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Based on observation, staff interview, document and record review, the hospital's Governing Body failed to ensure the hospital's operation was conducted in an effective, safe, and organized manner by failure to ensure: 1. Grievances were investigated in accordance with hospital policy; 2. Orders were in place for restraint use and that restraints were properly released every two hours; 3. Wound care was completed as ordered; 4. Timely medication administration; 5. Bathing was provided to patients per policy; and 6. Adequate nursing staff for close monitoring of patients to prevent adverse events and incidents.

The cumulative effects of this deficient practice have the potential to place patients at risk for unmet needs and care required to provide safe, effective treatment for the patients to improve healthcare outcomes.

Findings Include:

The hospital failed to uphold Patient's Rights when they failed to ensure grievances were investigated in accordance with hospital policy, ensure restraints were released every two hours and failed to ensure a physician's order for restraints was obtained before using restraints. (Refer to A0115)

The Hospital failed to ensure it had an adequately organized and staffed nursing service to provide 24-hour nursing care to meet all needs of the patients, who require wound care, timely administration of medication, bathing, release of restraints every two hours, and close monitoring of the patients to prevent adverse events and incidents. (Refer to A0385)

Based on policy reviews, record reviews, and interviews, the hospital failed to uphold Patient's Rights when they failed to ensure grievances were investigated in accordance with hospital policy, failed to ensure restraints were released every two hours and failed to ensure a physician's order for restraints was obtained before using the restraint.

The cumulative effects of this deficient practice have the potential to place patients at risk for unresolved care issues and concerns, inappropriate use of restraints having the potential to place patients at risk for harm.

Findings Include:

1. The hospital failed to ensure grievances were reviewed, investigated, and resolved in accordance with hospital policy. The hospital failed to investigate grievances for two of three patient grievances reviewed (Patient 24 and Patient 25) from 10/05/20 through 03/04/21. (Refer to A0119)

2. The hospital failed to ensure restraints were safely implemented, by releasing the restraints at least every two hours, in accordance with hospital policy for three of three patient records reviewed for restraint use (Patient 2, Patient 8, and Patient 9). (Refer to A0167)

3. The hospital failed to ensure a physician's order was obtained for the use of restraints for one of three patient records reviewed for restraints (Patient 2). (Refer to A0168)

Based on record review, policy review, and interview, the hospital failed to ensure it had an adequately organized, trained and staffed nursing service to provide 24-hour nursing care to meet all needs of the patients, who require wound care, timely administration of medication, bathing, release of restraints every two hours, and close monitoring to prevent adverse events and incidents.

The cumulative effects of this deficient practice have the potential to place all patients at risk for unmet nursing care needs, worsening of wounds, inappropriate use of restraints, poor hygiene and ineffective medications response and medication errors.

Findings Include:

1. The hospital failed to ensure that sufficient numbers of registered nurses (RNs) and nursing aides (NAs) were assigned to meet the needs of the patients. (Refer to A0392)

2. The hospital failed to provide nurses to supervise and evaluate the care of each patient. (Refer to A0395)

3. The hospital failed to ensure all registered nurses (RNs) maintained current Advanced Cardiac Life Support (ACLS) certification and all Nursing Assistants (NAs) maintained current Basic Life Support (BLS) certification. (Refer to A0397)

4. The Hospital failed to ensure medications were administered timely in accordance with hospital policy. (Refer to A0405)

Based on policy review, document review, and interview, the hospital failed to ensure grievances were reviewed, investigated, and resolved in accordance with hospital policy. The hospital failed to investigate grievances for two of three patient grievances reviewed (Patient 24 and Patient 25). This failure had the potential to affect the 38 current inpatients and any future patient admitted to the hospital.

Findings Include:

Review of the facility policy titled, "Complaint and Grievance Process," revised 10/01/17 and reviewed 10/01/20, showed ". . . 3. The patient and the patient's representative may inform the Hospital of a complaint or grievance verbally or in writing. . . 5. If the issue is resolved timely and no further action is needed, the issue will be considered a complaint. 6. If a complaint cannot be resolved timely by the Hospital staff member, it will be considered a grievance. . . 9. The Director of Quality Management and/or Chief Nursing Officer will investigate the circumstances surrounding the concern or complaint and review the issues with the Hospital's CEO [chief executive officer]. The investigative procedure should be completed, corrective action taken and a written response sent within 7 days of receipt of complaint. . ."

The total of seven grievances received from 10/05/20 through 03/04/21 were reviewed during the survey.

1. Review of the grievance submitted by Patient 24 on 11/18/20, showed, "Patient 24 has a trach [tracheostomy defined as an incision in the windpipe made to relieve an obstruction to breathing] - no speaking valve. Texts all things and sends to sister for staff to read. Last night at 2100 [9:00 PM] (11-17-20) RN [Registered Nurse] told the patient that she didn't know if and what he could eat. Pt. [patient] told RN he had to have a BM [bowel movement]. RN said she would get the CNA [certified nursing assistant]. CNA came in an hour later. Pt. tried to get up on EOB [edge of bed] to transfer to BSC [bedside commode], CNA, [name of Staff AA, Nursing Assistant (NA)], told pt. he wasn't allowed to get up and that he had to use the bedpan. Pt. told CNA he could use BSC and CNA said no. At 4:30 [AM] the patient was awake and wanted to get into the wc [wheelchair]. RN asked pt. if he knew it was 4:30 and he told them yes and that he was stiff from being in bed all night. CNA told pt. he better not pull on her hurt her "back [sic]." Pt stated RN and CNA stood over him talking about him and the CNA asking RN if she could give him anything. Pt. said he felt he was being treated as if he was a derelict. Sister has all of the text messages Pt sent to her as he was communicating with staff."

Review of the section of the grievance titled, "What immediate correction action was taken to resolve the complaint?" showed, "Sister called [name of liaison] at 0600 [6:00 AM] on 11-18-20. Pt. showed text messages to [name of Staff Q, Physician] during am [morning] rounds. I spoke with patient and sister. RN and CNA DNR'd [removed] from room."

There was no documentation, in the investigation, regarding Patient 24's grievance that included written employee statements or interviews with staff named in the grievance.

Review of Patient 24's grievance investigation by Complainant W, Interim Chief Nursing Officer, showed no employee statements or interviews were obtained.


2. Review of the grievance submitted by Patient 25's daughter to Staff B, Interim Director of Quality Management (IDQM) on 12/27/20 showed, ". . . Complaint or Concern: 1. Concern with lack of communication about mom's care 2. Phone not plugged in 3. Not contacted about transfer time change 4. Mom not getting out of bed 5. IV [intravenous] tubing, bed controls underneath her in the bed." Review of "What immediate corrective action was taken to resolve the complaint?" showed "Rehab Mgr [manager] spoke to daughter, [first name of daughter], and answered her questions and informed her that the leadership team would respond to all of her concerns."

Review of the section of the grievance titled, "Investigation and follow-up" showed, "A. Investigative Findings: (Attach copies of all written documentation utilized during investigation) Spoke to staff and reviewed patient chart, staff not able to take all of daughter's calls and had problem returning calls timely, staff asked pt [patient] about plugging in her cell and was told no by pt, transferred later than inspected [sic] time by transferring hospital, pt was gotten out of bed per chart, found no issues 9 pressure injuries, skin tears, bruises from cords or IV lines."

There was no documentation of medical record reviewed, written statements by staff involved in Patient 25's care, and/or interviews conducted by Staff B, IDQM, related to an investigation of this grievance.

During an interview on 03/04/21 at 5:05 PM, Staff B, IDQM, stated there was no documentation of the investigation conducted regarding the grievances of Patient 24 and Patient 25's daughter. Staff B, stated that Patient 25's grievance occurred during the holidays and that this was the reason for having no investigation documented. Staff B, offered no reason for lack of documented investigation for Patient 24's grievance.

Based on policy review, record review, and interview, the hospital failed to ensure restraints were safely implemented, by releasing the restraints at least every two hours, in accordance with hospital policy for three of three patient records reviewed for restraint use (Patient 2, Patient 8, and Patient 9). This failure had the potential to affect the five patients currently in restraints at this facility.

Findings Include:

Review of the facility policy titled "Restraint and Seclusion," revised October 2018, showed documentation must include removal of restraints every 2 hours or more often.

1. Review of Patient 2's EMR, under the "Chart review" tab, showed Patient 2 was admitted on 01/31/21 and expired on 02/08/21.

Review of Patient 2's electronic medical record (EMR), under the "Orders" tab, showed a physician's order for "soft wrist restraints," bilateral [both wrists], due to "interference with medical treatment," for 24 hours on 01/14/21 at 8:03 PM through 02/07/21 (ordered daily at 7:00 AM), except on 01/22/21 when there was no physician's order documented for restraints.

