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Based on record review and interview, the hospital failed to ensure the effective operation of the grievance process as evidenced by failure to have documented evidence of the interviews conducted to investigate 1 (#6) of 1 grievance received in September 2015.
Findings:

Review of the hospital policy titled "Grievance procedure Patient And family Louisiana", presented as a current policy by S1ADM, revealed that the Administrator logs the grievance allegation onto the "Complaint/Grievance Log" and contacts the patient and/or family and opens an investigation to determine validity of the grievance allegation within 48 hours of notification or receipt of the grievance allegation. The Administrator completes the investigation and the "Grievance Report" within 10 days of the date of notification or receipt of the grievance allegation. The Administrator maintains the "Complaint/Grievance Log", along with files and records of the facility of all resolved complaints and grievance investigations.

Review of the "Complaint And Grievance Log" for September 2015 submitted by S1ADM revealed a grievance was received from Patient #6's son. Further review revealed the "nature of complaint or grievance" was "unknown".

Review of the "Grievance Report", submitted by S1ADM and dated 09/17/15 related to Patient #6, revealed Patient #6's son and a female who accompanied him stated "they knew something happened when the patient was inpatient. Administrator asked (Patient #6's son) what happened and why did he appear so upset. He stated he couldn't tell me anything (after speaking to his attorney on his cell phone)..." Further review revealed the investigation findings included the following: review of the chart; no documentation or incidents were noted or reported to Risk management; interview with staff members. No documented evidence of the interviews conducted or witness statements were presented by S1ADM during the survey related to this grievance.

In an interview on 05/12/16 at 1:20 p.m., S1ADM indicated she had no documentation to present of interviews she conducted related to the grievance submitted by Patient #6's son.

Based on observation and interview, the hospital failed to ensure each patient had a right to privacy that included the right to dignity and comfort while in the hospital as evidenced by having Room "i" with no curtain in the window and bright sunlight shining into the room while Patient R1 was laying in the bed during an observation on 05/09/16 at 10:30 a.m. Patient R1 indicated the glare bothered him, and he had reported it about 2 days ago.
Findings:

Observation on 05/09/16 at 10:30 a.m. revealed the window in Room "i" had no curtain or shade in place with bright sunlight shining into the room. Further observation revealed Patient R1 was lying in the bed with his eyes open.

In an interview on 05/09/16 at 10:30 a.m., Patient R1 indicated the bright sunlight presented a problem for him due to the glare from the sun. He further indicated he had complained of the glare about 2 days ago to a MHT who said he/she would write it down, and "nothing's been done."

Based on observations and interviews, the hospital failed to ensure patients received care in a safe setting as evidenced by having all patient beds at the off-site campus with 3 cranks at the foot of each bed to be used to raise and lower the bed that presented a potential ligature risk; having patients' bathroom doors at the off-site campus secured with 3 hinges on each that were separated widely enough to facilitate potential ligature; having torn chairs in Room "a" and "o" that provided an infection control hazard; having uncontained plumbing in Rooms "b" and "c" that presented a potential ligature risk; having patient care equipment stored in Room "e" that was used to store patients' belongings brought from home; having caked-on glue on the walls of Rooms "a", "f", "g", "h", "j", "k", and "n"; chipped, peeling, and/or holes in sheetrock in Rooms "a", "g", "i", "m"; having caked-on dust on the grill of the ice machine in Room "a"; having a cord on a pair of pants located on the patient's shelf in Room "h" that presented a ligature risk; having a wall-mounted call bell holder in Room "f" that had 2 openings on each side of the plastic holder that could be a ligature risk if a cord was passed through the openings; and having 6 splintered areas on the wooden fence located in the outdoor area used by patients. These findings were also observed during a survey conducted at this hospital on 01/13/16.
Findings:

Observations during a tour of the off-site campus on 05/09/16 at 10:05 a.m. revealed the following observations:
1) All patient beds at the off-site campus had 3 cranks at the foot of each bed to be used to raise and lower the bed that presented a potential ligature risk.
2) All patients' bathroom doors at the off-site campus were secured with 3 hinges on each that were separated widely enough to facilitate potential ligature.
3) Room "a" had 7 chairs and Room "o" had 14 chairs with torn leather chair backs or seats that presented an infection control risk due to the inability to properly disinfect the chairs.
4) The wall of Room "a" near the sink had chipped sheetrock as well as the left wall at the entrance to the room. There was caked-on glue on the wall at the back of the sink. The grill of the ice machine had caked-on dust.
5) Rooms "b" and "c" had uncontained plumbing to the toilets that presented a potential ligature risk.
6) Room "e_ had 2 wheelchair foot rests and a lap buddy stored on the bottom shelf used to store patients' belongings brought from home.
7) Rooms "f", "g", "h", "j", "k", and "n" had caked-on glue on the walls.
8) Room "f" had a plastic call; bell holder mounted on the wall above the bed nearest the window that an opening on each side large enough to pass a cord that could be a potential ligature risk.
9) Rooms "g", "i", and "m" had peeling, chipped sheetrock on the walls and/or ceiling.
10) Room "h" had a pair of pants with a drawstring cord on the shelf that could be pulled to a length to provide a potential ligature risk.
11) Room "i" had a hole in the sheetrock behind the door (in the area where the door knob hit the wall) approximately 5-6 inches long, approximately 3 inches wide, and an approximate depth of 2 inches that could be used to hide contraband. The bathroom door had chipped wood with splinters present.
12) Room "n" had a television on the shelf with the cords wrapped behind the television that were accessible to patients and presented a potential ligature risk to ambulatory patients. There was Geri-chair with 2 large rips in the leather handle.
13) The outdoor area used by patients had 6 wooden fence boards with splintered areas.
These same observations were made during the previous survey conducted on 01/13/16.

In an interview on 05/09/16 at 10:25 a.m., S2RN confirmed the above findings at the off-site campus.

In an interview on 05/09/16 at 10:15 a.m., S1ADM confirmed the chairs in Room "o" had not been replaced since the previous survey.

In an interview on 05/11/16 at 1:25 p.m., S1ADM indicated they ran out of bathroom door hinges before they could change the hinges at the off-site campus. When asked why the cited deficiencies had not been corrected after the survey conducted on 01/13/16, S1ADM indicated S17POD addressed the main campus first and had not finished at the off-site campus yet.

Based on record reviews and interviews, the hospital failed to ensure patients were free from all forms of abuse or harassment as evidenced by failure of the hospital to identify and investigate patient abuse and report to DHH (#1) and investigate a patient bruise to rule out abuse (#6) for 2 (#1, #6) of 4 (#1, #4, #5, #6) patient abuse allegations reviewed from a total sample of 6 patients.
Findings:

Review of the hospital policy titled "Assessment And reporting Of Abuse, Neglect, Exploitation, And/Or Extortion Of Youth And Adults", presented as a current policy by S1ADM, revealed that the clinical staff is to notify the ADM or DON if abuse is suspected , and the ADM/DON will call the Regional Coordinator and inform of the alleged abuse. Further review revealed the facility must self-report internal allegations of abuse/neglect to maintain compliance with CMS (Centers for Medicare and Medicaid) Regulation 482.13(c)/LA R.S. (Louisiana Revised Statute) 40:2009.20. LA R.S. 40:2009.20 calls for reporting of knowledge of potential abuse incidents within 24 hours to either law enforcement or DHH. The final investigative report should incorporate the following: a copy of the investigation conducted by the hospital that includes a summary of the initial report, transcripts of interviews conducted with staff, patients, and other relevant witnesses, interview transcripts with alleged perpetrator(s) to include the name/title, date, and time of the interview, who conducted the interview, and the content of the interview, copies of documents that provide evidence of the validity or lack thereof of the allegation, a report indicating the type and numbers of staff on duty for the unit at which the event allegedly occurred, and conclusions reached by administration, and a description of actions taken by the facility. Further review revealed that under all circumstances, staff must ensure patient(s) from "compounded" trauma during an investigation of proposed abuse/neglect.

