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Tag No.: A0143
Based upon observation, interview, and record review, the facility failed to ensure patients were treated with dignity and respect regarding videotaping of patients while in treatment at the facility. Findings include:
Per record review on 12/3/13 the facility's Variance Report for 9/17/13 documents
"Camera monitor recorded [Patient #1] undressed while in Patient Room #4. Event was seen by Psych. techs. [Female #1] and [Male #2]. The report then documents "An email has been sent to management requesting that this camera be adjusted to prevent this situation from happening in the future ". Per record review of an email dated 9/19/13 at 11:11 A.M. the Director of Nursing Services "spoke with the attending [physician] to see how h/she would like to address the issue with the patient ... [the physician] is choosing to take no action one way or another at this time. We have done our bit for this issue ".
Per interview with the attending physician, on 12/4/13 at 11:20 A.M., the physician stated
"I don't know if anything was done ... I don't know if the camera angles were changed. I don't think we spoke with the patient about it. "
Per observation of the video monitors located at the nurses' station, on 12/5/13 at 2:30 P.M., the placement and angle of the video camera afforded views of inside patient room doorways, including Room #4 where Patient #1 was videotaped undressed on 9/17/13.
Per interview with the facility's CEO, on 12/5/13 at 2:53 P.M., [videotape of patients] "is saved on the BGS [Buildings and General Services] server for 34 days. I don't fully know how secure it is - it's a state server, it's not a contract".
Per interview with the facility's Director of Quality, on 12/5/13 at 12:54 P.M., h/she was not aware that the placement and angle of the video camera afforded views of inside patient room doorways, and confirmed that patients are not notified of this and how it could affect their privacy. H/she also confirmed that the patients are not notified that they are being videotaped during their stay at the facility, that there is no consent obtained from the patients prior to videotaping them.
Tag No.: A0144
Based on observation, staff interview and record review the facility failed to assure a safe environment was maintained for all patients. Findings include:
During a tour of the inpatient unit, at 11:59 AM on the morning of 12/2/13, a plastic knife was found lying on the bed in Patient #20's room. Per record review plastic utensils had also been found and removed from patient rooms, during weekly environmental safety checks, on the following dates: 8/29/13, (2) plastic knives and (1) plastic spoon were found in patient room #6; 9/15/13, (2) plastic knives and a plastic fork were found in patient room #7 and on 10/8/13 (3) plastic forks and (3) plastic knives were found under the mattress in patient room #6.
During interview, at 10:10 AM on the morning of 12/3/13, the ADON agreed that plastic eating utensils posed a safety hazard and could be used to inflict self harm or harm to others. S/he confirmed the utensils had been found during weekly environmental safety checks, on more than one occasion, in patient rooms and stated that the utensils are considered restricted items and should not be in patient rooms.
Tag No.: A0154
Based on record review and confirmed through staff interview the facility failed to assure the use of physical restraints was restricted to situations in which there was threat to the immediate safety of the patient or others, for 1 patient. (Patient #10). Findings include:
Per review the facility policy for Emergency Involuntary Procedures, revised on 9/5/2013, stated; "e. Emergency involuntary procedures may only be used to prevent the imminent risk of serious bodily harm to the patient, a staff member or others...."
Per record review, Patient #10, who was admitted on 7/27/13 on an involuntary basis, was restrained, with no evidence of imminent risk of serious bodily harm to self or others, for the purpose of removing the patient's boots. The Integrated Physician Admission Assessment, completed on 7/27/13, identified the patient with a chronic non-healing ulcer of the right foot, and a recent history of inpatient treatment at another acute care facility, on 7/10/13, for cellulitis (inflammation of tissue) of the foot. A medical consult,obtained on 7/29/13, confirmed the patient had venous stasis disease of the lower extremity, edema of the foot, ankle and lower leg and some slight tenderness of a healed ulcer on the foot. Recommendations for treatment included TED stockings or other support hose, lotion, and a dressing.
Per review of a CON (Certificate of Need) for Restraint, dated 8/16/13 at 10:30 AM, staff restrained Patient #10, using a brief hands on procedure, for the purpose of removing boots which the patient had refused to remove when asked to do so by staff. The Nursing assessment, for the need of restraint indicated the patient was asked to remove his/her boots because of the deteriorating venous ulcer, the patient responded that staff should speak with his/her lawyer, "started yelling and just wanted to go to [his/her] room. When [his/her] room was opened staff put a brief hands on and removed [his/her] boots." The Physician Initial Assessment of the Need for Restraints indicated the reason the procedure was initiated was to protect the patient, and stated that the patient had arrived to the hospital with a foot wound which had been healing well until s/he had started wearing his/her boots "and now is becoming red/swollen and irritated." The note further stated that the patient was "paranoid, illogical and loud", and would not engage in conversation or listen to voiced concerns about risk of cellulitis. Following the initiation of restraint and removal of the boot for the purpose of examining the wound site, a medical consult was obtained, on 8/16/13 at 5:00 PM, which stated, "exam refused, (chronic ulcer of dorsum of foot noted - unable to see if infection present)."
