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Based on interview and record review, the facility failed to ensure medical doctors (MD) updated the Responsible Party (RP 1) of the patient's health status for one of thirty sampled patients (Patient 1) in accordance with the facility's Medical Staff Bylaws Rules and Regulations.

This deficient practice resulted in RP 1 not being updated of Patient 1's health status by the physician from admission, on 7/24/22, until discharge, on 7/27/2022 (3 days).

Findings:

A review of Patient 1's Patient Information Sheet indicated Patient 1 was admitted to the facility on 7/24/2022 and discharged on 7/27/2022, against medical advice (AMA, a patient leaves the hospital against the advice of the doctor).

A review of Patient 1's History and Physical, dated 7/24/2022 at 5:04 a.m., indicated Patient 1's diagnosis included COVID-19 (coronavirus disease 2019, a new virus that can spread from person to person, causing respiratory illness).

During an interview, on 8/16/2022 at 9:02 a.m., the vice president of compliance, regulatory and quality (VPCRQ) stated the physician (MD 1) was off and would not be available for interview during the survey.

During an interview, on 8/16/2022 at 2:34 p.m., the Director of Medical Staff Services (DMSS) stated physicians should follow the Medical Staff Bylaws Rules and Regulations. The DMSS stated physicians need to communicate the plan of care with the patients and their responsible party, if not, it is considered inappropriate conduct.

During an interview, on 8/17/2022 at 9 a.m., the Director of Risk Management (DRM) stated that MD 1 failed to communicate with the Patient's RP 1.

During a concurrent interview and record review, on 8/17/2022 at 9:04 a.m., MD 3 stated he treated Patient 1 during his hospitalization. MD 3 stated Patient 1 was being treated for COVID-19 and endocarditis (an infection of the heart's inner lining, usually involving the heart valves). MD 3 stated he attempted to call RP 1 but was unsuccessful. MD 3 stated he did not document his effort to contact RP 1 in the progress notes. MD 3 reviewed all the physician progress notes and verified there was no documented communication with the physicians and the RP 1 until the actual day of Patient 1's discharge on 7/27/2022. MD 3 stated Patient 1 was discharged AMA.

During a concurrent interview and record review, on 8/17/2022 at 9:16 a.m., the Registered Nurse 1 (RN 1) stated she cared for Patient 1 while he was hospitalized. RN 1 stated that Patient 1's diagnosis included COVID-19 and he was not allowed to have any visitors. RN 1 stated RP 1 requested to speak to Patient 1's physicians everyday. RN 1 stated she informed physicians multiple times of RP 1's request. RN 1 stated that MD 2 stated she spoke with RP 1, however, there was no documentation in Patient 1's medical record. RN 1 stated on 7/26/2022, RP 1 specifically requested to speak with MD 1 on 7/26/2022 at 12:54 p.m.. RN 1 stated she informed MD 1 and he stated he would call RP 1 after he completed his rounds that day. RN 1 stated on 7/26/2022 at 6:23 p.m., RP 1 called and stated MD 1 never called and because of the lack of communication she and Patient 1 wanted to be discharged against medical advice (AMA). RN 1 stated the physicians usually document their communication with the family in the progress notes. RN 1 reviewed all of the physician progress notes and stated there was no documentation regarding physician's communication with RP 1 until 7/27/2022, the day Patient 1 was discharged AMA.

During a concurrent interview and record review, on 8/17/2022 at 10:06 a.m., lead registered nurse (RN 4) stated if a family member or responsible party request to speak with a physician, the physician should call the family or responsible party. RN 4 reviewed all of the physician progress notes and stated that there was no documentation in Patient 1's medical record of communication between the physicians and RP 1 until the actual day of discharge on 7/27/2022.

A review of Patient 1's discharge summary, written by MD 1, dated 7/27/2022 at 10:43 p.m., indicated Patient 1 was discharged on 7/27/2022 at 3:45 p.m.. The discharge summary also indicated that Patient 1 had a positive blood culture, infectious disease (ID) physician recommended a prescription for presumed endocarditis, but RP 1 refused intravenous (in the vein) antibiotics (a medication that fights bacterial infections).

