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Based on an interview and review of a hospice contract it was determined the governing body failed to implement a mechanism to evaluate the quality of each contracted service.

Findings:

The contract between the hospital and the Hospice agency was reviewed in the facility on 08/29/2011. According to the terms of the contract the hospital was responsible to develop policies and procedures consistent with the philosophy and concept of hospice and to designate a liaison "to work with the Director of Clinical Services in coordinating the services provided to hospice patients."

The Chief Nursing Officer was interviewed in the agency on 08/29/2011 at 10:30 A.M. She acknowledged the hospital had failed to develop policies and procedures consistent with the philosophy and concept of hospice and to designate a liaison "to work with the Director of Clinical Services in coordinating the services provided to hospice patients."

The Chief Nursing Officer was interviewed on 08/30/2011 during the survey exit and acknowledged the above noted deficiency.


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2. The Governing Body failed to ensure that the hospital provided Hospice respite care services as dictated by a contract with two hospice agencies. The hospital did not have policies and procedures related to: inpatient hospice services, providing in patient respite care or employee education related to the contracted services.

The Chief Nurse Executive (CNE) was interviewed on 8/29/2011 at 1:15 p.m. and a list of all hospital contract services was requested. The CNE stated that the hospital had a contract with two hospice agencies and presented the contracts. Hospice agency # 1 was owned and managed by the hospital's own employees. This contract included the hospital's agreement to provide in-patient respite care to the Hospice agency's patients, as needed. Contract # 2 included the hospital's agreement to provide in-patient respite care as needed, to ensure policies were developed and followed for in-patient hospice respite care and to ensure employees were trained in the hospice agency's philosophy regarding patient rights and end of life care. These policies and evidence of employee training evidence was requested. The CNE stated that the hospital did not have policies specific to respite patients. The CNE presented a policy labeled: "Comfort Care." This policy did not address hospice respite patients, employee education related to hospice care, end of life or the agency's philosophy.

Based on clinical record review, employee interview, facility policy and procedure review and during the course of a complaint investigation, the facility staff failed (1) to ensure four (Patient # 1, 3, 4 and 10) of 11 patients were accurately assessed and failed to develop a care plan related to fall risks; and (2) failed to ensure nursing employees were appropriately trained; and (3) failed to ensure the dignity of one patient in the survey sample, Patient # 3. The patient was not permitted to dress in her own clothing.

Findings:

The facility staff failed to ensure each patient received safe care. Patients were not (1) appropriately assessed for falls and the nursing care plan did not include intervention to prevent falls. The Quality Assurance Committee was aware that the nursing fall risk assessment (MORSE) was not being completed accurately and that the nursing care plans were insufficient. The QA committee took no action to ensure patients received safe care related to fall potential. The QA committee did not (2) ensure that nursing staff were trained to accurately complete the fall assessment or care plan development. (3) Patient # 3 was not permitted to dress in her own clothing.

1. Four of four patients in the survey sample that experienced a fall during their hospital admission were not accurately assessed or care planned to prevent falls:

A. Patient # 1 was identified the patient as having a high fall risk by the facility nursing assessment/fall risk assessment upon admission. The nursing care plan did not include interventions to prevent falls. The patient actually experienced a fall (5/24/2011) during his admission to the facility. The patient was assessed each shift for his risk of falling. The MORSE assessment was not consistently completed. Each time the assessment was completed, the nurses inconsistently scored the client. At times, the same nurse completed the assessment with different answers, although the answers could not have changed, such as: history of falls, secondary diagnosis, ambulatory aid, and gait. For Patient # 1, the assessment on 5/23/11 at 9:59 p.m. was scored by one nurse as having no history of falls, no secondary diagnosis and oriented with a total score of 35/125. Another nurse completed the assessment on 5/24/11 at 7:45 a.m. and scored the patient as having a fall risk, no secondary diagnosis and forgetful with a total score of 70/125. This assessment tool scored the patient from 0-125 with the higher the number scored, the higher the fall risk. The history and physical dated 5/23/11 revealed that the patient's primary diagnosis was Alzheimer's dementia with confusion and additional diagnoses of syncope episodes, trans-ischemic attacks (TIA's), bladder cancer with a urostomy bag, and a history of delirium.

