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Based on document review and interview the facility failed to ensure protection of patient rights related to the right of family members/designee to be informed of patient changes in condition so as to participate in the patient's treatment/plan of care in 1 (patient 1) of 10 closed medical records (MR) reviewed:

Findings include:

1. Policy/procedure, No. I-A. 9, Patient Rights and Responsibilities, revised/reviewed 6/18 indicated: "Receive information about your health status, course of treatment, prospects for recovery and outcomes of care, including unanticipated outcomes, in terms you can understand, tailored to the patient's age and language; have your family and/or agent, when appropriate, be informed of your care, including unanticipated outcomes, in order to participate in current and future decisions affecting your care and to participate in the development and implementation of your plan of care.

2. Policy/procedure, No. II-C.100, Change of Condition, revised/reviewed 8/17 indicated on page 2: "The patient's family/designee will be notified as needed of the change of condition unless the patient refuses and does not have a guardian that is required to be notified.

3. Review of patient 1's MR lacked documentation of communication to F1 regarding patient's change in medical condition related to increased swelling and bruising to right thigh/hip and left index finger.

4. On 1/9/19 at approximately 1215 hours, staff N9 (Medical Records) was interviewed and confirmed patient 1's MR lacked documentation of communication informing F2 of patient 1's change in medical condition.

Based on document review and interview the facility failed to ensure appropriate staffing based on patient acuity and safety in 3 (Unit 100, 200 and 300) of 3 area toured:

Findings include:

1. Policy/procedure, No. II-C.107, Nursing Staffing Plan, revised/reviewed 1/18 indicated: "Acuity that deviates from the projected needs is assessed and accommodated in the shift-to-shift allocation of staff. In addition to acuity, including patient diagnosis, age, functioning of the patients, co-occurring conditions, physical care, equipment, technology, emotional support, education for self care, social needs, discharge planning and patient safety are considered.

2. Review of staffing for the week of 11/18/18 through 11/24/18 lacked documentation of process to determine shift-to-shift staffing based on patient acuity, diagnosis, age, functioning, co-occurring conditions, physical care and patient safety.

3. Review of Incident Report Log indicated 10 patient falls occurred during the week of 11/18/18 through 11/24/18.

4. On 1/9/19 at approximately 1245 hours, staff N10 (Interim Chief Executive Officer [CEO]) was interviewed and was unable to verbalize how facility accounts for patient acuity and safety when scheduling nursing staff. Staff N10 confirmed the Incident Report Log indicated 10 patient falls occurred during the week of 11/18/18 through 11/24/18.

Based on document review and interview, the facility failed to ensure nursing staff documented the initiation time of a provider-ordered increased 'line-of-sight' observation level; by failing to monitor and resolve in a timely manner a patient's change in medical condition; and by failing to complete documentation of a patient transfer to another facility in 1 (patient 1) of 10 medical records (MR) reviewed:

Findings include:

1. Policy/procedure, No. II-C.113, Patient Observation Policy, revised/reviewed 11/18, indicated: "Observation levels can be increased or decreased by a provider order".

2. Policy/procedure, No. II-C.100, Change of Condition, revised/reviewed 8/17, indicated: "It is the policy of the hospital that providers will be notified of patients that have changes in their condition in a timely manner. Nursing staff will document these changes, provider's notifications, and any interventions and/or orders regarding the change in condition in the patient's medical record. The assessments, provider notification, and any interventions and/or orders received and carried out will be documented in the nursing notes of the patient's medical records along with the patient's response. The change in condition will continue to be monitored and documented until resolved or a clinical decision has been determined by a provider. Documentation should reflect when the change has been resolved. A sample list of possible changes in condition would include but not be limited to: complaint of pain, change in mobility or ambulation, onset of edema".

3. Policy/procedure, No. I-C.73, Transfer and Transport of a Patient, revised/reviewed 11/18, indicated: "The following forms are required to be completed when transporting the patient: Transfer/Transport Consent/Order. Continuing Care Transfer Information".

4. Review Nursing Reassessment note dated 11/17/18 at 1900 hours indicated the medical staff D1 instructed the staff to start the patient on 'line-of-sight' observation level. Review of Physician Orders indicated an order for the increased observation level of 'line-of-sight' was dated 11/18/18 at 1106 hours. Review of Every 15 Minute Patient Observation Monitoring sheet dated 11/18/18 lacks documentation of time 'line-of-sight' observation level was initiated.

5. Review of patient 1's MR lacked documentation of timely response by staff to address the patient change in medical condition. Review of Nursing Reassessment note dated 11/20/18 at 0615 hours indicated a change in the patient's medical condition. Review of Physician Orders indicated x-ray of right hip, pelvis and left index finger were ordered on 11/20/18 at 1005 and 1025 hours. Review of patient 1's MR lacked documentation x-rays were completed.

6. Review of patient 1's MR lacked documentation of transport documentation including the Continuation of Care form and Continuing Care Transfer Information form

7. On 1/9/19 at approximately 1215 hours, staff N9 (Medical Records) was interviewed and confirmed patient 1's MR lacked documentation of transfer/transport documentation.

8. On 1/9/19 at approximately 1245 hours, staff N10 (Interim Chief Executive Officer [CEO]) was interviewed and confirmed patient 1's MR lacked documentation of Radiology Reports for x-rays of right thigh, pelvis and left index finger as ordered per physician. Staff N10 confirmed nursing staff did not initiated x-rays as ordered by the physician. Staff N10 confirmed patient 1's MR lacked completed transfer/transport documentation as per facility policy/procedure. Staff N10 confirmed patient 1's MR lacked documentation of time an increased observation level of 'line-of-sight' was initiated.










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Based on document review and interview the facility failed to ensure staff update a patient's care plan in 1 (patient 1) of 10 medical records (MR) reviewed:

Findings include:

1. Policy/procedure, No. II-C.100, Change of Condition, revised/reviewed 8/17 indicated on page 2: "The nurse will also update/amend the patient's care plan as needed, regarding the change in condition".

2. Review of patient 1's MR lacked documentation of an update to the patient's plan of care regarding the change of condition related to the patient increased swelling to the right thigh/hip and left index finger as documented in the Nursing Reassessment note dated 11/20/18 at 0930 hours.

3. On 1/9/19 at approximately 1245 hours, staff N10 (Interim Chief Executive Officer [CEO]) was interviewed and confirmed patient 1's MR lacked documentation of an update/amendment to the patient's plan of care regarding the patient's change in medical condition.