HospitalInspections.org

Based on record review and interview, the medical staff failed to ensure the quality of care provided to each patient, in that,

A) 2 of 5 patient's (Patient #2 and #4) discharge summaries did not reflect their significant findings;

B) 1 of 5 patient's (Patient #4) consultation was not completed within 24 hours; AND

C) 1 of 5 patient's (Patient #4) operative report reflected the wrong procedure date and time.

Findings

A) Discharge summaries:
* Patient #2's Discharge Summary did not reflect the (significant findings) issue/incident of the 95 year old's safety due to the daughter's witnessed actions and any resolution prior to discharge to the same daughter. Patient #2's record documented an admission from 6/16/2023 to 6/26/2023 for a diagnosis of Ileus/Acute Cholecystitis. She was discharged home to the (same) daughter with hospice.

The Clinical Documentation (Nurse Progress notes) reflected:

~ 6/18/2023 at 04:31 PM spoke with registration. No MPOA (Medical Power of Attorney) on file from previous admissions. Will require daughter to present proper documentation...

~ 6/19/2023 at 01:55 AM nurse note described the incident, Dtr (daughter) behavior liable. Dtr found raising voice at pt. covering pt eyes. Pressing on face. Pressing on abdomen. Pulling at IV site. Being forceful with pt when trying to move pt herself after advising Dtr to call staff. Dtr noted swaying and being unsteady. Pt noted saying help me several times. Reported to charge will continue to monitor...

Nursing staff witnessed behaviors and actions by the patient's daughter that put the patient at risk. There was no notification of the physician, security, or police. There was no evidenced resolution of the safety concern prior to discharge of the patient to the same daughter.

During an interview on 2/07/2024 at 9:20 AM, Personnel #1 was asked to review Patient #2's discharge summary. The surveyor navigated to the discharge summary. Personnel #1 confirmed the issue was not included.


*Patient #4's Discharge Summary did not reflect the (significant findings) of amputation versus reattachment of partial and severed digits.

Patient #4's 8/23/2023 Discharge Summary reflected 58 year old male...work related incident when his left hand got caught in a lawn mower. Examination and xrays revealed a partially amputated ring finger and an open fracture on the middle finger. Surgery was performed for reattachment...

There is no mention of not reattaching the digits.

During record review and interview on 2/05/2024 at 1:27 PM, Personnel #1 was asked if the discharge summary reflected the digits could not be reattached or why. Personnel #1 stated no, ma'am.

B) Consultation:
Patient #4's surgical consultation was not completed within 24 hours.

Patient #4's 8/21/2023 at 12:18 PM Order: Consult (surgeon name) Reason for Consult: partial finger amputation.
Patient #4's 8/22/2023 at 16:41 PM Physician's first documentation after the consult order.

During record review and interview on 2/05/2024 at 1:27 PM, Personnel #1 was asked how long the physician has to perform the consult. Personnel #1 stated 24 hours. Personnel #1 was asked to confirm the consult was not completed within 24 hours. Personnel #1 stated yes ma'am, it was not.

C) Operative Report:
Patient #4's operative report reflected the wrong date and time.

Patient #4's 8/22/2023 Orthopedics Brief Operative Report reflected 16:41 Name of procedure: left middle and ring finger revision amputations...

Patient #4's Orthopedics Operative Report reflected Documented on 8/30/2023 12:50 PM...Surgery start date/time: 8/30/2023 12:50...Description of technique/procedure Date 8/22/2023...Procedure: left middle finger revision amputation...left ring finger revision amputation...

During record review and interview on 2/05/2024 at 1:27 PM, Personnel #1 was asked asked to confirm the operative report findings. Personnel #1 confirmed the findings.

The hospital's 12/30/2020 approved Medical Staff Rules & Regulations required

~ complete operative reports in a timely manner...

~ Consultations shall be obtained and completed within twenty-four (24) hours or sooner...when operative procedures are involved, the consultation note shall...be recorded prior to the operation...

~ Discharge summary...must include...significant findings...

.

Based on record review and interview, the hospital failed to protect and promote each patient's rights of care in a safe setting, in that,

3 of 5 patient's rights: (Patient #2, #3, and #5)

A) Patient #2: Nursing staff witnessed behaviors and actions by the patient's daughter that put the patient at risk. The physician, security, and police were not notified. There was no evidenced resolution of the safety concern prior to discharging the patient to the same daughter.

Patient #2: The patient was awake, alert, and oriented. The daughter was consulted for decisions versus the patient. There was no MPOA (Medical Power of Attorney) on file for the daughter.

Patient #2: Case Management did not document a social assessment for patient safety after the daughter's questionable behavior and actions were witnessed.

Patient #2: Case Management did not notify APS at discharge of discharging the patient to the daughter who was witnessed with questionable behaviors and actions toward the patient.

An Adult Protective Services (APS) case number 49696483 was closed after APS determined from a hospital nurse the patient was currently located in a safe place - the hospital. The hospital did not call APS at discharge.


B) Patient #3 did not receive nursing care as an admitted, emergency hold patient located in the emergency room. Nurse assessments, vital signs, pain assessment, medications, nutrition, and elimination were not evidenced.

C) Patient #5 developed a pressure ulcer/wound and multiple infections during his ICU (Intensive Care Unit) admission. There was no Wound Care Physician. The Wound Care Nurse did not follow the wound throughout admission until discharge.