Review of the documentation of restraint release, located under the "Flowsheets" tab, showed Patient 2's restraints remained in place without release on the following days and times:

01/15/21 from 4:00 AM to 8:00 AM - four hours without release;
01/15/21 from 2:00 PM to 8:00 PM - six hours without release;
01/16/21 from 12:00 AM to 8:00 AM - eight hours without release;
01/18/21 from 4:00 AM to 8:00 AM - four hours without release;
01/21/21 at 12:00 PM to 8:00 AM on 01/23/21 - 44 hours without release;
01/24/21 at 6:00 PM to 8:00 AM on 01/25/21 - 14 hours without release;
01/25/21 at 6:00 PM to 8:00 PM on 01/26/21 - 14 hours without release;
01/29/21 at 6:00 PM to 8:00 AM on 01/30/21 - 14 hours without release;
01/31/21 at 6:21 PM to 8:00 AM on 02/01/21 - 13 hours without release;
02/01/21 at 4:00 PM to 8:00 AM on 02/02/21 - 16 hours without release;
02/03/21 at 2:00 PM to 8:00 PM - six hours without release;
02/06/21 at 5:30 PM to 8:00 AM on 02/07/21 - 14 hours 30 minutes without release; and
02/07/21 at 6:00 PM to 8:00 AM on 02/08/21 - 14 hours without release.


2. Review of Patient 8's EMR, under the "Chart review" tab, showed Patient 8 was admitted on 02/26/21.

Review of Patient 8's EMR, under the "Orders" tab, showed a physician's order for "mittens untied" due to "interference with medical treatment on 02/27/21 at 4:01 AM and a physician's order for "soft wrist restraints," bilateral, due to "interference with medical treatment," for 24 hours on 02/27/21 at 8:08 PM and daily through an order documented on 03/03/21 at 7:19 AM (the day the medical record was reviewed).

Review of the use of restraints, located under the "Flowsheets" tab, showed the restraints remained in place without release on the following days and times:

02/27/21 at 8:00 AM to 12:00 PM - four hours without release;
02/28/21 at 12:00 AM to 8:00 AM - eight hours without release;
02/28/21 at 10:00 PM to 6:00 AM on 03/01/21 - eight hours without release; and
03/02/21 at 2:00 PM to 10:00 PM - eight hours without release.


3. Review of Patient 9's EMR, under the "Chart Review" tab, showed Patient 9 was admitted on 02/15/21.

Review of Patient 9's EMR, under the "Orders" tab, showed a physician's order for "soft wrist restraints," due to "interference with medical treatment," for 24 hours on 02/26/21 at 1:30 AM, and daily for 24 hours through the order written on 03/03/21 at 1:52 AM (the day the EMR was reviewed).

Review of the use of restraints, located under the "Flowsheets" tab, showed restraints remained in place without release on the following days and times:

02/28/21 at 6:57 AM to 10:00 AM - three hours 3 minutes without release;
02/28/21 at 10:00 PM to 1:46 AM on 03/01/21 - three hours 46 minutes without release;
03/01/21 at 12:00 PM to 4:00 PM - four hours without release;
03/01/21 at 4:00 PM to 8:00 PM - four hours without release; and
03/02/21 at 6:00 AM to 12:00 PM - six hours without release.

During interviews on 03/03/21 at 1:00 PM and 2:00 PM, Staff A, Interim Chief Nursing Officer (ICNO), stated restraints are supposed to be removed every two hours. Staff A, confirmed Patient 2, Patient 8 and Patient 9 did not have their restraints removed in accordance with the hospital's restraint policy.

Based on policy review, medical record review, and interview, the hospital failed to ensure a physician's order was obtained for the use of restraints for one of three patient records reviewed for restraints (Patient 2). This deficient practice has the potential to place patients at risk for inappropriate use of restraints.

Findings Include:

Review of the facility policy titled "Restraints and Seclusion," revised October 2018, showed a written order, based on an examination of the patient by the MD/DO [medical doctor/doctor of osteopathy] or LIP [licensed independent practitioner] is entered into the patient's medical record on a daily basis when restraint use is clinically appropriate.

Review of Patient 2's electronic medical record (EMR) under the "Flowsheets" tab, with Staff A, Interim Chief Nursing Officer (ICNO) showed Patient 2 was placed in restraints on 01/22/21. Review of Patient 2's "Physician Orders," located under the "Orders" tab, showed no documented evidence that a physician's order was obtained for restraint use on 01/22/21.

During an interview on 03/04/21 at 12:43 PM, Staff A, Interim Chief Nursing Officer, stated that Patient 2's EMR had no documented evidence that a physician's order was obtained for restraint use on 01/22/21.

Based on record review, document review, interview and observation, the hospital failed to ensure that sufficient numbers of registered nurses (RNs) and nursing aides (NAs) were assigned to meet the needs of the patients for seven of 26 patients sampled. This failure hindered the licensed staff from: 1. Performing wound care as ordered for two of two records reviewed for wound care (Patient 1 and Patient 6); 2. Administering timely medications for three of four records reviewed for medication administration (Patient 6, Patient 8, and Patient 2); 3. Providing direction and supervision of NAs in their delivery of patient baths for five of five records reviewed for bathing (Patient 2, Patient 5, Patient 6, Patient 8, and Patient 9); 4. Providing direction and supervision of NAs in periodically releasing patients from restraints per facility policy for three of three records reviewed for restraint use (Patient 2, Patient 8, and Patient 9; and 5. Providing close monitoring of patient's to prevent adverse events or incidents. These deficient practices have the potential to negatively impact the quality of care provided to all patients admitted to this facility.

Findings Include:

Review of the facility policy, "Staffing, Nursing," with revision date of 10/01/18, showed, The Chief Nursing Officer, or designee, is responsible for developing the staffing plan and schedule. The schedule is developed based on the acuity (scoring system based on complexity of care) of patients and the required skill level of the staff necessary to care for those patients ...The nurse/patient ratio varies depending on the acuity of the patients. There will be a sufficient number of profession registered nurses to provide direct patient care and supervise all licensed and non-licensed nursing staff.

1. Review of the facility policy titled, "Wound Documentation," issued 12/01/18, showed that dressing changes and wound site care are documented in the medical record (MR) or electronic medical record (EMR).

Review of the registered nurse (RN) "Job Description," revised 02/10/14, showed job-specific duties and competencies included the performance of wound care in accordance with policy, utilizing proper documentation tools.

a. Review of Patient 1's "Face Sheet," in the EMR showed he was admitted on 11/20/20 and discharged on 01/29/21. His admitting diagnosis was COVID-19 pneumonia.

Review of the "Skin/Wound/Assess/Care" tab, located under the "Chart review" tab, dated 11/20/20, by Staff Y, RN, the Wound Care Nurse, showed the following wounds on 11/20/20:

Left upper lateral posterior [side and back of the upper left leg] leg - 24 cm (centimeters) in length by 16 cm in width, no depth documented, with no odor and no drainage.
Pressure ulcer Stage 1 right heel - 4 cm by 4 cm by 0.1 cm (depth) with no drainage.
Pressure injury left lateral ankle - 5 cm by 1.5 cm by 0.1 cm with serosanguineous [thin clear fluid with blood present], thin watery pale pink drainage.
Pressure ulcer Stage 3 coccyx -7 cm by 12 cm by 0.1 cm with serosanguineous, thin watery pale pink drainage.
Pressure injury left heel - 6.9 cm by 5.5 cm with no depth with no drainage.

Review of "Physician Orders", located under the "Orders" tab, showed the following orders for daily or twice weekly wound care:

11/21/20 at 4:38 AM - clean left upper lateral thigh with normal saline, prep (preparation) with skin prep and allow to dry, apply Medipore (soft cloth adhesive wound dressing) and pad with soft cloth adhesive dressing daily.

11/21/20 at 8:35 AM - clean coccyx with normal saline, prep with skin prep and allow to dry, apply adhesive foam every Tuesday and Friday and when soiled.

11/25/20 at 6:25 PM - clean left lateral ankle with normal saline, prep with skin prep and allow to dry, cover with composite island dressing (a water-proof non-adherent soaker pad with an adhesive border and a barrier layer used on pressure ulcers) Tuesday and Friday and when soiled.

Review of Patient 1's "Wound Care Documentation," located in the EMR under the "Skin/Wound/Assess/Care" tab, showed wound care to the left lateral upper thigh was not performed daily by the RN assigned to Patient 1 on the following dates 11/23/20, 11/24/20, 11/27/20, 11/29/20, 11/30/20, 12/01/20, and 12/03/20.

Review of Patient 1's "Wound Care Documentation," located in the EMR under the "Skin/Wound/Assess/Care" tab, showed wound care to the coccyx was not performed by the RN assigned to Patient 1 on the following Tuesdays and/or Fridays: 11/27/20, 12/04/20, 12/08/20, 01/05/21, 01/12/21, 01/19/21, and 01/26/21.