Patient #1
Review of Patient #1's medical record revealed no documented evidence of Patient #1 having been choked by staff during patient care. Further review revealed S9RN was the RN working on 03/22/16, and S24MHT was assigned to Patient #1 on 03/22/16 with relief by S12MHT from 3:30 p.m. to 4:00 p.m.

In an interview on 05/11/16 at 9:20 a.m., S9RN indicated she was never told that S24MHT had slapped a patient, and if she had been told, she would have reported it immediately.

In an interview on 05/11/16 at 10:30 a.m., S12MHT indicated she remembered Patient #1. She further indicated she remembered working on a day when S24MHT was training other MHTs, but she didn't remember the specific day. She indicated she never observed S24MHT hitting Patient #1 but did hear Patient #1 "blurting out she choked me" in the bathroom when she was in the bathroom with another patient. She further indicated S24MHT was standing there and denied it. S12MHT indicated S24MHT was changing Patient 31 with a trainee, S15MHT, and S15MHT told her (S12MHT) that she saw S24MHT choke Patient #1. S12MHT indicated she told S15MHT to report it to the nurse. S12MHT indicated she also reported it to S9RN.

In a telephone interview on 05/11/16 at 12:20 p.m., S15MHT indicated she had never worked with psychiatric patients in a previous job. She indicated she remembered Patient #1. She indicated Patient #1 was "cutting up and cursing" in the shower, and S24MHT and she and 2 other MHTs were there when S24MHT "grabbed him by the neck and holding so tight and he screamed let me loose." She further indicated S24MHT "balled her fist but didn't hit him and was squeezing his neck." S15MHT indicated she reported the incident to D8DON, and Patient #1 "complained about his neck all night." S15MHT indicated she and another MHT wrote the incident up and gave it to S8DON.

In an interview on 05/11/16 at 12:55 p.m. with S8DON and S1ADM present, S8DON indicated the MHTs met with her about Patient 31 and S24MHT. She further indicated she didn't have anything written by the MHTs. S8DON indicated she met with S24MHT to ask about what happened when she (S24MHT) was changing Patient #1. She further indicated she asked S24MHT to show her what she did, and S24MHT demonstrated a CPI hold (demonstration by S8DON was her hand wrapped around the back of the patient's neck). She indicated she met with S15MHT and another MHT but doesn't remember which MHT. She indicated the MHTs asked her if it was alright to hold a patient like that, and "they showed the same exact thing S24MHT did." S8DON indicated S16LCSW was present when she interviewed S24MHT and also when she met afterwards with the 2 MHTs.

In an interview on 05/11/16 at 1:05 p.m., S16LCSW indicated she remembered meeting with S8DON and S24MHT. She further indicated she primarily met with S24MHT but only briefly with the other 2 MHTs. She indicated it was reported that Patient #1 was in the shower and was agitated, and the MHT reported that S24MHT was choking Patient #1, and he was saying "I can't breathe." S16LCSW indicated she asked S24MHT to explain her perception of the incident. S24MHT indicated to S16LCSW that she (S24MHT) was a trained EMT (emergency medical technician), and the maneuver she used was trying to protect Patient 31 from biting the MHTs, and it was a CPI technique. S16LCSW indicated she thought the 2 MHTs had documented a statement, but she didn't write a statement as being a witness to the interviews. She further indicated she thought the written statements were what began the need for interviews.

In an interview on 05/11/16 at 1:25 p.m., S1ADM indicated she didn't know anything about the allegation of abuse related to Patient #1 until she was interviewed about it during this survey. She confirmed if an inappropriate hold was used, it would be abuse by staff. After hearing about findings from interviews conducted, S1ADM indicated she should have done a self-report of abuse related to S24MHT, had she been told of the allegation.

In an interview on 05/11/16 at 2:15 p.m., S17POD indicated she was a certified CPI instructor as of February or March 2016. She further indicated there's a neck hold in CPI and showed the picture in the CPI manual. She further indicated CPI teaches how to get away from a patient (disengaging skills) and keep a patient from hurting staff. She further indicated holding a patient behind the neck is not a current CPI hold.

Patient #6
Review of Patient#6's "Physician Progress Notes" documented on 09/15/15 at 11:20 a.m. by S25NP revealed Patient #6 had an approximately 2 inches bruising almost borderline across the right upper arm"??? BP (blood pressure) cuff discussed (with) staff chg (charge) nurse." Further review revealed the assessment/plan included right upper arm contusion - continue to follow.

Review of Patient #6's "Skin and Braden Reassessment Documentation" documented by S8DON on 09/15/15 at 10:30 a.m. revealed "pt (patient) has a 2 inch bruise to R (right) upper arm in B/P cuff area."

In an interview on 05/12/16 at 10:44 a.m., S9RN indicated she vaguely remembered Patient #6. She further indicated when the MHT came to get her to look at Patient #6's bruise to the right upper arm, it looked like it was from a blood pressure cuff. She further indicated she reported it to the NP. S9RN indicated she didn't remember what size blood pressure cuff was used for Patient #6 and whether there had been any change in the size of the cuff after becoming aware of the bruise. When asked how she could know that it was from a blood pressure cuff and not abuse, S9RN indicated she had assessed the front and back of Patient #6's arm and didn't see any visible finger marks. She further indicated she raised the arm for S25NP to see it, and S25NP said it looked like it was from a blood pressure cuff. S9RN indicated such a bruise doesn't usually happen from a blood pressure cuff, but when a patient's skin is so thin, sometimes it will bruise.

In an interview on 05/12/16 at 11:00 a.m., S8DON indicated S25NP had recently had surgery and was not available to be interviewed.

In a telephone interview on 05/12/16 at 11:03 a.m., S13RN indicated she didn't remember Patient #6. After her nurse's note was read to her by the surveyor, S13RN indicated her checking integumentary assessment meant she did a skin assessment and observed the entire body. She indicated she worked on 09/14/15 and 09/15/15, and if she had seen a large bruise, she would have documented it.

In an interview on 05/12/16 at 1:20 p.m. with S1ADM and S8DON present, S8DON indicated she had asked staff who worked the night before the bruise was noted as well as the day the bruise was noted if Patient #6 had fallen or had an event that could have caused the bruise, but she didn't investigate it further. S8DON indicated all staff who had worked from the weekend through the day the bruise was noted were spoken with, but she did not document any interviews. S8DON and S1ADM had no documented evidence to provide of an investigation of the bruise to Patient #6's right upper arm to determine the cause of the bruise to rule out possible abuse.

Based on observations, record reviews, and interviews, the hospital failed to ensure the use of restraint was in accordance with a written modification to the patient's plan of care as evidenced by failure to have Patient #2's care plan was revised for the use of restraints for 1 (#2) of 1 patient observed in restraint from a sample of 6 patients.
Findings:

Observation on 05/09/16 at 12:55 p.m. revealed Patient #2 was in a Geri-chair with a lap tray in place in Room "n". Further observation revealed Patient #2 was attempting to remove the lap tray and was unsuccessful. During the observation S5MHT was heard telling Patient #2 to "try to relax."

Observation on 05/10/16 at 9:10 a.m. revealed Patient #2 was seated in the hall in a Geri-chair with a lap tray in place.

Review of the hospital policy titled "Seclusion and Restraints", presented as a current policy by S1ADM, revealed that a behavioral health restraint was defined as any manual method or physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely. Further review revealed the treatment team will review the occurrence and use of restraints and modify the patient's plan of care as needed.

Review of Patient #2's care plan revealed no documented evidence that it was modified when restraints were initiated.

In an interview on 05/11/16 at 1:45 p.m., S1ADM confirmed a lap tray is a restraint, and she couldn't say why an order wasn't obtained. She confirmed Patient #2's care plan was not modified to include the use of restraints in accordance with hospital policy.

