HospitalInspections.org

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Based on observation, medical record review, document review and staff interview, the facility staff failed to complete mandatory reporting for an Emergency Department (ED) patient in a situation of possible neglect/abuse by a family member.

Failure to do so creates risk that patients may be subject to preventable harm/poor health outcomes, including death and disability associated with abuse and/or neglect.

Reference: RCW Chapter 74.34
(16) " 'Vulnerable adult' includes a person: (a) sixty years of age or older ... "
(12) " 'Neglect' means ....an act or omission that demonstrates a serious disregard of consequences of such magnitude as to constitute a clear and present danger to the vulnerable adult ' s health, welfare, or safety ..."
(11) " 'Mandated reporter' is an ...health care provider..."

Findings:

1. On 1/22/2014 at approximately 2:30PM, Surveyor #1 heard a "Code Stroke" called over the facility intercom and went to the Emergency Department where the patient (Patient #1) was located. The patient was 72 years old and had been transported to the facility by ambulance. An Emergency Medical Technician (EMT), who had transported Patient #1 to the ED, was observed at the nurses station and stated to one of the RNs (Staff Member #1) that the patient was brought to the ED from home. At home the patient had been on the floor "face down" for 8-12 hours and the patient's spouse had tried to arouse her/him but the patient only grunted. After that time period, her/his spouse requested emergency assistance. Care was provided in the ED and eventually the patient was transported to another facility for ongoing care.

2. On 1/27/2014 upon review of the medical record by the surveyor it was determined that there were several entries that confirmed that staff were aware that the patient had been lying face down on the floor at home for several hours, including one entry later that day stating that the patient's spouse had poked her/him with needles a few times an hour but the patient remained unresponsive. Per EMT record, the patient was found at home in a pool of her/his emesis and urine.

3. On 1/27/2014 annual facility educational materials about elderly abuse and neglect were reviewed by the surveyor. The first sentence in the section under "Reporting" stated, "Elder abuse is a crime. Federal and most state laws require that you report suspected elder abuse, usually to an adult protective services (APS) agency ..." In another section of the materials it described the "Types of Abuse" as ... "Physical Abuse" and "Neglect". All nursing staff had used these materials as part of annual training.

4. On 1/27/2014 at around 12:30 PM the Chief Nursing Officer (Staff Member #2) was interviewed and stated that s/he expected/required staff to report suspected abuse and neglect of adults to Adult Protective Services. S/he also stated that the facility did not have a policy to direct staff in the reporting process and s/he thought a facility policy and procedure was needed. According to the Charge Nurse job description (08/2012), the charge nurse reports to the Chief Nursing Officer (CNO) and assists "with identifying and reporting ...incidents." However this incident had not been brought to the attention of the CNO.
Staff Member #2 confirmed that upon review of the patient's medical record and per her/his own staff interviews, s/he determined that facility staff had not reported potential neglect/abuse as required. Instead, the nursing staff provided related information to the facility that the patient was transferred to as part of the general patient transfer report.

Based on facility document review, staff interview and policy and procedure review, the facility failed to assure that monthly inspections of nursing unit medication stock were completed for a time period of approximately 60 days.

Failure to do so creates risk that patients may receive medications that are detrimental to their health and/or therapeutically substandard/ineffective.

Findings:

1. On 1/21/2014 at around 1:15 PM pharmacy inspection reports from the prior year were provided to Surveyor #1 by the Director of Pharmacy (Staff Member #4) for review. There was no documentation of pharmacy inspection of hospital nursing units since the end of November 2013.

2. Subsequent to document review above, the pharmacist was asked about the reason that pharmacy inspections were not completed for approximately 60 days. S/he stated that he was on vacation for a portion of one month in that time period.

3. On 1/27/2013 Surveyor #1 reviewed facility policy titled, "Monthly Inspection for Outdated Medications ". The second paragraph under "Policy" stated "The inspections will be conducted on the 3rd Thursday of each month..."
The third Thursday for the month due date for January 2014 was January 16 (5 days prior).

THIS IS A REPEAT CITATION.
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Based on review of facility policy, medical record review and interview, the facility failed to provide dietary services according to its' own policy for 2 of 3 patients.

Failure to do so creates risk that patients may become nutritionally compromised related to their hospital stay.

