complexity of the grievance and the investigation and decision making required. If the grievance cannot be resolved, or if the investigation is not or will not be completed within seven (7) days, the hospital should inform the patient or the patient's representative (verbally or in writing) that the hospital is still working to resolve the grievance and that the hospital will follow-up with a written response within thirty (30) days ... When a final resolution has been reached, a written response will be provided to the patient/designated representative ... "
* "Assure all required elements are included in the closing letter ... Patient name and location of services ... Name of the hospital contact person ... A restatement of the patient's/representative's complaint ... Steps taken to investigate the grievance ... Results of the investigation ... Actions taken based on results of the investigation ... Completion date ... "
* "Complete required documentation and data entry in appropriate locations."
* "Trending and Analysis ... Management reports will be available for managers and leadership to identify opportunities for improvement."
* The "Definitions" section reflected "Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. This includes staff neglect or indifference to infliction of injury or intimidation of one patient by another. Neglect is considered a form of abuse and is defined as a failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness."

2. Grievance documentation for Patient 13 was reviewed and reflected the "Date Complaint Received" was 09/28/2020. The grievance was categorized as "Complaint Type Care Issues." The "Initial Complaint Description" notes reflected "09/28/2020 ... Phone call from patient to complain about [his/her] time in PACU (mostly)." The "Case Narrative" notes dated 09/28/2020 reflected " ... I was left in the recovery rom [sic] for approximately two hours with severe pain ... and my blood pressure reaching over 190 ... When I inquired for the reason of being ignored ... I was told that my surgery was not important ... "
* Grievance documentation dated 10/20/2020 at 1551 from a NM reflected " ... I do see [his/her] blood pressure was up some, but if [he/she] was upset or frustrated, your BP is going to raise ... RN put a call out to Anesthesia to report [his/her] hypertension. Orders were received ... I will speak with (sic) RN that provided care for [him/her] in PACU ... " There was no documentation that reflected the discussion with the PACU RN occurred, or further investigation following a discussion.
* A written response submitted to the patient in response to the grievance, was reviewed. The written response was dated 10/26/2020, 28 days after the complaint was received. There was no documentation that reflected the hospital contacted or attempted to contact the patient either verbally or in writing within seven days of receipt of the grievance to inform the patient the hospital was still working to resolve the grievance and would follow-up with a written response within thirty (30) days, in accordance with hospital P&Ps.
* Review of the written response to the patient reflected "I shared your feedback with the nurse manager for our Post-Anesthesia Care Unit and [he/she] has addressed the issues you shared directly with the nurse assigned to you. Your feedback has also been shared with your surgeon." The written response lacked the steps taken to investigate the grievance.

3. Grievance documentation for Patient 14 was reviewed and reflected the "Date Complaint Received" was 10/21/2020. The grievance was categorized as "Complaint Type Care Issues" and "Complaint Sub Type Infection Control." The "Case Narrative" notes reflected "I spent hrs at ... ER on 10/17/20. What I saw was alarming ... No temperature checks or handing out masks ... people coming in without masks. One was extremely sick with a cough ... unmasked people stood in line for awhile ... No practicing social distancing ... I sat connected to an IV in the lobby, they put someone else right next to me ... Putting people at risk for Covid."
* A written email response submitted to the patient in response to the grievance dated 10/27/2020 was reviewed. The written response reflected "Thank you for contacting us regarding your experience at Legacy Good Samaritan ... I have shared your feedback with the appropriate leadership here ... so that they can continue to work with staff on solutions to these problems." The written response lacked the steps taken to investigate the grievance and the results of the investigation in accordance with hospital P&Ps.

4. a. Grievance documentation for Patient 15 was reviewed and reflected the "Date Complaint Received" was 11/06/2020. The grievance was categorized as "Complaint Type Care Issues." The "Initial Complaint Description" notes reflected "11/06/2020 ... Patient and [spouse] very unhappy with [physician] because they say [he/she] would not contact patient's GI surgeon regarding stitches left over from GI surgery that are causing [him/her] irritation and pain. [He/she] is also upset regarding incident of SOB the first night of [his/her] stay in RIO and feels [he/she] was not appropriately evaluated and treated and felt that [Respiratory Therapy] and nursing staff 'did not listen' to [his/her] concerns." There was no documentation that reflected a written notice of follow-up investigation and resolution was submitted to the patient, and no documentation that the hospital contacted or attempted to contact the patient either verbally or in writing to inform the patient or the patient's representative that the hospital was still working to resolve the grievance.

4. b. During an interview and review of the grievance documentation with the QPS1 and other hospital staff on 03/16/2021 at 0805, they confirmed finding 4. a.

5. a. Grievance documentation for Patient 18 was reviewed and reflected the "Date Complaint Received" was 11/17/2020. The grievance was categorized as "Complaint Type Care Issues." The "Initial Complaint Description" notes reflected "Patient reaches me by phone ... [he/she] says [he/she] had [his/her] annual mammogram here at LGS by a tech ... [He/she] said after imaging [he/she] was 'injured terribly' under both [his/her] breasts and had broken skin ... " There was no documentation that reflected the grievance had been investigated.
* A written response submitted to the patient in response to the grievance, was reviewed. The written response was dated 12/17/2020, 30 days after the complaint was received. There was no documentation that reflected the hospital contacted or attempted to contact the patient either verbally or in writing within seven days of receipt of the grievance to inform the patient the hospital was still working to resolve the grievance and would follow-up with a written response within thirty (30) days, in accordance with hospital P&Ps.
* Review of the written response to the patient reflected " ... your concerns were shared with the manager of the Legacy Good Samaritan Health Breast Center and the supervisor for the technologist who performed your study ... " The written response lacked the steps taken to investigate the grievance and the results of the investigation in accordance with hospital P&Ps.

5. b. During an interview and review of the grievance documentation with the QPS1 and other hospital staff on 03/16/2021 at 0810, the QPS1 acknowledged there was no documentation that reflected the grievance had been investigated.

6. Grievance documentation for Patient 19 was reviewed and reflected the "Date Complaint Received" was 11/24/2020. The "Initial Complaint Description" notes reflected " ... Patient reached me by phone to complain that ER tech who applied splint acknowledged [he/she] had never done it before and splint ended up coming loose ... I agree to share with leadership and follow up in two weeks to 30 days."
* A written response submitted to the patient in response to the grievance dated 12/23/2020 was reviewed. The written response reflected "I forwarded your concerns to the appropriate leadership in the emergency room so they can work with the technician ... " The written response lacked the steps taken to investigate the patient's grievance.

