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Based on document review and interview, it was determined that the Hospital failed to demonstrate well-organized nursing services to ensure: appropriate supervision and evaluation of care of patients at risk for decannulation (unintentional removal or dislodgement of an artificial airway); and the plan of care was updated to address patient's problem. As a result, it was determined that the Condition of Participation for Nursing Services 482.23 was not in compliance.

Findings include:

1. The Hospital failed to ensure that care of a patient at risk for decannulation was appropriately supervised and evaluated. See deficiency at A-395.

2. The Hospital failed to ensure the plan of care was updated to address the patient's problem. See deficiency at A-396.

The immediate jeopardy (IJ) began on 4/10/18 due to the Hospital's failure to ensure that care of a patient at risk for decannulation was appropriately supervised and evaluated. Subsequently, the patient fell and sustained a left clavicle fracture and left sided-subdural hematoma (bleeding in the skull).

An immediate jeopardy was identified on 6/7/2018. The IJ was announced on 6/7/18 at 4:14 PM, during a meeting, with the Chief Clinical Officer, Chief Executive Officer, Director of Quality, Senior Director of Clinical Operations, Vice President of Clinical Operations, and Vice President of Quality. The immediate jeopardy was not removed by the survey exit date of 6/8/18.

Based on document review and interview, it was determined that for 2 of 4 (Pt. #1 and Pt. #4) patients in restraints, the Hospital failed to ensure patients were monitored every 2 hours per policy.

Findings include:

1. The Hospital's policy titled, "Physical Restraints (Violent and Non-Violent Behavior) and Seclusion" (release date 06/2017), was reviewed on 6/4/18 and required, "Ongoing Safety Checks & Monitoring (at least every two hours ...) by the patient's clinical team of the patient's response to the restraints, including any changes in condition. ... Visually observe the patient at least every 2 hours for safety needs..."

2. The clinical record of Pt. #1 was reviewed on 6/4/18. Pt. #1 was a 48 year old male admitted on 4/4/18 with the diagnoses of acute respiratory failure and encephalopathy (brain damage). Pt. #1 was placed in restraints on 4/4/18 at 8:00 PM and remained in restraints until 4/6/18 at 8:00 AM. The restraints were reapplied on 4/6/18 at 10:00 PM and remained in restraints until 4/11/18 at 12:00 AM. The following restraint monitoring flow sheets lacked documentation of every 2 hour monitoring:
4/5/18 - 6:00 PM
4/9/18 - 8:00 PM and 10:00 PM
4/10/18 - 12:00 AM through 6:00 AM

3. The clinical record of Pt. #4 was reviewed on 6/4/18. Pt. #4 was a 41 year old male admitted on 4/6/18 with a diagnosis of respiratory failure. Pt. #4 was placed in restraints on 4/6/18 at 6:00 PM and remained in restraints until 4/24/18 at 8:00 AM. The restraints were reapplied on 4/30/18 at 8:00 PM and Pt. #4 remained in restraints until 5/2/18 at 3:15 PM. The following restraint monitoring flow sheets lacked documentation of every 2 hour monitoring:
4/10/18 - 4:00 AM and 6:00 AM
4/14/18 - circulation checks - 10:00 AM through 6:00 PM
4/15/18 - circulation checks - 12:00 AM through 6:00 PM
4/16/18 - 10:00 AM and 12:00 PM
5/1/18 - 8:00 PM and 10:00 PM
5/2/18 - 12:00 AM through 6:00 AM

4. During an interview, on 6/4/18 at 1:45 PM, the Nursing Supervisor (E#5) stated that patients in restraints need to be monitored at least every two hours and the checks need to be documented in real time.

Based on document review and interview, it was determined that for 1 of 4 (Pt. #4) patients in restraints, the Hospital failed to ensure alternatives were attempted prior to initiating restraints.

Findings include:

1. The Hospital's policy titled, "Physical Restraints (Violent and Non-Violent Behavior) and Seclusion" (release date 06/2017), was reviewed on 6/4/18 and required, "Clinical justification for restraint use, describing the unsafe situation and how it impacts the patient's safety including: ... What less restrictive measures have been considered or attempted."

2. The clinical record of Pt. #4 was reviewed on 6/4/18. Pt. #4 was a 41 year old male admitted on 4/6/18 with a diagnosis of respiratory failure. A physician's order for restraints dated 4/30/18 lacked documentation of "Alternatives Considered/Attempted Prior to Intervention."

