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Based on medical record reviews, staff interview and policy review, the hospital failed to ensure all Medicare patients signed and dated the Important Message from Medicare within two days of admission (A117), failed to ensure patients or their representatives were given the information and disclosures needed to make an informed decision about whether to consent to a procedure, intervention, or type of care that requires consent (A131) and failed to ensure the physical safety of patients (A144). The cumulative effect of these systemic practices resulted in a risk to the health and safety of all patients.

Based on medical record review and staff interview, the hospital failed to ensure all Medicare patients signed and dated the document entitled Important Message from Medicare regarding patient rights within two days of admission. This affected two patients of four Intensive Care Unit (ICU) records reviewed. (Patient #13 and #14) The census at the time of the survey was 240.

Findings include:

1) The medical record for Patient #13 was reviewed with Staff L on 02/13/14 at 10:35 AM. Staff L confirmed on this admission, 02/10/14, the only documentation at registration was a copy of the insurance card. No signed document entitled Important Message From Medicare About Your Rights was found in the record as of 11:00 AM.
On 02/13/14 at 11:00 AM Staff B and C confirmed the document entitled Important Message From Medicare About Your Rights was not signed for this admission, 02/10/14.

2) The medical record for Patient #14 reviewed with Staff L on 02/13/14 at 11:10 AM revealed Patient #14 was admitted on 02/11/14 with Medicare. Staff L confirmed no documentation of the Important Message From Medicare About Your Rights was signed for this admission.

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Based on medical record review, policy review and interview, the facility failed to ensure patients or their representatives were given the information and disclosures needed to make an informed decision about whether to consent to a procedure, intervention, or type of care for three patients of 11 medical records reviewed for informed consent. (Patient #11, #12 and #13) This had the potential to affect all of the facility's patients. The census at the time of the survey was 240.


Findings include:


1) The medical record review for Patient #11 was completed on 2/13/14. The record revealed Patient # 11 had a consent signed by an authorized representative for a thoracotomy on 2/7/14 at 8:10 AM, however, the consent form did not contain a signature by the practitioner attesting the explanation of the procedure to the patient or patient representative.

The facility's Informed Consent policy was reviewed on 2/13/14. The policy stated medical center personnel may obtain and witness the patient's signature after the practitioner has discussed the matter with the patient. The policy stated the nurse may obtain the patient's signature on such forms if they are not completed as long as they bear the physician's signature.

On 2/14/14 at 1:58 PM, Staff J was interviewed. Staff J reported the medical record did not contain any notation from the physician regarding the discussion of the procedure with the patient or patient's representative. Staff J confirmed the informed consent from 2/7/14 at 8:10 PM did not contain a physician's signature.


2) The medical record for Patient #12 was reviewed with Staff L, Admitting Registrar, on 02/13/14 at 2:50 PM. Staff L confirmed Patient #12's admission was 01/28/14. The record lacked a signed consent form to treat as of 02/13/14 or 16 days. Patient #12 was a current patient in the Intensive Care Unit (ICU).

Staff L confirmed the Consent to Anesthesia dated 01/28/14 was not dated and timed when signed by the authorized patient representative. The Permit for Invasive Procedure dated 01/29/14 for a central line placement and a Consent for Blood Transfusion signed by the brother (power of attorney) on 01/30/14 was not signed by the physician as evidence that risks and benefits were explained to the patient/ representative. Staff L confirmed on 02/13/14 at 2:55 PM this patient did have a central line placed and did receive a unit of blood and the consents were not completed as required.

3) The medical record for Patient #13 was reviewed with Staff L on 02/13/14 at 10:35 AM. Staff L confirmed on this admission, 02/10/14, the only documentation at registration was a copy of the insurance card. No signed consent for treatment was found as of 11:00 AM.

On 02/13/14 at 11:00 AM Staff B and C confirmed no consent for treatment was signed for this admission 02/10/14.
Staff L stated on 02/13/14 at 2:50 PM if a patient came through the Emergency Department (ED) the consent for treatment would be signed that day by the patient or authorized patient representative. If a patient was a direct admit to the floor then the consents would be signed the next day.

