HospitalInspections.org

26632

Based on record review, interview, and policy review, the provider failed to ensure:
*All unwitnessed patients' incidents including falls and bruises of unknown origin had been thoroughly investigated and those investigation results had been documented.
*A comprehensive policy and procedure for abuse investigation had been followed for one of one patient (7).
Findings include:

1. Interview on 3/17/15 at 3:00 p.m.with registered nurse (RN) C and the Medicare coordinator revealed:*A log was kept of patients' incidents that occurred within the facility.
*Those incidents included: unwitnessed falls, witnessed falls, and bruises of unknown origin.
*The investigation was completed and a short note was written by RN C in a computer file.
*RN C did not keep the notes of the investigation.
*RN C had been told not to keep notes as they could have been discoverable by an attorney.
*They agreed they could not prove that any incidents had been thoroughly investigated to rule out any form of abuse or neglect.

Review of the provider's undated Incident Log form revealed the log included:
*The patients name.
*The date and time of the incident.
*Whether it was observed or assisted.
*If any equipment was involved.
*If any alarm had been triggered.
*If the physician had been notified.
*If the patient had been seen by the physician.
*-If there had been any injury.
*If an X-ray had been completed.
*If the patients' cognition (mental awareness) had changed.
*Where the incident had occurred.
*There was no narrative to indicate if the incident had been fully investigated to rule out any type of abuse or neglect.

Review of the provider's reviewed 11/10/10 Patient Abuse Policy revealed:
*The purpose was to have appropriate reporting and follow-up in cases of suspected patient abuse.
*"Any alleged violations involving mistreatments, neglect, or abuse included injuries of unknown source, must be reported immediately to the department manager, who then immediately reports to the Medicare nurse/Social Services Coordinator and/or the Administrator."
*"In cases of unknown origin:
-1. The incident report will be completed [these forms are located at the nurses stations].
-2. Investigation will center around the incident report."
*"The DON [director of nursing] or Social Service Coordinator will be responsible for initiation and follow-up of the Patient Abuse Investigation Form, as well as assuring this policy and procedure is followed as outlined. After investigation is completed, these forms will be kept locked in the Director of Nursing office."

Surveyor: 20031
Interview on 3/17/15 at 5:05 p.m. with the swing bed coordinator revealed she had just completed incident reporting training in February of this year with all hospital staff. She stated it included a PowerPoint presentation.

Review of the psychotropic drugs/Moods and Behaviors/Abuse Reports (PMA) committee minutes dated 2/4/15 revealed the following:
"A. Charter Discussion:
1) Starting in March, these monthly meetings will be held on the 2nd Wednesday of the month.
5) Abuse reports will be reported and discussed."
"G. Abuse reports:
2. FRHS [Fall River Health Services] SW [Swing Bed]:
* ____ [initials of patient 7] c/o [complained of] rib pain; X ray revealed 3 broken ribs. Denied Abuse; DON [director of nursing] spoke w/ [with] staff and found out staff uses gate-belt to transfer resident. Resident passed away this morning [2/4/2015]. Resident declining before incident happened."
- "Recommendations: none."

26632

Based on record review, interview, and policy review, the provider failed to ensure one of one sampled patient's (7) care plan had been updated after a new fracture. Findings include:

1. Review of patient 7's medical record revealed:
*She had been admitted on 12/17/14.
*She had diagnoses that included: end stage heart failure, wound care, malnutrition, and pain control.
*She had complained of left sided rib pain on 1/27/15 during an afternoon physical therapy session.
*She was examined by the certified nurse practitioner (CNP) on that same day.
*The CNP encouraged nursing staff to medicate appropriately for pain.
*She continued to have complaints of left sided rib pain and was seen again by a physician on 1/29/15.
*X-rays were ordered, and she was found to have two and possibly three left rib fractures.