7. Grievance documentation for Patient 20 was reviewed and reflected the "Date Complaint Received" was 12/08/2020. The grievance was categorized as "Complaint Type Risk Management" and "Complaint Sub Type Patient Injury." The "Complaint Narrative" notes reflected the patient submitted a grievance related to an injury he/she incurred during a laparoscopic hysterectomy procedure.
* A written response submitted to the patient in response to the grievance dated 01/07/2021 was reviewed. The written response reflected "Your email and ... documents were forwarded to [physician] and the medical providers directly involved in your care as well as the appropriate leadership ... we have a process for peer review. This is an internal process, which serves as oversight and education ... " The written response lacked the steps taken to investigate the patient's grievance and the results of the investigation in accordance with hospital P&Ps.

8. Grievance documentation for Patient 21 was reviewed and reflected the "Date Complaint Received" was 12/10/2020. The "Date of Occurrence" was blank. The grievance was categorized as "Complaint Type Lost/Damaged Items." The "Initial Complaint Description" notes reflected " ... Missing wallet reported." The "Case Narrative" reflected " ... We have a past patient ... who continues to call us regarding [his/her] wallet ... [He/she] has called multiple times regarding this ... " Although the documentation reflected the complaint was received on 12/10/2020, it also reflected the patient "continues to call us" and has "called multiple times." Therefore, it was unclear when the patient initially submitted the grievance. For example, it was unclear if the patient called multiple times on 12/10/2020, or prior to 12/10/2020. There was no documentation that reflected a written notice of follow-up investigation and resolution was submitted to the patient.

9. Grievance documentation for Patient 22 was reviewed and reflected the "Date Complaint Received" was 12/21/2020. The grievance was categorized as "Complaint Type Environmental Issues." The "Initial Complaint Description" notes reflected " ... VM message from nursing staff yesterday that patient 'is not happy here.'" The "Case Narrative" reflected the following medical record entry: "Date of Service: 12/20/20 0757 ... Pt expressed multiple concerns this am during shift report ... does not feel safe here for reasons such as moldy food, rat poop on the floor, cleaning staff leaving [his/her] door all the way open when there is a sign posted to 'leave it open 3 inches', having to be stuck twice for [his/her] blood draw this morning ... also expressed concern about an unidentified staff member telling [him/her] [he/she] could not have a shower without supervision ... RN's addressed issues as able ... no evidence of rat poop at this time." There was no further investigation of the patient's grievance. There was no documentation that reflected a written notice of follow-up investigation and resolution was submitted to the patient, and no documentation that the hospital contacted or attempted to contact the patient either verbally or in writing to inform the patient or the patient's representative that the hospital was still working to resolve the grievance.

10. Grievance documentation for Patient 23 was reviewed and reflected the "Date Complaint Received" was 01/05/2021. The grievance was categorized as "Complaint Type Care Issues." The "Initial Complaint Description" notes reflected "Patient reaches me by phone to complain about interactions with staff during [his/her] visit ... felt that staff lacked compassion and displayed 'horrible bedside manner' which made [him/her] feel 'humiliated and suicidal' ... I agree to share feedback with appropriate leadership and follow up in two weeks to 30 days ... "
* A written response submitted to the patient in response to the grievance dated 02/01/2021 was reviewed. The written response reflected " I shared your concerns with the appropriate leadership ... so that they can work with staff members and consider ways for improving the elements of their care that you found deficient and upsetting." The written response lacked the steps taken to investigate the grievance and the results of the investigation in accordance with hospital P&Ps.

Based on interview, review of documentation in 3 of 11 medical records of patients who received hospital services (Patients 1, 3 and 10), and review of hospital P&Ps, it was determined the hospital failed to ensure the patient's or patient representative's right to be fully informed of the patient's health status in accordance with hospital P&Ps.
* Patient 1 was burned with cautery equipment during a surgical procedure and the patient or patient representative was not informed.
* Patient 3 experienced repeated falls and the patient's representative was not informed.
* Patient 10 experienced extensive, full thickness burns with blisters and repeated falls, and the patient's representative was not informed or was not informed timely.

Findings include:

1. Refer to the findings cited at Tag A144, CFR 482.13(c)(2) - Standard: Patient Rights: Care in Safe Setting. Those findings reflect the hospital's failure to ensure the patient/patient representative's right to be fully informed of the patient's health status in accordance with hospital P&Ps.


44104

Based on observations, interviews, review of medical records and incident documentation for 10 of 11 patients who received hospital services (Patients 1, 2, 3, 4, 5, 6, 8, 9, 10 and 11), review of hospital P&Ps, and review of other documentation, it was determined that the hospital failed to fully develop and implement P&Ps that ensured patients' rights were recognized, protected and promoted, and the right to receive care in a safe setting as follows:
* The hospital failed to develop and enforce P&Ps to ensure Patient 10 received care in a safe setting and was appropriately assessed and supervised and prevented from injuries:
- The patient was recovering from a stroke and had cognitive impairment, confusion, impulsivity and upper extremity weakness. Staff gave the patient a cup of hot water, left the patient unsupervised, and the patient spilled the hot water and sustained extensive full thickness burns with blisters, and pain. The hospital failed to develop and enforce P&Ps to ensure the patient was appropriately assessed, supervised, and prevented from being burned; and staff failed to provide the patient wound care in accordance with physician orders and WOCN recommendations, and the burn wounds developed increased slough.
- The patient fell from his/her wheelchair, got his/her arm stuck in the buckled wheelchair seatbelt after exhibiting agitation and repeatedly requesting the seatbelt be removed, and staff failed to assess the patient and intervene to prevent this from occurring.
- The patient fell another time, complained of head pain, required a head CT, and staff failed to assess the patient for injuries and check vital signs in accordance with hospital P&Ps.
- The hospital failed to conduct clear, complete and thorough investigations of these incidents, and follow up actions to ensure they did not recur.
* The hospital failed to conduct clear, complete and thorough investigations of patient incidents and follow up actions, including those of potential or actual abuse and neglect that involved potential or actual harm, for the following additional patients. Incidents included:
- Patient 1 who was burned with cautery equipment during a surgical procedure.
- Patient 11 who was burned on a stove in the RIO unit therapy kitchen.
- Patients 2, 3, 4, 5, 6, 8 and 9 who experienced skin tears, abrasions, hospital acquired pressure ulcers, other skin conditions, and repeated falls.