Findings

A) Patient #2: Nursing staff witnessed behaviors and actions by the patient's daughter that put the patient at risk. The physician, security, and police were not notified. There was no evidenced resolution of the safety concern prior to discharging the patient to the same daughter.

Patient #2: The patient was awake, and oriented. The daughter was consulted for decisions versus the patient. There was no MPOA (Medical Power of Attorney) on file for the daughter.

Patient #2: Case Management did not document a social assessment for patient safety after the daughter's questionable behavior and actions were witnessed.

Patient #2: Case Management did not notify APS at discharge of discharging the to the daughter who was witnessed with questionable behaviors and actions toward the patient.

Patient #2's record documented an admission from 6/16/2023 to 6/26/2023 for a diagnosis of Ileus/Acute Cholecystitis. She was discharged home to the (same) daughter with hospice.

The Emergency Department Record reflected 6/16/2023 complaint (C/O) ABD pain X 2 (abdominal pain times) days per hospice nurse. Pt is increasingly lethargic. Pt is able to nod to answer questions but baseline mentation...Objective assessment: Pt A/O x 3 Awake and Oriented...

The History and Physical reflected 6/16/2023 the patient is lethargic and resting in bed. She does open eyes to command and can answer simple questions. She states that she has pain in her abdomen and would like pain medication. She also states that she would like some ice chips for comfort...Oriented x 2-3, lethargic...

The Clinical Documentation (Nurse Progress notes) reflected:
~ 6/18/2023 at 04:31 PM spoke with registration. No MPOA on file from previous admissions. Will require daughter to present proper documentation...

~ 6/19/2023 at 01:55 AM Dtr (daughter) behavior liable. Dtr found raising voice at pt. covering pt eyes. Pressing on face. Pressing on abdomen. Pulling at IV site. Being forceful with pt when trying to move pt herself after advising Dtr to call staff. Dtr noted swaying and being unsteady. Pt noted saying help me several times. Reported to charge will continue to monitor...

~ 6/21/2023 13:46 PM at 12:34 (name) from Adult Protective Services phoned this nurse and inquired about patient's discharge status. Inquired if patient's daughter being aggressive toward patient. Inquired if patient daughter had POA (Power of Attorney). (Name) was advised that discharge is to be determined by MD (physician) after procedure. That this nurse haven't witnessed any aggression from the daughter towards the patient. That per daughter she has POA paperwork at home.

~ 6/26/2023 12:00 PM Palliative Care notes spoke to daughter downstairs in the lobby. She is very clear that she wants mom on comfort care...I asked about her going to the hospice IPU (inpatient unit) and she said no. I want mom at home...will get her home today...

The Case Management Report reflected:
~ 6/19/2023 3:49 PM social barrier: concern expressed regarding daughter's behavior/ability to care for pt at home. SW (social worker/case manager) assessment of social situation pending...Home with hospice services likely. APS to be notified upon discharge...

~ 6/21/2023 4:46 PM social barrier: daughter (name) suspected of behaving aggressively towards pt. Virtual sitter (camera visualization of the patient) placed to monitor such...APS to be notified upon discharge...

~ 6/23/2023 3:48 PM monitoring daughter (name) for aggressive behavior...APS to be notified upon discharge...

The 6/26/2023 Discharge Medication Instructions was signed by the (same) daughter.

The 6/19/2023 09:14 Incident report reflected (daughter name) towel over the pt eyes and was pressing on her face. Daughter was witnessed covering pt face with blankets, and ultimately placing a pillow over her face...Patient tearful, mouthed help me I am scared...
~ Investigation notes: patient daughter Janet has had concerning behavior since patient's admission. APS has been alerted. Virtual sitter being placed at patient's bedside as well. Daughter is MPOA, However, her behavior is alarming...
~ Impact of event: Unsafe condition Patients daughter is demonstrating behavior that is concerning for unsafe treatment of patient...

During record review and interview on 2/05/2024 ending at 2:42 PM Personnel #1 called Personnel #3 to ask about the abuse incident report and follow-up. Personnel #3 reviewed the record and directed Personnel #1 to the 6/19/2023 documentation. Personnel #3 stated we got a virtual camera for the room so someone would be monitoring the patient at all times. The door was left open as well. After the camera was started, the daughter did not show up as much. A niece started coming. The primary nurse was who called APS. Personnel #3 was asked if any of this was documented. Personnel #3 stated Not that I am seeing. No note on the follow-up.

Personnel #3 was asked if they had it the rest of the time. Personnel #3 stated Yes. Personnel #3 was asked if there was any other abuse. Personnel #3 stated no. Personnel #3 was asked if the physician was notified. Personnel #3 stated I don't see that documented. Personnel #3 was asked if the police were notified. Personnel #3 stated I don't see that. Personnel #3 was asked the patient's state. Personnel #3 stated she was awake, but weak. Her short and long-term memory were not intact.


B) Patient #3 did not receive nursing care as an admitted, emergency hold (ED Hold) patient located somewhere in the emergency room. Nurse assessments, vital signs, pain assessment, medications, interventions, nutrition, and elimination were not completed or evidenced. The patient was discharged at 18:49 PM without receiving any standard nursing care or ordered care.

The record does not document a location, bed, recliner, or chair for the patient.

The ED (Emergency Department) Patient Record (Nursing) ended on 5/17/2023 at 19:02 PM.

The Clinical Documentation Record (Inpatient Nursing) begins on 5/18/2023 at 0738 with documentation of sepsis screen without vitals being completed.

After 5/17/2023 at 19:02 PM when ER Hold status began, there are no assessments, pain assessments, vital signs, medications, interventions, nutrition, or elimination completed or documented.