Review of Patient 1's "Wound Care Documentation," located in the EMR under the "Skin/Wound/Assess/Care" tab, showed wound care to the left lateral ankle was not performed by the RN assigned to Patient 1 on the following Tuesdays and/or Fridays: 11/25/20, 12/01/20, 12/03/20, 12/06/20, 12/08/20, 12/10/20.

During an interview on 03/02/21 at 2:30 PM, Staff C, Quality Coordinator (QC), confirmed the above documentation and stated that the wound care was not documented as being performed.


b. Review of Patient 6's EMR showed Patient 6 was admitted on 02/14/21. The "Physician Progress Note" dated 02/15/21 showed reason for admission as, "Open abdominal wound with recent peritonitis (inflammation of the lining of the abdomen) from small bowel perforation.

Review of Patient 6's "Physician Orders," located in the EMR under the "Orders tab," showed an order on 02/19/21 at 12:00 PM for, "Q (Every) 6 hours-open pouch, removed saline moist gauze and silver, rinse wound, cut Reinforced Gelling Fiber AG (Alginate, an absorbent fiber) into a rope and lightly pack into wound. Place saline moist roll gauze onto wound. Gelling fiber and gauze should be placed into the wound as 1 piece each (do not cut either into multiple pieces). Ensure all dressing comes out at change time."

Review of Patient 6's "Flow Sheets," in the EMR wound care was not completed as ordered the following dates: 02/18/21, 02/19/21, and 02/26/21.

During an interview on 03/04/21 at 10:45 AM, with Staff C, QC, confirmed the dates the wound care was not performed as ordered for Patient 6

During an interview on 03/01/21 at 3:35 PM, Staff G, RN, stated, "most of my day is spent charting. . . [administering] insulin and antibiotics are first on my to-do list and wound care is last to the list."


2. Review of the facility policy titled, "Medications: Standard Administration Times," revised July 2020, showed, "Time-Critical Scheduled medications: medications where early or delayed administration of maintenance doses (to maintain a steady dose in the blood) of greater than 30 minutes before or after the scheduled dose may cause harm or result in substantial sub-optimal therapy (less than the desired effect) or pharmacological effect. . . Time-Critical Scheduled Medications 1. Scheduled Medication orders are considered Time-Critical when . . . Any order the physician (notation on order), pharmacist (Notation on MAR [medication administration record] entry), or nurse (notation on MAR entry) determine must be administered at a specific time. . . 2. Time-Critical Scheduled Medications should be administered within 30 minutes before or after the scheduled time. Review of the chart on page four of the policy listing Time-Critical Medications showed, "IV [intravenous] Antibiotics," was listed as a Time-Critical Medication."


a. Review of Patient 6's "Physician Orders," located in the EMR under the "Orders tab," showed an order on 02/19/21 at 12:00 PM for, "Daptomycin [an antibiotic] 350 mg [milligrams] in sodium chloride 0.9% [per cent] 100 ml [milliliters] IVPB [intravenous piggyback/small bag attached to the primary IV bag] every 24 hours at 200 ml per hour over 30 minutes."

Review of Patient 6's "MAR" in the EMR, from 02/21/21 through 03/01/21, showed Patient 6 received Daptomycin more than 30 minutes before and/or after the scheduled time on the following days and times:

02/20/21 at 1:44 PM - scheduled to be given at 12:00 PM
02/21/21 at 11:01 AM - scheduled to be given at 12:00 PM
02/23/21 at 2:26 PM - scheduled to be given at 12:00 PM
02/24/21 at 12:41 PM - scheduled to be given at 12:00 PM
02/25/21 at 1:38 PM - scheduled to be given at 12:00 PM
02/26/21 at 2:44 PM - scheduled to be given at 12:00 PM
03/01/21 at 2:40 PM - scheduled to be given at 12:00 PM
03/02/21 at 3:36 PM - scheduled to be given at 12:00 PM
03/03/21 at 3:06 PM - scheduled to be given at 12:00 PM


b. Review of Patient 8's "Physician Orders," located under the "Orders tab," showed an order dated 03/03/21 at 7:43 PM for, "Piperacillin-tazobactam [an antibiotic] 3.375 grams in sodium chloride 0.9% 100 ml IVPB every six hours at 200 ml per hour."

Review of Patient 8's "MAR" in the EMR showed Patient 8 received the first dose on 03/03/21 at 9:09 PM, with the second dose being administered on 03/04/21 at 1:14 AM (4 hours 5 minutes after the first dose was administered).


c. Review of Patient 21's "Physician Orders," located under the "Orders tab," showed an order dated 02/21/21 at 6:12 PM for, "Piperacillin-tazobactam 3.375 grams in sodium chloride 0.9% 100 ml IVPB every six hours at 200 ml per hour."

Review of Patient 21's "MAR" in the EMR showed Patient 21 received Piperacillin-tazobactam more than 30 minutes before and/or after the scheduled time on the following days and times:

02/21/21 at 11:24 PM - scheduled to be given at 12:00 PM
02/22/21 at 12:46 PM - scheduled to be given at 12:00 PM
02/23/21 at 1:06 PM and 7:14 PM - scheduled to be given at 6:00 PM
02/25/21 at 1:28 PM and 6:57 PM - scheduled to be given at 6:00 PM
02/26/21 at 11:17 AM and 11:24 PM - scheduled to be given at 12:00 PM
02/27/21 at 10:30 AM and 6:55 PM - scheduled to be given at 6:00 PM
02/28/21 at 12:57 AM, 6:43 AM, and 5:15 PM - scheduled to be given at 6:00 PM
03/01/21 at 4:48 AM, 3:19 PM, and 7:31 PM - scheduled to be given at 6:00 PM
03/02/21 at 5:22 AM and 12:44 PM - scheduled to be given at 12:00 PM


During an interview on 03/04/21 at 2:00 PM, Staff A, Interim Chief Nursing Officer (ICNO), confirmed the antibiotic administrations for Patient 6, Patient 8, and Patient 21 were given more than 30 minutes before and/or after the scheduled times as ordered. Staff A, stated that the times should have been 30 minutes before or after 12:00 AM, 6:00 AM, 12:00 PM, and 6:00 PM for Patient 21 and 30 minutes before and/or after 12:00 PM for Patient 6. Staff A, stated that Piperacillin-tazobactam should not have been administered to Patient 8 until 3:00 AM.


3. Review of the facility policy titled, "Guidelines and Protocols, Clinical," revised 10/01/20, showed patients are to be bathed/hair combed/shaved daily.

a. Review of Patient 2's EMR under the "Chart Review" tab, showed the patient was admitted on 01/13/21 and expired on 02/08/21.

Review of the EMR under the "Comfort & [and] Hygiene" tab under the "Flowsheets" tab, showed Patient 2 did not receive a daily bath on 01/16/21, 01/18/21, 01/21/21, 01/22/21, 01/26/21, 01/29/21, 01/31/21, 02/01/21, and 02/04/21. There was no documented reason why Patient 2 did not receive daily baths.


b. Review of Patient 5's EMR showed Patient 5 was admitted on 01/29/21.

Review of Patient 5's EMR under the "Comfort & Hygiene" tab under the "Flow Sheets," tab from 02/03/21 to 03/01/21 showed that Patient 5 received a total of five bed baths (two of these on the same date) during this time. There was no documented reason why Patient 5 did not receive daily baths.

During an interview on 03/02/21 at 12:05 PM, when asked about care, Patient 5 stated that she does not receive a bath every day. When asked if linens were changed, Patient 5 replied, "Not except when I get a bed bath." Patient 5 added, "My chux (disposable absorbent pad) has not been changed either." When asked when she last had a bed bath, Patient 5 responded, two or three days, maybe five, I know they (staff) are busy on the week-end."

During an interview on 03/04/21 at 10:45 AM, Staff C, QC, verified the documentation in Patient 5's EMR and confirmed that daily baths had not been given to Patient 5 per policy.


c. Review of Patient 6's EMR showed Patient 6 was admitted on 02/14/21.

Review of "Flow Sheets," in the EMR under the "Comfort & Hygiene" tab, from 02/21/21 to 03/01/21, showed that Patient 6 had received three bed baths during this time. All additional documentation notes showed that "Skin/incontinence cleanser/wipes" had been used for this patient for "peri care."

During an interview with Staff C, QC, on 03/04/21 at 10:45 AM, Staff C, QC verified the documentation noted above and confirmed Patient 6 did not receive a daily bath per policy.


d. Review of Patient 8's EMR showed Patient 8 was admitted on 02/26/21.

Review of Patient 8's "Flowsheets, in the EMR under the "Comfort & Hygiene" tab, from 02/26/21 to 03/04/21, showed Patient 8 did not receive a daily bath on 02/26/21, 02/27/21, 02/28/21, 03/01/, 03/02/21, 03/03/21, and 03/04/21. There was no documented reason why Patient 8 did not receive daily baths.


e. Review of Patient 9's EMR, under the "Chart Review" tab, showed Patient 9 was admitted on 02/15/21.