Based on observations, record reviews, and interviews, the hospital failed to ensure implementation of restraint was in accordance with the order of a physician or other licensed independent practitioner as evidenced by failure to have physician orders for a Geri-chair with an attached lap tray used as a restraint for an ambulatory patient who was unable to remove the lap tray for 1 (#2) of 1 patient observed in restraint from a sample of 6 patients. Findings:

Observation on 05/09/16 at 12:55 p.m. revealed Patient #2 was in a Geri-chair with a lap tray in place in Room "n". Further observation revealed Patient #2 was attempting to remove the lap tray and was unsuccessful. During the observation S5MHT was heard telling Patient #2 to "try to relax."

Observation on 05/10/16 at 9:10 a.m. revealed Patient #2 was seated in the hall in a Geri-chair with a lap tray in place.

Review of the hospital policy titled "Seclusion and Restraints", presented as a current policy by S1ADM, revealed that a behavioral health restraint was defined as any manual method or physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely. Documentation was to include the use of restraint in the medical record including observable behavior and least restrictive methods employed. The nursing progress note includes the behavior prior to initiation of the restraint, justification for the continuation throughout the course of the restraint, justification for release from restraint, and the patient's condition upon release. Restraints are used upon the written or verbal order of a physician. A physician/licensed independent practitioner (LIP) must see and evaluate the need for restraint within 1 hour after initiation of the intervention. In lieu of the physician/LIP, a trained RN may perform the one hour facer-to-face evaluation. When the time limit for the order expires, an in-person visual evaluation must be conducted by the LIP/physician/trained RN. The re-evaluation must occur every 8 hours for adults age 18 and over. The order should specify the length of time the restraint is authorized not to exceed 4 hours for adults ages 18 and older, the criteria and behavior to discontinue, precipitating events leading to the need for restraint/clinical justification, one-to-one observation will be initiated, and criteria for discontinuing restraints.

Review of Patient #2's nurses' notes revealed the following:
05/06/16 at 8:00 p.m. -motor/gait: psychomotor retardation; behavior: isolating, wandering, decreased energy;
05/07/16 at 4:00 p.m. - pacing and wandering into peers' rooms, needs redirection;
05/08/16 at 4:00 p.m. - pacing hall, wandering into peers' room, difficult to redirect.
Review of Patient #2's nurses' notes from the time of admission on 05/06/16 at 8:00 p.m. through the times of observations made on 05/09/16 at 12:55 p.m. and 05/10/16 at 9:10 a.m. revealed no documented evidence of the time Patient #2 was restrained in the Geri-chair with the lap tray in place.

Review of Patient #2's physician orders revealed no documented evidence of a physician's order for restraints.

In an interview on 05/09/16 at 3:20 p.m. with S1ADM, S8DON, S19RegD, and S2RN present, S2RN indicated they (didn't identify who "they" were) told her the lap tray was placed on the weekend, but she didn't know when it was done. She confirmed Patient #2's medical record doesn't have a physician's order for the use of restraints.

In an interview on 05/11/16 at 10:55 a.m., S2RN indicated she didn't get a physician's order for the restraint for Patient 32 after the interview on 05/09/16 at 3:20 p.m., because S8DON said she had gotten an order from S23MD to keep Patient #2 in the Geri-chair. She further indicated one of the MHTs asked S8DON yesterday if they should take Patient #2 out of the Geri-chair, and S8DON told the MHT no, that S23MD said Patient #2 could use the lap tray as long as he was taken out the chair every 2 hours and walked. S2RN indicated she didn't check the chart to see if there was a physician's order for the restraint. S2RN indicated she knew if an ambulatory patient was placed in a Geri-chair with a lap tray in place, it was considered a restraint. She offered no explanation for not removing the restraint or obtaining an order for it when she worked on 05/09/16.

In an interview on 05/11/16 at 11:15 a.m., S18RN indicated she worked 05/07/16 and 05/08/16. She further indicated Patient #2 was ambulatory unassisted during this time. She further indicated he didn't have the lap tray on the chair when she worked, except for mealtime, and she didn't know when it was applied. She further indicated she knew that a lap tray was a restraint.

In an interview on 05/11/16 at 1:45 p.m., S1ADM confirmed a lap tray is a restraint, and she couldn't say why an order wasn't obtained.

Based on observations, record reviews, and interviews, the hospital failed to ensure each order for restraint used to ensure the physical safety of the non-violent or non-self-destructive patient may be renewed as authorized by hospital policy as evidenced by failure to have physician orders to continue the use of a Geri-chair with an attached lap tray used as a restraint for an ambulatory patient who was unable to remove the lap tray for 1 (#2) of 1 patient observed in restraint from a sample of 6 patients.
Findings:

Observation on 05/09/16 at 12:55 p.m. revealed Patient #2 was in a Geri-chair with a lap tray in place in Room "n". Further observation revealed Patient #2 was attempting to remove the lap tray and was unsuccessful. During the observation S5MHT was heard telling Patient #2 to "try to relax."

Observation on 05/10/16 at 9:10 a.m. revealed Patient #2 was seated in the hall in a Geri-chair with a lap tray in place.

Review of the hospital policy titled "Seclusion and Restraints", presented as a current policy by S1ADM, revealed that a behavioral health restraint was defined as any manual method or physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely. Restraints are used upon the written or verbal order of a physician. The length of time restraint is authorized is not to exceed up to 4 hours for adults ages 18 and older.

Review of Patient #6's nurses' notes revealed the following:
05/06/16 at 8:00 p.m. -motor/gait: psychomotor retardation; behavior: isolating, wandering, decreased energy;
05/07/16 at 4:00 p.m. - pacing and wandering into peers' rooms, needs redirection;
05/08/16 at 4:00 p.m. - pacing hall, wandering into peers' room, difficult to redirect.
Review of Patient #2's nurses' notes from the time of admission on 05/06/16 at 8:00 p.m. through the times of observations made on 05/09/16 at 12:55 p.m. and 05/10/16 at 9:10 a.m. revealed no documented evidence of the time Patient #2 was restrained in the Geri-chair with the lap tray in place.

Review of Patient #2's physician orders revealed no documented evidence of a physician's order for restraints.

In an interview on 05/09/16 at 3:20 p.m. with S1ADM, S8DON, S19RegD, and S2RN present, S2RN indicated they (didn't identify who "they" were) told her the lap tray was placed on the weekend, but she didn't know when it was done. She confirmed Patient #2's medical record doesn't have a physician's order for the use of restraints.

Review of Patient #2's physician orders on 05/10/16 at 9:25 a.m. revealed no documented evidence of a physician's order for continuing the restraints.

In an interview on 05/11/16 at 10:55 a.m., S2RN indicated she didn't get a physician's order for the restraint for Patient #2 after the interview on 05/09/16 at 3:20 p.m., because S8DON said she had gotten an order from S23MD to keep Patient #2 in the Geri-chair. She further indicated one of the MHTs asked S8DON yesterday if they should take Patient #2 out of the Geri-chair, and S8DON told the MHT no, that S23MD said Patient #2 could use the lap tray as long as he was taken out the chair every 2 hours and walked. S2RN indicated she didn't check the chart to see if there was a physician's order for the restraint. S2RN indicated she knew if an ambulatory patient was placed in a Geri-chair with a lap tray in place, it was considered a restraint. She offered no explanation for not removing the restraint or obtaining an order for it when she worked on 05/09/16.

In an interview on 05/11/16 at 1:45 p.m., S1ADM confirmed a lap tray is a restraint, and she couldn't say why an order wasn't obtained when it was initiated and why the lap tray wasn't discontinued after the interview conducted on 05/09/16 at 3:20 p.m. or a physician's order wasn't obtained for continuation of the restraint.