The Discharge Summary reflected 5/18/2023 37-year-old female with no PMH (previous medical history) who presents to the ED (emergency department) from an outside facility for persistent abdominal pain after a fall. Her CT (cat scan) imaging was unremarkable except for constipation. She was evaluated by Gen Surgery and recommended for non-operative management. She had musculoskeletal pain that trauma related with concomitant constipation.

The 5/18/2023 12:49 PM Hospitalist Progress note added Norco and Robaxin prn pain...Continue Carafate and Protonix for possible PUD/GERD; added simethicone...Place on aggressive bowel regimen...Pending bed availability so may be a hindrance to diet and BM (bowel movements)...DC (discharge / conditional) home once tolerating diet and has a BM with pain relief...

The 5/17/2023 21:31 PM Trauma Consultation reflected PLAN: Admit to Hospitalist, Pain control, Trial diet, UA (urinalysis) to rule out UTl/cystitis (urinary tract infection)...CT (cat scan) does show large amount of stool in the colon. Will give patient bowel regimen...No plans for operative intervention, surgery will continue to follow...She states she is having difficulty initiating urination.

The Emergency Department Provider Report reflected 5/17/2023 The patient will be transported for further care and management or will be moved to an observation or inpatient service. I have communicated with the staff or medical practitioner taking over this patient's care. The patient has been stabilized within the capability of the emergency department. Although the emergency department has completed all appropriate management and is prepared to transport the patient to an observation or inpatient service, there are no available beds. Therefore, the patient will be placed in "ED Hold" status until such time as a bed becomes available...18:21 PM Admit for significant abdominal pain for which there is not a clear cause. Will observe...

The patient did not receive the medications that had been ordered including 5/17/2023 21:38 Senokot, 21:38 Miralax, 5/18/2023 00:56 Normal Saline 1000ml 75ml/hr, 05:01 Carafate, 06:00 Protonix, 08:00 Carafate, 12:30 Carafate, Lovenox 16:24, and 18:00 Carafate.

The patient did not receive PRN medications that had been ordered including Morphine, Norco, Robaxin, Tylenol, and Simethicone.

During record review and interview on 2/05/2024 at 10:40 AM, Personnel #1 navigated the record and confirmed the above findings. Personnel #1 was asked about documentation that shows the location of a patient. Personnel #1 stated we do not have a place to document that. The record says 1825 admitted; and off tracker 1936. This tells me they were admitted but an ER hold until a room could be available for her. Personnel #1 was asked if the patient could have been in the waiting room the whole time. Personnel #1 stated yes.


C) Patient #5 developed a pressure ulcer and multiple infections during ICU (Intensive Care Unit) admission. There was no Wound Care Physician. The Wound Care Nurse did not follow the wound throughout the admission until discharge.

Patient #5 on 8/08/2023 suffered a construction site fall, striking his head, and instantly could not move or feel below the nipple line. He did not have a pressure ulcer on admit. He was discharged on 9/30/2023.

The 9/30/2023 Discharge Summary reflected 65 year old...unable to feel or move anything from nipple line down...unable to move BLE (bilateral lower extremities)...initially admitted to ICU (intensive care unit)...transferred to the floor 8/31/2023...
~ Injuries: L scapula wing fracture, C7 bilateral posterior lamina fracture, T1-T4 SP fracture, L2 VB fracture, T5 VB anterior fracture, C6-T4 Posterior element fracture (T4 posterior/inferior VB endplate Fracture) C5-C6 Canal stenosis, Left parietal scalp laceration and hematoma ...
~ Acute and Active problems: Traumatic paralysis, acute pain, wheezing, UTI (urinary tract infection) sacral decubitus ulcer...
~ Procedures: 8/08 T4-5 laminectomy, T2-T7 PSF; 8/22 Tracheostomy; 8/23 rectal tube; 9/08 Sacral Decubitus ulcer debridement with negative pressure WV (wound vac) and FMS placement; 9/20 Excisional Debridement of sacral decubitus ulcer with NPWV (negative pressure wound vac) placement...
~Wound cultures were positive for (infections/named organisms) Clostridium Septicum, Bacteroides Fragilis and moderate growth of pseudomonas, E coli and Klebsiella...(Intravenous antibiotis) IV Vanc/Avycaz/Flagyl/Diflucan can be transitioned to PO (oral antibiotics) Bactrim DS for 2 weeks on discharge, per ID (Infectious Disease)...

During record review and interview on 2/05/2024 ending at 4:38 PM, Personnel #1 was asked about the visit. Personnel #1 navigated the record and confirmed the findings.

During an interview on 2/07/2024 at 11:00 AM, Personnel #4 (Wound Care) stated we examine wounds weekly and the primary care nurse completes the dressing change. Personnel #4 was asked if there was a wound physician. Personnel #4 stated no. We work under the current Hospitalist. Once a debridement is completed and a wound vac is placed, we do not follow the patient. (coordination of care) Physical Therapy change the wound vacs. Personnel #4 was asked how the patient could have developed this in the care of the hospital. Personnel #4 stated I can't speak to his physical condition which may play a part in the overall decline of his skin. Personnel #4 was asked about the wound becoming infected. Personnel #4 stated I don't know about any piece of that. I spoke to the coordinator about a surgical consult after the last picture which showed great decline. The surgical team did a debridement. Once the surgical team and physical therapy take over, we do not follow at all.