Per review of Nursing and Physician Progress notes from admission through the date the restraint was initiated on 8/16/13, there is no evidence that footwear had been assessed or considered as a contributing factor in the development or chronicity of the ulcer. In addition, although there is evidence that staff had visualized and assessed the patient's wound site on several occasions, there is no evidence of when the patient began wearing boots and no evidence that staff had ever requested the patient remove the boots, prior to the event in which restraint was used to remove them.
During interview, at 9:48 AM on 12/4/13, the physician responsible for the restraint order stated s/he had ordered the restraint and removal of the boot because there was concern the wound was getting worse, and s/he felt pressure on the wound site, from the boot, was contributing to the deterioration of the wound. S/he stated that staff had encouraged the patient, over the course of a few days, to remove the boot but the patient refused to do so and the boot was removed for the purpose of assessing the wound site and in an effort to avoid a recurrence of cellulitis. The physician further stated s/he had considered it a medical emergency, although not so much a concern of immediate harm, as chronic harm. S/he also confirmed the patient refused to allow assessment of the wound site following removal of the boot.
Tag No.: A0283
Based on staff interview and record review the facility failed to use information gathered from routine safety checks, quality review of restraint use and event reporting to identify opportunities for improvement in care provided to patients. Findings include:
1. During a tour of the inpatient unit, at 11:59 AM on the morning of 12/2/13, a plastic knife was found lying on the bed in Patient #20's room. Per record review plastic utensils had also been found and removed from patient rooms, during weekly environmental safety checks, on the following dates: 8/29/13, (2) plastic knives and (1) plastic spoon were found in patient room #6; 9/15/13, (2) plastic knives and a plastic fork were found in patient room #7 and on 10/8/13 (3) plastic forks and (3) plastic knives were found under the mattress in patient room #6.
During interview, at 10:10 AM on the morning of 12/3/13, the ADON agreed that plastic eating utensils posed a safety hazard and could be used to inflict self harm or harm to others. S/he confirmed the utensils had been found during weekly environmental safety checks, on more than one occasion, in patient rooms and stated that the utensils are considered restricted items and should not be in patient rooms. Despite the fact that restricted items continued to be identified during routine safety checks there was no evidence that any action had been taken to assure patients did not have access to the items.
2. Per record review on 12/3/13 a facility Variance Report identified a concern in which the surveillance camera located in the hallway of the inpatient unit, and utilized to provide ongoing monitoring of the area, afforded visual coverage through the entrance door of patient room #4. The report indicated that on 9/17/13, Patient #1 was observed, undressed while in his/her room. The report revealed an email had been sent to management to notify them of the concern regarding patient privacy and indicated that communication had occurred between the DON (Director of Nursing) and Patient #1's attending physician to determine a course of action regarding notification to the patient of the incident. There was further documentation that, "[the physician] is choosing to take no action one way or another at this time. We have done our bit for this issue ". Despite the knowledge, by members of the administrative staff that there was a concern regarding the surveillance monitor and patient privacy, there was no evidence that any action had been taken to ensure ongoing patient privacy. Per observation of the surveillance monitors, on 12/5/13 at 2:30 P.M., the placement and angle of the video camera afforded views of inside the doorways of patient room #4.
3. Per record review, Patient #10 was restrained, with no evidence of imminent risk of serious bodily harm to self or others, for the purpose of removing the patient's boots. The patient was admitted on 7/27/13, with a chronic non-healing ulcer of the right foot, and a history of recent inpatient treatment at another acute care facility, on 7/10/13, for cellulitis (inflammation of tissue) of the foot.
Per review of a CON (Certificate of Need) for Restraint, dated 8/16/13 at 10:30 AM, the Nursing assessment, for the need of restraint indicated the patient was asked to remove his/her boots because of the deteriorating venous ulcer, the patient responded that staff should speak with his/her lawyer, "started yelling and just wanted to go to [his/her] room. When [his/her] room was opened staff put a brief hands on and removed [his/her] boots." Documentation by the physician indicated the reason the procedure was initiated was to protect the patient, and stated that the patient had arrived to the hospital with a foot wound which had been healing well until s/he had started wearing his/her boots "and now is becoming red/swollen and irritated." The note further stated that the patient was "paranoid, illogical and loud", and would not engage in conversation or listen to voiced concerns about risk of cellulitis. Per review of Nursing and Physician Progress notes from admission through the date the restraint was initiated on 8/16/13, there is no evidence that footwear had been assessed or considered as a contributing factor in the development or chronicity of the ulcer. In addition, although there is evidence that staff had visualized and assessed the patient's wound site on several occasions, there is no evidence of when the patient began wearing boots and no evidence that staff had ever addressed a concern with use of the boot or requested the patient remove the boot, prior to the event in which restraint was used to remove them.
During interview, at 9:48 AM on 12/4/13, the physician responsible for the restraint order stated that staff had encouraged the patient, over the course of a few days, to remove the boot but the patient refused to do so and the boot was removed for the purpose of assessing the wound site and in an effort to avoid a recurrence of cellulitis. The physician further stated s/he had considered it a medical emergency, although not so much a concern of immediate harm, as chronic harm.
