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Based on interview and record review, the facility failed to protect and promote the rights of 3 (P-1, 2, 3) of 10 patients reviewed for patient rights, resulting in the potential for unsatisfactory outcomes. Findings include:

See Tags:

A0133- Right to informed consent
A0145- The right to be free from all forms of abuse or harassment.
A0166 - Restraints or Seclusion, written modification to the plan of care
A0175 - Restraints or Seclusion, monitoring

Based on observation, interview and record review the facility failed to provide baths and oral hygiene care for five (P2, P3, P4, P6, and P8) out of five patients reviewed for hygiene resulting in an adverse outcome.

See specific tag 0398 - failure to provide hygiene

Based on interview and record review, the facility failed to obtain informed consent for one patient (P3) out of four patients reviewed for consents resulting in the potential for harm.

P3
A review of P3s record revealed that they were admitted to the facility on 7/30/25 for a planned abdominal surgery. Further record review revealed that P3 had a medical history of atrial fibrillation (irregular heart rate), congestive heart failure, and high blood pressure. P3 had complications from the initial surgery and underwent an additional abdominal surgery on 8/5/25 and multiple additional invasive procedures throughout their hospitalization.

On 9/9/25 at 1118 AM P3s medical record was reviewed with Nursing Professional Development Generalist, Staff Q. Staff Q confirmed that there was no consent for the insertion of a percutaneous gastrostomy tube (feeding tube) placement that was performed on 9/3/25.

A review of an incident report dated 9/4/25 revealed the following: "PEG inserted in OR (operating room), no consent signed for PEG tube."

A review of a document titled "Invasive or Complex Procedures" revealed a consent for "Central Line Placement" dated 8/5/25 1310 states "telephone consent" on patient signature line but no indication of who gave the consent. On "witness to signature line" only one RN (registered Nurse) name is listed.

A review of a document titled "Permission for Surgical/Medical Procedures" for "Tracheostomy" dated 8/30/25 revealed no physician signature.

A review of a document titled "Permission for Surgical/Medical Procedures" for "Bronchoscopy" dated 9/3/25 revealed no physician signature.

A review of a document titled "Anesthesia Informed Consent" dated 9/3/25 1249 revealed "phone consent with wife" written on the signature line but only 1 RN signature listed on the witness line.

A review of a Document titled "Consent Invasive or Complex Procedures Placement of Wound vac in abdomen" dated 9/3/25 revealed no physician signature.

On 9/10/25 at 1100 during an interview, the Clinical Risk Specialist, Staff DD, explained that the missed PEG tube consent was discussed with facility leaders and with OR leadership and that they have opened an RCA (root cause analysis). They explained that they are interviewing staff to find out how that happened.

On 9/10/25 at 1110, during an interview, the Chief Nursing Officer, Staff B explained that the normal process for obtaining consent is the physician speaks with the patient and explains the risks of the procedure, the patient signs the consent and the nurse witnesses and counter signs. If a patient is unable to sign the next of kin or responsible party signs it and it is then signed by a nurse. Staff B explained that consents can be signed over the phone only with two nurses witnessing the consent and signing it.

A review of the facility's policy titled "Informed Consent Policy And Process For Verification of Informed Consent For Surgical/Medical And Other Procedures." Dated 9/23/24 revealed the following: "E. Requirements for Valid Consent Form. The following items ordinarily shall appear on the consent form prior to performing the procedure/treatment: 1. The patient's full name (affix patient's sticker with bar code if available); 2. The date and time of obtaining informed consent; this ordinarily shall precede the administration of pre-operative sedative medications; 3. The name of the Licensed Independent Practitioner(s) performing the procedure(s)/treatment(s); 4. The complete name of the procedure(s)/treatment(s) to be performed; 5. Any exceptions to anesthesia, if applicable; 6. The signature of the patient or Patient Surrogate; 7. The signature of the witness; ...J. Telephone, Telegram or Fax Consent. 1. Consent for a procedure/treatment obtained over the telephone or by telegram or fax ordinarily shall only be used if there is no other means to obtain informed consent. 2. The Licensed Independent Practitioner ordinarily shall discuss the purpose of the procedure/treatment, its benefits, risks, complications and alternatives, with the person giving the informed consent. The informed consent ordinarily shall be witnessed by having another person listening on the same line or by verifying the conversation with the person giving informed consent and documented in the medical record. 3. The Licensed Independent Practitioner documents the circumstances surrounding the telephone consent in the medical record. 4. The consent form and the medical record ordinarily shall indicate the name and address of the person giving informed consent, the names and signatures of the persons who heard the conversation, and the time of the conversation. 5. A consent form ordinarily shall be signed the next time the person giving the consent visits ... K. Process For Verifying Consent. 1. If the Licensed Independent Practitioner did not obtain the patient's or Patient Surrogate's signature on the consent form at the time of the informed consent discussion, the Licensed Independent Practitioner may request the nurse to obtain the patient's or Patient's Surrogate's signature on the consent form. 2. The unit personnel have the responsibility to see the consent form for the procedure/treatment has been signed prior to the procedure/treatment. 3. If the patient is scheduled for a procedure/treatment and the consent form has not been properly completed and signed, the patient will not be allowed to go to surgery and/or other applicable procedure area. The Licensed Independent Practitioner scheduled to perform the procedure/treatment and the procedure room ordinarily shall be notified.