Findings:

1. On 1/22/2014 facility policy titled "Nutrition Screening" (10-21-2013) was reviewed by Surveyor #1. In the section titled "Policy" it stated "All patients admitted to Summit Pacific Medical Center will have a Nutrition Screening within 24 hours of admission."


2. During review of the medical records it was noted that Patient #6 was admitted on 9/29/2013 after a fall. The patient had severe diarrhea and dehydration and was diabetic. The dietary screening form for the patient was found to be blank in the chart.

Patient#7 was admitted on 10/21/2013 after a re-do of heart surgery with multiple medical problems including diabetes, a chronic heart rate irregularity and treatment with a blood thinner (that requires dietary adjustments to therapeutic level). The dietary screening form for the patient was found to be blank in the chart.

Patient #8 was admitted to the hospital on 1/17/2014 after knee replacement surgery at another facility. The dietary screening form in the chart was filled out but not dated or signed. The same findings were noted for Patient #9 who was admitted on January 20, 2014 from another hospital and who had complaints of poor appetite and constipation for a week.


3. On 1/21/2014 at around 3:00 PM Surveyor #1 interviewed Patient #9 about her/his diet. The patient was admitted after a knee replacement at another facility. The patent stated that food provided during her/his 3-4 day hospital stay was not appropriate for her/his medical condition because s/he had a band surgically placed on her stomach and s/he was on a modified diet. The patient 's dietary screen did not reflect that information and the patient had not had a dietary consult.


THIS IS A REPEAT CITATION.
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Based on review of medical record and facility policy and procedure, the facility failed to obtain informed consent from 1 of 2 patients who received blood products.

Failure to do so creates risk that patients may receive blood products without their knowledge/consent.

Findings:
1. During review of the medical record of Patient #2 it was determined that the patient had been administered 3 units of packed red blood cells on 9/13/2014 for a blood disorder. However, a consent for blood administration had not been obtained from the patient prior to administration. The blood was not administered in an emergency situation.

2. On 1/27/2014 a policy titled: "Blood and Blood Products Administration" (2-14-13) was reviewed. The first section of the policy was titled "Informed Consent" and item "a." stated "An informed consent shall be completed prior to administration of Blood/Blood Components by the Provider."
This finding was confirmed with a RN (Staff Member #3).
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Based on record, policy and procedure review and staff interview, the facility failed to assess pain fully in 2 of 3 records.

Failure to do so creates risk that patients will suffer and be harmed by preventable pain.

Findings:

Pain Rating and Location

1.a. On 1/22/2014 Surveyor #1 reviewed a policy titled, Pain/Anxiety Discomfort Management " (10/21/13. On page 2 in the "Assessment" section it discussed rating pain intensity and under section "a." it discussed monitoring and documenting "all of the above" (including pain intensity) and the location of pain.

1. b. On 1/24/2014 Surveyor #1 reviewed the medical record of Patient #10 who received care in the ED on 9/6/2013 after a motor vehicle accident. The patient's level of consciousness was not affected and it was noted in the record that the patient had pain in the following locations: head, neck, chest and upper back. The pain was described as "moderate" in the medical record. In the RN notes from the Emergency Department the patient's pain was rated as 4/10 during triage and as 5/10 at the time of discharge. The RN notes did not include pain ratings by the location(s) of pain.

During the evaluation in the Emergency Department an aneurysm (weakening of the blood vessel wall) was identified in the major blood vessel in his upper chest. This condition produce pain in the neck, chest and upper back locations. The patient was discharged to the community after refusing referral to a surgeon for evaluation of the aneurysm in his chest, as well as medication management for very high blood pressure.

Re-assessment of Pain

2.a. On 1/22/2014 Surveyor #1 reviewed a policy titled, "Pain/Anxiety Discomfort Management" (10/21/13. On page 4 in the "Reassessment" section a. stated "At least once per shift, 30 minutes and two hours after pain, discomfort control intervention used by any member of the health care team."
Additionally, section F. contained the following underlined statement, " f.This ongoing reassessment should be done minimally every two (2) hours while active and ...the patient's ability to sleep does not always mean there is an absence of pain, anxiety, discomfort."

2. b. On 1/27/2014 the record of Patient #11 was reviewed. The patient was admitted for treatment of a collapsed lung and had a chest tube placed into her/his lung to help re-inflate it. The patient was ordered to receive three different types of pain medication due to the pain associated with the tube placement. Each medication could be given in a range from 3, 4 or 6 hours as needed.