Findings include:

1. a. The P&P titled "Patient Rights and Responsibilities," dated last revised "3/20," was reviewed. It reflected:
* "Legacy is committed to a Family-Centered Care model; engaging the patient and the family as members of the healthcare team, where appropriate ... As a member of the healthcare team, patients and their families are expected to participate fully in their care planning and their own treatment."
* "The patient or their representative (as allowed under State law) has the right to make informed decisions regarding their care ... "
* "A patient has the right to participate in the development and implementation of his or her plan of care. Patients are encouraged to make informed decisions about their healthcare."
* "Patients have the right to personal privacy and safety ... "
* "Patients have the right to be free from neglect, verbal, physical or mental, or sexual abuse, restraint or seclusion and corporal punishment. Legacy protects the right of patients to be free of restraint or seclusion when restraint or seclusion is not indicated for the protection of the patient's health or the safety of the patient, staff or others ... "

1. b. The P&P titled "Restraint and Seclusion for Patients," dated last revised "Dec 2020," was reviewed and reflected:
* "The patient has the right to be free from restraints of any form that are not medically necessary or are used as a means of coercion, discipline, convenience or retaliation by staff. A restraint can only be used if needed to improve the patient's well-being or in emergency situations if needed to ensure the patient's physical safety or safety of others. In either case, restraint or seclusion is only used when less restrictive interventions have been determined to be ineffective based on clinical justification."
* "Seatbelt" was listed on "Attachment #2" under "Approved Restraint Devices."

1. c. The P&P titled "Patient, Visitor, and Employee Incident Reporting," dated last revised "07/17," was reviewed. It reflected:
* "Objectives ... To provide a mechanism for reporting and documenting incidents inconsistent with the routine operations of the facility or care of a patient (sic) ... To support the review of incidents for risk management, patient safety and improvement opportunities."
* "Adverse event - An untoward, undesirable, and usually unanticipated event caused by patient care, treatment or services ... "
* "Incident - Any event, which may involve ... actual injury or potential injury to an individual or ... damage to hospital or clinic property."
* "Incident Report ... includes Patient Safety Alert (PSA) and Security Reports. A factual description of a particular incident, which provides information about the incident and related factors to facilitate further investigation ... "
* "Unanticipated Outcomes - An outcome that differs significantly from what would be expected during the usual course of patient care, treatment or services (e.g., adverse medication reaction, pressure ulcer acquired at a Legacy hospital). An unanticipated outcome may occur in the usual course of clinical care and or (sic) may not be a result of an adverse event or error."
* "Events should be evaluated to determine appropriate next steps which include but are not limited to the following ... Critical Incident Notification ... Root Cause Analysis and possible regulatory reporting of Serious Safety Events ... "
* "Roles and Responsibilities ... Any Legacy staff member or member of the Medical Staff ... Submits a PSA, as soon as possible, preferably before the end of the shift ... If you need immediate help with a patient or visitor event or the event requires action right away, do not wait. The PSA may not be seen right away, or what you think needs to happen may not be evident to others. Talk to the person in charge of your unit, the physician, the nursing supervisor (sic) the risk manager."
* "The Manager of the responsible unit ... Receives an email notice when a PSA is submitted ... Will assure review of the issue reported and will initiate the collection of additional relevant information, from anyone or any source who may have pertinent information ... When events that cross units or departments, the managers of those departments will work together to understand what happened and what needs to happen ... The Manager will investigate and document the investigation and actions taken to resolve the event ... The Manager may take a variety of actions including reporting the issue up the chain of command ... Based on the investigation the Manager will change the report status from NEW to OPEN, within 72 hours of the incident and ... The Manager will assure the event is resolved and the status change (sic) to CLOSED within 2 weeks."
* " ... Statistics and other information derived from the reports may be used to identify trends and implement patient safety, risk reduction and quality improvement programs."

1. d. The P&P titled "Adult Inpatients," dated last revised "Feb 2020," was reviewed. It reflected:
* "RN coordinates the interdisciplinary plan of care and applies the nursing process ... Complete initial bio-psychosocial nursing assessment within approximately four (4) hours of admission and document findings. Assessment parameters include head-to-toe ... "
* "Assess patients transferred between patient care areas: within approximately one hour (1) prior to and approximately one hour (1) following transfer and document findings."
* "Reassess vitals signs, pain, and relevant major body systems, with a maximum duration of approximately six (6) hours between observations as warranted by the patient's condition and nursing judgement, current or potential problems and document findings."
* "Document patient's response to interventions in the medical record."
* "Assess and document skin integrity, including all bony prominences and under medical devices, on admission and each shift thereafter ... Request referral for WOCN consultation per site availability for any patient who is admitted with a pressure ulcer, or develops a pressure ulcer at Stage II or above, and for suspected deep tissue injury and unstageable ulcers."
* "Observe skin integrity and provide skin care according to the plan of care."
* "Document presence of skin breakdown (open areas) and wounds utilizing descriptors (e.g. location, size, condition, as appropriate)."
* "Assess for changes in patient condition indicating complex care needs and initiate needed referrals."
* "Assess and document anticipated discharge needs. Initiate transition planning on admission and with changes in patient condition ... Review discharge instructions with patient/significant other. Evaluate understanding and intervene as appropriate ... Provide clear communication to patient and family around provision of care, treatment/interventions medications and discharge planning."
* "Key Point: Adjustments to the Plan of Care are to be documented."

1. e. The P&P titled "Inpatient Wound Ostomy Encounter, Initial and Follow Up," dated last reviewed "Oct 2019," was reviewed. It reflected:
* "Multidisciplinary Plan of Care: The RN, through application of the nursing process, coordinates and collaborates with the multidisciplinary team, within each discipline's scope of practice, in developing the patient's plan of care ... Treatments are initiated per Wound Ostomy Continence Nurse (WOCN) Standards."
* "Initial Assessment (when wound is first observed or identified, or initial ostomy encounter, it is the foundation for deciding treatment options) (sic) This initial assessment permits comparison with follow up data to determine if wound is progressing or deteriorating ... Wound description ... assessment with sizing (cm). Assessment for any signs of infection ... Photograph of all suspected pressure injuries, complex wounds ... "
* "Follow up assessment - frequency per Wound Nurse discretion depending on severity/complexity of the wound."