Based on interview and record review, the facility failed to ensure that alleged incident of patient abuse was timely identified, reported and remediated for one patient (P-2) of 10 patients reviewed resulting in possible negative outcomes for this patient. Findings include:

P-2 was a 30-year-old female admitted to facility on 6/10/25 with a chief complaint of low blood glucose, status post- seizure and altered mental status. Patient had a medical history of Type 1 diabetes mellitus with ketoacidosis without coma, anoxic brain injury (occurs when oxygen is cut off completely from the brain and can cause serious, permanent brain damage), encephalopathy (conditions that cause brain dysfunction that can appear as confusion, memory loss, personality changes and/or coma), hypothermia (a condition that occurs when core body temperature drops below 95 degrees Fahrenheit and is considered a medical emergency), abnormal behavior and cognitive impairment.

Record review revealed that on 6/19/25 mother of P-2 reported to the nursing staff that P-2 told her that she was being choked by the staff nurse earlier that day. Mother brought the concern forward to the charge nurse, Staff S. Review of the P-2 record did not produce any nursing documentation on 6/19/25 regarding the alleged incident. No incident report was filed by staff regarding alleged abuse on 6/19/25.

Further review of the records indicated that the incident report was filed by facility's Clinical risk specialist, Staff DD, based on the concerns brought forward by patient relations on 8/20/25. Review of the provided report on 9/10/25 indicated that it was in "in progress". Recent update, dated 9/09/25, indicated identified opportunities by the leadership and no recommendations for performance corrections, but "rather a need to educate the entire team on the improvement areas".
Staff education sign off documentation was requested, but not provided.

During the interview with Staff DD, on 9/10/25 at 1038, she recalled that she received concern from the patients' relations department and immediately submitted the incident report on 8/20/25. When asked if the incident report should be submitted by staff on the day of the event, she stated "yes, or as soon as possible".

During the interview with ICU Nurse manager, Staff M, on 9/10/25 at 1122, she described the process of reporting abuse/neglect in detail and stated that any staff suspected of abuse/neglect will be removed from duties pending investigation. Staff M shared that she assumed her role as the nurse manager in the beginning of July, 2025 and was not present on the unit the day of the incident (6/19/25). She learned about the incident when Staff DD notified her. As a result of this notification, she promptly educated the charge nurse, Staff S, regarding proper procedure for reporting suspected abuse/neglect. Staff M was asked if the nurse who was named as alleged abuser was suspended pending investigation at the time of the incident, Staff M said that the nurse was not suspended but re-assigned. When asked if all the ICU nurses received re-education regarding abuse/neglect identification and reporting process, she stated "no, not yet".

On 9/10/25 at approximately 1138, during interview with facility Chief Nursing Officer, Staff B, she stated that all clinical staff in a facility are mandatory reporters of any suspected incidents of abuse/neglect and should follow facility's policies.

Facility policy "Risk Identification Through Safety Event Reporting", dated 10/06/24, was reviewed and revealed:
"4. Policy
4.1. When and How to Complete a Safety Event Report
4.1.1. A safety event report will be initiated for the following circumstances: Any variation in the care of the patient, an adverse event for any patient and/or during any phase of organ transplantation, adverse patient outcomes, accidents involving patients or visitors, or situations with potential for patient or visitor injury.
4.1.2. A safety event report ideally should be completed by the staff involved in, observing, or discovering the safety or adverse event. In some cases, it will be necessary for another party who becomes aware of the safety or adverse event to report it.
4.1.3. The safety event report should be completed immediately, or as close as possible to the time it is discovered, to provide an accurate factual description of the event. A safety or adverse event with any harm to the patient requiring intervention requires staff to notify their entity manager/designee and the Clinical Risk Management Department immediately upon recognition."