A review of physician progress notes, titled "Internal Medicine, dated 7/24/2022 at 2:47 p.m., written by MD 2, 7/25/2022 at 2:45 p.m., written by MD 2, and 7/26/2022 at 8:37 p.m. written by MD 1, indicated there was no documentation regarding physician communication with Patient 1's responsible party (RP 1).

A review of physician progress (MD 3) notes, titled, "Infectious Disease," dated 7/25/2022 at 1:23 p.m., 7/26/2022 at 12:45 p.m., and 7/27/2022 at 1:34 p.m., indicated there was no documentation regarding physician communication with RP 1.

A review of a physician progress note (MD 5), titled, "Pulmonary," dated 7/26/2022 at 12:33 p.m., and 7/27/2022 at 11:15 a.m., indicated there was no documentation regarding physician communication with RP 1.

A review of a physician progress (MD 7) note, titled, "Cardiology," dated 7/27/2022 at 3:49 pm, indicated there was no documentation regarding physician communication with RP 1.

A review of nurses' notes titled, "Safety Assessment Notes," indicated the following:

a. On 7/26/2022 at 12:54 p.m., RN 1 informed MD 1 of RP 1's request to speak with him regarding Patient 1's condition.

b. On 7/26/2022 at 5:06 p.m., RN 1 spoke with RP 1, requesting to speak with MD 1 for an update.

c. On 7/26/2022 at 5:07 p.m., RN 1 informed MD 1 of RP 1's request to speak with him.

d. On 7/26/2022 at 6:23 p.m., RN 1spoke with MD 1 and informed him of RP 1's request for Patient 1 to be discharged since she has not been able to speak with a doctor of Patient 1's condition. Per MD 1, he will call RP 1 now.

e. On 7/26/2022 at 7:55 p.m., RN 7 called and spoke with MD 4 about RP 1's request to speak to an MD for updates.

f. On 7/26/2022 at 8:19 a.m., RN 1 spoke with MD 1, informed him RP 1 still had not heard back from him and was now requesting to take Patient 1 home. Additionally Patient 1 was refusing blood draws and echo this morning. Per MD 1, he will come see Patient 1 and then call RP 1.

g. On 7/27/2022 at 10:27 a.m., RN 1 indicated, per MD 1, he had not spoken to RP 1 yet, he will call her after he rounds on patients. Per MD 1, he was aware, RP 1 asking to take father AMA.

h. On 7/27/2022 at 12:15 p.m., RN 1 spoke with RP 1, who stated MD 1 had not called her yet.

i. On 7/27/2022 at 1:40 p.m., RN 1 indicated MD 1 stated he already spoke with RP 1 and RP 1 still wants to take Patient 1 AMA.

j. On 7/27/2022 at 3:07 p.m., RN 1 indicated Patient 1 left AMA.

A review of the facility's "Medical Staff General Rules and Regulations," dated 2021, indicated physician conduct and purpose of this rule was intended to address conduct which does not meet the professional standards expected of Medical Staff members and shall be the primary means for review and disciplining members for inappropriate or disruptive behavior. The document also indicated, "Inappropriate behavior", means conduct that was unwarranted and was reasonably interpreted to be demeaning or offensive. Persistent, repeated inappropriate behavior can become a form of harassment and thereby becomes disruptive, and subject to treatment as "disruptive behavior". Examples of inappropriate behavior include, but are not limited to, the following: Non communication: Refusal to communicate with responsible persons can be extremely disruptive in the patient care setting. This kind of conduct often results from individuals fighting or feuding, or lack of trust. It becomes disruptive at the point where important information should be communicated, but was not. Closely related are incomplete or ambiguous communications. This becomes disruptive when it diverts patient care resources into having to devote substantial and unnecessary time obtaining follow-up clarification.

Based on observation, interview, and record review, the facility failed to monitor a patient on soft-wrist restraint (devices that limit a patient's movement) to every two (2) hours according to facility's policy and procedure for 1 (one) of 2 (two) sampled patients (Patient 19).