Review of the "Flowsheets" under the "Comfort & Hygiene" tab, from 02/16/21 to 02/27/21 showed Patient 9 did not receive a daily bath on 02/16/21, 02/17/21, 02/18/21, 02/20/21, 02/23/21, 02/24/21, and 02/27/21. There was no documented reason why Patient 8 did not receive daily baths.


During an interview on 03/04/21 at 2:00 PM, Staff A, ICNO, confirmed that the documentation showed baths were not given daily to Patient 2, Patient 5, Patient 6, Patient 8, or Patient 9, per facility policy.

During an interview on 03/01/21 at 3:00 PM, Staff E, RN, stated, "The bed baths and turning [patients] may be lacking when short of a CNA."

During an interview on 03/01/21 at 3:35 PM, Staff G, RN, stated, "On a daily basis there are patients who don't get a bed bath. Quite often there are days in a row that patients don't get a bed bath."

During an interview on 03/01/21 at 4:20 PM, Staff K, NA, stated, "The NA has to make the decision of what won't get done, and the RNs don't make those decisions." She stated, "I report to the oncoming NA, not the RN about what has and hasn't been done." She stated that when one NA goes to break or lunch, she has to assist to cover that NA's patients.

During an interview on 03/02/21 at 8:50 AM, Staff L, NA, stated that she isn't able to bathe all her assigned patients every day. Staff L, NA stated, "Making sure a patient is cleaned is priority, but I may not be able to bathe a patient."


4. Review of the facility policy titled "Restraint and Seclusion," revised October 2018, showed documentation must include removal of restraints every 2 hours or more often.

a. Review of Patient 2's electronic medical record (EMR), under the "Orders" tab, showed a physician's order for "soft wrist restraints," bilateral [both wrists], due to "interference with medical treatment," for 24 hours on 01/14/21 at 8:03 PM through 02/07/21 (ordered daily at 7:00 AM), except on 01/22/21 when there was no physician's order documented for restraints.

Review of Patient 2's EMR, under the "Chart review" tab, showed Patient 2 was admitted on 01/31/21 and expired on 02/08/21. Review of the documentation of restraint release, located under the "Flowsheets" tab, showed the restraints remained in place without release on the following days and times:

01/15/21 from 4:00 AM to 8:00 AM - four hours without release;
01/15/21 from 2:00 PM to 8:00 PM - six hours without release;
01/16/21 from 12:00 AM to 8:00 AM - eight hours without release;
01/18/21 from 4:00 AM to 8:00 AM - four hours without release;
01/21/21 at 12:00 PM to 8:00 AM on 01/23/21 - 44 hours without release;
01/24/21 at 6:00 PM to 8:00 AM on 01/25/21 - 14 hours without release;
01/25/21 at 6:00 PM to 8:00 PM on 01/26/21 - 14 hours without release;
01/29/21 at 6:00 PM to 8:00 AM on 01/30/21 - 14 hours without release;
01/31/21 at 6:21 PM to 8:00 AM on 02/01/21 - 13 hours without release;
02/01/21 at 4:00 PM to 8:00 AM on 02/02/21 - 16 hours without release;
02/03/21 at 2:00 PM to 8:00 PM - six hours without release;
02/06/21 at 5:30 PM to 8:00 AM on 02/07/21 - 14 hours 30 minutes without release; and
02/07/21 at 6:00 PM to 8:00 AM on 02/08/21 - 14 hours without release.


b. Review of Patient 8's EMR, under the "Chart review" tab, showed Patient 8 was admitted on 02/26/21. Review of Patient 8's EMR, under the "Orders" tab, showed a physician's order for "mittens untied" due to "interference with medical treatment on 02/27/21 at 4:01 AM and a physician's order for "soft wrist restraints," bilateral, due to "interference with medical treatment," for 24 hours on 02/27/21 at 8:08 PM and daily through an order documented on 03/03/21 at 7:19 AM (the day the medical record was reviewed).

Review of the use of restraints, located under the "Flowsheets" tab, showed the restraints remained in place without release on the following days and times:

02/27/21 at 8:00 AM to 12:00 PM - four hours without release;
02/28/21 at 12:00 AM to 8:00 AM - eight hours without release;
02/28/21 at 10:00 PM to 6:00 AM on 03/01/21 - eight hours without release; and
03/02/21 at 2:00 PM to 10:00 PM - eight hours without release.


c. Review of Patient 9's EMR, under the "Chart Review" tab, showed Patient 9 was admitted on 02/15/21. Review of Patient 9's EMR, under the "Orders" tab, showed a physician's order for "soft wrist restraints," due to "interference with medical treatment," for 24 hours on 02/26/21 at 1:30 AM and daily for 24 hours through the order written on 03.03/21 at 1:52 AM (the day the EMR was reviewed).

Review of the use of restraints, located under the "Flowsheets" tab, showed restraints remained in place without release on the following days and times:

02/28/21 at 6:57 AM to 10:00 AM - three hours 3 minutes without release;
02/28/21 at 10:00 PM to 1:46 AM on 03/01/21 - three hours 46 minutes without release;
03/01/21 at 12:00 PM to 4:00 PM - four hours without release;
03/01/21 at 4:00 PM to 8:00 PM - four hours without release; and
03/02/21 at 6:00 AM to 12:00 PM - six hours without release.

During interviews on 03/03/21 at 1:00 PM and 2:00 PM, Staff A, Interim Chief Nursing Officer (ICNO), stated restraints are supposed to be removed every two hours. Staff A, ICNO confirmed Patient 2, Patient 8 and Patient 9 did not have their restraints periodically removed in accordance with the hospital's restraint policy.


5. Review of the "Patient Incident Log," on 03/03/21 at 9:30 AM, showed a total of 89 patient incidents reported from 12/02/20 through 02/28/21, 32 reported in December; 31 reported in January, and 26 reported in February. Review of a sample of 13 "Patient Incident Reports," showed the following:

a. Patient 10: The "Incident Report," dated 12/14/20, showed, "Order read: clean, skin prep with alginate AG (non-adhesive wound dressing) and cover with AB (Abdominal pad) Daily and PRN (as needed). Review of flow sheet showed that the assessment or dressing change was not completed on 12/12/20 or 12/13/20."

b. Patient 15: The "Incident Report," dated 12/28/20 showed, "The patient had been in restraints all night due to risk of self-decannulating (removal of a tube inserted into the body used for multiple medical reasons). Patient self-decannulated and did not have the right sided restraint on."

c. Patient 16: The "Incident Report," dated 12/29/20, showed, "Patient was found in bed with trach (tracheostomy tube/tube placed in the airway for breathing) laying on linens beside (patient). Patient was restrained but the ties were loose, and the patient was still able to reach mouth."

d. Patient 11: The "Incident Report," dated 12/29/20, showed, "Patient was found to have an unstageable PI (Pressure Injury) to gluteus area. No support surface orders (cushions to relieve pressure), no wound care treatment ordered. No prevention/treatment ordered."

e. Patient 17: The "Incident Report," dated 01/04/21 at 6:15 AM, showed, "Patient was found lying in bed with head towards the left side of bed and feet towards the foot board. NG (Nasogastric Tube/flexible tube passed through the nostrils) tube draped over the top of mattress, head of the bed and to the IV (intravenous) pole. Patient remains in bilateral (both sides of the body) wrist restraints. Noted that the last time patient was checked was at 4:35 AM."

f. Patient 18: The "Incident Report," dated 01/04/21 at 12:00 AM, showed, "Patient was found with no barrier between skin and heating pad/blanket. Patient was found with fluid-filled blisters noted to right back."

g. Patient 13: Two "Incident Reports" were reviewed. The report dated 01/12/21 showed, "Patient's boot had been washed due to soiling. Not on while drying." The report dated 01/20/21 showed, "Had an order to cleanse right ear, pat dry, skin prep (preparation) and apply foam. The documentation failed to show that the foam was applied."

h. Patient 20: The "Incident Report," dated 01/16/21, showed, "Patient had been placed on a Precedex (sedative) drip. The dynamap (noise mapping system) was not on the screen for observation of the O2 (oxygen) and BP (blood pressure) for continuous monitoring."

i. Patient 1: The "Incident Report," dated 01/20/21, showed, "Wound care was to be implemented and was four days late."

j. Patient 19: Two "Incident Reports," were reviewed. Both reports, dated 01/25/21 and 01/26/21, showed, "The patient had removed Dobhoff (nasogastric tube). Both hands remained restrained."

k... Patient 6: The "Incident Report," dated 02/18/20 at 11:00 AM, showed, "Wound care to open ABD (Abdominal)-Moist gauze change ever six hours r/t exposed bowel. Wound care omitted on 2/18/21 at 11:00 and 1700 (5:00 PM). At 5:15 PM on the same date, the (hollow tube with a long needle) got displaced. The nurse replaced the Huber needle and restarted the TPN (total parenteral nutrition/feeding given through the veins) through the patient's left chest port (a reusable intravenous access). TPN infiltrated (punctured the vein, allowing escape of fluid) into tissue of the upper chest and left breast. Dry gangrene (death of tissue) was noted."