Based on record reviews, observations, and interviews, the hospital failed to ensure a Registered Nurse supervised and evaluated the nursing care for each patient as evidenced by:
1) Failure to clarify physician orders for PRN medications and parameters for oxygen saturation levels for 1 (#3) of 4 (#1, #2, #3, #6) patient records reviewed for physician orders from a total sample of 6 patients.
2) Failure to follow physician orders for V/S (#3), oxygen saturation levels (#3), timely dietary consult (#3), and labs (#1, #2) for 3 (#1, #2, #3) of 4 (#1, #2, #3, #6) patient records reviewed for implementation of physician orders from a total sample of 6 patients.
3) Failure to notify the physician of patients' change in health status regarding decreased oxygen saturation levels (#3), decreased weight (#3), and skin rash (#3, #6), and skin tear (#2) for 3 (#2, #3, #6) of 4 (#1, #2, #3, #6) patient records reviewed for notification of the physician with a change in patient condition from a total sample of 6 patients.
4) Failure to accurately assess and document wounds for 2 (#2, #3) of 2 patient records reviewed with wounds from a total sample of 6 patients.
5) Failure to obtain physician orders for wound care for skin tears (#2) and rash (#3, #6) for 3 (#2, #3, #6) of 3 patient records reviewed with wounds or rashes from a total sample of 6 patients.
6) Failure to implement fall precautions for 1 (#2) of 1 patient observed on fall precautions from a total sample of 6 patients.
7) Failure of the RN to implement physician orders for one-to-one (1:1) observation for 1 (#2) of 1 patient record reviewed and patient observed with orders for 1:1 observation from a total sample of 6 patients.
Findings:

1) Failure to clarify physician orders for PRN medications and parameters for oxygen saturation levels:
PRN Medications:
A review of a policy entitled, Medication Management, presented as current with an effective date of 01/11/16, revealed medication orders that are written as PRN must include indication for use of the PRN medication. Incomplete order is not implemented until clarified with the provider. The nurse/pharmacist is to clarify any medication order which is illegible or improperly written prior to administration/dispensing. The RN/LPN reviews the physician's medication order for content and clarity. If the order is not clear, the physician shall be contacted for clarification.
Review of the medical record for patient #3 revealed she was an 80-year-old female admitted to the hospital on 04/15/16 at 8:00 p.m. from a nursing home. Admitting diagnoses included Dementia with Behavioral Disturbances, Constipation, Bowel and Bladder Incontinence, and Chronic Obstructive Pulmonary Disease (COPD).
Review of Patient #3's medical record revealed and order dated 04/16/16 which included, in part: "Mucinex 600 mg every 12 hours for five days, then PRN; Pro-air inhaler every 4 hours while awake for 3 days, then PRN. . ."vital signs every 8 hours with pulse oximetry."
Review of the medical record revealed the nursing staff did not clarify physician orders for indications of when to administer the Pro-air inhaler every 4 hours PRN and the Mucinex every 12 hours. Further review revealed there was no clarification order obtained from the physician for acceptable/unacceptable parameters for the oxygen saturation levels with indications for specific interventions for low oxygen saturation levels.
In an interview on 05/10/16 at 1:32 p.m., S8DON reviewed the medical record and confirmed there was no clarification of physician orders for the PRN administration of Mucinex and Pro-air inhaler, and there was no clarification of physician orders for the acceptable/unacceptable parameters for the oxygen saturation levels, and the nurse should have obtained clarification from the physician for the above-referenced orders.

In an interview on 05/10/16 at 2:12 p.m., S6LPN indicated she was not sure when to use the inhaler and/or the Mucinex, and she did not know what the indications were for administration of the inhaler and Mucinex medications because the physician had not written indications for PRN administration of the medications. She further indicated she would probably give the inhaler medication to the patient if she noticed he patient was short of breath.

Parameters for oxygen saturation:
Review of a policy and procedure entitled, Pulse Oximetry and Oxygen Use, presented as current with an effective date of 01/11/16 revealed, in part: "Procedure: E. Interpreting the results: a. Normal oxygen saturation is considered to range between 97% and 99%. b. Readings between 93% and 97% may be normal for some patients; on the other hand, some patients may be very sick with a reading of greater than 97%. c. Readings of 90% or less may indicate that the patient needs oxygen therapy. Promptly notify the physician for further assessment should a reading of 90% or less be obtained."
Review of Patient #3's medical record revealed and order dated 04/16/16 which included, in part: "vital signs every 8 hours with pulse ox." Further review of the medical record revealed the nursing staff did not clarify physician orders for defining acceptable and unacceptable oxygen saturation levels for Patient #3.
In an interview on 05/10/16 at 1:32 p.m., S8DON reviewed the medical record and confirmed there was no documented evidence of the clarification of the physician's order for obtaining oxygen saturation levels which defined acceptable and unacceptable oxygen saturation levels for Patient #3.

In an interview on 05/10/16 at 2:12 p.m., S6LPN indicated she considered an acceptable oxygen saturation level to be between 95% and 100%. When asked what oxygen saturation level assessment should be reported immediately, she responded, "I guess anything below 95%." S6LPN reviewed the medical record for Patient #3 and confirmed there was no documented evidence that the physician had been notified of any abnormal oxygen saturation levels.

2) Failure to follow physician orders for V/S, oxygen saturation levels, timely dietary consult, and labs:
Lab:
Review of the hospital policy titled "Protocols For Diagnostic Studies", presented as a current policy by S1ADM, revealed that diagnostic procedures will be ordered and completed based on the physician/licensed independent practitioner determination for the need for the test/procedure.

Review of the "Laboratory Services Agreement" with Company A revealed that routine phlebotomy services will be provided according to the schedule in Attachment B. State Phlebotomy services/courier services will be available seven days a week between the hours of 8:00 a.m. to 9:00 p.m. only, and may incur an additional charge billed directly to the client. Review of attachment B revealed Company A will provide (in the early a.m.) for the collection of specimens and to pick up of any specimens collected by the client according to the following schedule: there was no documented evidence that the choices of Monday, Tuesday, Wednesday, Thursday, Friday, as needed were checked. There was no documented evidence that lab services were provided by the hospital 24 hours a day, 7 days a week.

Patient #1
Review of Patient #1's physician orders revealed an order on 03/30/16 at 1:54 p.m. to draw a CMP (complete metabolic profile) in the a.m.

Review of the lab result for the draw done on 03/31/16 revealed the specimen was grossly hemolyzed, and S9RN was notified. There was no documented evidence in the medical record that S9RN notified the physician or NP of the delay in obtaining the blood results. Further review revealed the specimen drawn on 04/01/16 was grossly hemolyzed.

Review of the documentation by S25NP on 04/02/16 revealed the CMP was grossly hemolyzed, and the test was to be redrawn on Monday. Review of the test results from Monday's (04/04/16) CMP revealed the Potassium level was 6.8 (critical result). Patient #1 was transferred to an acute care hospital for evaluation and treatment of Chronic Kidney Disease Stage IV and Hyperkalemia.

Patient #2
Review of Patient #2's admit orders of 05/06/16 at 8:00 p.m. revealed orders to draw a CBC (complete blood count), RPR (rapid plasma reagin), Urinalysis with Culture and sensitivity, CMP, TSH (thyroid stimulating hormone), and Folate Level.

Review of Patient #2's lab results revealed his labs were drawn on 05/09/16, 3 days after admit.

In an interview on 05/11/16 at 9:20 a.m., S9RN indicated she doesn't ever recall having labs drawn on the weekend.

In an interview on 05/11/16 at 12:20 p.m., S1ADM indicated the lab order is supposed to written as a "stat" order if the physician/NP wants it drawn on the weekend. After presenting the lab agreement and review revealed lab services were contracted to be provided 7 days a week 24 hours a day, S1ADM confirmed the hospital didn't provide lab services 24 hours a day, 7 days a week.