Per interview, at 2:54 PM on 12/4/13, the Quality Manager confirmed that all incidents of restraint/seclusion are reviewed for quality purposes and that the restraint use for Patient #10 had been reviewed. S/he stated that per his/her review of the restraint "I would not have characterized this as an emergency, but that it could be an emergency at some point." The manager agreed that there were potential missed opportunities for improvement with each of the aforementioned examples.
Tag No.: A0395
Based on record review and confirmed through staff interview nursing failed to complete a comprehensive assessment of the care needs for one patient admitted with a chronic skin ulcer. (Patient #10). Findings include:
Per record review, Patient #10, who was admitted on 7/27/13 on an involuntary basis, had an Integrated Physician Admission Assessment, completed on 7/27/13, that identified a chronic non-healing ulcer of the right foot, and a recent history of inpatient treatment at another acute care facility, on 7/10/13, for cellulitis (inflammation of tissue) of the foot. A skin assessment was conducted as part of the Nursing admission assessment and identified a pressure ulcer of the right lateral foot. Although the assessment directed "if any pressure ulcer or risk factor present, complete Braden Scale" (an assessment to determine risk of developing pressure ulcer based on specific criteria including contributing factors), there was no evidence that a Braden Scale assessment had ever been completed. A medical consult, conducted on 7/29/13, confirmed the patient had venous stasis disease, and recommended wound management interventions to include use of support stockings and a dressing. However, although the patient had been admitted with leather boots, there is no evidence that his/her footwear had been assessed or considered as a contributing factor in the development or chronicity of the ulcer, there were no pressure reducing interventions identified to assist in promoting healing of the ulcer and the patient was allowed to wear the boots. The record indicated that staff had visualized and assessed the patient's wound site on several occasions, but there was no indication of when the patient began wearing the boots and no evidence that staff had ever requested the patient remove the boots, until 8/16/13 at 10:30 AM, at which point staff restrained Patient #10, for the purpose of removing the boots. The Physician Initial Assessment of the Need for Restraints indicated the reason the procedure was initiated was to protect the patient, and revealed that the patient had arrived to the hospital with a foot wound which had been healing well until s/he had started wearing his/her boots "and now is becoming red/swollen and irritated."
During interview, at 9:48 AM on 12/4/13, the physician responsible for the restraint order stated s/he had ordered the restraint and removal of the boot because there was concern the wound was getting worse, and s/he felt pressure on the wound site, from the boot, was contributing to the deterioration of the wound.
The ADON (Associate Director of Nursing) confirmed during interview on the afternoon of 12/4/13, that a Braden Scale assessment had not been conducted, and should have been. S/he further confirmed that the wound management plan did not include identification of pressure reducing footwear to promote healing of the ulcer and acknowledged there was no indication that staff had evaluated the patient's boots as a potential contributing factor in the development of the ulcer.
Tag No.: A0701
Based on staff interview and facility maintenance records review the facility failed to ensure the condition of the physical plant and the overall hospital environment is maintained in such a manner that the safety and well-being of patients are assured. Findings include:
Based on review of the Preventative Maintenance Log there was no evidence that testing had occurred on the facility's generator from July, 2013 through November, 2013. The Facility Manager was able to seek and retrieve evidence of testing for all missing tests except the month of November which s/he admitted was unavailable because s/he just learned while retrieving the missing information that the November generator test was not conducted. Upon interview on December 3, 2013 at 3:00 PM, the Facility Manager confirmed testing of the generator should occur on a monthly basis and that the generator testing for the month of November had not been conducted. S/he further confirmed that s/he was unaware that the November test had not been conducted until brought to his/her attention by the surveyor. The Facility Manager also confirmed that there was no formal process in place for assuring ongoing consistent preventative maintenance on the generator.
Tag No.: B0116
Based on record review and staff interview, the facility failed to provide psychiatric evaluations that tested memory in 5 of 8 active sample patients (E, F, J, K, L), and failed to report insight and judgment in measurable, behavioral terms for 6 of 8 active sample patients (E, F, G, I, J, K). This compromises the database from which diagnoses are determined and from which changes in response to treatment interventions may be measured.
Findings include:
A. Record Review
1. In the initial psychiatric assessment of Patient E, dated 9/16/13, memory was described as "not fully tested", and insight and judgment described as "poor."
2. In the initial psychiatric assessment of Patient F, dated 10/21/13, memory was "not tested", insight and judgment were "poor."
3. In the initial psychiatric assessment of Patient G, dated 1/16/13, insight and judgment were "poor."
4. In the initial psychiatric assessment of Patient I, dated 12/6/13, insight and judgment were "fair."
5. In the initial psychiatric assessment of Patient J, dated 12/31/13, memory was "not tested", and insight and judgment were "poor."
6. In the initial psychiatric assessment of Patient K, dated 9/20/13, memory was "not tested", and insight and judgment were "poor."
7. In the initial psychiatric assessment of Patient L, dated 9/16/13, memory was described as "unable to test."
B. Staff Interview
During an interview on 2/4/14 at 2:30 p.m., MD2 confirmed the above findings.