The hospital's 7/01/2020 Patient Rights policy required treat all patients with respect and dignity...Ensure that there is no harassment...availability of services...admission, transfer, or discharge of patients...in the care provided...ensure all patient's receiving care...are informed of their rights...surrogate decision maker if authorized to make care decisions for the individual should he or she lose decision-making capacity or choose to delegate...when the individual is without decision making capacity...right to receive considerate and respectful care...individualized care that fosters the patient's comfort and dignity, and is delivered in a setting that is free from abuse, discrimination, and harassment...

.

Based on record review and interview, the hospital failed to complete performance improvement including implement actions, measure actions success, and track performance to ensure that improvements are sustained, in that,

in 2 of 2 investigations (A) Patient #2/Incident, and B) Patient #5/Wound) the hospital failed to complete the quality process.

A) Patient #2/Incident
The hospital's incident investigation did not document resolution of the abuse issue, recognize the lack of documentation by nursing and social work, and implement education on the process to ensure improvement.

B) Patient #5/Pressure ulcer/Wound
The hospital failed to document an incident report, root cause review, recognize the lack of documentation, and implement education on the process to ensure improvement.

Findings

A) Patient #2/Incident
The hospital's incident investigation did not document resolution of the abuse issue, recognize the lack of documentation by nursing and social work, and implement education on the process to ensure improvement.

Nursing staff witnessed behaviors and actions by the patient's daughter that put the patient at risk. The physician, security, and police were not notified. There was no evidenced resolution of the safety concern prior to discharging the patient to the same daughter.

Case Management did not document a social assessment for patient safety after the daughter's questionable behavior and actions were witnessed. Case Management did not notify APS at discharge of discharging the to the daughter who was witnessed with questionable behaviors and actions toward the patient.

An Adult Protective Services (APS) case number 49696483 was closed after APS determined from a hospital nurse the patient was currently located in a safe place - the hospital. The hospital did not call APS at discharge.

The record documented an admission from 6/16/2023 to 6/26/2023 for a diagnosis of Ileus/Acute Cholecystitis. She was discharged home to the (same) daughter with hospice.

The Clinical Documentation (Nurse Progress notes) reflected:
~ 6/18/2023 at 04:31 PM spoke with registration. No MPOA (Medical Power of Attorney), on file from previous admissions. Will require daughter to present proper documentation...
~ 6/19/2023 at 01:55 AM nurse note described the incident, Dtr (daughter) behavior liable. Dtr found raising voice at pt. covering pt eyes. Pressing on face. Pressing on abdomen. Pulling at IV site. Being forceful with pt when trying to move pt herself after advising Dtr to call staff. Dtr noted swaying and being unsteady. Pt noted saying help me several times. Reported to charge will continue to monitor...
~ 6/21/2023 13:46 PM at 12:34 (name) from Adult Protective Services phoned this nurse and inquired about patient's discharge status. Inquired if patient's daughter being aggressive toward patient. Inquired if patient daughter had POA. (Name) was advised that discharge is to be determined by MD after procedure. That this nurse haven't witnessed any aggression from the daughter towards the patient. That per daughter she has POA paperwork at home.
~ 6/26/2023 1200 Palliative Care notes spoke to daughter downstairs in the lobby. She is very clear that she wants mom on comfort care...I asked about her going to the hospice IPU (inpatient unit) and she said no. I want mom at home...will get her home today...

The Case Management Report reflected:
~ 6/19/2023 3:49 PM social barrier: concern expressed regarding daughter's behavior/ability to care for pt at home. SW assessment of social situation pending...Home with hospice services likely. APS to be notified upon discharge...
~ 6/21/2023 4:46 PM social barrier: daughter (name) suspected of behaving aggressively towards pt. Virtual sitter placed to monitor such...APS to be notified upon discharge...
~ 6/23/2023 3:48 PM monitoring daughter (name) for aggressive behavior...APS to be notified upon discharge...

The 6/26/2023 Discharge Medication Instructions was signed by the (same) daughter.

The 6/19/2023 09:14 Incident report reflected Impact of event: Unsafe condition Patients daughter is demonstrating behavior that is concerning for unsafe treatment of patient...behavior that is concerning for unsafe treatment of patient...Primary action to prevent recurrence: Monitor trends and patterns.

During record review and interview on 2/05/2024 ending at 2:42 PM Personnel #1 called Personnel #3 to ask about the abuse incident report and follow-up. Personnel #3 reviewed the record and directed Personnel #1 to the 6/19/2023 documentation. Personnel #3 stated we got a virtual camera for the room so someone would be monitoring the patient at all times. The door was left open as well. After the camera was started, the daughter did not show up as much. A niece started coming. The primary nurse was who called APS. Personnel #3 was asked if any of this was documented. Personnel #3 stated Not that I am seeing. No note on the follow-up. Personnel #3 was asked if there was resolution of the abuse prior to discharge. Personnel #3 stated it is not documented.

Personnel #3 was asked if they had it (virtual camera) the rest of the time. Personnel #3 stated Yes. Personnel #3 was asked if there was any other abuse. Personnel #3 stated no. Personnel #3 was asked if the physician was notified. Personnel #3 stated I don't see that documented. Personnel #3 was asked if the police were notified. Personnel #3 stated I don't see that. Personnel #3 was asked the patient's state. Personnel #3 stated she was awake, but weak. Her short and long-term memory were not intact.

