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Based on record review, observation, and interview, the hospital failed to protect and promote the rights of 3 of 3 patients (Patients #15, #1, #4).


1) Patient #15 had a complaint regarding her care and was unaware of the patient advocacy program. Hospital staff failed to ensure that information whom to contact to file a grievance was posted on the unit.

Refer to A118


2) Although in a healthy weight range, Patient #1 had lost ten pounds within the month prior to his hospital admission and had requested a kosher diet with organic food items. Hospital staff failed to honor Patient #1's right to freedom of choice by not providing food items that acknowledged the patient's religious and physical needs.

Refer to A 129


3) Patient #4's was emergently restrained on 12/16/16. A day later, Patient #4 complained of left shoulder pain and was sent to an acute care hospital Emergency Department. Patient #4 had a fractured collar bone, sustained bruises, and complained of high intensity pain. Hospital Staff failed to ensure Patient #4 received care in a safe environment to prevent injury.

Refer to A144

Based on record review, interview, and observation, the hospital failed to ensure the right of one of one patient (Patient #15) to be informed of how to contact the hospital's Rights Protection Officer and/or Patient Advocate.


Findings included:


On 12/29/16 at 1145, Patient #15 requested to speak to the surveyor and stated that she had not received medications to treat her pain and anxiety for the previous two days. Patient #15 denied awareness of the patient advocacy program.


Observation on the hospital's adult unit on 12/29/16 at 1155 reflected there was no information regarding the hospital's patient advocacy program posted for patient view.


Hospital Employee #6 acknowledged the finding and retrieved a document with patient advocacy information from he nurses' station and placed it on the wall.

Based on record review and interview, the hospital failed to ensure the rights of one of one patient (Patient #1) to receive menu and food choices that acknowledged the patient's religious preferences and physical needs. Patient #1 had lost ten pounds within a month prior to his hospital admission and had requested a kosher/organic diet.



Findings included:


Patient #1's Physician Admission Orders dated 12/15/16 at 2153 reflected an order for an organic diet.


Patient #1's Integrated Assessment/Nursing dated 12/16/16 at 0200 reflected the patient had lost ten pounds in the month prior to his admission


Patient #1's Daily Nursing Assessment Flow Sheet dated 12/16/16 at 0700 reflected the patient requested a kosher meal.


Patient #1's Nutritional Consultation dated 12/16/16, untimed, reflected the patient had requested "organic foods and kosher meats and foods for religious reasons." Hospital Employee #17 recommended that Patient #1 ate "food...[Patient #1] can tolerate." There was no mention of organic or kosher foods to accommodate the patient's religious request.


Hospital Employee #5 was interviewed on 12/29/16 at 1200 and denied that Patient #1's request for a kosher and/or organic diet was addressed. Hospital Employee #5 was surveyor asked to provide documentation that Patient #1 received the physician ordered organic diet. None was provided.


Hospital Employee #8 denied during an interview on 12/29/16 at 1255 that that kosher diet recommendations were applied for Patient #1.


Hospital Policy titled POC 203 Dietary Department Role in Protecting Patient Rights dated 09/2011 reflected the procedure for dietary service department staff to "honor the patient's right to freedom of choice by providing menu/food choices that acknowledge the patient's religious and physical needs..."

Based on record review, observation, and interview, the hospital failed to ensure the right to receive care in a safe setting for one of one patient (Patient #4). Patient #4 was emergently restrained on 12/16/16. A day later, Patient #4 complained of left shoulder pain and was sent to an acute care hospital Emergency Department. Patient #4 had a fractured collar bone, sustained bruises, and complained of high intensity pain. Hospital The patient suffered from a broken collar bone while hospitalized.


Findings included:


Patient #4's Admission Orders dated 12/10/16 at 2235 reflected the patient's admission diagnoses that included Bipolar Disorder.



Patient #4 was interviewed on 12/29/16 at 1110. The patient was surveyor observed with dark bruising on her upper left arm and stated she had a "fracture in ...[her] shoulder and collar bone and need Tylenol #3 ..."