1. f. The P&P titled "Skin Tears," dated last reviewed "Feb 2018," was reviewed. It reflected:
* "Definition: The International Skin Tear Advisory Panel (ISTAP) defines a skin tear as 'a wound caused by shear, friction and/or blunt force resulting in separation of the skin layers. A skin tear can be partial thickness (separation of the epidermis from the dermis) or full-thickness (separation of both the epidermis and dermis from underling structures)."
* "Key Point: Skin tears are acute wounds that have a high risk of becoming complex chronic wounds. Skin tears have been reported in the literature to have prevalence rates equal to or greater than those of pressure injuries ... "
* "Treatment ... Assess the flap or pedicle and determine the type of skin tear ... Assess the fragility of the surrounding skin ... Promote healing and patient comfort with appropriate dressing selection by choosing a dressing that will ... Maintain moist wound healing versus a dry dressing ... Protect the peri-wound skin ... Control or manage exudate ... Control or manage infection ... "
* " ... Document presence of the skin tear as a wound in the LDA flow sheet ... Document assessment findings in the Assessment flow sheet."
* "Obtain orders from LIP for wound care ... Request CWOCN referral for complicated skin tears or concerns ... "

1. g. Review of the P&P titled "Prevention of Falls and Fall Related Injury Adult," dated last reviewed "Feb 2020" reflected:
* "Expected Patient Outcomes: Care provided will assist the patient in meeting the following expectations ... An individualized fall and fall injury prevention plan based on identified risk factors ... Involvement in decision-making, implementation and educational processes related to fall prevention."
* "Multidisciplinary Care Plan: The RN coordinates the Multidisciplinary plan of care and applies the nursing process ... For all patients ... Identify patients upon admission who are at risk for falling and injury related to falling by completing the Morse Fall Scale for all patients ... Morse determines increased risk for falling due to ... History of falls, immediate or within last three months ... Secondary diagnoses ... Use of ambulatory devices(s) ... IV/Saline Lock ... Impaired gait or transferring ability ... Reassess and document fall risk each shift, upon transfer from another unit, and with any change in status, and after a fall."
* "Additional factors that increase risk for falling include but are not limited to impaired mobility, condition, diagnosis, nursing judgement, medical interventions, medications, etc."
* "Initiate the multidisciplinary Plan of Care with identified risks and interventions as appropriate ... Pain-assess pain and intervene appropriately ... "
* "Post Fall Procedure ... Assess patient for injury including range of motion, mobility, pain, bruising, lacerations, etc. ... Assess vital signs, mental status, and perform neurological checks ... Assess degree of injury ... 0 = no injury ... 1 = mild (contusion, abrasion) ... 2 = Moderate (sprain, deep laceration) ... 3 = Severe (fracture, change of mental status) ... 4= Death ... Perform Morse Fall risk assessment and revise care plan as warranted ... "
* "Procedures ... Complete Post-fall huddle with the team at the bedside and review the incident report in real time. Document post-fall huddle in the ICARE including interventions that need to be changed or modified ... Notify the physician of fall ... Notify patient's family/representative ... Write a narrative progress note to include description of factors surrounding fall, assessment, Morse Fall Score, interventions provided ... Complete ... ICARE ... For High Risk Patients ... Evaluate and treat patient risk factors for falls ... Implement fall prevention measures ... "

2. a. The medical record of Patient 10 reflected the patient experienced a recent stroke and was admitted to the hospital's RIO unit on 12/23/2020 for acute inpatient rehabilitation. The record reflected the patient who had upper extremity weakness, cognition impairment, impulsivity, confusion, and aphasia was not appropriately supervised and assisted, and subsequently sustained extensive full thickness burns with blisters and pain after spilling hot water on his/her inner thighs; and the patient additionally sustained repeated falls, one of which resulted in the patient's arm being stuck in his/her buckled wheelchair seatbelt. The medical record reflected the following:

* Recreation Therapist note dated 12/24/2020 at 1456 reflected "Assessment ... Decreased endurance, Decreased cognition, Decreased vision/peripheral skills, Decreased communication, Decreased LUE coordination, Decreased RUE coordination ... "

* PT notes dated 12/29/2020 at 1437 reflected " ... could not follow cues for sequencing due to aphasia/confusion ... "

* SLP notes dated 12/29/2020 at 1451 reflected "Progress (12/24-12/30/20) ... patient demonstrates an expressive and receptive aphasia as well as cognitive-communication impairment ... disoriented to year, month, specific location ... ability to identify pictured items, shapes, letters is significantly impaired and likely exacerbated by impulsivity ... [patient] is not safe to be left alone, [he/she] is lacking the communication skills necessary to call for help or use [his/her] phone to call someone ... is unsafe to be left alone to manage daily tasks due to [his/her] inability to sequence, plan and execute ... unable to problem solve ... If left alone, patient would likely fall or hurt [him/herself] ... "

* PT notes dated 12/29/2020 at 1519 reflected "'I just want out of this thing (seatbelt). I'm going home ...'"
* PT notes dated 12/29/2020 at 1836 reflected " ... Impaired gait ... Impaired balance ... Bilateral LE generalized weakness ... Fatigue ... "

* RN notes dated 12/31/2020 at 1424 reflected the patient's right and left upper extremities were "weak."
* RN notes dated 12/31/2020 at 1622 reflected " ... approx 1545, pt screamed out ... Myself and [name] RN entered room to found (sic) pt's hot tea on floor and on [his/her] upper thighs. We assisted patient to undress and noted upper lower legs red and tender to touch. Cold pack and emotional support provided. Moments later, CNA ... called us in to address new blisters appearing. [Physician] present on unit and notified ... " There was no documentation the patient's representative was informed of the burn incident. During an interview and review of the medical record with the RIO ANM and other hospital staff on 02/08/2021 at 1110, the RIO ANM stated the patient had two patient representatives, a [family member] and a caregiver. The RIO ANM stated the family member and the caregiver should have been informed of the burn incident and he/she confirmed there was no documentation in the record that reflected they were informed.