During an interview and review of "Patient Incident Reports," on 03/03/21 at 9:30 AM, Staff B, IDQM, confirmed the accuracy of the reports noted above, and stated, regarding Patient 18, "The patient was not checked by the RN as (the patient) should have been. Staff B, agreed there were a large number of incidents which reflected lack of patient monitoring. When asked, Staff B, IDQM did not agree that staffing issues impacted the numbers or types of incidents at this facility.

During an interview on 03/01/21 at 3:00 PM Staff E RN stated, "My job is terrible because of staffing. I was told when I was hired (01/13/21) that I would have four patients assigned to me, sometimes five. Now five (patients) are the norm. They (administration) want us to document in real time which is unrealistic." Staff E, RN further stated, "The charge nurse (nurse supervisor) makes patient assignments by acuity level. These patients have increased risk for airway problems. We have to give meds (medications), do assessments, wound care, tube feedings, PRN (as needed) pain meds. I have to help with bed baths, turning patients and moving patients out of bed. We cannot give bed baths every day, but they should be every day.".

During an interview on 03/01/21 at 3:35 PM, Staff G, RN, stated, "Yesterday (02/28/21) started out with six RNs with six patients each. At 10:00 AM, another RN came on duty and my assignment was changed. We are almost guaranteed to have five patients assigned every day now. I was told when I was hired (08/29/20) that I never would have more than four patients and that having five patients would be a bad day. It is hard to give good care. I have to help with ADL's (Activities of Daily Living) such as bed baths. It is not unusual (for patients) not to get a bath or shower. It is unsafe to have five patients; having six patients is unrealistic. I have to give meds, check blood sugars, give Insulin, do IVs, and charting." When asked which patient care functions had to be left incomplete due to lack of time, Staff G, RN responded, "Wounds are last on my list."

During an interview on 03/01/21 at 4:30 PM, Staff K, NA, stated, "I am assigned 13 patients today. I can't give proper care. I'm supposed to get patients up two times each day, feeding, rounding (going from patient to patient), bed baths. Twelve of my 13 patients require total care. Only one can provide their own care. I make my own decisions about patient care priorities. We are understaffed; they work us too hard."

During an interview on 03/02/21 at 8:50 AM Staff L, NA, stated, "I have nine patients today. I could have a whole hall by myself -17 patients. Ten to 13 is my average (patient assignment) for total care, bathing. Every 30-45 minutes I have to clean a patient up, especially when I'm on South Wing. It's not safe to clean patients by myself. I may have to wait for someone to help me. We usually bathe half of the patients, the even numbers (room numbers), on my shift. Nurses help to fill in. I get clean linen for the unit for the next shift. I take dietary carts to the kitchen."

During an interview on 03/02/21 at 9:15 AM, Staff H, RN, reported that she had been assigned five patients today. Staff H, RN, stated, "One of my patients was just taken off of profonol [sic] (a cardiac medication) drip. One of my other patients has bilateral tubes and is confused. A third patient is not demanding but is not able to call for help (requiring close supervision and monitoring)." Staff H, RN, further stated, "I need to do complex tasks for these patients." Staff H, RN, stated, "Thirteen patients for NAs is too many. From my experience, six-seven patients for the NA is a reasonable assignment. If the NA has so many patients, I would not expect them to do all of the baths. I want the best for my patients; the patient load needs to be less."

During an interview on 03/02/21 at 9:50 AM, Staff I, RN, stated, "Staffing is determined by acuity (a scoring system based on complexity of care) after assessing each patient. I think the acuity level could be updated." When asked if Staff I, RN, felt the number of patients assigned to each RN was realistic, she responded, "Not all the time ... I have addressed with management that patient admissions should be held. I talked to business (personnel) about stopping admissions. I have talked to this Chief Executive Officer (CEO) about admissions ... I have not asked if patient census could be lowered." Staff I, RN also stated that staffing definitely affects resignations (of staff). Staff I, RN, stated, "They (staff) talk about this. They express to me that they have not been heard. I know what it is like to be on the floor, I know staffing has been a major issue for staff. They feel like 'they are brushed under the rug."

During an interview on 03/02/21 at 10:25 AM, Staff A, Chief Nursing Officer (CNO), stated, "Nurses are staffed based on acuity. NA assignments are based on census. Nurses can be assigned patients with acuity with a total of 12 points. Last time the acuity system was revised was in 2018." When asked if she agreed that the staffing acuity system needed to be revised, Staff A, CNO replied, "It should be reviewed." Staff A, CNO stated that there is nothing in the acuity system to upgrade (acuity level) based on numbers of high-level tasks required by the RNs and stated that NAs are assigned based on "activities." Staff A, CNO failed to explain what "based on activities meant when asked by the surveyors. When asked if Staff A, CNO had requested that the census be reduced, she responded, "We may hold or delay admissions. We had used the staff pool. We have given bonuses for overtime." When asked if Staff A, CNO agreed that the facility has enough staff to care for the patient's problem, she replied, "We have staffing issues at times, but we look at it daily. We do not have a staffing problem. We had a conversation last week about how to fully staff. I talked last week with governing board." Staff A, CNO stated that their aim for NAs' patient assignments is seven to one on Day shift and six to one on Night shift.

During interview with the Chief Executive Officer (CEO) on 03/02/21 at 11:30 AM, the CEO stated that the facility did not have a nursing problem. When asked if the facility had considered capping (decreasing) the patient census until staffing numbers had improved, the CEO responded, "We haven't seen the need to do that. We are looking at staffing (nursing) issues day to day and may delay a patient admission."

Based on policy review, medical record review, and interview, the hospital did not provide nurses to supervise and evaluate the care of each patient by failing to: 1. Ensure the registered nurses (RNs) performed wound care according to physician orders for two of two patient records reviewed for wound care (Patient 1 and Patient 6); 2. Ensure nursing staff performed required daily baths for five of five patient records reviewed for daily baths (Patient 2, Patient 5, Patient 6, Patient 8, and Patient 9); 3. Ensure the RN supervised the release of restraints every two hours as required by hospital policy for three of three patient records reviewed for restraint use (Patient 2, Patient 8, Patient 9); and 4. Ensure nursing staff obtained a physician's order for restraints for one of three patient records reviewed for restraint use (Patient 2). This deficient practice has the potential to negatively impact the skin integrity and overall well-being of all patients in the facility.

Findings Include:

1. Review of the facility policy titled, "Wound Documentation," issued 12/01/18, showed dressing changes and wound site care are documented in the MR [medical record] or EMR [electronic medical record].

Review of the RN "Job Description," revised 02/10/14, showed job-specific duties and competencies included performance of wound care in accordance with policy, utilizing proper documentation tools.

a. Review of Patient 1's "Face Sheet" in the EMR showed an admission date of 11/20/20 and discharged on 01/29/21. Review of Patient 1's EMR under the "Skin/Wound/Assess/Care" tab, located under the "Chart review" tab, showed documentation by Staff Y, Registered Nurse (RN), the Wound Care Nurse, of the following wounds on 11/20/20:

Left upper lateral posterior [side and back of the upper left leg] leg - 24 cm (centimeters) in length by 16 cm in width, no depth documented, with no odor and no drainage.
Pressure ulcer Stage 1 right heel - 4 cm by 4 cm by 0.1 cm (depth) with no drainage.
Pressure injury left lateral ankle - 5 cm by 1.5 cm by 0.1 cm with serosanguineous [thin clear fluid with blood present], thin watery pale pink drainage.
Pressure ulcer Stage 3 coccyx -7 cm by 12 cm by 0.1 cm with serosanguineous, thin watery pale pink drainage.
Pressure injury left heel - 6.9 cm by 5.5 cm with no depth with no drainage.

Review of Patient 1's "Physician Orders", located in the EMR under the "Orders" tab, showed the following wound care orders:

11/21/20 at 4:38 AM - clean left upper lateral thigh with normal saline, prep (preparation) with skin prep and allow to dry, apply Medipore (soft cloth adhesive wound dressing) and pad with soft cloth adhesive dressing daily.

11/21/20 at 8:35 AM - clean coccyx with normal saline, prep with skin prep and allow to dry, apply adhesive foam every Tuesday and Friday and when soiled.

11/25/20 at 6:25 PM - clean left lateral ankle with normal saline, prep with skin prep and allow to dry, cover with composite island dressing (a water-proof non-adherent soaker pad with an adhesive border and a barrier layer used on pressure ulcers) Tuesday and Friday and when soiled.

Review of Patient 1's "Wound Care Documentation," located in the EMR under the "Skin/Wound/Assess/Care" tab, showed wound care to the left lateral upper thigh was not performed daily by the RN assigned to Patient 1 on the following dates: 11/23/20, 11/24/20, 11/27/20, 11/29/20, 11/30/20, 12/01/20, and 12/03/20. The "Progress Note," dated 12/11/20, by the Wound Care Nurse showed this wound was considered resolved, therefore wound care was discontinued.