3. During an interview, on 6/4/18 at 1:45 PM, the Nursing Supervisor (E#5) stated that restraint alternatives need to be documented with every restraint order.

Based on document review and interview, it was determined that for 1 of 4 (Pt. #4) patients in restraints, the Hospital failed to ensure patients were evaluated daily to determine if restraints could be discontinued.

Findings include:

1. The Hospital's policy titled, "Physical Restraints (Violent and Non-Violent Behavior) and Seclusion" (release date 06/2017), was reviewed on 6/4/18 and required, "Ongoing assessment (at least daily) by an RN (Registered Nurse) of the patient's behavior, whether the unsafe situation is resolved and whether the criteria for discontinuing the restraints are met."

2. The clinical record of Pt. #4 was reviewed on 6/4/18. Pt. #4 was a 41 year old male admitted on 4/6/18 with a diagnosis of respiratory failure. Pt. #4 was placed in restraints on 4/6/18 at 6:00 PM and remained in restraints until 4/24/18 at 8:00 AM. The restraints were reapplied on 4/30/18 at 8:00 PM and Pt. #4 remained in restraints until 5/2/18 at 3:15 PM. The following restraint monitoring flow sheets lacked documentation of a daily assessment for the continued need for restraints: 4/10/18, 4/14/18, 4/15/18, and 5/1/18.

3. During an interview, on 6/4/18 at 1:45 PM, the Nursing Supervisor (E#5) stated that the nursing staff evaluates and documents whether the restraints should continue or can be discontinued. This is done on a daily basis.

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Based on document review and interview, it was determined that for 1 of 1 (Pt. #1) clinical record reviewed of a patient with a fall resulting in serious physical injury, the Hospital failed to ensure that care of a patient at risk for decannulation (unintentional removal or dislodgement of an artificial airway) was appropriately supervised and evaluated.

Findings include:

1. Pt. #1's clinical record was reviewed on 6/4/18 and 6/5/18. Pt. #1 was a 48 year old male, admitted on 4/4/18 with diagnoses of acute respiratory failure and encephalopathy (brain disease, damage, or malfunction) secondary to recent cerebral hemorrhage (bleeding inside the brain).

-The Respiratory Care notes dated 4/4/18 and 4/7/18 included the following, "Decannulation [unintentional removal or dislodgement of an artificial airway] risk factors":
- 4/4/18: "pulling at lines (high risk), impaired cognitive ability (high risk)"
- 4/7/18: "immature tracheostomy (artificial airway), trach(eostomy) discomfort/irritation (high risk), coughing tendency (high risk)."

-A Physician's Progress Note of a fall on 4/6/18 (dictated at 10:44 PM) included, "Rapid response called and upon arrival patient down on the floor right side of the bed sitting up/ He had blood on the right side of his chest and had a small abrasion on the right side of scalp. But he stated he felt fine and had no pain ... He will need a sitter or restraints for the night. Since his surgery he is confused. He fell tonight attempting to stand. He is non-ambulatory [unable to walk] and a fall risk."

-An order for restraints (bilateral soft wrist) was obtained on 4/6/18 at approximately 10:00 PM after Pt. #1's fall.

-A Nurse's note dated 4/7/18 included, "Self extubation/decannulation: at 4/7/18 16:48:00 [4:48 PM]. Treatment initiated: reinserted tube."

-Pt. #1 had an order dated 4/10/18 at 8:00 AM for bilateral soft wrist restraints due to: "Risk of injury to self-due to inability to understand or remain oriented" and "Disturbing monitoring equipment or necessary treatment modality (i.e. pulling at Lines/Tubes/Drains)."

-A Nurse's Progress Note on 4/10/18 included, "Patient fall: at 4/10/2018 21:00:00 [9:00 PM]. Comment: [E#1] CNA [Certified Nursing Assistant] was in patient's room giving him a bath at the time the incident occurred."

-CT (computed tomography) scan results from 4/10/18 at approximately 11:00 PM indicated that Pt. #1 sustained a left clavicle fracture and a left-sided subdural hematoma.

2. The Incident Report of Pt. #1's fall on 4/10/18 (created by the Director of Quality E#6 on 4/11/18) was reviewed on 6/4/18. The report included, " ... Functional level prior to Event: Extensive assistance ... Totally dependent ... Patient [Pt. #1] with witnessed fall from bed with injury. Pt previously identified as fall risk with floor mats, bed alarm, yellow gown and signage present. Pt resides across from the nurses station for monitoring. Pt also currently in bilateral wrist restrains due to recent decannulation ... CNA [E#1] bathing patient with left restrain on and right restraint off. CNA [Certified Nursing Assistant] washed up his front side and when changing the patient position to wash the backside, the patient fell onto his left side on the floor mats. Pt [patient] landed on the padded floor with the left wrist restraint still in place."