* PT notes dated 12/31/2020 at 1655 reflected "Patient newly injured with burns from hot tea on anterior thighs. Not emotionally able to participate in therapy at this time."

* A physician order dated 12/31/2020 at 1647 reflected Silvadene 1 % cream "1 Application" BID. The order was discontinued on 01/08/2021 at 1257. The order was incomplete as it did not include the site or sites of Silvadene application.

* OT notes dated 01/01/2021 at 0856 reflected "Apparent pain at burn site on B thighs."

* COTA notes dated 01/04/2021 at 1201 reflected "Wheelchair Seat Belt Alarm/Mobility: Continues to be required for patient safety." There was no further information about the type of seatbelt, an assessment about whether the patient could self release the seatbelt, or consideration for the patient's request to have the seatbelt removed on 12/29/2020.

* WOCN notes dated 01/04/2021 at 1542 reflected:
- "Wound History: Spilled hot drink on legs."
- "Bilateral thighs: Open wound beds with adherent slough and red tissue. Multiple serous filled blisters; partially ruptured. Draining yellow serous drainage. Peri wound skin with bright red, tissue. Left injury is greater than right."
- "Wound 12/31/20 Burn; Blister Leg Anterior; Left; Upper red burn areas with large blisters (Active) ... Non-staged ... Full thickness ... Wound Length (cm) 25 cm ... Wound Width (cm) 29 cm ... Depth (cm) ... 0.1 ... "
Wound 12/31/20 Burn; Blister Leg Anterior; Right; Upper red burn area with blister (Active) ... Full thickness ... Wound Length (cm) 12.5 ... Wound Width (cm) 10 ... Additional details/comments lower 7cm x 7cm ... "
- "Pain Management: Gentle wound care. Patient unable to tolerate complete cleansing/debridement of non viable tissue ... "
- "Recommendations/Treatment: Washed wound with mild soap/water. Removed non viable tissue; loose peeling skin. Drained compromised blisters as anticipated they would drain eventually. Rinsed and patted dry. Applied Silvadene to open wounds to decrease microbial load, promote autolysis and offer comfort. Covered remaining areas of red injured skin with Xeroform to prevent sticking and keep moist. Covered with large Sorbex pads to cushion and manage drainage. Secured with roll gauze and Stocking net. Change daily."
- "Plan: WOS to assess twice weekly. Bedside staff to perform wound care per orders. Please call or reconsult WOS if concerns or questions arise prior to reassessment."
- The WOCN notes included photos of the bilateral thigh burn wounds that were consistent with the WOCN's written descriptions.
The WOCN recommendations were inconsistent with the physician orders above dated 12/31/2020 at 1647 and not discontinued until 01/08/2021 at 1257 that reflected Silvadene 1% cream was to be applied BID. There was no documentation in the record that the RN or WOCN clarified the orders. This was confirmed during an interview and review of the medical record with WOCN1, RIO ANM and other hospital staff on 02/08/2021 at 1230. The RIO ANM stated the "floor RN" should have called the doctor and clarified the orders to reflect the WOCN's recommendations. The RIO ANM confirmed there was no documentation in the record that reflected that had been done.

The record reflected wound care to the burn wounds was not carried out in accordance with WOCN recommendations. Examples included:
- RN notes dated 01/05/2021 at 1459 for the left leg burns reflected only "Dressing reinforced." There was no documentation dressings were changed daily in accordance with the WOCN recommendations.
- RN notes dated 01/06/2021 for the right and left leg burns contained no documentation the dressings were changed daily in accordance with the WOCN recommendations.
- RN notes dated 01/07/2021 at 1719 for the right leg burns reflected only "Dressing reinforced." There was no documentation dressings were changed daily in accordance with the WOCN recommendations.
- On 01/04/2021, the MAR reflected Silvadene was applied topically at 0900, 1541 and 2321 and not once daily in accordance with the WOCN recommendations.
- On 01/05/2021, the MAR reflected Silvadene was applied topically at 1200 and 2005, and not once daily in accordance with WOCN recommendations.
- On 01/06/2021, the MAR reflected Silvadene was applied topically at 1000 and 2100, and not once daily in accordance with WOCN recommendations.
These findings were confirmed during an interview and review of the medical record with the RIO ANM, WOCN1 and other hospital staff on 02/08/2021 at 1225.

* CNA notes dated 01/04/2021 at 1700 reflected "Pt got out of bed and attempted to walk around room, as I came in pt stumbled over [his/her] feet and fell backwards onto the bed."

* Physician notes dated 01/04/2021 at 1724 reflected "Paged by nurse with concerns ... patient is oriented to self but not otherwise ... somnolence all day ... the patient got up and tried to walk, felt backwards into bed - and, per CNA, might have hit [his/her] head (on bedrail?) ... [He/she's] complaining of headache of 8/10 intensity but falling asleep in between sentences ... Ischemic stroke patient on lithium and with variable but potentially increased somnolence and confusion ... Plan: Stat head CT ... I told the nurse to have very low threshold for calling rapid response and/or calling me back."

* There was no documentation the RN assessed the patient after the fall in accordance with hospital P&Ps. Although the patient possibly hit his/her head on the bed rail and experienced a headache of 8/10, there was no progress note by the RN with a description of factors surrounding the fall, no head and body assessment, no vital signs, and no neurological checks in accordance with hospital P&P. The record reflected vital signs were not documented until two hours later on 01/04/2021 at 1900 and those reflected pulse was elevated at 115, BP 119/87, Resp 18, Temp refused, and SpO2 97%. There was no documentation the patient's family/representative was informed of the fall in accordance with the hospital's P&P. These findings were confirmed during an interview and review of the medical record with the RIO ANM and other hospital staff on 02/08/2021 at 1540. The RIO ANM stated if the nurse thought a patient potentially hit their head, they should "check in on the patient and do neuro checks." The RIO ANM stated neuro checks included hand grips, pupils, orientation and strength assessments. However, the RIO ANM confirmed there was no documentation those were done.

* RN Care Conference notes dated 01/06/2021 at 0124 unclearly reflected "Safety: [patient] has had NO FALLS at RIO. Bed and wheelchair alarms are in place ... " The documentation was contradictory to the CNA and physician notes on 01/04/2021 above that reflected the patient "fell backwards into bed."