During an interview on 2/07/2024 at 2:15 PM, Personnel #1 was asked about the incident report not reflecting actions implemented after the incident report. Personnel #1 confirmed actions were not documented. Personnel #1 was asked if there was resolution of the abuse prior to discharge. Personnel #1 stated it is not documented.

B) Patient #5/Pressure ulcer/Wound
The hospital failed to document an incident report, root cause review, recognize the lack of documentation, and implement education on the process to ensure improvement.

Patient #5 developed a hospital acquired pressure ulcer and hospital acquired multiple infections during his ICU (Intensive Care Unit) admission.

There was no incident report for Patient #5's hospital acquired pressure ulcer.

The incomplete "Wound Drill Down Form" required answers to questions. Many of the questions were left blank, with no discernable answers indicated on the form. The form reflected the wound discovery date/time 9/07/2023, no indicated time. The form did not offer a root cause determination or document physician notification.

During an interview on 2/07/2024 at 11:00 AM, Personnel #4 was asked how the patient could have developed this in the care of the hospital. Personnel #4 stated I can't speak to his physical condition which may play a part in the overall decline of his skin. Personnel #4 was asked who complete the daily wound care and preventative measures. Personnel #4 stated the primary nurse. Personnel #4 was asked if she had completed most of the weekly wound care visits. Personnel #4 stated I did up to when the Burn/Trauma team took over and placed a wound vac. Physical Therapy does the wound vacs. Personnel #4 was asked to confirm that Wound Care Nursing does not follow a wound through admission until discharge. Personnel #4 stated no. Personnel #4 was asked who complete the daily wound care and preventative measures. Personnel #4 stated the primary nurse.

Personnel #4 was asked for the incident report on Patient #5's hospital acquired wound. Personnel #4 stated I am not familiar with needing to do an incident report.

Personnel #4 was asked for the root cause review required by the policy. Personnel #4 stated she was not sure if one was done. Personnel #4 was asked to retrieve and return to continue the interview. Personnel #4 returned at 11:17 AM with what she called a drill down for the wound. Personnel #4 was asked how the drill down was completed. Personnel #4 stated we ask the manager on the floor to do the drill down. They are supposed to be drilling down and looking through the chart at the event to see what happened. Personnel #4 was asked what do you do with this when it is done. Personnel #4 stated we file it. Personnel #4 was asked nothing else. Personnel #4 stated no. Personnel #4 was asked what was determined by the drill down. Personnel #4 stated we just fill it out and file it.

Personnel #4 was asked if there was a Wound Care doctor involved. Personnel #4 stated no. Personnel #4 was asked she works under. Personnel #4 stated whichever Hospitalists is on at the time. Personnel #4 was asked for a plan of action or completed education. Personnel #4 stated there had not been an action plan. I go back to the units and do ongoing teaching like roaming inservices. Personnel #4 was asked for any education documentation. Personnel #4 stated we don't have any way to document that.

The August 2022, revised "Pressure Injury Prevent" policy required The nurse will notify provider/practitioner of any new or existing wound...Root cause review should be done for all hospital acquired pressure injuries, Stage III and above, including DTIs (deep tissue injuries...All notifications will be documented in the EHR...Pressure injuries acquired throughout the hospital stay should be reported via the facility-specific event reporting system...

Root Cause Analysis for Hospital-Acquired Pressure Injury https://pubmed.ncbi.nlm.nih.gov/31274857/
The process of RCA begins with being certain the wound is a pressure injury using differential diagnoses of similar appearing skin disease and injury, followed by an examination of the processes of care (human roots) for missed actions or inactions that are linked to development of a particular pressure injury. The final step of RCA is a critical examination of the system (including people and processes) to look for modifiable trends or patterns are identified that are used to prevent recurrences.

The hospital's January 2021 effective "Abuse Assessment & Intervention" policy required
To ensure appropriate process to deal with allegations of patient abuse...abuse, neglect, or family violence...failure to report suspected cases is a misdemeanor in the State of Texas...An accounting of Disclosure should be filed in (EHR) for each outside agency contacted with patient information...if the patient's attending physician is not aware of the suspected abuse, (s)he should be notified by the staff member making the report...If possible, the patient should be interviewed alone about the cause of observed injuries...Interview the patient, family, and significant others to obtain relevant information as part of a thorough psychological assessment...collaborate with medical staff...documentation in the medical record should include assessment in regard to the suspected abuse or neglect, the nature of interventions proposed and enacted, including the contact information of persons or agencies pertinent to the patients situation...

The hospital's May 2018 effective date "Documenting the Provision of Care" required patient-centered care...RNs (registered nurses) are responsible for reviewing and analyzing the data, drawing conclusions, and taking appropriate actions...

The hospital's December 2000 effective "Assessment/Re-assessment of Patients and/or Standards of Care" required A registered nurse assumes responsibility for the analysis of the admission data collected and the performance and timely documentation of the nursing physical assessment...PRN for any change in condition...

.

Based on record review and interview, the facility failed to ensure a registered nurse supervised and evaluated the nursing care for each patient, in that,

3 of 5 patients (Patient #2, #3, and #5)

A) Patient #2: Nursing staff witnessed behaviors and actions by the patient's daughter that put the patient at risk. The physician, security, and police were not notified. There was no evidenced resolution of the safety concern prior to discharging the patient to the same daughter.

An Adult Protective Services (APS) case number 49696483 was closed after APS determined from a hospital nurse the patient was currently located in a safe place - the hospital. The hospital did not call APS at discharge.

B) Patient #3 did not receive nursing care as an admitted, emergency hold patient located in the emergency room. Nurse assessments, vital signs, pain assessment, medications, nutrition, and elimination were not evidenced.

