HospitalInspections.org

Based on interview and record review the facility failed to obtain consent to treat for one (1) of twenty (20) records review for consents. (Patient #2)

Findings include:

Review of the facility provided INFORMED CONSENT POLICY (dated 8/24/2015) reflected:

"Policy Statement: It is the policy of the ....Hospital District to obtain voluntary informed consent from all patients or their legally authorized representative prior to the start of any care, treatment or service involving more than a slight risk of harm to te patient's physical and / or mental health. Informed consent allows the patient to fully participate in care, treatment or service decision.
...6. The consent form is the final step in the process - memorializing in writing that the disclosurres process has taken place to the satisfaction of the patient and that the patient authorized the providers to perform the discussed procedure or treatment...."

Review of Patient #2's consent form dated 2/07/16 reflected the patient had not signed the consent to treat form.

During an interview on afternoon of 3/7/16, in the conference room, Staff #1, CNO confirmed the findings.

Based on Observation, interview, and record review the facility failed to adequate quality assurance program monitoring when it failed to evaluate the provision of patient care;

A. Patient #8 was administered antibiotics before collecting blood cultures for a patient diagnosed with Pneumonia; and

B. Patient #2 was not provided Occupational Therapy (OT) and Speech therapy (ST) following a stroke.

Findings include:

A. Review of Patient #8's Physician Notes reflected an 84 year old male admitted on 9/14/16 with a chief complaint of left lower lobe pneumonia.

Review of Patient #8's Laboratory records reflected there were no blood cultures drawn.

Review of the facility' Protocol for Pneumonia Policy (undated) reflected " ...Blood cultures x 2 from separate sites. Should be done prior to antibiotics ...."

B. Review of Patient #2's Physician Notes, dated 2/07/16, reflected a 77 year old female admitted to the facility's Swing Bed Unit for a chief complaint of Bilateral Lower Extremity Weakness and Expressive Aphasia following a possible microembolic stroke.

Further review reflected " ...Pt [sic] is to Receive P.T/O.T/S.T .... (Physical Therapy)" " ..family states significant decrease in pt's normal activities of daily living as well. Family states expressive aphasia is still noted and her cognitive and receptive functions have not returned to her normal baseline...."

Review of Patient #2's Physician's Orders, dated 2/07/16, did not reflect an order for O.T and S.T.

During an interview on 3/8/16 in room 302, Patient #2's daughter state, "We brought my mother into the facility to get PT, OT, and ST therapy. It has been over a month and all she has received is PT. My mother has forgotten words she used to know and she used to be able to zip and button her cloths and now she can't."

During an interview on 3/8/16, in the afternoon, in the conference room, Staff #1, Chief Nursing Officer stated the facility does not provide OT and ST therapy.


During an interview on 3/8/16 at 1:50 p.m., in the conference room, Staff #1, Chief Nursing Officer confirmed the finding.

Based on interview and record review the facility failed to provide residents an opportunity to participate in their care plan and treatment plan for two (2) of two (2) residents residing on the Swing Bed Unit. (Resident #2 and #4)

Findings Include:

During an interview on 3/7/16 at 12:45 p.m. in patient room 302, Patient #2's daughter stated, "My mother has been here a month and she was brought in to get physical, occupational, and Speech therapy. The facility has not provided the Occupational and Speech therapy." When Patient #2's daughter was asked if she attended and participates in Patient #2's care plan meetings #2's daughter stated, "We haven't been informed of any care conferences."

During an interview on 3/7/16 at 1:15 p.m. in patient room 306, when Patient #4 was asked if she attended and participates in her care plan meetings Patient #4 stated, "I have not been invited to any meetings."

Review of the facility provided policy INTERDISCIPLINARY COMPUTERIZED PLANNING FOR SWING BED PATIENT CARE (dated 9/24/2015) reflected: ..."POLICY: ...shall provide an individualized plan of care for all patients ...
The facility's Care Plan policy does not include a provision for the patient or family attendance.

During an interview on 3/08/16, in the conference room, Staff #1, Chief Nursing Officer, confirmed the findings.

Based on observation, interview and record review the facility failed to provide an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental, and psychosocial well-being of each resident.; and failed to ensure the acitivity program was directed by a qualified activities director.

Findings Included:

During an interview on 3/7/16 at 12:45 p.m., in patient room 302, Patient #2's daughter stated, "My mother has been here a month and she hasn't been offered any activity; there aren' t any activities here."

Review of Patient #2's Activity Assessment dated 2/7/16 reflected a preference for, word find puzzles and lotion rubs.

Review of Patient #2's Care Plan, on 3/7/16, did not include the activity preferences and Patient #2's Medical Record did not reflect any activities were offered.

During an interview on 3/7/16 at 1:15 p.m. in patient room 306, Patient #4 stated, "I like to read." Patient #4 stated, "I haven ' t been offered any reading materials"; "I'm not aware of any activities."

Review of Patient #4"s Activity Assessment dated 2/24/16 reflected a preference for reading materials/ read to, watching TV/ videos, talking/conversing.

Review of Patient #4's Care Plan, on 3/7/16, did not include the activity preferences and Patient #4's Medical Record did not reflect any activities were offered.

Review of the facility provided ACTIVITY PROGRAM Policy (dated 3/26/15) reflected:
" ...Policy Interpretation and Implementation:
1. Our activity program is designed to encourage restoration to self-care and maintenance of normal activity which is geared to the individual resident's needs.
2. Activities are scheduled daily and residents are given an opportunity to contribute to the planning, preparation, conducting, cleanup, and critique of the program.
3. Our activity program consists of individual, and small and large group activities which are designed to meet the needs and interests of each resident and includes as a minimum:
a. Social activities;
b. Indoor and out-of-doors[sic] activities;
c. Activities away from the facility
d. Religious programs;
e. Creative activities;
f. Intellectual and educational activities;
g. Exercise activities;
h. Individualized activities;
i. In-room activities;
j. Community activities. ..."

During an interview on 3/7/16 at 2:30 p.m. Staff # 1, the Chief Nursing Officer, stated, "The facility recently hired an Activity Director, but she hasn ' t taken over the Activity duties yet." Staff #1, Chief Nursing Officer confirmed the above findings.

Based on interview and record review the facility failed to provide residents an opportunity to participate in their care plan and treatment plan for two (2) of two (2) residents residing on the Swing Bed Unit. (Resident #2 and #4)

Findings Include:


Review of the facility provided policy INTERDISCIPLINARY COMPUTERIZED PLANNING FOR SWING BED PATIENT CARE (dated 9/24/2015) reflected: ..."POLICY: ...shall provide an individualized plan of care for all patients ...
The facility's Care Plan policy does not include a provision for the patient or family attendance.

During an interview on 3/08/16, in the conference room, Staff #1, Chief Nursing Officer, confirmed the findings.