A form in the chart was titled "PAIN ASSESSMENT" which included a pain rating scale, the intervention (pain medication in this case) and a post-pain scale. However, the post-pain scale was not timed to determine the appropriateness of time interval at which pain re-assessment occurred.

The patient received 1-2 pain medication administrations daily over a period of 3 days. The post-intervention pain assessments on the form occurred once every 12 hours over a period of three days through 1/22/2014 6:35 PM. Four of 5 of the post-intervention pain assessments were recorded as "sleeping". Most of the pain ratings on the vital signs sheet were not related to the timing of pain medication administration.

2c. On 1/21/2014 at approximately 10:00 AM Patient #11 was interviewed by Surveyor #1. Prior to the surveyor entering the room s/he was told by a RN (Staff Member #7) that the patient had been sleeping. The patient was found to be lying still with his eyes closed and did not appear to be sleeping. S/he described her/his pain as 11/10 related to the presence of the chest tube and stated that s/he avoided movement due to pain. The patient had received pain medication approximately 3 ? hours prior and the post-pain re-assessment for that dose was recorded as "sleeping."
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Reference: ?483.10(b) Notice of Rights and Services (1) The facility must inform the resident both orally and in writing in a language that the resident understands of his or her rights ...

Based on review of facility document and interview, the facility failed to inform swing bed patients of all of their rights in writing.


Failure to do so creates risk that patients/representatives will be denied the opportunity to exercise their rights and participate in the care process.


Findings:


1. On 1/22/2014 a document titled, "TRANSITIONAL CARE PATIENT RIGHTS AND RESPONSIBILITIES" was reviewed by Surveyor #1. It was noted that the following content was omitted from the document: right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion.


2. According a RN (Staff Member #3) during an interview on 1/23/2014, the above document was the up-to-date version of the patient rights form provided to all swing bed patients upon admission to inform them of their rights.

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Based on review of policy and procedure, staff interview, medical record review, staff interview and a facility document, the facility failed to provide 3 of 4 swing bed patients with written notice of their discharge and reasons for their discharge from the facility.

Failure to do so creates risk that patients will not be fully informed of the discharge plan and therefore cannot exercise rights regarding discharge from the hospital.


Findings:

1. On 1/27/2014 the facility policy titled "Discharge Planning" for the Swing Bed Department was reviewed by Surveyor #1. It stated that the Social Worker will act as the Discharge Planner. The policy detailed numerous activities related to discharge planning however the only item related to patient and family interaction prior to discharge was about being a resource person in developing realistic plans and selection of available alternatives.

2. On 1/21/2014 during an interview with the facility social worker (Staff Member #5) and Surveyor #1, s/he stated that s/he was responsible for discharge planning for all swing bed patients. S/he related that s/he worked closely with all swing bed patients/representatives developing plans for discharge and documented accordingly in the medical record.

3. On 1/27/2014 the medical records of swing bed patients discharged from the facility were reviewed by Surveyor #1. Patient #3 was in the facility from 9/25/2013 to 10/9/2013 for care of an infection at an abdominal tube site and had multiple medical problems. Patient #4 was in the facility from 8/30/2013 to 9/16/2013 for care after having a total hip replacement at another facility.
For both patients the records contained a blank form titled "NOTICE OF TRANSFER OR DISCHARGE FROM SWING BED" which contained blank fields for the reason the patient was being transferred or discharged, the effective date of transfer and where the patient was being transferred or discharged to. There were no patient/representative signatures on the form.

Also a third patient's record (Patient #5) was in the facility from 12/6/2014 to 12/19/2013 for care for a hip fracture after a fall. The patient had other multiple serious medical problems. The record contained the form titled "NOTICE OF TRANSFER OR DISCHARGE FROM SWING BED" and it was signed and dated by the patient's responsible party however the areas for other information about discharge specifics (where the patient was discharged to and why, etc.) were left blank.

4. On 1/23/2014 the job description of the social worker was reviewed by Surveyor #1. There were multiple references to discharge planning duties however it did not contain duties for written notification of patients/representatives about the final discharge plan/placement. The social worker reported to the Nurse Manager of the unit.
On the same day Nurse Manager (Staff Member #3) of the swing bed unit stated s/he was not aware of social worker duties related to written notification to patient/representatives about discharge plans.
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