C) During his ICU (Intensive Care Unit) admission, Patient #5 developed

a hospital acquired pressure ulcer/wound which required multiple debridement surgeries, wound vac placement, and did not heal prior to discharge on 9/26/2023; and

multiple hospital acquired infections requiring intravenous antibiotics throughout admission and transitioned to oral antibiotics at discharge.

Findings

A) Patient #2:
Nursing staff witnessed behaviors and actions by the patient's daughter that put the patient at risk. The physician, security, and police were not notified. There was no evidenced resolution of the safety concern prior to discharging the patient to the same daughter.

Patient #2's record documented an admission from 6/16/2023 to 6/26/2023 for a diagnosis of Ileus/Acute Cholecystitis. She was discharged home to the (same) daughter with hospice.

The Emergency Department Record reflected 6/16/2023 complaint (C/O) ABD pain X 2 (abdominal pain times) days per hospice nurse...Objective assessment: Pt A/O x 3 Awake and Oriented...

The History and Physical reflected 6/16/2023 She does open eyes to command and can answer simple questions. She states that she has pain in her abdomen and would like pain medication. She also states that she would like some ice chips for comfort...Oriented x 2-3...

The Clinical Documentation (Nurse Progress notes) reflected:
~ 6/19/2023 at 01:55 AM nurse note described the incident, Dtr (daughter) behavior liable. Dtr found raising voice at pt. covering pt eyes. Pressing on face. Pressing on abdomen. Pulling at IV site. Being forceful with pt when trying to move pt herself after advising Dtr to call staff. Dtr noted swaying and being unsteady. Pt noted saying help me several times. Reported to charge will continue to monitor...

~ 6/21/2023 13:46 PM at 12:34 (name) from Adult Protective Services phoned this nurse and inquired about patient's discharge status. Inquired if patient's daughter being aggressive toward patient. Inquired if patient daughter had POA. (Name) was advised that discharge is to be determined by MD after procedure. That this nurse haven't witnessed any aggression from the daughter towards the patient. That per daughter she has POA paperwork at home.

~ 6/26/2023 1200 Palliative Care notes spoke to daughter downstairs in the lobby. She is very clear that she wants mom on comfort care...I asked about her going to the hospice IPU (inpatient unit) and she said no. I want mom at home...will get her home today...

The Case Management Report reflected:
~ 6/19/2023 3:49 PM social barrier: concern expressed regarding daughter's behavior/ability to care for pt at home. SW assessment of social situation pending...Home with hospice services likely. APS to be notified upon discharge...

~ 6/21/2023 4:46 PM social barrier: daughter (name) suspected of behaving aggressively towards pt. Virtual sitter placed to monitor such...APS to be notified upon discharge...

~ 6/23/2023 3:48 PM monitoring daughter (name) for aggressive behavior...APS to be notified upon discharge...

The 6/26/2023 Discharge Medication Instructions was signed by the (same) daughter.

The 6/19/2023 09:14 Incident report reflected (daughter name) towel over the pt eyes and was pressing on her face. Daughter was witnessed covering pt face with blankets, and ultimately placing a pillow over her face...Patient tearful, mouthed help me I am scared...
~ Investigation notes: patient daughter Janet has had concerning behavior since patient's admission. APS has been alerted. Virtual sitter being placed at patient's bedside as well. Daughter is MPOA, However, her behavior is alarming...
~ Impact of event: Unsafe condition Patients daughter is demonstrating behavior that is concerning for unsafe treatment of patient...

During record review and interview on 2/05/2024 ending at 2:42 PM Personnel #1 called Personnel #3 to ask about the abuse incident report and follow-up. Personnel #3 reviewed the record and directed Personnel #1 to the 6/19/2023 documentation. Personnel #3 stated we got a virtual camera for the room so someone would be monitoring the patient at all times. The door was left open as well. After the camera was started, the daughter did not show up as much. A niece started coming. The primary nurse was who called APS. Personnel #3 was asked if any of this was documented. Personnel #3 stated Not that I am seeing. No note on the follow-up.

Personnel #3 was asked if they had it the rest of the time. Personnel #3 stated Yes. Personnel #3 was asked if there was any other abuse. Personnel #3 stated no. Personnel #3 was asked if the physician was notified. Personnel #3 stated I don't see that documented. Personnel #3 was asked if the police were notified. Personnel #3 stated I don't see that.


B) Patient #3
Patient #3 did not receive nursing care as an admitted, emergency hold (ED Hold) patient located somewhere in the emergency room. Nurse assessments, vital signs, pain assessment, medications, interventions, nutrition, and elimination were not completed or evidenced. The patient was discharged at 18:49 PM without receiving any standard nursing care or ordered care.

The record does not document a location, bed, recliner, or chair for the patient.

The ED Patient Record (Nursing) ended on 5/17/2023 at 19:02 PM.

The Clinical Documentation Record (Nursing) begins on 5/18/2023 at 0738 with documentation of sepsis screen without vitals being completed.

After 5/17/2023 at 19:02 PM when ER Hold status began, there are no assessments, pain assessments, vital signs, medications, interventions, nutrition, or elimination completed or documented.

The patient was discharged at 18:49 PM without receiving any standard nursing care or ordered care.