Review of Patient 1's "Wound Care Documentation," located in the EMR under the "Skin/Wound/Assess/Care" tab, showed wound care to the coccyx was not performed by the RN assigned to Patient 1 on the following Tuesdays and/or Fridays: 11/27/20, 12/04/20, 12/08/20, 01/05/21, 01/12/21, 01/19/21, and 01/26/21.

Review of Patient 1's "Wound Care Documentation," located in the EMR under the "Skin/Wound/Assess/Care" tab, showed wound care to the left lateral ankle was not performed by the RN assigned to Patient 1 on the following Tuesdays and/or Fridays: 11/25/20, 12/01/20, 12/03/20, 12/06/20, 12/08/20, 12/10/20. The "Progress Note," dated 12/11/20, by the Wound Care Nurse showed this wound was considered resolved, therefore wound care was discontinued.

During an interview on 03/03/21 at 9:20 AM, Staff Y, RN, Wound Care Nurse, stated that Patient 1's coccyx wound was healing, and Patient 1 had only a skin tear to the middle back on the day of discharge, 01/29/21.

During an interview on 03/02/21 at 2:30 PM, Staff C, QC (Quality Coordinator), confirmed that the wound care was not documented as being performed on the dates noted above for Patient 1.


b. Review of Patient 6's EMR showed Patient 6 was admitted on 02/14/21. The "Physician Progress Note," dated 02/15/21 stated reason for admission and "Physician Orders," as,
"Open abdominal wound with recent peritonitis from small bowel perforation. Multiple abdominal surgeries including exploration laparotomy with small bowel resection and repair of perforation Q (Every) 6 hours-open pouch, removed saline moist gauze and silver, rinse wound, cut Reinforced Gelling Fiber AG (Alginate) into a rope and lightly pack into wound. Place saline moist roll gauze onto wound. Gelling fiber and gauze should be placed into the wound a 1 piece each (do not cut either into multiple pieces). Ensure all dressing comes out at change time."

Review of Patient 6's "Flow Sheets," in the EMR wound care was not completed as ordered on the following dates: 02/18/21, 02/19/21, and 02/26/21.

During an interview with Staff C, QC, on 03/04/21 at 10:45 AM, she confirmed the dates the wound care was not performed as ordered for Patient 6 as noted above.

During an interview on 03/01/21 at 3:35 PM, Staff G, RN, stated, "Most of my day is spent charting. . . [administering] insulin and antibiotics are first on my to-do list and wound care is last to the list."


2. Review of the facility policy titled, "Guidelines and Protocols, Clinical," revised 10/01/20, showed patients are to be bathed/hair combed/shaved daily.

a. Review of Patient 2's EMR, showed Patient 2 was admitted on 01/31/21 and expired on 02/08/21.

Review of the EMR under the "Comfort & [and] Hygiene" tab under the "Flowsheets" tab, showed Patient 2 did not receive a bath on 01/16/21, 01/18/21, 01/21/21, 01/22/21, 01/26/21, 01/29/21, 01/31/21, 02/01/21, and 02/04/21.

b. Review of Patient 5's EMR showed Patient 5 was admitted on 01/29/21. The "Physician Progress Note," dated 01/30/21 showed reason for admission as "Respiratory failure, on high-flow oxygen. Patient recovering from COVID."

During an interview on 3/2/21 at 12:05 PM, Patient 5 stated, "I do not receive a bath every day." When asked if linens were changed, Patient 5 replied, "Not except when I get a bed bath." Patient 5 added, "My chux (disposable absorbent pad) has not been changed either." When asked when she last had a bed bath, Patient 5 responded, two or three days, maybe five, I know they (staff) are busy on the week-end."

Review of Patient 5's "Flow Sheets," in the EMR from 02/03/21 to 03/01/21 showed that Patient 5 had received a total of five bed baths (two of these on the same date) during this time period. All additional documentation notes showed that "Skin/incontinence cleanser/wipes" had been used for this patient for "peri care (to the groin area only)."

During an interview on 03/04/21 at 10:45 AM, Staff C, QC, verified this information in Patient 5's EMR and confirmed that daily baths had not been given to Patient 5 per policy.


c. Review of Patient 6's "Flow Sheets," in the EMR from 02/21/21 to 03/01/21 showed that Patient 6 had received three bed baths during this time period. All additional documentation notes showed that "Skin/incontinence cleanser/wipes" had been used for this patient for "peri care."

During an interview on 03/04/21 at 10:45 AM, Staff C, QC verified the documentation noted above and confirmed Patient 6 did not receive a daily bath per policy.

d. Review of Patient 8's EMR, showed Patient 8 was admitted on 02/26/21.

Review of the "Flowsheets, "under the "Comfort & Hygiene" tab in the EMR, showed Patient 8 did not receive a bath on 02/26/21, 02/27/21, 02/28/21, 03/01/, 03/02/21, 03/03/21, and 03/04/21.


e. Review of Patient 9's EMR, showed Patient 9 was admitted 02/15/21.

Review of the "Flowsheets", under the "Comfort & Hygiene" tab, showed Patient 9 did not receive a bath on 02/16/21, 02/17/21, 02/18/21, 02/20/21, 02/23/21, 02/24/21, and 02/27/21.

During an interview on 03/04/21 at 2:00 PM, Staff A, ICNO, confirmed that the documentation showed baths were not given daily to Patient 2, Patient 5, Patient 6, Patient 8, or Patient 9, per facility policy.

During an interview on 03/01/21 at 3:00 PM, Staff E, RN, stated, "The bed baths and turning [patients] may be lacking when short of a CNA."

During an interview on 03/01/21 at 3:35 PM, Staff G, RN, stated, "On a daily basis there are patients who don't get a bed bath. Quite often there are days in a row that patients don't get a bed bath."

During an interview on 03/01/21 at 4:20 PM, Staff K, NA, stated, "The NA has to make the decision of what won't get done, and the RNs don't make those decisions." She stated, "I report to the oncoming NA, not the RN about what has and hasn't been done." She stated that when one NA goes to break or lunch, she has to assist to cover that NA's patients.

During an interview on 03/02/21 at 8:50 AM, Staff L, NA, stated that she isn't able to bathe all her assigned patients every day. Staff L, NA stated, "Making sure a patient is cleaned is priority, but I may not be able to bathe a patient."


3. Review of the facility policy titled "Restraint and Seclusion," revised October 2018, showed documentation must include removal of restraints every two hours or more often.

Review of Patient 2's electronic medical record (EMR), under the "Orders" tab, showed a physician's order for "soft wrist restraints," bilateral [both wrists], due to "interference with medical treatment," for 24 hours on 01/14/21 at 8:03 PM through 02/07/21 (ordered daily at 7:00 AM), except on 01/22/21 when there was no physician's order documented for restraints.

Review of the documentation of restraint release, located under the "Flowsheets" tab, showed the restraints remained in place without release remained in place without release on the following days and times:

01/15/21 from 4:00 AM to 8:00 AM - four hours without release;
01/15/21 from 2:00 PM to 8:00 PM - six hours without release;
01/16/21 from 12:00 AM to 8:00 AM - eight hours without release;
01/18/21 from 4:00 AM to 8:00 AM - four hours without release;
01/21/21 at 12:00 PM to 8:00 AM on 01/23/21 - 44 hours without release;
01/24/21 at 6:00 PM to 8:00 AM on 01/25/21 - 14 hours without release;
01/25/21 at 6:00 PM to 8:00 PM on 01/26/21 - 14 hours without release;
01/29/21 at 6:00 PM to 8:00 AM on 01/30/21 - 14 hours without release;
01/31/21 at 6:21 PM to 8:00 AM on 02/01/21 - 13 hours without release;
02/01/21 at 4:00 PM to 8:00 AM on 02/02/21 - 16 hours without release;
02/03/21 at 2:00 PM to 8:00 PM - six hours without release;
02/06/21 at 5:30 PM to 8:00 AM on 02/07/21 - 14 hours 30 minutes without release; and
02/07/21 at 6:00 PM to 8:00 AM on 02/08/21 - 14 hours without release.


Review of Patient 8's EMR, under the "Chart review" tab, showed Patient 8 was admitted on 02/26/21.

Review of Patient 8's EMR, under the "Orders" tab, showed a physician's order for "mittens untied" due to "interference with medical treatment on 02/27/21 at 4:01 AM and a physician's order for "soft wrist restraints," bilateral, due to "interference with medical treatment," for 24 hours on 02/27/21 at 8:08 PM and daily through an order documented on 03/03/21 at 7:19 AM (the day the medical record was reviewed).

Review of the use of restraints, located under the "Flowsheets" tab, showed the restraints remained in place without release on the following days and times:

02/27/21 at 8:00 AM to 12:00 PM - four hours without release;
02/28/21 at 12:00 AM to 8:00 AM - eight hours without release;
02/28/21 at 10:00 PM to 6:00 AM on 03/01/21 - eight hours without release; and
03/02/21 at 2:00 PM to 10:00 PM - eight hours without release.