Staff B stated on 02/13/14 at 4:30 PM there was no policy on signing consents.








31597

Based on medical record review and staff interviews, the facility failed to ensure the physical safety of one of one discharged patient medical record reviewed who experienced three falls and the development of wounds not initially present at the time of admission during the course of two different hospitalizations. A total of 11 medical records were reviewed and the census at the time of the survey was 240.

Findings include:

1) The electronic medical record for Patient #2 was reviewed with Staff C beginning on 02/12/14 and completed on 02/14/14 at 4:00 PM. Two of three admissions for Patient #2 were reviewed: 05/01/13-05/09/13 and 08/15/13-09/17/13.

Patient #2 was admitted to the facility's step-down telemetry unit on 05/01/13 with diagnoses of dizziness and near syncope (episode of fainting) and the nursing admission assessment was completed at 7:30PM. Patient #2 was alert and oriented at the time and review of the nurse's musculoskeletal assessment revealed Patient #2 reported experiencing muscular weakness/paralysis, gait changes, and decreased ability to complete activities of daily living (ADL) within the last seven days. Patient #2 also reported experiencing two or more falls at home in the past month, and Patient #2's gait was documented as unsteady on admission.

Review of the safety assessment revealed Patient #2 was identified as a "Risk for Falls" with a total Fall Risk Score of 11. A score of four (4) or more indicates a patient is at risk for falls and the hospital's "Falls Prevention Protocol" was to be initiated. The Falls Prevention Protocol for Patient #2 was initiated at that time.

Per the facility's Fall Prevention Program policy (9.12), the following interventions were to be implemented: yellow arm band physically placed on the patient, yellow magnet placed in the patient's room, fall risk potential for injury on the patient's plan of care.

The Nursing Activity Flow Records for Patient #2 were also reviewed for the period of time 05/03/13 - 05/09/13. The flow records are evidence that specific standards for a patient, including "activity" and "safety", were met. One of the activity standards included turning and repositioning the patient every two hours, and one of the safety standards included ensuring the patient's bed alarm was on. The flow records are completed at the end of each nursing and/or nursing assistant shift, with eight or 12 hours being a normal shift.

Nursing Activity Flow Records dated 05/03/13 at 04:41AM and 11:22 AM revealed the activity and safety standards for Patient #2 had been met. The next Nursing Activity Flow Record was completed at 03:45 AM on 05/04/13, approximately 16 hours later, and lacked evidence staff completed the activity or safety standard checks.


Review of a nursing note written on 05/04/13 at 01:20 AM revealed the following recorded information:

"Pt found lying down near her doorway face down. Pt responds to verbal stimuli with moaning. Alert to person only. Hematoma noted to left side of her forehead. PERRLA, 2mm. Bleeding noted to left hand with one open area. Bleeding controlled. Pt returned back to bed." Physician paged.

A stat CT (computed tomography)) scan of the head/brain was ordered on 05/04/13 at 01:49AM. Results of the scan were documented as "1. New thin parafalcine acute subdural hematoma and areas of possible subarachnoid hemorrhage around the right frontal lobe."

At 01:54AM on 05/04/13 after the fall, a nursing note indicated "bed alarm activated."

At 03:30 AM on 05/04/13 Staff Q, wrote a progress note indicating Patient #2 was assessed after the fall and noted Patient #2 was alert and oriented times three with no neurological deficits with the plan for Patient #2 to be transferred to ICU (intensive care unit) for monitoring and repeat CT scan of the head/brain in 36 hours.


Patient #2 was then transferred from ICU back to the hospital's step-down telemetry unit on 05/05/13 at 7:32 PM. The next Nursing Activity Flow Record was completed on 05/06/13 at 8:00 PM, approximately 27 hours after the previous one (05/05/13 at 5:00PM), at which time the activity and safety standards were reportedly met.


On 05/07/13 at 10:35AM review of a neurosurgery progress note revealed "pt had a fall last night" per nurse's report. Physical exam revealed Patient #2 was "alert, irritable, flat affect, poor eye contact. Patient with very limited verbal communication. Uncooperative." Patient #2 was eventually discharged to home with care of family on 05/09/13 at 5:40 PM.



