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A. Based on document/record review and interview, it was determined for 1 of 10 patients (Pt #1), the Hospital failed to ensure patient hygiene needs were met. Findings include:

1. The policy titled "Bed Bath" (revised April 5, 2013) was reviewed on 11/13/13. The policy stated "... Depending on the patient's overall condition and duration of hospitalization, he may have a complete or partial bath daily."

2. The medical record of Pt #1 was reviewed with the Credential Trainer, EPIC (E3) on 11/12/13 thru 11/13/13. Pt #1 was admitted 8/9/13 with the diagnoses severe headache, lung cancer with brain metastasis, cerebral edema, emesis (persistent), and dehydration.
A) There was no documentation of a bath provided on 8/10/13. On 8/11/13 at 9:20 AM, Patient Care Technician (PCT) (E19) documentation stated "per patient". There was no documentation to state what "per patient" meant (face, partial, complete, or what care the patient was able to provide per self). An interview was conducted with PCT (E12) on 11/13/13 at 11:30 AM, with the Family Care Center Manager (E6) present. The following was stated by E12 concerning Pt #1's care on 8/10/13 and 8/11/13 day shift. " I had him both Saturday and Sunday. Saturday, he was very lethargic. I offered him a bath but he refused it. He was incontinent and involuntary of urine and stool. I changed his bed linen and his gown, but he wouldn't let me give him a bath ... On Sunday, he got a bath. I didn't document any of this in his chart. I forgot to ... "
B) On 8/12/13 at 9:17 AM, PCT (E11) documentation stated "bath, completed". An interview was conducted with PCT (E11) on 11/13/13 at 11:20 AM, with E6 present. The following was stated by E11 concerning Pt#1's care of Pt #1 on 8/12/13. "I had him on Monday when he was discharged. I didn't hear any complaints from the family. When they arrived, he was already dressed and bathed. I had an orientee with me, so we were able to take care of him together. I remember the room smelled and so did the patient. I had to roll up his pants and underwear because they were really bad. We put on disposable underwear and a gown and maybe scrubs. The night shift PCT reported that he smelled and wouldn't take his shorts off for them ..."
C) An interview was conducted with E6 and E3 on 11/13/13 at 1:20 PM, concerning Pt #1's hygiene and the Hospital policy. Both stated it is the expectation that bathing and hygiene is offered daily and documented, regardless of the type of bath. Both further stated E19 is a night shift PCT and were uncertain as to why the documentation was completed on day shift, unless E19 was charting after the end of the shift. When asked what "per patient" means, both stated that it would mean the patient was independent in doing their bath, without any help. Both agreed it does not state what the patient actually performed, whether it was a face being washed, a partial bath, or a complete bath.

B. Based on document/record review and interview it was determined for 3 of 10 (Pts #1, #6, and #9) patients, pre/post pain intervention assessments and every 2-4 hour pain assessments when pain is present was not conducted in accordance with the Hospital policy.
Findings include:

1. The policy titled "...Tip Sheet #10: REVISED: Pain Assessment Documentation" (revised 1/26/13) was reviewed on 11/13/13. The policy stated "Process Note: ...Pain also needs to be assessed with every administration of pain medication and reassessed at the appropriate time frame based on the route of administration ... Required Assessment/ Documentation Includes: ... Route of medication: I.V. Push ... Reassess Pain at Peak of Medication: 15-30 minutes ... Route of medication: By Mouth ... Reassess Pain at Peak of Medication: 15-30 minute range or 30-60 minute range."

2. The policy titled "Pain Management" (revised July 10, 2012) was reviewed on 11/13/13. The policy stated "Pain should be assessed at admission and be reassessed at regular intervals ... 11. Assess each patient regarding the need for pain and symptom management. Reassess the patient following interventions, and revise treatments as appropriate based on assessment results ... Periodic Pain Assessment and Re-assessment ... Prior to administration of an analgesic medication. After any intervention for pain ... At a minimum of every 2-4 hours while pain is present."

3. The medical record of Pt #1 was reviewed with E3 on 11/12/13 thru 11/13/13. The following pain medications were documented on Pt #1's Medication Administration Record (MAR), between 8/10/13 and 8/12/13, without documentation of pre-intervention pain assessment and/or post-intervention pain reassessments as follows:
A) For 4 of 5 doses of Morphine 2 mg IV (intravenous) administered, no pre or post intervention assessment.
B) For 2 of 4 doses of Morphine Immediate Release (MSIR) 15 mg tablets administered, no pre intervention assessment.
C) For 3 of 4 doses of Morphine Immediate Release (MSIR) 15 mg tablets administered, no post intervention assessment.
D) For 1 of 2 doses of Norco 5/325 mg tablets times, no pre intervention assessment.
E) For 2 of 2 doses of Norco 5/325 mg tablets times, no post intervention assessment.

2. The medical record of Pt #6 was reviewed with E6 on 11/13/13. Pt #6 was admitted 11/10/13 with a diagnosis of traumatic pneumothorax. Pharmacy tracking documentation stated 5 Norco tablets were administered for pain management between 11/11/13 thru 11/13/13 with no nursing documentation of pre and/or post-intervention reassessments as follows:
a) no pre-intervention pain assessment times 2 doses.
b) no post-intervention pain assessment times 4 doses.

3. The medical record of Pt #9 was reviewed with E6 on 11/13/13. Pt #9 was admitted 10/28/13 with a diagnosis of clostridium difficile. Pt #9 had an order dated 10/29/13 for Morphine 1-2 mg (milligrams) intravenously every 2 hours as needed for pain. Pharmacy tracking documentation stated 38 morphine injections were administered between 11/6/13 thru 11/13/13 with no documentation of pre and /or post-intervention pain assessments:
a) no pre-intervention pain assessment times 8 doses.
b) no post-intervention pain assessment times 15 doses.