V/S and oxygen saturation levels:
Review of a policy and procedure entitled, Vital Signs Monitoring, presented as current with an effective date of 01/11/16, revealed, in part: "Purpose: To ensure that abnormal vital signs readings are reported to all licensed and independent practitioners in a timely manner and to establish a guide for nursing staff. Nursing Staff: Trained nursing staff (MHT, LPN/LVN, or RNs) will obtain all patients' vital signs according to physician's orders or as needed based on nursing judgment."
Patient #3 Review of the medical record for patient #3 revealed she was an 80-year-old female admitted to the hospital on 04/15/16 at 8:00 p.m. from a nursing home. Diagnoses included Dementia with Behavioral Disturbances, Constipation, Bowel and Bladder Incontinence, and Chronic Obstructive Pulmonary Disease (COPD).
Review of Patient #3's medical record revealed an order dated 04/16/16 which stated "vital signs every 8 hours with pulse oximetry." Further review of the Vital Signs and Graphic sheet revealed Patient #3's vital signs and oxygen saturation levels were assessed twice per day from admission through the current date (05/09/16) instead of every 8 hours as ordered by the physician. Further review of the Vital Signs and Graphic sheet revealed the vital signs and oxygen saturation levels assessments were not timed from the date of admission through 05/09/16.
In an interview on 05/09/16 at 3:45 p.m., S8DON reviewed the MD orders and agreed the orders were for the vital signs to be done every 8 hours with a pulse oximetry reading. S8DON reviewed Patient #3's medical record, and she confirmed there was no documented evidence that vital signs and oxygen saturation levels were assessed every 8 hours as ordered, and the vital signs and oxygen saturation level assessments did not have the times documented for any of the assessments performed. S8DON agreed the vital signs and oxygen saturation levels should have been assessed and timed every 8 hours.

Timely Dietary Consult: A review of a policy and procedure entitled, Nutritional Consults Assessment/Reassessment, presented as current with an effective date of 01/11/2016, revealed, in part: "The assessment is to be completed within 3 days of inpatient stay or 5 outpatient sessions unless ordered as STAT."

Review of the medical record for patient #3 revealed she was an 80-year-old female admitted to the hospital on 04/15/16 at 8:00 p.m. from a nursing home. Diagnoses included Dementia with Behavioral Disturbances, Constipation, Bowel and Bladder Incontinence, and Chronic Obstructive Pulmonary Disease (COPD).

A review of the physician's orders dated 04/15/16 (date of admission) revealed an order (#7) "Dietary Consult for: Triggers per screening." Further review of the medical record revealed the RD completed the dietary consult on 04/22/16.

3) Failure to notify the physician of patients' change in health status regarding decreased oxygen saturation levels, decreased weight, and skin rash, and skin tear:
A review of a policy entitled, Early Response Intervention to Deteriorating Patient Condition/Change in Condition, presented as current with a revised date of 01/11/16, revealed it is the policy of the facility to improve recognition and response to changes in a patient condition. This facility identifies unexpected acute illnesses which pose life-threatening situations for our patients. This facility identifies (1) for situations in which an individual's psychological health is deteriorating and they are becoming a threat to themselves or to others; (2) respiratory/cardiopulmonary arrest, and (3) response to abnormal changes fluctuation in a patient's status: I&O, CBG glucose levels, and Vital Signs. Upon identification of early warning signs of deterioration in a patient's condition, the facility has selected the following early recognition/response methods for abnormal change/fluctuations in patient status, such as I&O, nursing vital sign monitoring, CBG glucose levels (nursing glucometer monitored for obtaining CBG level sliding scale, and vital signs (nursing vital signs monitoring). Should a patient be experiencing any status changes, the staff will notify the nurse who will in turn notify the medical physician on site or on call; nurse should ask for a second nursing assessment and opinion, call DON if second nurse not available, implement physician's orders. Keep physician abreast of significant changes. Further review of the policy and procedure revealed acceptable and unacceptable oxygen saturation levels were not included in this policy and procedure.
Decreased oxygen saturation levels: Review of a policy and procedure entitled, Pulse Oximetry and Oxygen Use, presented as current with an effective date of 01/11/16 revealed, in part: "Procedure: E. Interpreting the results: a. Normal oxygen saturation is considered to range between 97% and 99%. b. Readings between 93% and 97% may be normal for some patients; on the other hand, some patients may be very sick with a reading of greater than 97%. c. Readings of 90% or less may indicate that the patient needs oxygen therapy. Promptly notify the physician for further assessment should a reading of 90% or less be obtained."
Patient #3
Review of the medical record for patient #3 revealed she was an 80-year-old female admitted to the hospital on 04/15/16 at 8:00 p.m. from a nursing home. Diagnoses included Dementia with Behavioral Disturbances, Constipation, Bowel and Bladder Incontinence, and Chronic Obstructive Pulmonary Disease (COPD).
Review of the medical record for Patient #3 revealed the following documented oxygen saturation levels below 95%: (not inclusive of all assessments through 05/08/16): O2 Sat: 04/17/16: No time: "Day": 94%; O2 Sat: 04/18/16: No time: "Evening": 90%; O2 Sat: 04/20/16: No time: "Day": 94%; O2 Sat: 04/21/16: No time: "Day": 91%; O2 Sat: 04/23/16: No time: "Day": 94%; O2 Sat: 04/24/16: No time: "Evening": 92%; O2 Sat: 04/25/16: No time: "Day": 91%: O2 Sat: 04/27/16: No time: "Day" and "Evening": 94%; O2 Sat: 04/30/16: No time: "Day": 94%; O2 Sat: 05/01/16: No time: "Evening": 90%; O2 Sat: 05/02/16: No time: "Evening": 92%; O2 Sat: 05/03/16: No time: "Evening": 90%; O2 Sat: 05/04/16: No time: "Day": 94%; and "Evening": 93%, etc.
In an interview on 05/09/16 at 3:45 p.m., S8DON reviewed the medical record and confirmed there was no documented evidence of the times the vital signs assessments were performed, and the assessments should have contained documentation of the times the assessments were performed.

In an interview on 05/10/15 at 1:50 p.m., S8DON reviewed the medical record and confirmed the above-referenced oxygen saturation levels, and confirmed there was no documented evidence in the medical record the patient's physician had been notified of the oxygen saturation levels below 95%, and the physician should have been notified.

In an interview on 05/10/16 at 2:12 p.m., S6LPN indicated she considered an acceptable oxygen saturation level to be between 95% and 100%. When asked what oxygen saturation level assessment should be reported to the physician, she responded, "I guess anything below 95%." S6LPN reviewed the medical record for Patient #3 and confirmed there was no documented evidence that the physician had been notified of any abnormal oxygen saturation levels.

Decreased Weight: A review of a policy and procedure entitled, Nutritional Consults Assessment/Reassessment, presented as current with an effective date of 01/11/2016, revealed, in part: "Policy: Nutritional consults are to be ordered for patients at nutritional risk by the attending physician so that the RD can conduct a nutritional assessment to evaluate the nutrient needs of the individual and provide recommendations, counseling, and instruction. The assessment is to be completed within 3 days of inpatient stay or 5 outpatient sessions unless ordered as STAT. Reassessments and follow-ups are conducted as ordered by physician or initiated by RD and may include addressing and documenting changes in nutritional status and progress of nutritional intervention. Reassessments. Patients will be reassessed by RD: . . .When significant change occurs in condition or diagnosis; Upon identifying a patient with a 5% weight loss since admit, nursing notifies MD and RD within 24 hours. Treatment Plans: Nutritional issues will be incorporated into the treatment plan as relevant."
A review of a policy and procedure entitled, Early Response Intervention to Deteriorating Patient Condition/Change in Condition, presented as current with a revised date of 01/11/16, revealed in part: ". . .B. Early Warning Signs: I&O Status: A patient has a weight loss of 2 pounds or greater."
A review of the medical record for Patient #3 revealed an initial weight of 184 pounds (while patient was in the Geri-chair). The weight of the Geri-chair was documented as 74.1 pounds. A review of documentation provided by Patient #3's nursing home revealed the patient's weight on 03/04/16 was 142 pounds. On 04/25/16 the patient's weight was documented as 142 pounds; on 04/28/16 as 139 pounds; on 05/02/16 as 134 pounds, on 05/09/16 as 133 pounds.
In an interview on 05/10/16 at 1:08 p.m., S8DON reviewed the medical record and indicated the patient's initial weight of 184 pounds was not accurate because staff had neglected to subtract the weight of the Geri-chair. S8DON confirmed the documented weight on the Geri-chair was 74.1 pounds, and she confirmed there was no documented evidence in the medical record the physician had been notified of Patient's #3's weight loss of 9 pounds since admission to the hospital, and no documented evidence the RD had been consulted for a reassessment.