On 08/15/13, Patient #2 was admitted again to the hospital's step-down telemetry unit with diagnoses of abdominal pain and weakness and the nursing admission assessment was completed at 11:09 PM. Patient #2 was alert and oriented at the time and review of the nurse's musculoskeletal assessment revealed Patient #2 reported experiencing muscular weakness/paralysis, gait changes, and decreased ability to complete activities of daily living (ADL). Patient #2 also reported experiencing two or more falls at home in the past month, and Patient #2's gait was documented as unsteady on admission.

Review of the safety assessment revealed Patient #2 was identified as a "Risk for Falls" with a total Fall Risk Score of 7. Once again the Falls Prevention Protocol for Patient #2 was initiated at that time. The Nursing Activity Flow Records for Patient #2 were then reviewed for the period of time 08/15/13-09/17/13. The first documented activity flow record was on 08/16/13 at 2:08 PM, approximately 14 hours after Patient #2 was admitted and revealed the activity and safety standards were met.


On 08/16/13 at 8:00 PM a nursing note revealed Patient #2 was calling out and "found lying across bed, unable to sit up." Patient #2 was then re-oriented. At 8:30PM and 9:00PM nursing notes revealed Patient #2 was receiving peritoneal dialysis. At 10:05 PM a nursing note contained the following information,:

"staff nurse heard calling for help. several staff members to room, states he heard noise from room, finding patient laying on floor, flat on back. pts eyes open but not talking now, pupils checked. left 2 mm, not seeing reaction, right 2 mm sluggish. after 90 sec or so, pt moving head and talking, able to state name and that" he/she "was up going to bathroom. able to move extremities. denies pain in extremities, back or buttocks. does c/o head hurting. abrasion, with scant bleeding noted with mild edema noted right side of occipital area. able to stand pt to walk back to bed, weak but able to be weight baring. vitals obtained, neuro checks done. bed alarm on."

A physician progress note was written at 10:39 PM on 08/16/13. The physician indicated he/she was paged to assess Patient #2 at 10:15 PM, following the fall. Patient #2 complained of a headache at that time and didn't recall falling. Patient #2 was described as confused but alert and oriented times three. Red area noted on "posterior head" and bilateral knee abrasions. Cranial nerves II-XII were intact. Following physical assessment, the physician ordered a CT of the head and neurological checks and vital signs every four hours.


At 11:40 PM Patient #2 was then taken for the CT scan. Impression following that CT scan was: 1) "bifrontal left larger than right hemorrhagic contusion" and 2) "small bilateral subdural hematomas with no significant shift or hydrocephalus."

Patient #2 was then transferred to the Intensive Care Unit (ICU) on 08/17/13 at 01:40 AM. The next documented Nursing Activity Flow Record was on 08/18/13 at 06:40 AM, while Patient #2 was in the ICU. There were no documented Nursing Activity Flow Records for 08/17/13.

A repeat CT scan was then done on 08/17/13 at 06:13 AM. Impression following this scan was 1) "no substantial change in bifrontal hemorrhagic contusions, 2) thin subdural hematomas along the left cerebral hemisphere and the right temporoparietal region have shown minimal change" and 3) there is a nondisplaced calvarial fracture through the parietal bones."


Patient #2 was then seen by Neurosurgery on 08/18/13 at 07:45AM per progress note. The assessment and plan included "frontal contusion" and right frontal subdural hematoma status post fall on hospital day two. No surgical intervention needed at that time.

Patient #2 was transferred from ICU back to the step-down telemetry unit. Staff documented the activity and safety standard check on 08/19/13 at 1:37 PM, approximately 24 hours after the previous check on 08/18/13 at 8:30 PM.


Patient #2 was then seen by Internal Medicine on 08/24/13 at 10:50 AM and described as "minimally responsive" with increased respiratory rate per progress note. Assessment revealed diagnoses of acute respiratory failure, metabolic encephalopathy and subdural hematoma with poor prognosis.

A final CT scan of the head/brain was done on 08/31/13 at 2:47PM. Impression at that time was 1) "moderate to severe leukoencephalomalacia in the left frontal, left occipital and right temporal lobes showing no significant change." Leukoencephalomalacia refers to softening of the white matter of the brain most likely related to hemorrhaging (bleeding) in the brain.