4. Interview with E3 (for Pt #1) and E6 (for Pts #6, #9) were conducted during medical record reviews 11/12/13 thru 11/13/13. Both E3 and E6 stated that through an internal record review investigation, during the survey, that pain assessment for pre-intervention and post-intervention has been problematic with ongoing education and monitoring required. Both confirmed that the Hospital's policy for pre and post pain assessments was not followed.

A. Based on document/record review and interview, it was determined for 1 of 1 patients (Pt #1) record, the Hospital did not provide wound/skin care in accordance with Hospital policy.
Findings include:

1. The policy titled "Wound Prevention and Treatment" was reviewed with the Credential Trainer, EPIC (E3) on 11/13/13. The policy stated " Process: 1. A Braden risk assessment score of 18 or less triggers a Best Practice Alert for a Clinical Practice Guideline to be added to the patient ' s care plan activity ... The RN shall initiate Skin Care Guidelines and Clinical Practice Guideline interventions and document in the care plan ... Skin Care Guidelines: 2. If pressure ulcer/ wound present: c) Contact your unit wound resource RN (Registered Nurse) and notify physician. Request order(s) for type of dressing to apply ... 4. a) Initiate turning schedule at least every 2 hours and position off affected area ... e) Consider use of Mepilex sacral sacral dressing for protection- place over dry skin, date, lift and replace q (every) 24 hrs (hours) to check skin condition and document. Change q Monday ... 5. Enter dietary screen for nutritional assessment and recommendations if scores 18 or less on the Braden Risk Assessment scale. 6. Initiate measures for correction or control of incontinence and or moisture .... "

2. The medical record of Pt #1 was reviewed with the Credential Trainer, EPIC on 11/12/13 thru 11/13/13. Pt #1 was admitted on 8/9/13 with the diagnoses severe headache, lung cancer with brain metastasis, cerebral edema, emesis (persistent), and dehydration. The Braden Risk Assessments for 8/9/13 thru 8/12/13 were reviewed. The assessments stated Pt #1's risk
score was 16-17 throughout his hospitalization. On 8/10/13 at 1:12 AM, nursing documentation stated Pt #1's wound on the right lower leg was cleansed with normal saline, Hydrogel was applied and covered with Mepilex.

3. On 11/14/13 at 12:00 PM, an interview was conducted with the Credential Trainer, Inpatient Physicians (E7) . Pt #1's skin care interventions, wound care orders, and staff compliance with the Hospital's Wound Prevention and Treatment policy were then reviewed with the following findings confirmed by E7's independent review of Pt #1's medical record. E7 stated on 8/10/13 at 1:12 AM, "they (the staff) applied the guidelines to the care plan chart, but the suggested interventions within the guidelines (such as turning every 2 hours, measures to reduce shear and friction, measures for incontinence care) were not followed or documented against. If the Skin Care guidelines or the Clinical Practice Guidelines are implemented, they feed into the skin interventions section of the patient care documentation. Staff are then expected to document their care interventions in this area. There isn't any documentation to show that they followed these interventions. The area is blank throughout Pt #1's hospitalization. When the care plan was initiated, the nurse (E9), who is a wound resource nurse, assessed the wound, took pictures, measured the wound, and performed wound care (cleansing with normal saline, applying Hydrogel and Mepilex). There was no documentation that the physician was notified and no order for the wound care. If it (the dressing) is just Mepilex, we don't have to have an order, but since Hydrogel was used, we would need an order. All the rest of the dressing documentation stated that the dressing was dry and intact. As for the entering a referral for the dietician to do an assessment and recommendations if the Braden score is less than 18, on 8/10/13 at 12:59 AM, the nurse (E8) documented a referral was not indicated, but I can't tell why. In our computer system, there should be a notation here that says the patient had a Braden score of less than 18 that triggered a nutritional assessment by the dietician. Then we go to the referral section and pick the one for the dietician and under comments, we put again that the Braden score was less than 18. The nursing staff did not follow our policy in caring for Pt #1's skin/wound care."

B. Based on document/record review and interview, it was determined for 1 of 10 patients(Pt #6), the Hospital failed to educate the patient on pain management and the plan of care. Findings include:

1. The policy titled "Pain Management" (Lippincott 2013) stated that patients and families should be educated about their role in pain management, informed of limitations, adverse effects and work with the patient to develop a care plan using pain management interventions taught from that education. The policy stated education provided is to be documented.

2. The policy titled "Patient Controlled Analgesia and Authorized Agent Controlled Analgesia" (effective date 7/10/12) stated the PCA (Patient Controlled Analgesia) pumps are used following education.

3. The medical record for Pt #6 was reviewed with the Manager, Family Care Center (E6) on 11/12/13 at 3:45 PM. Pt #6 was admitted 11/10/13 with a diagnosis of traumatic pneumothorax post fall. On 11/10/13 at 9:30 PM, there was a physician order for Dilaudid 0.5 mg injections in the Emergency Department and then on 11/11/13, a Dilaudid PCA was started. There was no documentation Pt #6 was educated on pain, pain management or interventions although pain was being managed with a narcotics injection on 11/10/13 then a PCA pump was initiated and utilized 11/11/13 thru 11/12/13.

4. An interview was conducted with E6, during Pt #6's medical record review on 11/12/13 at 3:45 PM. E6 stated there was no documentation to indicate the patient was provided any education on pain management, limitations, adverse effects, or pain interventions by the nursing staff from admission to present date.