Review of Patient 9's EMR, under the "Chart Review" tab, showed Patient 9 was admitted on 02/15/21.

Review of Patient 9's EMR, under the "Orders" tab, showed a physician's order for "soft wrist restraints," due to "interference with medical treatment," for 24 hours on 02/26/21 at 1:30 AM and daily for 24 hours through the order written on 03.03/21 at 1:52 AM (the day the EMR was reviewed).

Review of the use of restraints, located under the "Flowsheets" tab, showed restraints remained in place without release on the following days and times:

02/28/21 at 6:57 AM to 10:00 AM - three hours 3 minutes without release;
02/28/21 at 10:00 PM to 1:46 AM on 03/01/21 - three hours 46 minutes without release;
03/01/21 at 12:00 PM to 4:00 PM - four hours without release;
03/01/21 at 4:00 PM to 8:00 PM - four hours without release; and
03/02/21 at 6:00 AM to 12:00 PM - six hours without release.

During interviews on 03/03/21 at 1:00 PM and 2:00 PM, Staff A, Interim Chief Nursing Officer (ICNO), stated restraints are supposed to be removed every two hours. Staff A, confirmed Patient 2, Patient 8 and Patient 9 did not have their restraints removed in accordance with the hospital's restraint policy.


4. Review of the facility policy titled "Restraints and Seclusion," revised October 2018, showed a written order, based on an examination of the patient by the MD/DO [medical doctor/doctor of osteopathy] or LIP [licensed independent practitioner] is entered into the patient's medical record on a daily basis when restraint use is clinically appropriate.

Review of Patient 2's EMR, under the "Flowsheets" tab, showed Patient 2 was placed in restraints on 01/22/21. Review of Patient 2's "Physician Orders," located under the "Orders" tab, showed no documented evidence that a physician's order was obtained for restraint use on 01/22/21.

During an interview on 03/04/21 at 12:43 PM, Staff A, Interim Chief Nursing Officer, stated that Patient 2's EMR had no documented evidence that a physician's order was obtained for restraint use on 01/22/21.

Based on review of job descriptions, personnel files, and interview, the hopsital failed to ensure registered nurses (RNs) maintained current Advanced Cardiac Life Support (ACLS) certification for one of two RN personnel files reviewed (Staff S, RN). Also, the facility failed to ensure Nursing Assistants (NAs) maintained current Basic Life Support (BLS) certification for one of two NA personnel files reviewed (Staff U, NA). These failures could lead to staff performing incorrect and/or inadequate procedures for any patient experiencing a cardiac or respiratory emergency at this hospital.

Findings Include:

Review of the RN "Job Description," revised 02/10/14, showed qualifications included "BLS required at hire" and "ACLS required within 6 months of hire."

Review of the NA "Job Description," revised 03/06/18, showed qualifications included "BLS required within 90 days of hire."

Review of Staff S, RN's, personnel file showed Staff S's, ACLS certification expired November 2020. There was no documented evidence of current ACLS certification presented during the survey.

Review of Staff U, NA's, personnel file showed Staff U's, BLS certification expired 02/28/19. No current BLS certification was presented during the survey.

During an interview on 03/03/21 at 10:27 AM, Staff Z, Human Resource Coordinator (HRC), stated that they didn't have an updated ACLS certification for Staff S, RN and that they didn't have "the updated BLS certification for Staff U, NA, after it expired in 2019. Staff Z stated that they didn't discover it was expired until an audit of personnel records 02/24/21." Staff Z, confirmed Staff U, NA worked while not having confirmation of a current BLS certification from 02/29/19 until Staff U, was suspended on 03/01/21. Staff Z, reported conducting, "audits monthly." When asked why Staff Z, didn't catch the expired BLS for Staff U, for 2 years, Staff Z, stated, "probably because the file wasn't organized."

During an interview on 03/04/21 at 2:00 PM, Staff A, Interim Chief Nursing Officer, stated, "ACLS is required of all RNs, and BLS is required of all NAs."

Based on policy review, record review, and interviews, the hospital failed to ensure medications were administered timely in accordance with hospital policy for time-critical scheduled medications for three of four patient records reviewed for medication administration (Patient 6, Patient 8, and Patient 21). This deficient practice has the potential to decrease the effectiveness of medications for all four patients whose records were reviewed for medications administration at this facility.

Findings Include:

Review of the facility policy titled, "Medications: Standard Administration Times," revised July 2020, showed, Time-Critical Scheduled medications: medications where early or delayed administration of maintenance doses (to maintain a steady dose in the blood) of greater than 30 minutes before or after the scheduled dose may cause harm or result in substantial sub-optimal therapy (less than the desired effect) or pharmacological effect. . . Time-Critical Scheduled Medications 1. Scheduled Medication orders are considered Time-Critical when . . . Any order the physician (notation on order), pharmacist (Notation on MAR [medication administration record] entry), or nurse (notation on MAR entry) determine must be administered at a specific time. . . 2. Time-Critical Scheduled Medications should be administered within 30 minutes before or after the scheduled time. Review of the chart on page four of the policy listing Time-Critical Medications showed, "IV [intravenous] Antibiotics," was listed as a Time-Critical Medication.

Review of Patient 6's physician orders, located in the electronic medical record (EMR) under the "Orders tab," showed an order on 02/19/21 at 12:00 PM for, "Daptomycin 350 mg [milligrams] [an antibiotic] in sodium chloride 0.9% [per cent] 100 ml [milliliters] IVPB [intravenous piggyback/small bag attached to the primary IV bag] every 24 hours at 200 ml per hour over 30 minutes.'

Review of Patient 6's "MAR" in the EMR showed Patient 6 received Daptomycin more than 30 minutes before and/or after the scheduled time on the following days and times:

02/20/21 at 1:44 PM - scheduled to be given at 12:00 PM
02/21/21 at 11:01 AM - scheduled to be given at 12:00 PM
02/23/21 at 2:26 PM - scheduled to be given at 12:00 PM
02/24/21 at 12:41 PM - scheduled to be given at 12:00 PM
02/25/21 at 1:38 PM - scheduled to be given at 12:00 PM
02/26/21 at 2:44 PM - scheduled to be given at 12:00 PM
03/01/21 at 2:40 PM - scheduled to be given at 12:00 PM
03/02/21 at 3:36 PM - scheduled to be given at 12:00 PM
03/03/21 at 3:06 PM - scheduled to be given at 12:00 PM


Review of Patient 8's physician orders, located under the "Orders tab," showed an order on 03/03/21 at 7:43 PM for "Piperacillin-tazobactam [an antibiotic] 3.375 grams in sodium chloride 0.9% 100 ml IVPB every six hours at 200 ml per hour."

Review of Patient 8's "MAR" in the EMR showed Patient 8 received the first dose on 03/03/21 at 9:09 PM, with the second dose being administered on 03/04/21 at 1:14 AM (4 hours 5 minutes after the first dose was administered).


Review of Patient 21's physician orders, located under the "Orders tab," showed an order on 02/21/21 at 6:12 PM for Piperacillin-tazobactam 3.375 grams in sodium chloride 0.9% 100 ml IVPB every six hours at 200 ml per hour.

Review of Patient 21's "MAR" in the EMR showed Patient 21 received Piperacillin-tazobactam more than 30 minutes before and/or after the scheduled time on the following days and times:

02/21/21 at 11:24 PM - scheduled to be given at 12:00 PM
02/22/21 at 12:46 PM - scheduled to be given at 12:00 PM
02/23/21 at 1:06 PM and 7:14 PM - scheduled to be given at 6:00 PM
02/25/21 at 1:28 PM and 6:57 PM - scheduled to be given at 6:00 PM
02/26/21 at 11:17 AM and 11:24 PM - scheduled to be given at 12:00 PM
02/27/21 at 10:30 AM and 6:55 PM - scheduled to be given at 6:00 PM
02/28/21 at 12:57 AM, 6:43 AM, and 5:15 PM - scheduled to be given at 6:00 PM
03/01/21 at 4:48 AM, 3:19 PM, and 7:31 PM - scheduled to be given at 6:00 PM
03/02/21 at 5:22 AM and 12:44 PM - scheduled to be given at 12:00 PM


During an interview on 03/04/21 at 2:00 PM, Staff A, Interim Chief Nursing Officer (ICNO), confirmed the above-listed antibiotic administrations for Patient 6, Patient 8, and Patient 21 were given more than 30 minutes before and/or after the scheduled times as ordered. Staff A, stated that the times should have been 30 minutes before or after 12:00 AM, 6:00 AM, 12:00 PM, and 6:00 PM for Patient 21 and 30 minutes before and/or after 12:00 PM for Patient 6. Staff A, stated that Piperacillin-tazobactam should not have been administered to Patient 8 until 3:00 AM.