By 12:00 PM on 08/25/13, Patient #2 was intubated (on a ventilator to assist with breathing) and sedated in the hospital's Intensive Care Unit as evidenced by a progress note written by Internal Medicine. At that time Patient #2 was noted to be suffering from acute respiratory failure, septic shock, pneumonia, urinary tract infection with e. coli, c. diff colitis, and free air under diaphragm.


On 09/02/13 at 10:07 AM review of a pulmonary progress note revealed the current plan for Patient #2's care was discussed and the family requested do not resuscitate/comfort care arrest (DNR-CCA) status for Patient #2. On 09/12/13 Palliative Care documented Family expressed a desire to change Patient #2's code status again from DNR-CC to DNR-CCA after Patient #2's mental status was note to be improved. Patient #2 reportedly expressed a desire to go home at that time. Discharge planning continued per progress note.


Patient #2 was last seen by Palliative Care on 09/16/13 at 4:13 PM. Patient #2 was described as alert when awakened, very weak and with lower extremity skin issues.

On 09/17/13, Staff Q wrote Patient #2 was "stable for discharge" to extended care facility.

Review of The initial Skin/Tissue Assessment completed by nursing on 08/15/13 revealed the following wounds on admission:

#1 arms, back, shoulder, trunk and legs with red, black and pink bruising
#2 skin tear on left elbow, red in appearance and left open to air
#3 skin tear to left knee, red in appearance and left open to air
#4 skin tear to right forearm, red in appearance and left open to air
#5 bruising on coccyx, red in appearance and left open to air.

Skin/Tissue Assessment on 08/19/13 at 07:30 AM revealed wounds #1-3 remained unchanged, wound #4 had an unknown clean and dry dressing in place with no indication of when the wound was last examined or the dressing changed, and wound #5 on the coccyx continued to measure 0.5 cm by 0.5 cm. Barrier cream was applied and a notation revealed Patient #2 was to be turned every two hours.

Skin/Tissue Assessment at 7:47 PM a new wound, wound #7 was first documented at this time. Patient #2's bilateral heels were described as reddened, "pink and mushy."

The next noted change in the Skin/Tissue Assessment was on 08/20/13 at 4:00 PM. and revealed wound #7 bilateral heels were still reddened but only the right heel was noted be elevated on a pillow.

The first documented notation regarding Patient #2's wounds by a physician was on 09/05/13 at 11:05AM. by Palliative Care that identified Patient #2 had a coccyx wound. On 09/06/13 at 10:48 AM Palliative Care wrote that Patient #2's right great toe and bilateral heels were purple in color.

On 09/10/13 at 6:00 PM Patient #2 was seen by Staff Q at which time documentation revealed Patient #2's "right foot toe cyanotic/gangrene" with blisters and Patient #2 was also noted to have a sacral decubitus ulcer. Podiatry was consulted.

Podiatry completed their first examination of Patient #2 on 09/11/13 at 08:40 AM. Assessment revealed ischemic changes to right digits and pressure ulcers to left heel and right ankle. Recommendation was for doppler study, offloading and wound protection per review of progress note.

Patient #2 was seen and examined by Podiatry again on 09/12/13 at 5:00 PM. Assessment revealed pressure ulcers to left heel and right ankle with eschar and necrosis/gangrene to first, second and fourth toes on right foot. The recommendation was for santyl (ointment) to eschar areas daily and silvadene (cream) to toes on right foot.

.On 09/15/13 Patient #2 was seen and examined by Podiatry before discharge per progress notes. The following notes were documented: "dry necrotic changes again noted toes 1, 2, 4" on right foot, eschar right ankle and left heel still present but show improvement. Healing potential was noted to be poor and recommendation was to continue local wound care and monitor for signs and symptoms of infection.