B. Patient # 3 was identified as a high falls risk by the nursing staff. The nursing care plan did not include goals or interventions related to her risk of falling. The patient actually experienced a fall (6/8/11) and the care plan did not evidence a review or revision after this event to prevent additional falls. The Unit III Manager (RN # 1) was interviewed on 8/31/2011 at 2:00 p.m. and the care plan was reviewed. RN # 3 acknowledged the care plan did not include goals or interventions appropriate to the patient assessment and needs. RN # 3 stated that the computerized program did not allow for the nurse to individualize the care plan in the area of falls. This patient's falls risk assessment (MORSE) was also inconsistently and inaccurately completed, at times by the same nurse. Her score fluctuated as follows:
6/7/11@ 1:48 p.m.-75
6/7/11 @1:48 p.m.-75
6/7/11 @ 8:10 p.m.-25
6/8/11 @8:53 a.m.-55
6/8/11 @9:00 p.m.-25
6/9/11 @8:24 a.m.-70
6/9/11@8:05 p.m.-40
6/10/11@10:14 a.m.-35
6/12/11@7:55 a.m.-85.
These assessments were frequently completed by the same nurse, with varied answers to questions that did not change.

C. Patient # 4 experienced a fall during his admission to the facility. The nursing care plan did not include goals or interventions to prevent further falls. The nursing care plan was not reviewed or revised after an actual fall. The falls risks assessments were inconsistently coded and did not accurately reflect the patient's actual status.

D. Patient # 10 experienced a fall during his admission to the facility. The nursing care plan did not include goals or interventions related to falls prevention. The care plan was not reviewed or revised after an actual fall. The MORSE assessment was not consistently completed with accurate depiction of the patient's status.

2. Nursing employees were not adequately trained to assess patients for a risk of falling.

During the course of an investigation related to patient falls (see 1. above) the employee training records were reviewed. Five of 7 nurses (licensed employees reviewed) did not have evidence of education related to falls prevention or the completion of the facility's fall risk assessment (MORSE).
LPN # 1-No evidence of training.
LPN # 2-No evidence of training.
RN # 3-MORSE training completed in 2004 .
RN # 2-MORSE training completed 8/11/09.
RN # 3-No evidence of MORSE training.

The Quality Assurance/Performance Improvement Director and the Risk Manager were interviewed on 8/31/2011 regarding the above concerns. The Quality Assurance Director stated that she was aware of the concerns related to the completion of the falls risk assessment accuracy and the care plan development and revision. The Quality Assurance Director stated they were continuing to monitor the issue, when evidence of corrective action was requested. No evidence of additional or initial employee training on the two identified concerns were presented during the survey.

3. Patient # 3 was not permitted her right to dress in her own clothing.

On 8/29/2011 and 8/30/2011 a complaint investigation was conducted. One allegation of the complaint stated that Patient # 3, who was receiving in-patient hospice respite care services, was not permitted to dress in her own clothing. The allegation stated that the clothing was provided to the facility, upon Patient # 3's admission, for a five day stay but was not used as the patient was dressed in a hospital gown daily.

On 8/29/2011 at 3:20 p.m. the facility's Customer Service Coordinator/Grievance Investigator (Employee # 7) was interviewed regarding the above allegation. The Consumer Relations Director stated that she received a grievance (complaint) from the patient's representative on 6/15/2011 and had investigated the allegations. Employee # 7 presented the facility's complaint investigation. The"Record of Complaint/Grievance" document- with the intake date 6/15/2011, was reviewed. The document revealed that Employee # 7 received the complaint by phone, and the complaint included an allegation that the patient was not permitted to dress in her own clothing. This hand-written document revealed that the complaint closure or resolution was completed on 7/11/11 as evidenced by Employee # 12's signature. Employee # 3 stated that she forwarded this complaint to the Unit Manager (RN # 1) as part of her investigation. The information forwarded to RN # 1 included: "Daughter stated she sent a change of clothes for the patient to have everyday and all she wore in the hospital was a hospital gown and diapers." The Unit Manager's (RN # 1) response: "This patient was incontinent of bowel and bladder, so we did not put her clothes form home on her as this is too difficult when changing and cleaning after bowel movements." This response did not include a date or the RN's signature or other means to validate his response. A complaint resolution letter was completed by Employee # 7 on 7/18/2011 and mailed to the complainant. The letter did not address the complainant's voiced grievance related to Patient # 3's right to wear her own clothing.