* SLP notes dated 01/07/2021 at 0930 reflected " ... Ed/discussion re: reasoning behind use of seatbelt 'Can you help me get rid of this shit?' ... After explanation, pt appeared with eased frustration and improved understanding."

The next WOCN notes dated 01/08/2021 at 1326 reflected the burn wounds had more slough and the treatment orders were changed as follows:
- "Assessment:Patient anticipated to discharge soon. Re-eval wound status and plan of care for 3x weekly dressings."
- "Bilateral thighs: Open wound beds with more adherent slough to wound beds. Multiple serous filled blisters; partially ruptured and non viable tissue trimmed off with scissors. Draining yellow serous drainage. Peri wound skin redness is improved. Left injury is greater than right."
- Wound 12/31/20 Burn; Blister Leg Anterior; Left; Upper red burn areas with large blisters (Active) ... Wound Bed Assessment Tan/Yellow; Red;Moist ... Closure Not approximated ... Drainage Amount Moderate ... Description Serous ... Non-staged Wound Description Full thickness ... Peri-Wound Skin Fragile; Red ... "
- "Wound 12/31/20 Burn; Blister Leg Anterior; Left; Upper red burn areas with large blisters (Active) ... Wound Bed Assessment Tan/Yellow; Red;Moist ... Closure Not approximated ... Drainage Amount Moderate ... Drainage Description Serous ... Non-staged Wound Description Full thickness ... Peri-Wound Skin Fragile; Red ... "
- "Recommendations/Treatment: Washed wound with mild soap/water. Removed non viable tissue; loose peeling skin. Rinsed and patted dry. Applied warmed MediHoney gel to open wounds to decrease microbial load, promote autolysis. Covered right leg with small sacral Mepilex and 4x4 Mepilex. Cover left leg with (2) large sacral Mepilex. Secured with Stocking net. Change every other day."
- "Plan: WOS to assess weekly. Bedside staff to perform wound care per orders. Please call or re-consult WOS if concerns or questions arise prior to reassessment."

The record lacked documentation that reflected wound care orders for the burns were carried out in accordance with WOCN recommendations. Examples included:
- The RN notes dated 01/10/2021 reflected MediHoney was applied and dressings were changed to bilateral legs burn wounds at 0746 and 2200, and not once daily in accordance with the WOCN recommendations.
- The RN notes dated 01/11/2021 reflected MediHoney was applied and dressings were changed to bilateral legs burn wounds at 0800 " ... due to previous dressing off." The notes reflected MediHoney and dressing were changed again at 2219. However, there was no documentation that described the reason MediHoney was applied and dressings changed again at 2219 contrary to WOCN recommendations.
This was confirmed during an interview and review of the medical record with the RIO ANM and WOCN1 on 02/08/2021 at 1240. The WOCN1 confirmed the MediHoney was applied and dressings changed more frequently than recommended. The WOCN1 stated "If you leave the wound alone for a day or two between dressing changes, it allows the wound to rest. MediHoney is definitely made to be changed twice or three times a week."

* RN notes dated 01/08/2021 at 1722 reflected "RN walking past patients room, visualized patient calling out and sitting on floor. Appears to have slid forward out of w/c, R arm stuck in still-buckled seatbelt above [his/her] head. Appears patient has loosened seatbelt. 2PA to get patient sitting back in w/c, no injuries noted, patient able to move RUE and has full ROM. Patient reports [he/she] needed to toilet. Assisted to toilet with small urinary incontinence noted, patient able to have BM. VSS, reported to primary nurse." Although the notes reflected VSS, there was no documentation that reflected what the vitals signs were. Vital signs were not recorded after the fall until more than two hours later on 01/08/2021 at 1954, and those did not include pulse rate. There was no further progress note by the RN including no assessment of the patient with regard to the wheelchair seatbelt to determine if it physically restrained the patient, and was safe and appropriate with consideration of the patient's agitation and repeated requests to remove the seatbelt, and subsequent fall with his/her arm "stuck" in the seatbelt. This was confirmed during an interview and review of the medical record with the RIO ANM and other hospital staff on 02/08/2021 at 1530.

The Interdisciplinary care plan reflected:
- "Intervention: Use postural supports as needed"
- "Frequency: PRN Dates: Start: 12/23/20"
- "Description: Chest belts, seat belts, arm trough." The care plan was unclear and lacked further information about the "PRN" postural supports, including whether all or some of those should be used for the patient. For example, it did not include the type of "seatbelt" and whether the patient could self release the seatbelt and when it should be "buckled" versus not buckled. It did not include interventions for when the patient exhibited agitation and requested staff to remove the seatbelt. During an interview with the RIO ANM and RIO RSM on 02/08/2021 at 1545, they stated that all patients who needed a wheelchair on the RIO unit were routinely provided a wheelchair with the same type of buckle style seatbelt, and no patients were assessed to determine if they could self release the seatbelt or if the seatbelt physically restrained the patients.

* OT notes dated 01/10/2021 at 0830 reflected " ... Pt received seated in w/c very agitated this morning ... tended to fall asleep mid sentence. Pt occasionally yelling out throughout interaction ... observed pulling at seatbelt asking that it be removed. Communicated with nursing that pt was not agreeable to therapy session. Nursing to followup (sic)." There was no OT, RN or other assessment of the patient to determine the reason the patient was pulling at the seatbelt and requesting that it be removed, including the potential for pain and agitation related to the buckled seatbelt in close proximity to the patient's extensive thigh burns. There was no assessment of the patient by the OT, RN or other staff to determine if the seatbelt physically restrained the patient, and no modification to the patient's plan of care to address his/her agitation and requests to remove the seatbelt.

* Physician notes dated 01/11/2021 at 0320 reflected "Paged by nurse around midnight with concern of pain related to burns on thighs. Pain significant despite having received tylenol and ibuprofen around 9:45 PM. This likely contributes to agitation/yelling, which was prominent throughout the day on Sunday."