The last Skin/Tissue Assessment by nursing was completed on 09/17/13 at 08:30 AM. The following documented wounds were present prior to Patient #2's discharge with no mention of the toe wounds:

Wound #1 - arms, back, shoulders, trunk and legs with scant amount of serous drainage, wounds red and black in color, left open to air
Wound #2 - skin tear on left elbow, red and purple in color, left open to air
Wound #3 - skin tear to left knee, black in color, left open to air
Wound #4 - skin tear to right forearm with serosangiounous drainage, yellow and pink in color, left open to air
Wound #5 - pressure ulcer on coccyx, purple, pink, red, yellow and black in color, moderate amount of serosanguinous drainage, no documented dressing in place
Wound #6 - bruising to anterior chest, purple in color with serous drainage, left open to air
Wound #7 - bilateral heel pressure ulcers, purple and black in color, santyl ointment and unknown dressing in place
Wound # 8 - head, red, purple and pink in color, with two scabs left open to air

Staff C was made aware of and confirmed the above findings following completion of the record review on 02/14/14 at 4:00 PM.

Based on medical record reviews, staff interviews and review of facility policy, the hospital failed to ensure nursing care provided to patients was appropriate and sufficient to meet all of the patient's needs (A392) and to ensure nursing staff developed and kept current a plan of care for each patient (A396). The cumulative effect of these systemic practices resulted in a risk to safety and health of all patients.

Based on medical record review and staff interviews, the facility failed to ensure the registered nurse followed the wound assessment Braden Scale and failed to deliver care as ordered for two patients of 11 medical records reviewed (Patient #9 and Patient #10) and failed to ensure nursing care provided to one of one discharged patient whose medical record was reviewed was appropriate and sufficient to meet all of the patient's needs.(Patient #2) This lack of care resulted in three falls, an episode of acute respiratory distress, and the development of wounds not initially present at the time of admission during the course of two different hospitalizations. The census at the time of the survey was 240.


Findings include:


1) The medical record for Patient #10 was reviewed on 02/13/14 at 12:00 PM and revealed the start of care date was 02/09/14. Patient #10 was admitted as observation status initially until 02/11/14 when admitted to floor.
The admission wound assessment dated 02/09/14 at 10:15 PM indicated Wound #1(left under arm area) was extremely deep and painful and a Stage IV pressure ulcer. Wound #2 (left elbow) was identified as a pressure ulcer and Stage II. Wound #3 (left hip) was identified as a pressure ulcer, moderate drainage with a foul odor and Stage IV. Wound #4 (low back area) was a pressure ulcer and Stage II. Wound #8 (right shoulder) was a pressure ulcer with moderate foul odor drainage and Stage IV. Below each wound assessment was a section which indicated "Measure on Admission/Identification and then every seven days, length, width and depth." All five staged wounds were left blank with no documentation of any wound measurements.

Wounds #5, #6 and #7 were identified as a scab or peeling and left open to air.

A review of the Skin and Wound Care Guideline procedure on 02/13/14 at 11:00 AM identified Stage II as partial thickness skin loss presenting a shallow crater or ulcer with a pink red wound bed without dead skin. Stage IV was identified as full thickness tissue loss with exposed bone, tendon or muscle. Dead skin may be present on part of the wound bed. This often includes undermining and tunneling.

On 02/11/14 at 3:50 PM the Patient Care Coordinator for the seventh floor (Staff H) stated skin assessments are completed every eight hours and documented.

The registered nurse (Staff I) caring for patient #10 interviewed on 02/11/14 at 4:20 PM stated Patient #10 came in with "very extensive wounds." The left under arm area (wound #1) was "very deep with tunneling a good two inches." Staff I stated for the first two days there was not a doctor's order for wound care so we just put dry sterile dressings on.

On 02/11/14 at 4:30 PM the record for Patient #10 reviewed with Staff I revealed the first documentation of tunneling for wound #1 was on 02/10/14 at 3:00 PM that indicated tunneling at 12 o'clock position with no documentation of depth of tunneling. The next documentation of tunneling was on 02/11/14 at 12:15 PM, by Staff I, that indicated the 12 o'clock position of the tunnel with no depth documented. Staff I confirmed no documentation of the tunnel depth or of any wound measurements as of 02/11/14 at 4:30 PM.

On 02/13/14 at 10:00 AM Staff C stated all decubitus ulcers (pressure ulcers/bedsores) are to be measured.