The Vice President of Nursing Services was interviewed on 8/30/2011 at 9:20 a.m. regarding the facility's policies on patient rights and respite care. The VP stated that all patients have the right to dress in their own clothes. The facility's complaint investigation was reviewed with the VP and she stated that Patient # 3 "Should" have been permitted to dress in her own clothing.

The facility's policy regarding patient's rights was requested and the "Patient Services Guide" was presented by the Chief Nurse Executive. The guide included a section: "Patient Rights & Responsibilities." Listed as a patient rights: Privacy and Confidentiality....To wear appropriate personal clothing and religious or other symbolic items, as long as the do not interfere with diagnostic procedures or treatment."

The Unit III Nurse Manager (RN # 1) was interviewed on 8/30/2011 at 9:50 a.m. and he stated that Patient # 3 was dressed in a hospital gown during her respite admission (6/7-6/12/2011). RN # 1 stated that the patient had numerous incontinent episodes and was placed in a hospital gown to facilitate changing her incontinence briefs. The clinical record was reviewed with RN # 1 at this time. The patient's care record and nursing documentation did not evidence loose or unusually excessive bowel movements at any time.

The patient's representative was interviewed by telephone by a Medical Facilities Inspector on 8/30/2011 at 11:40 a.m. The patient representative stated that Patient # 3 was receiving Hospice services and the hospice agency arranged for a respite admission. Five changes of clothing were left with the patient upon her admission to the facility. The representative stated the clothes were not used and the patient arrived home in a hospital gown, when transported by ambulance. The patient's representative stated that the patient was elderly and confused and that the Hospice agency assured her that the hospital (facility) would dress her in her own clothes and care for her in the manner that the Hospice agency did, when she was home. The representative stated that Patient # 3 was incontinent of bowel and bladder at home, and was dressed in an incontinence brief and her own clothes daily.

The facility's contract with the Hospice agency which followed the patient at home, was reviewed. The contract stated that the hospital would comply with the Hospices' own philosophy's and employees would be educated in this. A review of the hospital's training records revealed that all staff caring for Hospice Respite patients, did not receive this education.

No further information was provided during this survey to evidence that Patient # 3's right to dress in her own clothing was not violated.

Based on review of selected data from the hospital's Quality Assessment and Performance Improvement Program and interviews it was determined the hospital failed to analyze performance improvement information collected regarding patient falls.

Findings:
The hospital's Quality Assessment and Performance Improvement Program patient fall data was reviewed on 08/30/2011. The data failed to contain information regarding in-depth analysis of the factors contributing to the falls.

Two members of the hospital's Quality Assessment and Performance Improvement Committee (Risk Manager and Quality Assurance Director) were interviewed in the hospital on 08/30/2011 at 3:00 P.M.. Both acknowledged that data had not been collected to enable the program members to conduct an in-depth analysis of the factors contributing to the falls, for example, where, when, time, staffing, or any issues related to the current fall risk assessment tool utilized by the hospital. The inspector asked what type of patient alarm system the hospital used in the patient rooms. Both responded they did not know.

The Chief Nursing Officer was interviewed during the survey exit on 08/30/2011 and acknowledged the above noted deficiency.

Based on review of medical records and interviews it was determined the hospital failed to take action aimed at performance improvement regarding the hospital's fall risk assessment tool and nursing care plans.

Findings:

Eleven (11) medical records were reviewed in the hospital on 08/29-30/2011. Four (4) of the eleven (11) contained documentation of the patients falling during their hospitalization (#'s 1, 3, 4, and 10). The fall risk assessments on the patients who fell, failed to contain evidence of the nursing staff documenting their risk assessments accurately and consistently. For example, the first question on the fall risk assessment pertains to the patient having a history of falling. Frequently this would be marked yes and no by the same nurse. In addition, the care plans for the patients who fell, failed to contain documentation of nursing interventions.