Patient #4's initial skin assessment documented on the Integrated Assessment/Nursing dated 12/10/16 did not reflect bruising on the patient's upper left arm.



Physician Orders dated 12/17/16 at 1145 reflected the physician ordered Patient #4 to be sent to the acute care hospital.


Daily Assessment Nursing Flow Sheet dated 12/17/16 at 1250 reflected Patient #4 complained of "clavicle/shoulder pain [on] left side ...bruise and swelling noted." A pain score of 10 out of 10 (with 10 as the worst score) was noted for the 0700 to 1500 shift.


Acute Care Hospital Emergency Department document dated 12/17/16 at 1451 reflected Patient #4 was discharged. Diagnoses included Clavicle Fracture.


Hospital Employee #5 was interviewed on 12/29/16 at 1400. She stated Patient #4 "had a restraint and x-ray found a fractured clavicle." Hospital Employee #5 acknowledged the patient did not have the injury on admission and stated the cause was "undetermined at this time."

Based on record review, interview, and observation, the hospital failed to ensure that a registered nurse supervised and evaluated the care of 5 of 5 patients (Patients # 4, #1, #2, #3, and #11), and assessed and/or reassessed the patients according to their needs.


1) Patient #4 suffered an injury during her hospital stay and had to be emergently evaluated for a broken collar bone at an acute care hospital. The patient complained of high intensity pain in her left shoulder and had bruising. Hospital nursing staff failed to assess the patient's pain for almost 44 hours after her return from acute care hospital Emergency Department.

Refer to A395


2) Patient #1 had suffered a head injury prior to his hospital admission and was diagnosed with Epilepsy. Nursing staff failed to assess the patient's blood pressure on admission and did not follow up with nursing assessments of Patient #1's severely fluctuating blood pressure readings noted by technicians.

Refer to A395


3) Patient #2 had high blood pressure on admission and told the nurse he did not feel well. Nursing staff failed to reassess the patient to ensure he was medically stable and did not follow up on his fluctuating blood pressure readings for two days after admission.

Refer to A395


4) Patient #3 was admitted with high diastolic blood pressure. Nursing staff failed to address the patient's blood pressure for three days following his admission according to hospital policy. No vital signs were obtained on the patient's fifth hospital day.


Refer to A395


5) Patient #11 was admitted with a skin lesion that had the potential to spread to other patients and/or staff. Nursing staff failed to assess the lesion on admission and for the following 20 hospital days.


Refer to A395

Based on record review, observation, and interview, hospital nursing staff failed to supervise and evaluate the nursing care for 5 of 5 patients (Patient #4, #1, #2, #3, #11) based on the patients' needs, physician orders, and/or hospital policy.


1) Patient #4's vital signs were not assessed as ordered. In addition, seven days into her hospital stay, the patient was sent for emergency evaluation of her shoulder pain at an acute care hospital. Although the patient had a confirmed diagnosis of a left broken clavicle upon return, nursing staff failed to reassess the patient's pain for almost two days,



2) Patient #1 was admitted with a medical history of head injury and epilepsy and suffered a seizure shortly after his hospital admission. Although technicians noted Patient #1 had severely fluctuating blood pressure, nursing staff failed to document Patient #1's vital signs on admission and did not follow up with a nursing reassessment of the patient's vital signs,



3) Patient #2 was admitted with a hypertensive stage 2 blood pressure reading and verbalized feeling sick. Nursing staff failed to reassess the patient and did not follow-up on his fluctuating blood pressures for two days after admission,



4) Patient #3's admission data included high blood pressure. Nursing staff failed to address the patient's blood pressure for three days following his admission according to policy. No vital signs were taken on the patient's fifth hospital day,



5) Patient #11 was admitted with a skin lesion potentially spreadable to other patients and staff. Nursing failed to assess the lesion on admission and for 20 days following the patient's admission.