Skin Rash: A review of the medical record revealed Patient #3's initial skin assessment documented on 04/15/16 at 8:00 p.m. on the Skin and Braden Reassessment Documentation form revealed, in part, the patient's skin was intact with bruises to left upper extremity and bilateral hands. Further review revealed the bruises were not identified (documented) on the body diagram. Review of the Skin and Braden Reassessment Documentation documented on 04/24/16 revealed the following, in part: Bruising to entire left upper arm and top of right wrist; rash to groin and lower left leg, skin tear to back of left arm, top of left wrist, also tear to upper left arm." Further review revealed there was no documented evidence in the medical record that the physician was notified of the patient's rashes.

In an interview on 05/10/16 at 2:40 p.m., S8DON reviewed Patient #3's medical record and confirmed there was no documented evidence that the physician had been notified about the development of the rash identified on the patient, and there should have been documentation the physician had been notified about the rash.

Patient #6
Review of Patient #6's medical record revealed a "Skin and Braden Reassessment Documentation" was documented by S9RN on 09/12/15 at 10:00 a.m. that included an assessment of "yeast looking rash under B (bilateral) breast..." There was no documented evidence that S9RN reported to the yeast rash to a physician or NP for orders for treatment.

Review of a Skin and Braden Reassessment Documentation" documented by S8DON on 09/15/15 at 10:30 a.m. revealed patient has "yeast under bil. (bilateral) breast." There was no documented evidence S8DON reported the yeast to a physician or NP for orders for treatment.

In an interview on 05/12/16 at 10:44 a.m., S9RN indicated she would "absolutely" report her assessment of a patient having a yeast rash to a physician. When informed of her assessment of Patient #6 on 09/12/15 with a yeast rash and no documented evidence of a report being made to a physician, S9RN had no explanation to offer.

In an interview on 05/12/16 at 1:20 p.m., S8DON indicated she "would like to say she would have informed the NP of her findings (related to her assessment of yeast on 09/15/15) but can't say 100% of the time she would." She confirmed there was no documented evidence that she had reported her findings to the NP.

Skin Tear:
Review of an "Incident/Accident Report" documented by S18RN on 05/08/16 at 2:25 p.m. revealed Patient #2 was seated in a Geri-chair, fidgety, with increasing movements, throwing his arms back and forth, and hit his arm on the side of the chair and obtained 2 skin tears to the left forearm. There was no documented evidence that the physician or NP was notified of the injury and no physician orders for treatment. Further review of the report revealed the LPN administered first aid.

Review of Patient #2's nursing note for 05/08/16 revealed no documented evidence that the injury occurred, an assessment of the skin tears by a RN, the treatment provided, and notification of the physician/NP to obtain orders for treatment.

In an interview on 05/09/16 at 3:20 p.m. with S1ADM, S8DON, S19RegD, and S2RN present, S2RN indicated the night nurse informed of Patient #2's skin tears. She further indicated the LPN had not performed wound care yet today, and she didn't know if there were physician orders for wound care, because she hadn't looked at the orders yet this day.

In a telephone interview on 05/09/16 at 3:30 p.m., S18RN indicated she called the NP, but she didn't return the call. She further indicated she didn't call the NP back, and she didn't attempt to call the physician. S18RN indicated she also wasn't able to contact the patient's daughter, and she did not report this information to the oncoming nurse when she left at the end of her shift. She further indicated she wasn't sure what first aid the LPN did. She indicated she applied pressure while the LPN went to get supplies, and he took over. She confirmed she didn't measure the wounds and didn't get physician orders for treatment.

4) Failure to accurately assess and document wounds:
Review of a policy entitled, Skin and Wound Care, presented as current with an effective date of 01/11/16, revealed, in part: "...A weekly skin assessment and risk evaluation is performed by the nurse on geriatric patients. The nursing staff will utilize a wound care book to organize and communicate the individual patient treatments. Pictures of the wounds are posted to each patient's wound care treatment guides in the wound care book. Procedure: ...Once discharged all pictures are filed in the closed record. Wound Care Procedure: 1. If patient is identified to have a wound a picture is taken and documentation of the wound made in the progress notes. 2. The nurse opens a wound care treatment guide on the patient in the wound care book. 3. Places picture of the wound, a copy of the orders and a copy of the progress note in the patient wound in the book. 4. Passes on in report the wound care book and reports on all patients that are in wound care protocol or wound care prevention. 5. Updates with ongoing pictures, orders and copies of progress notes in the wound care book as they occur. Prevention Protocol Procedure: ...Nurse. ...Will document initial wound findings in the admit nursing assessment and indicate on the figure/drawing of the person on the nursing assessment form; A picture of the wound will be taken on admit and findings of the assessment of the wound to provide a baseline; Pictures will be retaken as a comparison of progress or worsening at a minimal every two days; Nursing will utilize the wound assessment guidelines to describe and document the wound in a consistent and accurate manner. The description may include as relevant the location, type, where acquired, stage, length; Wound description will be documented in the progress notes when wound care is performed. Wound length, width, and depth will be measured in centimeters weekly."
Patient #2
Review of an "Incident/Accident Report" documented by S18RN on 05/08/16 at 2:25 p.m. revealed Patient #2 obtained 2 skin tears to the left forearm.

Review of Patient #2's nursing note for 05/08/16 revealed no documented evidence of an assessment of the skin tears by a RN that included measurements and a description of the wound area, the treatment provided, and notification of the physician/NP to obtain orders for treatment.

In a telephone interview on 05/09/16 at 3:30 p.m., S18RN confirmed she didn't measure the wounds and didn't get physician orders for treatment.

Patient #3
Review of the medical record for patient #3 revealed she was an 80-year-old female admitted to the hospital on 04/15/16 at 8:00 p.m. from a nursing home. Diagnoses included Dementia with Behavioral Disturbances, Constipation, Bowel and Bladder Incontinence, and Chronic Obstructive Pulmonary Disease (COPD).
Review of the Skin and Braden Reassessment Documentation documented on 04/24/16 revealed the following, in part: Bruising to entire left upper arm and top of right wrist; rash to groin and lower left leg, skin tear to back of left arm, top of left wrist, also tear to upper left arm." Further review of the medical record revealed there were no measurements of the wound tears documented in the medical record.
In an interview on 05/10/16 at 2:40 p.m., S8DON reviewed Patient #3's medical record and confirmed there was no documentation of the skin tear dimensions, and no pictures of the wounds, and there should have been documentation of the wounds' dimensions and pictures taken and placed in the medical record of the skin tears according to the policy and procedure.

5) Failure to obtain physician orders for wound care for skin tears and rash:
Patient #2
Review of an "Incident/Accident Report" documented by S18RN on 05/08/16 at 2:25 p.m. revealed Patient #2 obtained 2 skin tears to the left forearm.

Review of Patient #2's nursing note for 05/08/16 revealed no documented evidence of notification of the physician/NP to obtain orders for treatment.

In a telephone interview on 05/09/16 at 3:30 p.m., S18RN confirmed didn't get physician orders for treatment.

Patient #3
Review of the medical record for patient #3 revealed she was an 80-year-old female admitted to the hospital on 04/15/16 at 8:00 p.m. from a nursing home. Diagnoses included Dementia with Behavioral Disturbances, Constipation, Bowel and Bladder Incontinence, and Chronic Obstructive Pulmonary Disease (COPD).
Review of the Skin and Braden Reassessment Documentation documented on 04/24/16 revealed the following, in part: Bruising to entire left upper arm and top of right wrist; rash to groin and lower left leg, skin tear to back of left arm, top of left wrist, also tear to upper left arm."

In an interview on 05/10/16 at 2:40 p.m., S8DON reviewed Patient #3's medical record and confirmed there was no documented evidence the physician was contacted for wound care orders for Patient #3's skin tears and rash, and there should have been.

Patient #6
Review of Patient #6's medical record revealed a "Skin and Braden Reassessment Documentation" was documented by S9RN on 09/12/15 at 10:00 a.m. that included an assessment of "yeast looking rash under B (bilateral) breast..." There was no documented evidence that S9RN reported to the yeast rash to a physician or NP for orders for treatment.