This deficient practice resulted to two missed assessments for Patient 19's wrists with soft wrist restraint between 8/16/2022 2:00 a.m. and 8/16/2022 7:50 a.m. and had the potential for circulation on the wrists being too restrictive not protect the patient's safety.

Findings include:

A review of Patient 19's History and Physical (H&P), dated 8/1/2022, indicated Patient 19 was admitted on 8/1/2022 with acute hypoxemic respiratory failure (not enough oxygen in the blood) and gastroenteritis (intestinal infection).

A review of Patient 19's Restraint Order, dated 8/15/2022, indicated reason for restraint order was for, "Repeated attempts to remove IV (intravenous or within a vein), NG (nasogastric tube, a special tube that carries food and medicine to the stomach through the nose), or other tubing." Order indicated, "Restraint type(s): soft wrist-both."

During a concurrent observation and interview, on 8/16/2022 at 9:59 a.m., with Nurse Manager 3 (NM 3), Patient 19 was observed in room with bilateral (both sides) soft restraints (a device that is placed on the wrist with Velcro to limit a patient's movement). NM 3 stated, assessment of restraints every 2 (two) hours should be documented per policy.

During a concurrent interview and record review of Patient 19's Restraint Assessment, on 8/16/2022 at 9:55 a.m., NM-3 stated Patient 19's Restraint Assessment was reviewed between 8/16/2022 2:00 a.m. and 8/16/2022 7:50 a.m. NM-3 stated, documentation and evidence of restraint assessment for Patient 19 on 8/16/2022 4:00 a.m. and on 8/16/2022 6:00 a.m. was not found in the medical record (2 assessments missed).

A review of facility policy titled, "Restraint Use", effective date 8/1996, revised date 8/2021, indicated under section 6.8.2, Ongoing monitoring content - At a minimum of every 2 hours, the patient assessment will include the following: circulation, hydration needs, elimination needs, level of distress and agitation, cognitive functioning, nutritional needs, range of motion, evidence that the restraint is still needed, and evidence that the restraint device is still the lease restrictive way to protect the patient's safety.

Based on interview, and record review, the facility failed to ensure nursing staff developed a nursing care plan according to facility's policy and procedure on care planning for 1 (one) of 15 patients (Patient 16). Patient 16 had no initial care plan for a bacterial skin infection on admission.


This deficient practice resulted in the delay wound care for Patient 16, who was admitted on 8/8/2022. Patient 16's initial care plan for the bacterial skin infection was initiated on 8/12/2022 four (4) days after admission.

Findings include:

A review of Patient 16's History and Physical (H&P), dated 8/8/2022, indicated Patient 16 presented to the Emergency Room for "Worsening left lower face and lip swelling." H&P indicated, assessment of left facial and lip cellulitis (potentially serious bacterial skin infection; the affected skin is swollen and is typically painful and warm to the touch).

During an interview on 8/16/2022 at 8:50 a.m., with Nurse Manager (NM 3), NM 3 stated, care plans should be initiated within 24 hours of admission.

A review of Patient 16's skin assessment, dated 8/8/2022 at 10:40 p.m., indicated "Lip swelling/pain."

A review of Patient 16's Tissue Analytics: Wound, dated 8/9/2022, indicated a photo of Patient 16's wound, with "Wound location: lower lips."

A review of Patient 16's Plan of Care, titled "Wound", printed date 8/16/2022, indicated care plan was documented on 8/12/2022, with "Goals: optimal wound healing."

During a concurrent interview and record review on 8/16/2022 at 3:30 p.m., Patient 16's Plan of Care, titled "Wound," documented on 8/12/2022, was reviewed with the Director of Performance Improvement (DPI). DPI stated, Patient 16's initial wound care plan was initiated on 8/12/2022.

A review of facility's policy titled "Documentation, General Guidelines", Effective Date 7/1997, Reviewed Dates: 10/2021, indicated "6.0 Nursing Care Plans: 6.1 When patients are admitted initiated care plans as soon as possible and within 24 hours."