Findings included:



1) Patient #4's Admission Orders dated 12/10/16 at 2235 reflected the patient's vital signs were to be taken three times daily for three days and "then daily if stable."



Patient #4's Daily Nursing Assessment Flow Sheets dated 12/11/16, 12/12/16, and 12/13/16 did not reflect that nursing staff assessed the patient's vital signs three times daily as ordered. No vital signs were documented on 12/17/16.



Patient #4 was interviewed on 12/29/16 at 1110. She volunteered to show the surveyor dark bruising on her upper left arm and stated she had a "fracture in ...[her] shoulder and collar bone and need Tylenol #3 ..."



Daily Nursing Assessment Flow Sheet dated 12/17/16 at 1250 reflected Patient #4 complained of clavicle/shoulder pain [on] left side ...bruise and swelling noted." A pain score of 10 out of 10 (with 10 as the worst score) was noted for the 0700 to 1500 shift. The physician ordered Patient #4 to be sent to the acute care hospital where she was emergently treated and returned with a confirmed diagnosis of a fractured clavicle. There was no evidence that nursing staff assessed the patient's shoulder pain as to quality and intensity for 44 hours following the patient's visit to the acute care Emergency Department. The shift pain assessments dated 12/17/16 for the 1500 to 2300, 2300 to 0700 shift and on 12/18/16 timed for the 0700 to 1500, 1500 to 2300, and 2300 to 0700 shifts were left blank.



Hospital Employee #4 acknowledged the above findings on 12/29/16 at approximately 1540.




2) Patient #1's Physician Attestation dated 12/27/16 at 1441 reflected the patient's 12/15/16 admission and 12/22/16 discharge dates. Final diagnoses included Bipolar Disorder and Epilepsy.



Patient #1's Psychiatric Evaluation dated 12/16/16 at 1647 reflected that the patient's history included an incident where his "head was slammed to the ground ...onset of seizures ..."



Patient #1's Physician Admission Orders dated 12/15/16 at 2153 reflected to take the patient's vital signs three times daily for three days.



Patient #1's Integrated Assessment/Nursing dated 12/16/16 at 0200 did not have documented blood pressure, temperature, pulse, and respiration.



Patient #1's Daily Nursing Assessment Flow Sheet dated 12/16/16 at 0700 reflected the patient's statement that he did not feel well and "...began turning red, then pale...seized while sitting in lab chair..." There was no evidence of nursing assessment of Patient #1's vital signs on 12/16/16 and 12/17/16.



Patient #1's Daily Nursing Assessment Flow Sheet dated 12/18/16 during the 0700 to 1500 shift reflected Patient #1's blood pressure was 143/78 mmHg. There were no vital signs documented for the following two shifts.



Patient #1's Behavioral Health Technician (BHT) Flow Sheet dated 12/15/16 at 2230 reflected Patient #1's blood pressure of 154/114 mmHg. There was no evidence that the charge nurse was notified. A second blood pressure documented to be 157/102 mmHg was untimed. No nursing assessment was done..



BHT Flow Sheet dated 12/16/16 at 0730 noted the patient's blood pressure was 116/81. Twelve and one-half hours later the patient's blood pressure was noted to be 152/91. There was no evidence that the nurse assessed the patient.



Hospital Employee #5 acknowledged the above findings during an interview on 12/19/16 at approximately 1400.



Hospital Policy POC 137 titled Patient Assessment and Treatment Process was dated 09/2011 and reflected patient routine vital signs were "assessed three times per day for the first three days and then daily."



3) Patient #2's Psychiatric Evaluation dated 12/17/16 at 1704 reflected the patient's 12/13/16 admission. Diagnoses included Psychosis, Crohn's Disease, and Multiple Concussions secondary to Motor Vehicle Accident.



Patient #2's Integrated Assessment /Nursing Assessment dated 12/13/16 at 1900 reflected the patient's blood pressure was 153/106 mmHg. The patient stated "I'm not feeling good." There was no evidence of a blood pressure recheck.