Review of a Skin and Braden Reassessment Documentation" documented by S8DON on 09/15/15 at 10:30 a.m. revealed patient has "yeast under bil. (bilateral) breast." There was no documented evidence S8DON reported the yeast to a physician or NP for orders for treatment.

In an interview on 05/12/16 at 10:44 a.m., S9RN indicated she would "absolutely" report her assessment of a patient having a yeast rash to a physician. When informed of her assessment of Patient #6 on 09/12/15 with a yeast rash and no documented evidence of a report being made to a physician, S9RN had no explanation to offer.

In an interview on 05/12/16 at 1:20 p.m., S8DON indicated she "would like to say she would have informed the NP of her findings (related to her assessment of yeast on 09/15/15) but can't say 100% of the time she would." She confirmed there was no documented evidence that she had reported her findings to the NP, and there were no orders for treatment of the yeast rash in the medical record.

6) Failure to implement fall precautions:
Review of Patient #2's physician admit orders revealed an order for fall precautions.

Review of Patient #2's "At Risk For Falls (ARF) Score Sheet" completed on 05/06/16 revealed he scored a 46, with a score greater than 17 being a high risk. Further review revealed fall precautions for high risk included placing a yellow fall risk arm band on the patient and placing a fall precaution sign on the patient's chart.

Observation on 05/09/16 at 12:55 p.m. revealed Patient #2 was seated in a Geri-chair in the Day Room and was not wearing a yellow fall risk arm band. Further observation revealed his medical record was not labeled with a fall precaution sign.

Observation on 05/12/16 at 8:55 a.m. revealed Patient #2 was seated in the Day Room and was not wearing a yellow fall risk arm band.

In an interview on 05/12/16 at 8:55 a.m., S1ADM indicated yellow arm bands are placed each morning, but they come off. She confirmed Patient #2 was not wearing a yellow fall risk arm band. She offered no comment when informed that his medical record did not have a label or fall precaution sticker as required by hospital policy.

7) Failure of the RN to implement physician orders for 1:1 observation:
Review of Patient #2's physician admit orders revealed an order for 1:1 observation on 05/06/16 at 8:00 p.m.

Review of Patient #2's nursing notes and MHT observation records revealed he was placed on every 15 minutes observation from the time of admission on 05/06/16 until the review of the record on 05/09/16.

In an interview on 05/09/16 at 3:20 p.m. with s1ADM, S8DON, and S19RegD present, S19RegD confirmed Patient #2's physician orders were for 1:1 observation. S7LPN joined the interview and indicated the 1:1 observation level was incorrectly checked. S1ADM indicated she spoke with S23MD who said he didn't order the patient to be on 1:1 observation. S19RegD indicated the nurse who did the chart check should have caught that Patient #2 wasn't being observed at the level ordered and clarified what observation was actually ordered.


31048

Based on record review and interview, the hospital failed to ensure the staff developed and kept current an individualized, updated care plan with measurable goals for 3 (#2, #3, #6) of 4 (#1, #2, #3, #6) patient records reviewed for care plans from a total of 6 sampled patients. Findings:
Review of a policy and procedure entitled, Treatment Planning; Integrated/Multidisciplinary, presented as current, revealed, in part: Purpose: To document and implement treatment objectives/interventions, services necessary and discharge planning activities for the identified goals derived from the assessment process throughout the course of patient's treatment to promote positive patients' outcomes. Policy: the multi-disciplinary treatment team, under the direction and supervision of the attending physician, shall develop an integrated written, comprehensive Treatment Plan with specific goals and objectives necessary to address deficits identified in the assessment process. The Treatment Plan shall be initiated as a component of the admissions process with continual development and formulation by the attending physician and multi-disciplinary treatment team, with the patient's involvement, throughout the course of treatment. The treatment plan includes defined problems and needs, measurable goals and objectives based on assessed needs, strengths and limits, frequency of care, treatment and services, facilitating factors and barriers, and transition criteria to lower levels of care. The admitting nurse initiates individualized treatment problem/nursing diagnosis list as identified in the assessment; revises and develops nursing and medical components of the treatment plan based on additional findings from patient assessments, problems, needs, strengths and limitations, and physician orders; and revises plan based on changes in condition and physician's orders received. All physician orders will be added to the Treatment Plan.
Patient #2 Review of Patient #2's medical record revealed his diagnoses included Major depressive Disorder, Severe Cognitive Disorder, Hypertension, Hyperlipidemia, and Hematuria.
Review of Patient #2's "Multidisciplinary Integrated Treatment Plan Problem List" revealed his problems included alteration in mood related to diagnosis of depression with suicidal ideations, high risk related to falls, and potential for self harm related to Depression, suicidal ideations, and poor impulse control.
Review of the individual care plans for Patient #2 revealed the goals were not measurable and stated in behavioral terms as evidenced by the following goals: demonstrate stabilized mood as evidenced by increased socialization, increased mood, increase in organized thought processes and demonstrate increased ability to focus during conversations. There was no documented evidence that care plans were developed to address Patient #2's medical problems of Hypertension, Hyperlipidemia, and Hematuria.
Patient #3 A review of the medical record for Patient #3 revealed she was an 80-year-old female admitted to the hospital on 04/15/16 at 8:00 p.m. from a nursing home. Diagnosis was Dementia with Behavioral Disturbances, Constipation, Bowel and Bladder Incontinence, and COPD.
Review of the care plans for Patient #3 revealed, in part, a care plan for the diagnoses of COPD. The care plan did not address the physician's orders for assessments of O2 saturation levels, and specific acceptable levels of oxygen saturation for Patient #3. The scheduled medications ordered were not specifically identified by name, dosage, frequency, and there were no PRN medications listed on the care plan that were ordered by the physician. The patient also had a documented episode of "chest congestion, wet cough, and watery eyes" in which the Licensed Independent Practitioner was notified. This change in the patient's respiratory status was not documented on the patient's care plan.
In an interview on 05/10/16 at 2:00 p.m., S8DON agreed and confirmed the care plan for COPD was incomplete and was not updated with assessments and interventions, and the care plan should have been individualized, complete, and updated with all patient condition changes and orders by the physician.
Review of the care plan for "Falls" revealed, in part, a short term goal listed as (patient will) "Verbalize understanding to request assistance as needed with 4 days." The patient has severe dementia, and is not capable of understanding, following commands, and requesting any assistance.
Further review of Patient #3's medical record revealed Patient #3 did not have a care plan for constipation, bowel and bladder incontinence, alteration in nutritional status related to the 9 pound weight loss, and alteration in skin integrity with the identified skin tear documented on 04/19/16, and the skin tears identified on the weekly "Skin and Braden Reassessment Documentation" sheet on 04/24/16.
In an interview on 05/10/16 at 1:30 p.m., S8DON reviewed Patient #3's medical record and confirmed the patient did not have comprehensive, individualized, complete and updated care plans for the above-referenced conditions, and Patient #3 should have had the appropriate care plans in her medical record.
Patient #6
Review of patient #6's Psychiatric evaluation revealed her provisional/admitting diagnoses included Major Depressive Disorder with Suicidal Ideation, early cognitive declining, Hypertension, and Vitamin Deficiency.

Review of Patient #6's "Multidisciplinary Integrated Treatment Plan Problem List" revealed her identified problems were alteration in perception related to disease process as evidenced by threatening behaviors, alteration in health maintenance related to medical treatment of Hypertension, and high risk for falls related to cognitive deficit.

Review of the individual care plans for Patient #6 revealed the goals were not measurable and stated in behavioral terms as evidenced by the following goals: have improved responses to situations; decrease aggressive/agitated behavior; demonstrate an understanding of treatment regimen to maintain medical condition at optimal level.
In an interview on 05/11/16 at 1:25 p.m., S1ADM confirmed the patients' care plans should include plans for medical problems. She indicated that the goals should be measurable and stated in behavioral terms.