Facility policy "Abuse/Neglect: Investigation of Alleged Abuse Within the Organization" dated 6/07/22, was reviewed and revealed:
"A. Abuse Allegation or Observation:
1. When a patient receiving treatment in a facility alleges or is suspected of having experienced abuse, neglect or exploitation, the nurse responsible for the patient's care is to contact the Nursing Supervisor, security, and social services to initiate appropriate required reporting.
B. Protection of the Patient:
2. If the alleged or suspected abuse, neglect or exploitation involves an employee, Human Resources will be notified, and the employee will not be allowed to provide patient care until completion of the investigation".

Based on interview and record review, the facility failed to consistently document the use of restraints in a plan of care for 2 patients (P-1 and 2) of 5 patients reviewed with restraint use, resulting in possible negative outcomes for these patients. Findings include:

P-1: This 96-year-old female with a past medical history of cancer, coronary artery disease, chronic anemia, myocardial infarction, hypertension, chronic kidney disease, gastritis, hypothyroidism, glaucoma, cataract, and dementia was admitted to the facility on 7/19/25 for a blood transfusion.

Record review indicated soft wrist restraints were ordered on 7/20/25 at 0829 for risk of harm to self/others. The plan of care was initiated on 7/20/25 at 0548 and included the following problems: adult inpatient plan of care, absence of hospital acquired illness or injury, optimal comfort and wellbeing, readiness for transition of care, fall injury risk, chronic confusion, and anemia. The clinical nursing notes/plan of care dated 7/20/25 at 1150 failed to include initiation of soft wrist restraints. The record also failed to include care plan documentation on the evening shift of 7/20/25. On 7/21/25 at 0503, nonviolent restraint, absence of harm or injury was added to the plan.


45246


P-2 was a 30-years-old female admitted to facility on 6/10/25 with a chief complaint of low blood glucose, status post- seizure and altered mental status. Patient had a medical history of Type 1 diabetes mellitus with ketoacidosis without coma, anoxic brain injury (occurs when oxygen is cut off completely from the brain and can cause serious, permanent brain damage), encephalopathy (conditions that cause brain dysfunction that can appear as confusion, memory loss, personality changes and/or coma), hypothermia (a condition that occurs when core body temperature drops below 95 degrees Fahrenheit and is considered a medical emergency), abnormal behavior and cognitive impairment.

P-2 had a provider order dated 6/10/25 1430 for 2-point non-violent soft restraint (due to intubation and mechanical ventilation). Nursing care plan was established for non-violent restraints, initiated on 6/10/25 and resolved on 7/02/25.

Further medical record review revealed the following missing documentation for the plan of care for restraints:day shifts on 6/13/25, 6/16/25, 6/20/25, 6/22/25, 6/24/25, 6/25/25, 6/26/25, and 6/29/25 and a night shift on 6/27/25.

During the interview with an ICU (intensive care unit) registered nurse, Staff T, on 9/09/25 at approximately 1055, she stated that care plans for restraints need to be updated every shift and there is a notification in a chart to remind nurses to do that.

Policy: 8168 Restraints: Care of the Patient in Restraints (effective 7/21/24). States, "Documentation in the medical record will include the following: ...assessments, reassessments for continued need, ongoing monitoring to assure the patient's safety and other needs are met, individualization of interdisciplinary plans of care ..."

Policy: 17004 Patient Plan of Care (effective 7/21/24), states, "Documentation of patient progress and an outcome/summary statement is recommended on change in patient condition and minimally twice per day for hospitalized patients."

Based on interview and record review, the facility failed to assess 1 (P-1) of 5 patients reviewed with restraint use, resulting in the potential for unmet patient needs and poor patient outcomes for these patients. Findings include:

P-1: This 96-year-old female with a past medical history of cancer, coronary artery disease, chronic anemia, myocardial infarction, hypertension, chronic kidney disease, gastritis, hypothyroidism, glaucoma, cataract, and dementia was admitted to the facility on 7/19/25 for a blood transfusion.

Record review indicated soft wrist restraints were ordered on 7/20/25 at 0829 for risk of harm to self/others. The soft wrist restraints were discontinued on 7/20/25 at 1842 and modified to Keyed/Leather/Fabric restraints which were discontinued on 7/21/25 at 0750. Keyed/Leather/Fabric restraints were restarted on 7/21/25 at 0930 and discontinued at 1330.