Patient #2's Daily Nursing Assessment Flow Sheets dated 12/14/16 and 12/15/16 did not reflect nursing documentation of Patient #2's blood pressure and/or other vital signs.



Patient #2's BHT Flow Sheet dated 12/15/16 reflected the patient's blood pressure of 122/79 mmHg at 0730 and 165/97 mmHg at 2139. There was no evidence that nursing staff was reassessed the fluctuating patient blood pressure.



The American Heart Association noted that a patient blood pressure of 153/106 was classified as hypertension (high blood pressure) stage 2 (http://www.heart.org/HEARTORG/Conditions/HighBloodPressure/GettheFactsAboutHighBloodPressure/Understanding-Blood-Pressure-Readings_UCM_301764_Article.jsp#.WHf4eU2FOpp



4) Patient #3's Integrated Assessment/Nursing dated 12/12/16 at 1900 reflected the patient suffered from Hypertension. The patient's blood pressure was noted to be 146/97 mmHg.



Patient #3's Daily Nursing Assessment Flow Sheets dated 12/14/16 and 12/15/16 did not reflect nursing assessment of the patient's blood pressure.



Patient #3's Daily Nursing Assessment Flow Sheet and BHT Flow Sheets dated 12/17/16 did not reflect any vital signs.



Patient #3's Daily Nursing Assessment Flow Sheet dated 12/19/16 at 1707 reflected Patient #3's blood pressure was 156/78. There was no evidence the nurse reassessed the patient's blood pressure.




5) Patient #11's Admission Orders dated 11/25/16 at 1800 reflected the patient's medical diagnoses that included a "lesion" on the patient's left inner arm.



Patient #11's Psychiatric Evaluation dated 11/26/16 at 2038 noted the patient had a "skin eruption" on the left inner arm.



Patient #11's History and Physical Examination dated 11/27/16 at 1300 reflected the patient had an infection on her left arm, questionably "Tinea (ringworm)."



Integrated Assessment/Nursing dated 11/25/16 reflected Patient #11's skin assessment did not have a skin lesion.



Daily Nursing Assessment Flow Sheets dated 11/26/16 through 12/16/16 did not address Patient #11's skin lesion.



The Mayo Clinic noted that "ringworm often spreads by direct skin-to-skin contact with an infected person ..." (http://www.mayoclinic.org/diseases-conditions/ringworm/home/ovc-20232303)

Based on record review and interview, the facility failed to ensure that its therapeutic diet manual was updated and approved by the dietician and medical staff.


Findings included:


Record review of the hospital's dietary menu on 12/29/16 at 1255 reflected a 2008 date. There was no evidence that of review by the hospital dietician or medical staff.


Hospital Employee #8 acknowledged the findings during an interview on 12/29/16 at 1255.

Based on observation, record review, and interview, the Hospital failed to ensure that the emergency equipment was maintained at an acceptable level of safety and quality. The oxygen tank needed during Patient #12's episode of unresponsiveness did not have enough pressure and had not been checked for functionality for more than three weeks.



Findings included:



The surveyor observed Patient #12 unresponsive next to her hospital bed on 12/28/16 at 1515. The patient's facial color was ashen. An unidentified staff member stated that Patient #12 was three months pregnant and had a seizure. Hospital Employee #18 attempted to change the setting on the oxygen tank next to the patient. On 12/28/16 at 1520 Employee #18 transported the oxygen tank to a room behind the nurses' station, retrieved a new tank, and stated that "the first one did not have enough pressure."

On 12/28/16 at 1545, Hospital Employee #6 reviewed the oxygen tank checklist and stated it "had not been updated since the second [December 2, 2016]."

Record review of the Hospital's oxygen and automated external defibrillator (AED) checklist dated December 2016 reflected the expectation for staff to check the oxygen tank and defibrillator nightly for pressure and/or charge. The spaces dated 12/03/16 through 12/28/16 were left blank.

Patient #12's Integrated Assessment/Nursing dated 12/27/16 at 2130 reflected a seizure disorder. Patient #12 was pregnant.