Based on observation, interview, and document review the hospital failed to prevent transmission of infections by not disinfecting a thermometer between uses for three of three observations of thermometer use. The facility also failed to secure a patient drainage bag off the floor for one of one patients observed with a drainage bag (Patient 14). Failure to disinfect equipment has the potential to result in a risk for transmission of disease and infection to all patients in the facility.

Findings include:

Review of facility policy, "Cleaning: Environment, Patient Equipment and Medical Devices (January 2019) showed "The standard of cleanliness is that all parts of the equipment including the underneath be visible clean with no blood and body substances, dirt, debris, dust, adhesive tape, stains or spillage ... Patient room furniture ... should be visibly clean with no blood/body substances, dirt, debris, dust adhesive tape, stains or spillage ... All equipment will be cleaned and disinfected according to manufacturer's guidelines."

Review of "Brentwood Infrared Thermometer Instruction Manual (type of thermometer used by this facility for screening staff and visitors for infection symptoms)" and the accompanying document "Non-contact Infrared Thermometers/FDA (Federal Department of Administration)," showed "For cleaning between uses, follow the instructions in the Cleaning and Disinfection section of the product instructions. There were no directions for cleaning in the manual.

Review of the procedure, "Inpatient Wound Manual (112/01/2018) failed to include directions for the drainage bag to prevent infections.

1. Upon entry to the facility on 03/01/21 at 8:00 AM, Staff O, Receptionist who was assigned the task of screening staff and visitors for COVID symptoms took the temperature of the two surveyors, followed by the screening of a visitor. When she took the temperature of the surveyors, she touched the ear of each surveyor with the thermometer. The Receptionist failed to clean the thermometer between uses on the surveyors and prior to using the thermometer on the visitor.

When asked by the surveyor about the policy for cleaning the thermometer, Staff O, Receptionist, responded, "I clean it at the beginning and ending of my shift and when I hand it off' to another staff member." When told that Staff O, Receptionist, had touched the ear of both surveyors, she replied, "I was not aware that I touched you or I would have cleaned it."

Review of the information provided by Staff B, Interim Director of Quality Management (IDQM) for the "Brentwood Infrared Thermometer" utilized for COVID symptom screening by the facility failed to include information about when the thermometer should be cleaned.

During an interview on 03/01/21 at 9:15 AM, Staff B, IDQM, stated that the screeners are taught that the thermometer is to be cleaned if a person being screened is touched. Staff B, IDQM, stated, "The thermometer should have been cleaned."

During an interview on 03/01/21 at 10:17 AM, Staff C, Quality Coordinator (QC) stated that she trained the staff responsible for screening staff and visitors for COVID symptoms. Staff C, QC, stated that she taught the screeners to clean the thermometer if it touches the person being screened.


2. On 02/03/21 at 11:10 AM, during a tour of the nursing unit, the drainage bag (catching fluid from an abdominal fistula abscess) (abscess caused by leakage of material into the abdominal cavity from an inflammatory bowel perforation) for Patient 14 was observed touching the floor beside the bed. When Staff A, Interim Chief Nursing Officer (ICNO), also present for this observation, saw this, Staff A, ICNO, called Staff F, Registered Nurse (RN) to the bedside. Staff F, RN, stated, "The patient must have dislodged the tube." Staff F, RN, then fastened the tube and bag to the bed linens above the bed.

Based on policy review, record review, and interview, the hospital failed to document evidence that a patient's medical information and post discharge needs were communicated to the post-acute care service provider at discharge for one of three patient records reviewed for discharge planning (Patient 1). This deficient practice has the potential to place patients at risk for unmet post discharge needs, care and service.

Findings Include:

Review of the facility policy titled, "Discharge Planning," revised 09/01/20, showed discharge planning will be performed by the Director of Case management (DCM) or case manager (CM). The goal of discharge planning is to sustain a continuous treatment plan, safely meeting the patient's clinical and functional needs while preventing readmissions and decreasing the risk of adverse health consequences. The hospital will provide the necessary medical information, to appropriate facilities, agencies, or outpatient services, as needed, for follow-up or ancillary care.

Review of the facility policy titled, "Case Management Medical Record Documentation and Documentation Retention," revised 01/01/20, showed Case Management documentation will be immediately placed in the open medical record upon completion. Documenting details of specific discharge planning activities demonstrates the hospital's organization of the patient's post discharge care: All referrals made for post discharge care, including providers who decline services Limited or unavailable service providers in the geographic area of choice, sequential discussion with the patient and/or the patient representative throughout the patient's stay demonstrating the planning process, including challenges causing delays to the discharge plan.

Review of Patient 1's "Inpatient Discharge Summary," in the EMR under the "Chart Review" tab, documented by Staff DD, Physician, showed Patient 1 was admitted on 11/20/20 and discharged on 01/29/21.

Review of Patient 1's "Wound Progress Note," located under the "Chart Review" tab, documented by Staff CC, Registered Nurse (RN) on 01/29/21 at 12:49 PM, showed that at discharge Patient 1 had a wound to the medial back that was 1.1 cm (centimeters) in length, 1.1 cm in width, and no depth with serosanguineous (thin watery, pale pink) drainage. The wound management orders included, "medical grade honey and a foam dressing." Further review showed Patient 1 had a Stage 3 pressure ulcer to the coccyx that was 5.4 cm in length, 7.2 cm in width, and no depth with serosanguineous, thin watery, pale pink drainage.

Review of Patient 1's "After Visit Summary," in the EMR, dated 01/29/21 showed, "Wound Care Instructions Coccyx - clean wound gently with normal saline, rinse and pat, do not rub wound bed. Apply skin prep to surrounding skin and allow to dry. Place adhesive foam over wound bed. Change foam 3-4 xs [times] weekly or sooner if soiled." There was no documented evidence of instructions for wound care to the medial back as shown in the "Wound Progress Note" of 01/29/21 at 12:49 PM.

Review of Patient 1's "CM Progress Note" in the EMR dated 01/26/21 at 2:04 PM by Staff X, CM, located under the "Chart Review" tab, showed, "Current Discharge Plan: Home with HH [home health]. Caregivers will come in on 1/28/21 at 11:00 AM for trach [Tracheostomy, an incision in the windpipe made to relieve an obstruction to breathing] training. Oxygen will be delivered to the home on 1/28/21. The goal is to discharge the patient home on 1/29/21 and the respiratory therapist from [name of agency] will come out to the home to educate the caregivers on respiratory equipment."

Review of Patient 1's EMR, under the "Chart Review" tab showed an undated form with the name of a home health agency, address of the agency, and contact information (telephone number) of the agency.

There was no documented evidence in Patient 1's EMR that the "After Visit Summary," dated 01/29/21 had been provided to the patient or representative, or that the home health agency had been sent Patient 1's medical information, and that wound care had been discussed with the home health agency to determine if wound care supplies needed to be sent with Patient 1 at discharge.

During an interview on 03/01/21 at 1:10 PM, Staff C, Quality Coordinator (QC), stated they usually scan the signed copy of the "After Visit Summary" into the EMR, but Patient 1's was not signed, possibly because Patient 1 was a quadriplegic. Staff C, QC stated that the summary would usually show if wound care supplies were provided at discharge. Staff C, QC stated Patient 1's supplies were probably not given, because Patient 1 was going to have home health, who would provide wound care supplies.

During an interview on 03/03/21 at 9:00 AM, Staff X, CM, stated she ordered DME [durable medical equipment] at discharge, including an air compressor, suction machine, cough assist machine, oxygen concentrator, portable oxygen concentrator, nebulizer, trachs and trach care kits, and these items were delivered to the home. Staff X, CM stated that she didn't order wound care supplies, because home health provides wound care and the wound care supplies needed after discharge. Staff X, CM stated that home health was going to be at Patient 1's home upon arrival, because Patient 1 required 24/7 care. Staff X, CM, confirmed there was no documentation in the record showing that Patient 1 or his representative received the "After Visit Summary," dated 01/29/21, that included wound care instructions, or that the home health agency had been contacted, and what medical information was relayed to the home health agency regarding Patient 1's care.

During an interview on 03/03/21 at 9:20 AM, Staff Y, RN, Wound Care Nurse, stated that she routinely sees each wound care patient on the day of discharge and does wound care before the patient leaves. Staff Y stated that she could not remember if she sent wound supplies home with Patient 1 at discharge. Staff Y stated that when she does send wound care supplies with a patient at discharge, she doesn't document doing so in the patient's medical record. Staff Y stated that, routinely, if a patient had supplies in their room, they would be sent home with the patient at discharge.

During an interview on 03/04/21 at 8:45 AM, Staff X, CM, recalled speaking with someone at the home health agency to which Patient 1 was being referred but could not recall documenting this conversation. Staff X, CM stated that, based on what the home health agency's staff reported, the home health staff was to be at Patient 1's home when Patient 1 arrived, but was unable to provide documentation of that conversation.