3. The Hospital's policy titled, "Decannulation Prevention Program" (released 10/2016), was reviewed on 6/5/18 and required, "The respiratory therapist ... will determine ... the decannulation risk ... patients identified as at risk or high risk for airway decannulation will be placed on airway precautions and interventions [including:] ... Any patient who is considered to be at risk or high risk will always have at least two staff members to assist with turning and repositioning for bathing or any other purposes ... Any patient, who becomes decannulated unintentionally, will be considered at high risk ... Other attributes that result in a high risk designation include: patient pulling at lines, history of decannulation, mobility risk (patient independently attempts to reposition self or get out of bed), communication barrier, coughing tendency, tracheostomy discomfort/irritation and/or impaired cognitive ability..."

4. The Hospital's Job Description for Staff Nurse (updated 2014), was reviewed on 6/5/18 and required, "... Essential Functions... Directs, supervises and evaluates nursing care provided to patients. Assigns or delegates tasks based on the needs and condition of the patient, potential for harm, complexity of the task..."

5. On 6/6/18 at approximately 11:00 AM, the Hospital's "Decannulation Prevention Competency Demonstration Record" sheet (review date 1/1/2015) for Registered Nurses and Cetified Nurses Assistants was reviewed and required, "...Ensures turning, positioning and patient transfer competency has been completed by staff member... Recognizes that (the Hospital) considers all patient with an artificial airway are considered at risk for decannulation...Places signage to ensure that patient always has two staff members to assist with turning and repositioning..."

6. During an interview with another CNA working on Unit D (E#4) on 6/4/18 at 10:35 AM, E#4 stated, "I usually give 3 to 4 baths per day. I wash all parts of the patient that I can, then ask for help to turn the patient if necessary to complete the bath. If the patient is smaller or can help turn themselves, I will do the bath by myself." E#4 did not indicate any other circumstance when 2 staff members would be required for bathing.

7. During an interview on 6/5/18 at 10:05 AM with the Pt. #1's Primary Nurse (E#2) on the evening of 4/10/18, E#2 stated that Pt. #1 was alert to self but not to anything else including place or time. Pt. #1 was confused and did not answer questions appropriately. Pt. #1 had periods of restlessness and was very impulsive and should have two people present while bathing. E#2 stated, "The requirement for two people is in a policy but I don't remember the name of it." E#2 stated that E#1 (Certified Nursing Assistant / CNA of Pt. #1 on Unit D) did not ask her (E #2) for help to bathe Pt. #1 on the night of the fall (4/10/18).

8. E#1 (Certified Nursing Assistant / CNA of Pt. #1 on Unit D) stated during an interview on 6/5/18 at 11:10 AM, that there were no specific staffing or supervision requirements that would require a second staff member to assist with patient care as long as the staff felt they could perform the tasks on their own. E#1 stated, "If we felt like we could do it [patient care] by ourselves, we did it...The patient [Pt. #1] wasn't combative so I felt like I could do it."

9. Interviews were conducted with the Director of Quality Management (E#6) between 6/5/18 to 6/6/18:

- During the interview with the Director of Quality Management (E#6) on 6/5/18 at approximately 10:30 AM, E#6 stated that only patients on ventilators require two staff members for patient care and repositioning since the ventilator tubing creates a decannulation risk. "We follow a Decannulation policy for that." E #6 stated that the annual training, which includes the self-decannulation prevention program, was provided to staff (Certified Nursing Assistants and Registered Nurses). E#6 incorrectly stated, when interviewed at this time, the Hospital's current policy on Decannulation Prevention.

- During an interview on 6/5/18 at approximately 2:15 PM, E#6 confirmed that the Restraint Orders were restarted on 4/10/18 due to Pt. #1's "impulsive behavior" to try and get out of bed and also pull at his tubes (trach and feeding).

- During an interview on 6/6/18 at 2:15 PM, E#6 stated that audits from the Root Cause Analysis of Pt. #1's fall on 4/10/18 have been focused on restraints and fall prevention. No specific audits or tools were done to track whether staff are following the "Decannulation Prevention" policy which requires two staff members present for care of patients at risk decannulation.