Two employees (Risk Manager and Quality Assurance Director) who serve on the hospital's Quality Assessment and Performance Improvement Committee were interviewed on 08/30/2011 at 3:00 P.M.. They acknowledged they were aware there were issues with the fall risk assessments and care plans and that no action had been taken regarding performance improvement interventions. Evidence of re-training related to the inaccurate falls risk assessment and care plans was requested but was not presented during the survey.

The Chief Nursing Officer was interviewed during the survey exit on 08/30/2011 and acknowledged the above noted deficiency.

Based on clinical record review, employee interview and facility policy and procedure review, and during the course of a complaint investigation, the facility staff failed to ensure that a nursing care plan was developed based on nursing assessed risks and patient needs, for five of 11 reviewed patients, Patient #'s 1, 2, 3, 4, 10 and 11.

Findings:

Eleven patient's clinical records were reviewed by two Medical Facilities Inspectors on 8/30/2011 and 8/31/2011. Six of 11 patient's care plans did not include nursing interventions and/or diagnosis based on the nursing assessments and identified patient needs:

1. Patient # 1 was admitted to the facility for hospice respite care services. The nursing assessments identified the patient as having a high fall risk by the facility nursing assessment/fall risk assessment. The patient actually experienced a fall (5/24/2011) during his reviewed admission to the facility. The nursing care plan did not include goals or interventions related to this assessed risk/problem. The clinical record did not evidence a care plan collaboration between the contracted hospice and the facility. The facility care plan did not include the hospice plan of care, or any indication that the patient was receiving respite services.

2. Patient # 2 was admitted to the facility for hospice respite care services. The nursing care plan did not include goals and interventions related to hospice services, respite care or end of life care.

3. Patient # 3 was admitted to the facility for hospice respite care services. The patient was identified as a high falls risk by the nursing staff. The nursing care plan did not include goals or interventions related to her risk of falls or hospice and respite care. The patient actually experienced a fall (6/8/11) and the care plan did not evidence a review or revision after this event to prevent additional falls. The Unit III Manager (RN # 1) was interviewed on 8/31/2011 at 2:00 p.m. and the care plan was reviewed. RN # 3 acknowledged the care plan did not include goals or interventions appropriate to the patient assessment and needs. RN # 3 stated that the computerized program did not allow for the nurse to individualize the care plan in the area of falls. No reason was given for the omission of hospice/respite care services.

4. Patient # 4 experienced a fall during his admission to the facility. The nursing care plan did not include goals or interventions to prevent further falls. The nursing care plan was not reviewed or revised after an actual fall.

5. Patient # 10 experienced a fall during his admission to the facility. The nursing care plan did not include goals or interventions related to falls prevention. The care plan was not reviewed or revised after an actual fall.

6. Patient # 11 was admitted to the facility for hospice respite care services. The nursing care plan did not reflect this and did not include goals or interventions related to end of life care. The care plan and clinical record did not include evidence of collaboration with the Hospice plan of care.

The facility policy "Inpatient Fall Prevention" stated: "...3. Interventions will be based on the initial fall assessment and whenever there is a change in the reassessment score." The facility did not have a policy related to Hospice care or respite care services. The facility admission assessment and "assessment of nursing care needs" policy did not address respite or hospice care services.

It was also noted that for each patient (# 1-11) that the nursing fall risk assessment was frequently inaccurate and was inconsistently documented, from shift to shift and frequently by the same evaluating nurse.

RN # 3 and the Vice President of Nursing Services was interviewed on 8/31/2011 at 3:00 p.m. RN # 3 stated that the fall score drives the nursing interventions and care plan development.

The facility Risk Manager and Quality Assurance/Performance Improvement Director were interviewed on 8/31/2011 at 3:30 p.m. The Risk Manager stated that the Safety Committee and Quality Assurance program had recognized the inaccurate and inconsistent falls risk assessment being completed by the facility's nursing staff. The Risk Manager also stated that the care plan "issues" had also been identified. No evidence of action taken related to these identified issues was presented during this survey.