The Discharge Summary reflected 5/18/2023 37-year-old female with no PMH (previous medical history) who presents to the ED (emergency department) from an outside facility for persistent abdominal pain after a fall. Her CT (cat scan) imaging was unremarkable except for constipation. She was evaluated by Gen Surgery and recommended for non-operative management. She had musculoskeletal pain that trauma related with concomitant constipation.

The 5/18/2023 12:49 PM Hospitalist Progress note added Norco and Robaxin prn pain...Continue Carafate and Protonix for possible PUD/GERD; added simethicone prn...Place on aggressive bowel regimen...Pending bed availability so may be a hinderance to diet and BM...DC home once tolerating diet and has a BM with pain relief...

The 5/17/2023 21:31 PM Trauma Consultation reflected PLAN: Admit to Hospitalist, Pain control, Trial diet, (Urinalysis) UA to rule out (Urinary Tract Infection) UTl /cystitis...CT (cat scan) does show large amount of stool in the colon. Will give patient bowel regimen. No plans for operative intervention, surgery will continue to follow...She states she is having difficulty initiating urination.

The Emergency Department Room Provider Report reflected 5/17/2023 The patient will be transported for further care and management or will be moved to an observation or inpatient service. I have communicated with the staff or medical practitioner taking over this patient's care. The patient has been stabilized within the capability of the emergency department. Although the emergency department has completed all appropriate management and is prepared to transport the patient to an observation or inpatient service, there are no available beds. Therefore, the patient will be placed in "ED Hold" status until such time as a bed becomes available. 18:21 PM Admit for significant abdominal pain for which there is not a clear cause. Will observe...

Patient did not receive ordered medications including
~ 5/17/2023 21:38 Senokot, 21:38 Miralax,
~ 5/18/2023 00:56 Normal Saline 75 milliliters/hour, 05:01 Carafate, 06:00 Protonix, 08:00 Carafate, 12:30 Carafate, Lovenox 16:24, and 18:00 Carafate.

Patient did not receive (as needed) PRN medications ordered including Morphine, Norco, Robaxin, Tylenol, and Simethicone.

During record review and interview on 2/05/2024 at 10:40 AM, Personnel #1 navigated the record and confirmed the above findings. Personnel #1 was asked about documentation that shows the location of a patient. Personnel #1 stated we do not have a place to document that. The record says 18:25 admitted; and off tracker 19:36. This tells me they were admitted but an ER hold until a room could be available for her. Personnel #1 was asked if the patient could have been in the waiting room the whole time. Personnel #1 stated yes.


C) Patient #5
During his ICU (Intensive Care Unit) admission, Patient #5 developed

a hospital acquired pressure ulcer/wound which required multiple debridement surgeries, wound vac placement, and did not heal prior to discharge on 9/26/2023; and

multiple hospital acquired infections requiring intravenous antibiotics throughout admission and transitioned to oral antibiotics at discharge.

Patient #5 on 8/08/2023 suffered a construction site fall, striking his head, and instantly could not move or feel below the nipple line. He did not have a pressure ulcer on admit. He was discharged on 9/30/2023.

The 9/30/2023 Discharge Summary reflected 65 year old...unable to feel or move anything from nipple line down...unable to move BLE (bilateral lower extremities)...
~ Acute and Active problems: Traumatic paralysis, acute pain, wheezing, UTI (urinary tract infection) sacral decubitus ulcer...
~ Procedures: 8/08 T4-5 laminectomy, T2-T7 PSF; 8/22 Tracheostomy; 8/23 rectal tube; 9/08 Sacral Decubitus ulcer debridement with negative pressure WV (wound vac) and FMS placement; 9/20 Excisional Debridement of sacral decubitus ulcer with NPWV (negative pressure wound vac) placement...
~Wound cultures were positive for Clostridium Septicum, Bacteroides Fragilis and moderate growth of pseudomonas, E coli and Klebsiella...(Intravenous antibiotics) IV Vanc/Avycaz/Flagyl/Diflucan can be transitioned to PO (orally) Bactrim DS for 2 weeks on discharge, per ID (Infectious Disease)...

During record review and interview on 2/05/2024 ending at 4:38 PM, Personnel #1 was asked about the visit. Personnel #1 navigated the record and confirmed the findings.

During an interview on 2/07/2024 at 11:00 AM, Personnel #4 was asked how the patient could have developed this in the care of the hospital. Personnel #4 stated I can't speak to his physical condition which may play a part in the overall decline of his skin. Personnel #4 was asked about the wound becoming infected. Personnel #4 stated I don't know about any piece of that. I spoke to the coordinator about a surgical consult after the last picture which showed great decline. The surgical team did a debridement. Once the surgical team and physical therapy take over. We do not follow at all.

The hospital's January 2021 effective "Abuse Assessment & Intervention" policy required
To ensure appropriate process to deal with allegations of patient abuse...abuse, neglect, or family violence...failure to report suspected cases is a misdemeanor in the State of Texas...

Neglect is defined as failure by another individual to provide a person with the necessities of life including, but not limited to food, shelter, clothing, and the provision of medical care...

An accounting of Disclosure should be filed in (EHR) for each outside agency contacted with patient information...if the patient's attending physician is not aware of the suspected abuse, (s)he should be notified by the staff member making the report...If possible, the patient should be interviewed alone about the cause of observed injuries...Interview the patient, family, and significantothers to obtain relevant information as part of a thorough psychological assessment...collaborate with medical staff...documentation in the medical record should include assessment in regard to the suspected abuse or neglect, the nature of interventions proposed and enacted, including the contact information of persons or agencies pertinent to the patients situation...