10. An interview with a Day Shift Supervisor (E#7) was conducted on 6/6/18 at 1:15 PM. Given Pt. #1's clinical and fall scenario, E#7 stated that having two staff members for providing care would be an appropriate measure to take in caring for this patient. E#7 added that since this patient was clearly at risk for decannulation based on his history, two staff members should be present for patient safety. Furthermore, E #7 said that having more than one staff member to assist with the bath could have prevented this patient from falling. E#7 stated that, "Typically restraints are released during bathing and repositioning, so having two people present would be best because if one had to turn around to grab something, the other person could still keep their eyes on the patient."

11. An interview with a Day Shift Supervisor (E#5) was conducted on 6/7/18 at 10:30 AM. E#5 stated that all patients at risk for decannulation should be repositioned with two staff members present. E#5 stated that a sign should be placed by the bed to indicate the patient has a decannulation risk.

Based on document review and interview, it was determined for 3 of 3 (Pt. #1, Pt #7, and Pt. #14) patients' care plans reviewed, the Hospital failed to ensure that the plan of care was updated to address the patients' needs.

Findings include:

1. Pt. #1's clinical record was reviewed on 6/4/18 and 6/5/18. Pt. #1 was a 48 year old male, admitted on 4/4/18 with diagnoses of acute respiratory failure and encephalopathy (brain disease, damage, or malfunction) secondary to recent cerebral hemorrhage (bleeding inside the brain). The clinical record indicated that Pt. #1 had a tracheostomy tube (artificial airway), a high risk for self-decannulation (unintentional removal or dislodgement of an artificial airway), which required 2 staff assistance during turning and repositioning for bathing. However, Pt. #1's care plan did not indicate that 2-person assistance was required with turning and repositioning.

2. On 6/5/18 at approximately 10:30 AM, the clinical record of Pt. # 7 was reviewed. Pt. #7 was a 62 year old male admitted on 5/21/18 with a diagnosis of acute postprocedural respiratory failure. On 5/21/18, the clinical record indicated that a Registered Nurse identified Pt. #7 in need of contact isolation precaution due to MRSA (methycillin resistant staphylococcus aureus). However, as of survey date 6/5/18, Pt. #7's plan of care has not been updated to include contact isolation as a problem.

3. On 6/6/18 at approximately 10:00 AM, the clinical record of Pt. #14 was reviewed. Pt. #14 was a 60 year old female admitted on 5/18/18 with a diagnosis of peritoneal abscess. The clinical record indicated that Pt. #14 had a tracheostoy tube (artificial airway). During the review, Pt. #14's nurse (E #10) stated that Pt. #14 required 2 person assistance with turning and repositioning while bathing. However, Pt. #14's plan of care did not indicate that 2 person assistance was required with turning and repositioning while bathing.

4. On 6/5/18 at approximately 11:00 AM, the Hospital's policy titled, "Assessment/Re-assessment - Interdisciplinary Patient" (release date 6/2017) was reviewed and required, "...1. Care provided to each patient is based on an assessment of the patient's... physical needs... Policy... 4. Assessment and data collection performed by licensed health care professionals will include and address... c. Data analysis to develop a plan of care to meet the patient's care or treatment needs."

5. On 6/5/18/at approximately 2:00 PM, the Hospital's policy titled, "Decannulation Prevention Program" (release date 10/2016) was reviewed and required, "...Procedure...5. Any patient who is considered to be at risk or high risk will always have at least two staff members to assist with turning and repositioning for bathing or any other purpose... 12. The respiratory therapist will initiate an at risk decannulation care plan. This care plan will be scheduled... for those facilities on ProTouch (electronic medical record) and all caregivers may document against the interventions..."

6. On 6/6/18 at approximately 11:00 AM, the Hospital's "Decannulation Prevention Competency Demonstration Record" sheet (review date 1/1/2015) for Registered Nurses and Certified Nurses Assistants was reviewed and required, "Ensures turning, positioning and patient transfer competency has been completed by staff member... Recognizes that (the Hospital) considers all patient with an artificial airway are considered at risk for decannulation..."

7. On 6/5/18 between 10:30 AM and 3:00 PM, interviews were conducted with E #6 (Director of Quality Management) regarding Pt. #7. E #6 stated that the identified problem was part of the kardex (a summary of patient's needs) but not the plan of care of the clinical record. E #6 stated that the the Hospital documents on the Pro Touch electronic medical record.