The Chief Nurse Executive, Chief Executive Officer, the Quality Assurance/Performance Improvement Director and the Vice President of Nursing Services were interviewed on 8/31/2011 at 5:45 p.m. and they acknowledged the above concern. No further information was provided during the survey to evidence compliance with this regulation.

See A0289 for additional information.

Based on clinical record review, staff interview, policy and procedure review and during the course of a complaint investigation, the facility staff failed to ensure medications were administered according to physician's orders for one of 11 reviewed patient's, Patient # 3.

Findings:

A complaint was investigated on 8/30/11 and 8/31/11. The complaint alleged that Patient # 3 did not receive physician's ordered eye drops, utilized for the diagnosis of glaucoma. Patient # 3 was admitted to the facility for hospice respite services. The complaint alleged that the patient's family provided the ordered medication upon admission, but was not administered to the patient.

The patient's clinical record was reviewed and it included physician's orders for "Travatan 0.004%, 1 drop at bedtime." The Medication Administration Record (MAR) revealed that the patient did not receive Travatan during her admission, 6/7/11-6/12/11. At each area provided on the MAR to document the administration of Travatan, each nurse documented "UTO." The Unit III Manager (RN # 3) was interviewed on 8/31/11 at 11:00 a.m. and he stated "UTO" indicated the nurse was "UNABLE TO OBTAIN" the patient's medication and it was not available from the hospital pharmacy. RN # 3 stated that the family had delivered the medication when the patient was admitted on 6/7/11, and the medication was placed in the medication drawer however the evening shift nurses were not aware of this and did not administer the medications. RN # 3 stated that the hospital's pharmacy did not have the medication available, and the patient did not receive the medication during her admission. RN # 3 stated that the evening shift nurses did not know the medication was in the patient's medication drawer. RN # 3 reviewed the clinical record and stated that the record did not contain evidence of physician notification of the unavailability of the medication.

The facility policy "Unavailable Medication" stated: "Physicians' will be notified when ordered medications are not available." The policy stated that the physician could omit a medication at his discretion or provide orders for a substitution. The policy did not provided further procedures for the nurse to follow in the event a medication was not available from the pharmacy. The policy "Medication Management-Selection/Procurement stated that in the event a medication was ordered by a physician which was not included in the Pharmacy's formulary: "...the pharmacy shall obtain the non-formulary mediation from another hospital community pharmacy or other approved source..." The facility staff did not present evidence that an attempt was made to procure the physician's ordered medications.

The Chief Nurse Executive, Chief Executive Officer, the Quality Assurance/Performance Improvement Director and the Vice President of Nursing Services were interviewed on 8/31/2011 at 5:45 p.m. and they acknowledged the above concern. No further information was provided during the survey to evidence compliance with this regulation.

Based on clinical record review, staff interview, policy and procedure review and during the course of a complaint investigation, the facility staff failed to ensure a complete clinical record was maintained for one of 11 clinical records reviewed, Patient # 3.

Findings:

During the course of a complaint investigation, which alleged that Patient # 3 fell during her hospitalization, the clinical record was reviewed. The nursing progress notes and care plan did not include documentation that the patient experienced a fall. The facility's Chief Nurse Executive was interviewed on 8/30/11 at 1:15 p.m. and the facility's incident/falls investigations were requested. A review of these reports revealed that Patient # 3 had fallen on 6/8/2011. On 8/31/2011 at 11:30 a.m. the Unit III Manager (RN # 3) was interviewed and the clinical record was reviewed. RN # 3 stated that the record did not contain a post fall nursing assessment, a care plan related to falls interventions or documentation of the fall. The RN stated "Yes, I would expect" nursing documentation of such an event.

The facility policy "Medical Records" was reviewed and it stated: "...Documentation is required at (hospital name) when there is an abnormality or problem noted. Documentation is required for any changes in the patient's condition..."

The Chief Nurse Executive, Chief Executive Officer, the Quality Assurance/Performance Improvement Director and the Vice President of Nursing Services were interviewed on 8/31/2011 at 5:45 p.m. and they acknowledged the above concern. No further information was provided during the survey to evidence compliance with this regulation.