The hospital's May 2018 effective date "Documenting the Provision of Care" required patient-centered care, where the patient is the primary decision-maker in their case...RNs (registered nurses) are responsible for reviewing and analyzing the data, drawing conclusions, and taking appropriate actions...Patient Notes are used in a limited capacity to document unusual assessments or events that are not addressed in the standardized documentation...

The hospital's December 2000 effective "Assessment/Re-assessment of Patients and/or Standards of Care" required Assessments are documented in the patient's medical record...Ongoing percentage of meal consumption/nutritional intake is assessed after every meal and documented in the medical record...Initial Assessment that includes an evaluation of the patient's physical, psychosocial, religious, and cultural status...assist in identifying his/her care/treatment needs...A registered nurse assumes responsibility for the analysis of the admission data collected and the performance and timely documentation of the nursing physical assessment...within 12 hours...Medical Surgical/Telemetry/Orthopedics: Vital signs, including but not limited to blood pressure, heart rate, oxygen saturation, and respiratory rate every 4 hours and PRN for any change in condition...Intake and output - total a minimum of every shift ...height and weight on admission...pain assessment performed on admission and once per shift and PRN with appropriate interventions...Assessment/re-assessment every shift unless otherwise ordered...falls...skin risk...sepsis screening every shift...Initial assessment is initiated within 1 hour and completed within 12 hours...

Risk Factors for Pressure Injuries in Adult Patients: A Narrative Synthesis - PMC (nih.gov)

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Based on record review and interview, the hospital failed to develop, and keep current, a nursing care plan for each patient that reflects the patient's goals and the nursing care to be provided to meet the patient's needs, in that,

1 of 5 patients care plan (Patient #2) was not updated on discovery of the safety concern that put the patient at risk.

Findings

Patient #2:
Nursing staff witnessed behaviors and actions by the patient's daughter that put the patient at risk. The physician, security, and police were not notified.

There was no update to the care plan for the issue or follow up. There was no evidenced resolution of the safety concern prior to discharging the patient to the same daughter.

Patient #2's record documented an admission from 6/16/2023 to 6/26/2023 for a diagnosis of Ileus/Acute Cholecystitis. She was discharged home to the (same) daughter with hospice.

The History and Physical reflected 6/16/2023 She does open eyes to command and can answer simple questions. She states that she has pain in her abdomen and would like pain medication. She also states that she would like some ice chips for comfort...Oriented x 2-3...

The Clinical Documentation (Nurse Progress notes) reflected:
~ 6/19/2023 at 01:55 AM nurse note described the incident, Dtr (daughter) behavior liable. Dtr found raising voice at pt. covering pt eyes. Pressing on face. Pressing on abdomen. Pulling at IV site. Being forceful with pt when trying to move pt herself after advising Dtr to call staff. Dtr noted swaying and being unsteady. Pt noted saying help me several times. Reported to charge will continue to monitor...

The 6/19/2023 09:14 Incident report reflected (daughter name) towel over the pt eyes and was pressing on her face. Daughter was witnessed covering pt face with blankets, and ultimately placing a pillow over her face...Patient tearful, mouthed help me I am scared...
~ Investigation notes: patient daughter Janet has had concerning behavior since patient's admission. APS has been alerted. Virtual sitter being placed at patient's bedside as well. Daughter is MPOA, However, her behavior is alarming...
~ Impact of event: Unsafe condition Patients daughter is demonstrating behavior that is concerning for unsafe treatment of patient...

During record review and interview on 2/05/2024 ending at 2:42 PM Personnel #1 called Personnel #3 to ask about the abuse incident report and if the care plan was updated. Personnel #1 navigated the record and stated no.

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Based on record review and interview, the facility failed to provide for the discharge including provision and transmission of the patient's necessary medical information (current course of illness, treatment, post-discharge goals of care, and treatment preferences at the time of discharge to the patient and any post-acute care service providers and suppliers, facilities, agencies, and other outpatient service providers and practitioners responsible for the patient's follow-up or ancillary care), in that,

5 of 5 patient (Patient #1, #2, #3, #4, and #5) discharge instructions did not reflect anything other than current medications (missing the post acute course of illness, treatment, post-discharge/outpatient goals of care, DME/durable medical equipment, services, and follow-up service provider appointments).

Findings

Patient #1, #2, #3, #4, and #5 discharge instructions did not reflect anything other than current medications (missing the post acute course of illness, treatment, post-discharge/outpatient goals of care, DME/durable medical equipment, services, and follow-up service provider appointments including Home Health/Hopsice services, and provider appointments).

Patient #1 reflected medications only. There was no information on follow up providers or time frames for appointments.

Patient #2 reflected medications only. There was no DME. There was no information on Home Health/Hospice. There was no wound care. There was no information on follow up providers or time frames for appointments.

Patient #3 reflected medications only. There was no information on follow up providers or time frames for appointments.

Patient #4 reflected medications only. There was no wound care. There was no information on follow up providers or time frames for appointments.

Patient #5: There was no discharge instructions including signature page, medications, DME, Home Health, wound care, information on follow up providers or time frames for appointments.

Each patient signature page reflected medications with signature. There was no additional information printed or attached to the page.

During record review and interview, Personnel #1 was asked for each discharge instruction signed by the patient at discharge. Each patient signature page reflected medications with signature. There was no additional information printed or attached to the page. Personnel #1 stated the nurse prints them and there are attachments. Personnel #1 could not evidence this. Personnel #1 stated the instructions used to have the information on the page. There had been a system change that may have taken this away.