The restraint monitoring flowsheet indicated fluids and food/meal were offered every two hours. On 7/21/25 at 0500, food/meal was offered and P-1 declined. The intake flowsheet was reviewed and indicated on 7/20/25 at 0815, P-1 consumed 25% of breakfast. The record failed to include documentation of intake for lunch or dinner. On 7/21/25 at 1005, P-1 consumed 75% of breakfast. The record failed to include documentation of intake for lunch or dinner. On 7/22/25 at 0815, intake was documented at 0% and at 1232, breakfast was documented at 75%.

These findings were reviewed and acknowledged with the manager of nursing education (Staff R) at time of discovery.

Policy: 8168 Restraints: Care of the Patient in Restraints (effective 7/21/24). States, "Documentation in the medical record will include the following: ...assessments, reassessments for continued need, ongoing monitoring to assure the patient's safety and other needs are met, individualization of interdisciplinary plans of care ..."

Based on observation, interview and record review the facility failed to provide baths and oral hygiene care for five (P2, P3, P4, P6, and P8) out of five patients reviewed for hygiene resulting in an adverse outcome.

P2
A record review revealed that P2 was admitted to the facility on 6/10/25 for seizure. Further record review revealed they had a past medical history of type 1 diabetes. P2 was intubated and mechanically ventilated on 6/10/25, was extubated and reintubated on 6/20/25 and again extubated and reintubated on 6/29/25. P2 was transferred to another facility for a higher level of care on 7/2/25.

A review of P2's Oral care flowsheet revealed multiple missed instances of oral care on 21 out of 23 inpatient days with some days having more than one missed occurrence and some days no oral care was done at all.

P3
A review of P3s record revealed that they were admitted to the facility on 7/30/25 for planned abdominal surgery. Further record review revealed that P3 had a medical history of atrial fibrillation (irregular heart rate), congestive heart failure, and high blood pressure. P3 had complications from the initial surgery and underwent an additional abdominal surgery on 8/5/25 after which they remained intubated on a mechanical ventilator.

A review of the Document titled bathing/skin care flowsheet revealed the following:
P3 received a partial bath only on 8/7/25, 8/8/25, and 8/9/25, and no bath on 8/11/25 and 8/18/25.
A review of a document titled "Oral care flowsheet" revealed that 25 days out of 37 inpatient days had missed occurrences of oral care. Some days had multiple missed occurrences and there were multiple occurrences when P3 did not receive oral care for over 24 hours.

On 8/15/25 P3 received oral care at 0600 then 6 hours later at 1233 then 11 hours later at 2335.

On 9/8/25 during a medical record review with Lead Clinical Specialist, Staff F, a nurses note dated 8/16/25 revealed the following: "Bath started at 2200. Patients abdominal wounds leaking and dressings needing to be changed. When dressing were removed bil (bilateral) JP (jackson pratt) drains and pen rose drain were seen but the abdominal wound had 5 staples in the middle not connecting to other side of skin. Area cleaned and new dressings applied. Afterwards 1 maggot was found on the bed pad on the right side of the patient's abdomen/thigh. During dressing changes no evidence of maggots were found and location for maggot was undetermined. Prior to the turns during the bath patient was suctioned and excessively large amount of thick secretions was removed from mouth/throat. Shortly afterwards during the turn of bath 3-4 maggots came out of the patients mouth and more (unknown number but estimated 20-30+ were suctioned out for the next 20-30 minutes), 6 maggots were placed in a specimen container. No maggots were found in vent tubing but respiratory came and replaced all tubing anyway. New tubing and suction canisters were placed and old suction canisters contained "visually 15+ maggots". (surgeon) messaged an image of worsening abdominal wound and the new development of maggots found in mouth. NO REPLY. House doctor called and order placed to have specimen sent to lab to confirm parasite. Specimen sent to lab.

Lab report dated 8/16/25 0840 stated: "Narrative: Fly larvae (maggots) not otherwise specified."

Physician note dated 9/19/25 stated the following: "Off antibiotic, noted maggots found on patient's oral airway per documentation from last week"

Review of a CT scan result ordered 8/22/2025 1756 PM and resulted 8/22/25 1900 stated the following: "CLINICAL DATA: Diffuse/interstitial lung disease suspected pulmonary congestions, possible maggots exposure."

P4
A review of P4s medical record revealed that they were admitted to the facility on 9/4/25 for nausea and vomiting and had a past medical history of asthma, arthritis, breast cancer, GERD (gastroesophageal reflux disease), fibromyalgia, and hypertension (high blood pressure).