Interview on 3/18/15 at 9:30 a.m. with the physical therapist revealed:*She had recommended using a sling type method to transfer patient 7 from the bed to the wheelchair and beside commode.
*She had instructed the nurse on duty on 1/30/15, and the nurse was to have instructed the certified nursing assistants (CNA) on how to transfer patient 7 to minimize pain.
*She had instructed CNAs A and B herself on how to transfer the patient using that method.

Review of patient 7's 12/17/14 care plan revealed it had been initiated on 12/17/14. There were problems identified that included:
*Activity tolerance related to weakness, weight loss, and ejection fraction of 15% (poor heart function).
*Alteration in comfort with pain related to pressure ulcers.
*Impaired skin integrity related to her poor appetite and inactivity.
*Alteration in cardiac (heart) output related to ejection fraction of 15 percent (%).
*Risk for falls related to activity intolerance, ejection fraction of 15%, and weakness.
*Those care plans had been reviewed and signed weekly by the medicare team and director of nursing.
*The last review had been on 2/2/15.
*There was no update to the care plan in relation to her fractured ribs.

Review of patient 7's patient information Kardex (form used for a quick look at patient needs) revealed:*Her activity was listed "As tolerated" with assistance of one staff person and a walker.
*Her privileges included bed rest with assistance of one staff.
*She required assistance with dressing and personal hygiene.
*There was no change to the Kardex that included her new transfer protocol as outlined by the physical therapist on 1/30/15.

Review of the nursing staff meeting minutes dated 1/8/15 revealed "9. Kardexes are still not getting completely filled out which is a problem with quality assurance. They used to have the care plans, which are now separately done and put on the chart. The problem is that they are not being filled out as they should be, i.e. new orders not being transcribed and updated. 24 hr [hour] chart checks should be looking at this."

Surveyor: 20031
Review of the staff meeting minutes dated 9/4/14 revealed the following:
*"12. Swing Bed Charting: ____ [swing bed coordinator name].
- Discussion on the new charting and new care plans.
- Care Plans: They are being kept under Nurse's Notes tab.
- The related to area isn't always being filled out and not completely signed off.
- Documentation should look at the patient and their care plan as a whole."

Interview on 3/18/15 at 11:00 a.m. with the swing bed coordinator revealed she had completed care plan utilization training in July 2014. Review of that nursing education revealed the following:
*"1. Choose care plans reflecting patient's status, admission and past medical history. Must include at least 2 additional care plans other than falls and pain.
*4. May document additional "patient specific" goals or interventions.
*7. Weekly review will be done by DON (director of nursing) and Medicare Coordinator."

Surveyor: 26632
Interview on 3/18/15 at 1:30 p.m. with registered nurse C revealed:
*She agreed the care plan for patient 7 had not been updated after a diagnosis of left sided rib fractures.
*She stated during the weekly Medicare meetings each patient's care plan was reviewed.
*She agreed patient 7's care plan had been signed by the DON as having been reviewed.
*She did an audit of care plans and Kardexs but only to ensure they had been started. She did not review them for their content.

Review of the provider's revised 2/2/11 Care Planning - Swing Bed Patient policy revealed:
*The plan of care should have been individualized, based on the diagnosis and patient assessment.
*Those disciplines consulting in the care of the patient shall contribute to the plan as appropriate to the patient's status and diagnosis.
*The plan of care should have been updated weekly with revisions reflecting the reassessment of needs for the patient.
*The Kardex system was the ever changing plan of care for each patient, and was filled out in pen. As the goals were met, the goal was highlighted and date completed, and a new measurable goal was established for the patient.
*The Kardex would be filled out completely on each patient.

Review of the provider's 11/5/14 24 Hour Chart Check policy revealed:*Nursing would conduct a twenty-four hour chart/Kardex check upon admission of a patient, then again after midnight and then again every twenty-four hours during the night shift after midnight, to ascertain all orders have been carried out appropriately and in a timely manner.
*The Kardex must be checked to make certain all new orders and updated information had been placed on it.
*The auditing nurse would also make sure the care plans had been documented on each Wednesday night at midnight.