31048

Based on record reviews and interviews, the hospital failed to ensure a discharge planning evaluation included an evaluation of the likelihood of a patient's capacity for self-care or of the possibility of the patient being cared for in the environment from which he entered the hospital as evidenced by failure to have documented evidence of an assessment of tentative living arrangements during the discharge planning evaluation for 1 (#1) of 6 patient records reviewed for discharge planning from a total sample of 6 patients.
Findings:

Review of the hospital's policy titled "Discharge Planning", presented as a current policy by S1ADM, revealed that discharge planning commences upon admission to any program. The admitting nurse implements a tentative discharge plan during the time of admission and documents same on treatment plan. The treatment team members updates/reviews post discharge plans during weekly staffing meetings or more frequently if needed. Discharge planning should encompass the following areas: review of the precipitation events and stressors which led to current treatment and what resources there patient will need to deal with these events/stressors post-discharge; review of any daily living changes patient may need to decrease relapse potential; review of community resources needs of patient post-discharge and the availability of same; family's needs post discharge; patient's/family's continued education needs; cost feasibility of plan; orders for continuing care to meet physical and psychosocial needs for discharge or transfer.

Review of S26LCSW's psychosocial assessment that included discharge planning, conducted and documented on 03/19/16 at 12:20 p.m., revealed that Patient #1's living situation was unknown at this time due to the patient's confusion and agitation. Further review revealed she was unable to reach family contacts to obtain further information. Further review of the "Discharge Planning" section titled "Tentative Living Arrangements" revealed no documented evidence that any selections were checked.

Review of Patient #1's "Treatment Plan Review and Update With Physician Certification" signed by the physician on 03/22/16 at 4:30 p.m. and on 03/29/16 at 3:30 p.m. revealed "Documentation of Family/Significant Other Involvement" included that Patient #1's family wants nursing home placement.

Review of Patient #1's medical record revealed no documented evidence of documentation by Social Service related to discharge planning after 03/19/16 through the date he was transferred to an acute care hospital for medical treatment on 04/04/16.

Review of Patient #1's Discharge Summary revealed "Social Services were working with Elderly Protective Services on securing nursing home placement for this patient." There was no documented evidence in the medical record of communication between Social Services and Elderly Protective Services related to Patient #1.

In an interview on 05/11/16 at 9:20 a.m., S9RN indicated the nurse's role in discharge planning is to meet each week to discuss patients at the treatment meeting where discharge planning is discussed. She further indicated a family session is held to see what will happen after discharge, and this would be documented on the progress note by the psychiatrist.

In an interview on 05/11/16 at 1:05 p.m., S16LCSW indicated discharge planning starts on admit with the nursing staff who lets the social worker know if nursing home placement is requested. She further indicated the treatment team discusses what's best for the patient, then the case manager takes over and does resources with the family. She further indicated the case manager, who is on vacation this week, documents the discharge planning on the patient's chart. She indicated S26LCSW works PRN and was not available to be interviewed.

Based on record reviews and interviews, the hospital failed to ensure the patient and family members or interested persons were counseled to prepare them for post-hospital care as evidenced by failure to have documented evidence of counseling with Patient #6's son prior to her discharge for 1 (#6) of 6 patient records reviewed for discharge planning from a total sample of 6 patients.
Findings:

Review of the hospital's policy titled "Discharge Planning", presented as a current policy by S1ADM, revealed that discharge planning commences upon admission to any program. Further review revealed the therapist and utilization review coordinator contacts the the post-discharge reference to ascertain the suitability of placement, schedule any appointments, and to facilitate coordination of the transfer, coordinates transportation arrangements, and notifies the patient and family of the date transfer will occur. Further review revealed prior to discharge or transfer to a lower level of care (preferably within 48 hours of discharge), the nurse/therapist conducts a discharge conference with the patient (and family as appropriate) to finalize living arrangements and post-treatment care plans to meet ongoing needs for care and services, and reviews the patient's medication regimen and educates on medications.

Review of Patient #6's "Psychiatric Progress Note" documented by S20Psychiatrist on 09/15/15 revealed she has attention-seeking behavior, sliding self to the floor and yelling, screaming, and being very angry at times, and is not sleeping well at night. The plan was to continue to monitor her. Further review revealed continued stay criteria included decompensation of mood and affect continues to prevent functioning ability at a lower level of care, thought process disorganization prevents functional adaptation, disease process severely inhibits social integration and functioning, unable to effectively manage mental illness, and activities of daily living in social, vocational, and function area denies significant impairment. Criteria for discharge was listed as absence of aggressive behavior, improved mood and affect, improved thought process, improved social functioning, effective management of mental illness, medication compliance, and improved activity of daily living.

Review of the Discharge Summary documented by S20Psychiatrist on 09/16/15 revealed "On September 16, 2015, the patient was showing sign of improvement. No agitation or aggression noted. The patient's sleep and appetite are improved. No auditory or visual hallucinations. The patient was tolerating the combination of medication without any problems. The patient's mood is stable. Medically she was stable and as such, she was discharged with medical advice."

Review of Patient #6's "Social Services/Case Management" notes revealed a note was documented on 09/09/15, the date of admission, and on 09/16/15, the day of discharge. The note of 09/16/15 revealed the case manager spoke with Patient #6's son to inform him she was being discharged on 09/16/15. There was no documented evidence of counseling with Patient #6's son to prepare for post-hospital care.

In an interview on 05/12/16 at 11:03 a.m., S8DON indicated S20Psychiatrist is currently in Pakistan and unavailable for interview.

In an interview on 05/12/16 at 1:00 p.m., S23MD indicated S20Psychiatrist isn't working at the hospital any longer. When asked how a patient can meet criteria for hospitalization one day and be discharged the following day, S23MD indicated sometimes we look at the baseline of where the patient is, such as Patient #6 wanting to jump off the building had improved, but other things remained the same. When asked about Patient #6 being discharged without psychiatric re-evaluation (after the documentation of criteria for continued stay the previous day), S23MD reviewed the discharge summary and indicated it would have been better if S20Psychiatrist had documented the lack of suicidality and accomplishment of goals. He confirmed that was not documented by S20Psychiatrist. He further indicated he would not have discharged Patient #6 if she was going home rather than to an assisted living center where there was some level of supervision.

In an interview on 05/12/16 at 1:20 p.m., S1ADM indicated the case manager no longer works at the hospital. After reviewing the chart, S1ADM indicated the chart "doesn't show progressive discharge planning."

Based on record reviews and interviews, the hospital failed to ensure the facility to which the patient was transferred or discharged to received a medication list that was reconciled to identify changes made during the patient's hospitalization including prescription and over-the-counter medications and herbal as evidenced by failure to have a list that compared medications taken prior to admission to medications begun during hospitalization for 1 (#6) of 6 patient records reviewed for discharge planning from a total sample of 6 patients.
Findings:

Review of the hospital's policy titled "Discharge Planning", presented as a current policy by S1ADM, revealed that discharge planning commences upon admission to any program. Further review revealed prior to discharge or transfer to a lower level of care (preferably within 48 hours of discharge), the nurse/therapist conducts a discharge conference with the patient (and family as appropriate) to finalize living arrangements and post-treatment care plans to meet ongoing needs for care and services, and reviews the patient's medication regimen and educates on medications.

Review of Patient #6's medical record revealed no documented evidence that at discharge her medications were reconciled to identify changes made during the patient's hospitalization from her pre-hospital medications including prescription and over-the-counter medications and herbal.

In an interview on 05/12/16 at 10:44 a.m., S9RN indicated at discharge they list the discharge medications. She further indicated she compares the list to the medications listed on the admit reconciliation list, but she doesn't document the comparison and changes made. She indicated she doesn't give the changes from pre-hospital medications to those started during hospitalization and ordered to continue upon discharge to the patient.

In an interview on 05/12/16 at 1:20 p.m., S1ADM indicated the case manager no longer works at the hospital. After reviewing the chart, S1ADM indicated the chart "doesn't show progressive discharge planning." She further indicated the documentation of discharge medications doesn't meet the regulatory requirements.