A review of P4s "bathing and skin care flowsheet" revealed no documentation of a bath on 9/4/25, 9/5/25, or 9/8/25.
On 9/9/25 at 1345 a chart review was conducted with staff Q who confirmed that P4 had not received a bath on 9/4/25, 9/5/25, or 9/8/25. Staff Q also confirmed that there was no oral care documented for the entirety of P4s hospitalization.

P6
A review of P6s medical record revealed that they were admitted to the facility on 9/5/25 with difficulty breathing and had a medical history of dementia, hypothyroid, high blood pressure, and chronic obstructive pulmonary disease.
A review of P6s oral care flowsheet revealed no oral care documented on 9/5/25 or 9/6/25.

P8
A review of P8s medical record revealed that they were admitted on 8/1 for a urinary tract infection and had a medical history of neurogenic bladder with a suprapubic catheter, bilateral below knee amputation, diabetes mellitus, high blood pressure, and seizure.

A review of P8s bathing and skin care flowsheet revealed they did not receive a bath during their hospitalization 8/1/25-8/5/25. These findings were reviewed and acknowledged at the time of discovery by Nursing Professional Development Generalist (Staff Q).

On 9/9/25 at 1056 a chart review was conducted with Nursing Professional Development Generalist, staff Q. Staff Q confirmed that P8 had not received a bath during their hospitalization and also confirmed that there was no documentation of oral care during P8s hospitalization.

On 9/8/25 at 1104 Nurse Aide, Staff K, explained that patients should get baths every day and if they refuse the aide should try again later and also let the nurse know. Staff K explained that everyone should get a toothbrush and toothpaste and that oral care should be documented.

On 9/8/25 at 1130 during an interview, Intensive Care Unit (ICU) Registered Nurse, Staff O explained that ICU patients should get baths every day and should receive oral care every 4 hours to prevent infections.

On 9/8/25 at 1130 during an interview, the ICU nurse manager, staff M explained that ICU patients should get baths every day and should get oral care every 4 hours especially if they are on a ventilator. During the interview Staff M confirmed that P3 did have a maggot infestation in their mouth and throat.

On 9/10/25 at 1021 the Clinical Risk Specialist, staff DD, was interviewed. Staff DD explained that any issues are entered into a reporting system and are looked at within 24 hours then the issue gets sent to the appropriate department leadership for follow up. Staff DD explained that if a situation has caused harm or has the potential to cause harm they do an investigation and a chart review. If there has been harm then they will initiate an RCA (root cause analysis). Staff DD explained that the RCA meetings are then held and there are 30, 60, and 90 day follow ups and that they also work with the legal team and the patients and families to come to a resolution.
Staff DD was then queried regarding P3s maggot infestation. Staff DD explained that an incident report was entered about the situation and that they involved legal and worked with unit and facility leadership regarding the disclosure of the issue to P3s family. Staff DD explained that after chart review they did not see any gaps in care regarding suctioning or oral care and that everything seemed to be appropriate. Staff DD explained that there was no harm to the patient so an RCA was not initiated. Staff DD explained that the ICU nurse manager and facility CNO were involved and that the current status of the case is still open and they are waiting for an action plan.

On 9/10/25 at 1030 the Chief Nursing Officer, Staff B explained that they did a chart review and saw good oral care. Staff B explained that it wouldn't take long for fly larvae to form and hatch and explained that they eat dead tissue and debris. Staff B explained that they were part of the disclosure to P3s wife and that it took a few days to discuss the situation with P3s wife because they wanted to discuss it in person.

A review of the facilities policy titled "GUIDELINE Inpatient Bathing and Hygiene Guideline for Adult and Pediatrics" revealed the following: Minimal Hygiene Expectations Grid. Adult and ICU Patients (dated 7/21/2024). States, Daily CHG Bathing or Colloidal Silver Bathing* (where available when CHG allergy is noted) o Moisturize Skin with CHG Compatible Moisturizer o No basin bathing (excluding burn patients during CHG bathing or EEG Hair Care) o Oral Care frequency: o Artificial Airway - every 4 hours o No artificial airway - BID (twice daily) or TID (three times daily)o Prior to extubation only - complete CHG oral care. Pediatric and Adult Non-ICU Patients o Daily Bathing - which may include CHG or colloidal silver bathing o Moisturize Skin with CHG Compatible Moisturizer o Oral Care Frequency: o Artificial Airway - every 4 hours o No artificial airway - BID or TID"