2. b. Regarding Patient 10: Review of an incident document reflected that on 12/31/2020 at 1530 the "Pt spilled hot tea on self while sitting up in wheelchair." The documentation further reflected:
* "Contributing Factors (Reported) ... Patient Factors ... Physical Environment Condition/Design."
* "Specific Event Type" followed by "Burn."
* "Severity Level (Reported)" followed by "Harm - Temporary - Minor Treatment."
* "Party Involved/Notified/Witnesses" followed by "Not Specified."
* "Follow-up Notes" recorded by the RIO ANM on 01/04/2021 at 1309, four days after the incident, reflected "Awaiting WOCN review before closing. Placed notification on report sheet alerting staff do not give [him/her] hot beverages. Also adding sign to hot water spigot as a reminder to staff. Will also consult OT as I have noted the patient has some 'shakiness' holding beverages and needs [his/her] food cut up. [He/she] may need more support for improving [his/her] function in the area prior to discharge. Update: Patient was seen by wound care. Treatment regimen continued. Will be followed by WOCN prn after initial consult. Verified that [his/her] Caregiver was informed about the burn by the primary RN."

2. c. Another incident document regarding Patient 10 with "Entered Date" 01/07/2021 reflected that on 12/31/2020 at 1450 "This writer gave patient a cup of hot tea from the hot water dispenser from the kitchen area on the 6th floor. A cover was not put on the cup and was placed on the overbed table for the patient to have. This writer walked out of the room and the patient spilled hot water on [his/her] lap. Two nurses went in to the room immediately." The documentation further reflected:
* "Specific Event Type" followed by "Burn."
* "Severity Level (Reported)" followed by "Harm - Temporary - Minor Treatment."
* "Party Involved/Notified/Witnesses" followed by "Not Specified."
* "Follow-up Notes" dated 01/08/2021 at 1012, eight days after the incident, reflected "Reviewed patient care after incident ... huddle with team, pt with mild wound care after incide

Based on observations, interviews, review of medical records and incident documentation for 10 of 11 patients who received hospital services (Patients 1, 2, 3, 4, 5, 6, 8, 9, 10 and 11), review of hospital P&Ps, and review of other documentation, it was determined that the hospital failed to develop and enforce P&Ps to ensure patients' rights were recognized, protected and promoted and all components of an effective abuse and neglect prevention program were evident, including thorough, complete, clear and timely investigations and follow up actions of potential abuse or neglect as defined by CMS, and potential or actual harm, to ensure those incidents did not recur. Patient incidents included:
* Patient 10 who was recovering from a stroke and had cognitive impairment, confusion, impulsivity and upper extremity weakness. Staff gave the patient a cup of hot water, left the patient unsupervised, and the patient spilled the hot water and sustained extensive full thickness burns with blisters, and pain.
- In another incident, Patient 10 fell from his/her wheelchair, and got his/her arm stuck in the buckled wheelchair seatbelt after exhibiting agitation and repeatedly requesting the seatbelt be removed.
- In another incident, Patient 10 fell, complained of head pain after the fall, and required a head CT.
* Patient 1 who was burned with cautery equipment during a surgical procedure.
* Patient 11 who was burned on a stove in the RIO unit therapy kitchen.
* Patients 2, 3, 4, 5, 6, 8 and 9 who experienced skin tears, abrasions, hospital acquired pressure ulcers, other skin conditions, and repeated falls.

The CMS Interpretive Guideline for this requirement at CFR 482.13(c)(3) reflects "Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment, with resulting physical harm, pain, or mental anguish. This includes staff neglect or indifference to infliction of injury or intimidation of one patient by another. Neglect, for the purpose of this requirement, is considered a form of abuse and is defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness."

Further, the CMS Interpretive Guideline reflects that components necessary for effective abuse protection include, but are not limited to:
o Prevent.
o Identify. The hospital creates and maintains a proactive approach to identify events and occurrences that may constitute or contribute to abuse and neglect.
o Protect. The hospital must protect patients from abuse during investigation of any allegations of abuse or neglect or harassment.
o Investigate. The hospital ensures, in a timely and thorough manner, objective investigation of all allegations of abuse, neglect or mistreatment.
o Report/Respond. The hospital must assure that any incidents of abuse, neglect or harassment are reported and analyzed, and the appropriate corrective, remedial or disciplinary action occurs, in accordance with applicable local, State, or Federal law.

Findings include:

1. Refer to the findings cited at Tag A144, CFR 482.13(c)(2) - Standard: Patient Rights: Care in a Safe Setting. Those findings reflect the hospital's failure to ensure patients received care in a safe setting; and failed to ensure investigations and follow up actions to incidents of potential abuse and neglect with actual or potential harm, were conducted and were timely, clear, and complete to prevent recurrence.


44104

Based on observations, interviews, review of medical records and incident documentation for 10 of 11 patients who received hospital services (Patients 1, 2, 3, 4, 5, 6, 8, 9, 10 and 11), review of medical record documentation for Patient 7, review of grievance documentation for 9 of 13 patients selected from the grievance log (Patients 13, 14, 15, 18, 19, 20, 21, 22 and 23), review of hospital P&Ps, and review of other documentation, it was determined the hospital failed to develop, implement, and maintain an effective QAPI program to ensure the provision of safe and appropriate care to patients in the hospital that complied with the Conditions of Participation.

The findings identified during the survey reflect the hospital's limited capacity to provide safe and adequate care and services and represent a Condition-level deficiency of CFR 482.21, CoP: Quality Assessment and Performance Improvement.

Findings include:

1. Refer to the findings cited under Tag A115, CFR 482.13 - CoP Patient's Rights.

2. Refer to the findings cited under Tag A385, CFR 482.23 - CoP Nursing Services.

Based on observations, interviews, review of medical record and incident documentation for 9 of 9 patients reviewed for provision of nursing services (Patients 1, 2, 3, 4, 6, 8, 9, 10 and 11), review of hospital P&Ps, and review of other documentation, it was determined that the hospital failed to ensure the RN supervised and evaluated patients' conditions in accordance with hospital P&Ps in the following areas:
* The hospital failed to develop and enforce P&Ps to ensure Patient 10 received care in a safe setting and was appropriately assessed and supervised and prevented from injuries as follows:
- The patient was recovering from a stroke and had cognitive impairment, confusion, impulsivity and upper extremity weakness. Staff gave the patient a cup of hot water, left the patient unsupervised, and the patient spilled the hot water and sustained extensive full thickness burns with blisters and pain. The hospital failed to develop and enforce policies and procedures to ensure RN staff appropriately assessed, supervised, and prevented the patient from being burned; and RN staff failed to provide the patient wound care in accordance with physician orders and WOCN recommendations, and the burn wounds developed increased slough.
- The patient fell from his/her wheelchair, got his/her arm stuck in the buckled wheelchair seatbelt after exhibiting agitation and repeatedly requesting the seatbelt be removed, and RN staff failed to assess and supervise the patient, and intervene to prevent this from occurring.
- The patient fell another time, complained of head pain, and required a head CT, and RN staff failed to assess the patient for injuries and check vital signs in accordance with hospital P&Ps.
* Patient 1 was burned with cautery equipment during a surgical procedure and RN staff failed to assess and monitor the burn; and failed to include the burn in the patient's discharge information that addressed post-hospital care in accordance with hospital P&Ps.
- Patient 11 was burned on a stove in the RIO unit therapy kitchen and RN staff failed to notify the physician, failed to assess and monitor the burn; and failed to include the burn in the patient's discharge information that addressed post-hospital care in accordance with hospital P&Ps.
* RN staff failed to complete post fall assessments and processes, including but not limited to vital signs, neurological checks, post fall huddles, physician notifications, and patient family/representative notifications in accordance with hospital P&Ps.
* RN staff failed to assess and monitor patient skin conditions; failed to notify the physician or other LIP of new skin conditions and obtain treatment orders; and failed to carry out WOCN recommendations for patients who experienced skin tears, abrasions, pressure ulcers, and other skin conditions in accordance with hospital P&Ps.
* Physician orders and WOCN recommendations for patient skin conditions were incomplete, inconsistent and unclear, and RN staff failed to clarify the orders.
* RN staff failed to develop and keep current a nursing care plan that included goals, nursing care, and interventions in accordance with hospital P&Ps.

The findings identified during the survey reflect the hospital's limited capacity to provide safe and adequate care and services and represent a Condition-level deficiency of CFR 482.23, CoP: Nursing Services.

Findings include:

1. Refer to the findings cited at Tag A395, CFR 482.23(b)(3) - Standard: Nursing Services: RN Supervision of Nursing Care; and Tag A144, CFR 482.13(c)(2) - Standard: Patient Rights: Care in Safe Setting. Those findings reflect the hospital failed to ensure the RN supervised and evaluated the nursing care of patients in accordance with hospital P&Ps.

2. Refer to the findings cited at Tag A396, CFR 482.23(b)(4) - Standard: Nursing Services: Nursing Plan of Care and Tag A144, CFR 482.13(c)(2) - Standard: Patient Rights: Care in Safe Setting. Those findings reflect the hospital's failure to ensure the RN developed and kept current a nursing care plan that included goals, nursing care, and interventions based on an assessment of the patients' individualized needs in accordance with hospital P&Ps.

3. Refer to the findings cited under Tag A115, CFR 482.13 - CoP Patient's Rights.

Based on observations, interviews, review of medical record and incident documentation for 9 of 9 patients reviewed for provision of nursing services (Patients 1, 2, 3, 4, 6, 8, 9, 10 and 11), review of hospital P&Ps, and review of other documentation, it was determined that the hospital failed to ensure the RN supervised and evaluated patients' conditions in accordance with hospital P&Ps in the following areas:
* The hospital failed to develop and enforce P&Ps to ensure Patient 10 received care in a safe setting and was appropriately assessed and supervised and prevented from injuries as follows:
- The patient was recovering from a stroke and had cognitive impairment, confusion, impulsivity and upper extremity weakness. Staff gave the patient a cup of hot water, left the patient unsupervised, and the patient spilled the hot water and sustained extensive full thickness burns with blisters, and pain. The hospital failed to develop and enforce policies and procedures to ensure RN staff appropriately assessed, supervised, and prevented the patient from being burned; and RN staff failed to provide the patient wound care in accordance with physician orders and WOCN recommendations, and the burn wounds developed increased slough.
- The patient fell from his/her wheelchair, got his/her arm stuck in the buckled wheelchair seatbelt after exhibiting agitation and repeatedly requesting the seatbelt be removed, and RN staff failed to assess and supervise the patient, and intervene to prevent this from occurring.
- The patient fell another time, complained of head pain after the fall, and required a head CT, and RN staff failed to assess the patient for injuries and check vital signs in accordance with hospital P&Ps.
* Patient 1 was burned with cautery equipment during a surgical procedure and RN staff failed to assess and monitor the burn; and failed to include the burn in the patient's discharge information that addressed post-hospital care in accordance with hospital P&Ps.
- Patient 11 was burned on a stove in the RIO unit therapy kitchen and RN staff failed to notify the physician, failed to assess and monitor the burn; and failed to include the burn in the patient's discharge information that addressed post-hospital care in accordance with hospital P&Ps.
* RN staff failed to ensure post fall assessments and processes were completed, including but not limited to vital signs, neurological checks, post fall huddles, physician notifications, and patient family/representative notifications in accordance with hospital P&Ps.
* RN staff failed to assess and monitor patient skin conditions; failed to notify the physician or other LIP of new skin conditions and obtain treatment orders; and failed to carry out WOCN recommendations for patients who experienced skin tears, abrasions, pressure ulcers, and other skin conditions in accordance with hospital P&Ps.
* Physician orders and WOCN recommendations for skin conditions were incomplete, inconsistent and unclear, and RN staff failed to clarify the orders.

Findings include:

1. Refer to the findings cited at Tag A144 that reflect the hospital failed to ensure patients received care in a safe setting; and failed to ensure the RN supervised and evaluated the nursing care of patients in accordance with hospital P&Ps.


44104

Based on interview, review of medical record and incident documentation for 4 of 9 patients reviewed for provision of nursing services (Patients 1, 2, 10, and 11), review of hospital P&Ps, and review of other documentation, it was determined the hospital failed to ensure the RN developed and kept current a nursing care plan that included goals, nursing care, and interventions to be provided based on an assessment of the patients' individualized needs in accordance with hospital P&Ps. Those included:
* Patient 1 who was burned with cautery equipment during a surgical procedure.
* Patient 2 who had extensive skin abrasions.
* Patient 10 who fell from his/her wheelchair, got his/her arm stuck in the buckled wheelchair seatbelt after exhibiting agitation and repeatedly requesting the seatbelt be removed.
* Patient 11 who was burned in the RIO unit therapy kitchen on a stove.

Findings include:

1. Refer to the findings cited at Tag A144 that reflects the hospital failed to ensure the RN developed and kept current a nursing plan of care in accordance with hospital P&Ps.