On 02/13/14 at 12:10 PM Staff B stated all observation status patients are treated the same as admitted patients and all stageable wounds are required to be measured on admission and every week. Staff B stated there is not a policy on wound care or wound measuring. The wounds are assessed using the Braden Scale which prompts the nurse to measure the wound and when to make referrals.

02/13/14 at 12:30 PM Staff B confirmed no wound measurements or tunnel depth were done on any of the five stage able wounds (Wound #1, #2, #3, #4 and #8) from start of care 02/09/14 to 02/13/14 (five days).

The record review for Patient #10 on 02/13/14 at 12:40 PM with Staff B and C revealed an order by the Physician Assistant (PA) dated 02/10/14 for Metronidazole 1% gel to be applied three times a week and as needed. The order did not specify the location for application of the gel. On 02/13/14 at 12:45 PM Staff C stated the gel was to be applied to the wounds. Staff C stated the pharmacy scheduled it Monday-Wednesday-Friday at 9:00 AM.

Review of the medication administration history on 02/18/14 at 11:55 AM with Staff B and C revealed on 02/10/14 (Monday) at 8:12 AM the Patient Care Coordinator for 7th Floor (Staff H) documented the wound ointment was not given due to the patient being NPO (nothing by mouth). On 02/12/14 (Wednesday) at 9:00 AM documented held due to the patient off the floor. On 02/14/14 (Friday) again documented held due to off the floor.

Staff B, C and J confirmed on 02/18/14 at 12:00 PM this medication had not been started since ordered 02/10/14 and no documentation of the physician notified.

2) The record review on 02/11/14 for Patient #9 revealed a 92 year old patient was admitted through the emergency room on 02/09/14 at 8:30 PM with vomiting, diarrhea and fever. Patient #9 has a Foley catheter (tube inserted in the bladder to drain the urine), nasogastric (NG) tube (feeding tube in the nose) and generalized weakness.

The registered nurse (RN) (Staff G) for Patient #9 confirmed mouth care every shift, turning every two hours and Foley catheter care every shift needs to be done for this patient.

The Director of the Eight Floor (Staff F) stated on 02/11/14 at 3:10 PM the Activity Standards include turning and repositioning the patient at least every two hours if not performing independently. The Hygiene Standards include oral hygiene twice a day and as needed if unable to do. If the patient has a Foley then catheter hygiene is done every shift.

A review of the Activity Standards and Hygiene Standards documented by the RN every shift from start of care 02/09/14 to 02/11/14 revealed no documentation of any Activity and Hygiene Standards done from 02/10/14 at 12:06 AM to 02/11/14 at 3:18 AM (27 hours without mouth care and turning) and no documentation of Foley catheter care given from 02/10/14 at 12:06 AM to 02/11/14 at 9:20 AM (33 hours without Foley care).

Staff F confirmed on 02/11/14 at 4:50 PM no documentation of Activity and Hygiene Standards for Patient #9.

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3) The medical record for Patient #2 was reviewed electronically with Staff C beginning on 02/12/14 and completed on 02/14/14 at 4:00PM. The following admissions for Patient #2 were reviewed during that time: 05/01/13-05/09/13 and 08/15/13-09/17/13.

Patient #2 was admitted to the facility's step-down telemetry unit on 05/01/13 with diagnoses of dizziness and near syncope (episode of fainting) and the nursing admission assessment was completed at 7:30PM. Patient #2 was alert and oriented at the time and review of the nurse's musculoskeletal assessment revealed Patient #2 reported experiencing muscular weakness/paralysis, gait changes, and decreased ability to complete activities of daily living (ADL) within the last seven days. Patient #2 also reported experiencing two or more falls at home in the past month, and the patient's gait was documented as unsteady on admission.

Review of the safety assessment revealed Patient #2 was identified as a "Risk for Falls" with a total Fall Risk Score of 11. A score of four or more indicates a patient is at risk for falls and the hospital's "Falls Prevention Protocol" was to be initiated. The Falls Prevention Protocol for Patient #2 was initiated at that time.

Per the facility's Fall Prevention Program policy (9.12), the following interventions were to be implemented: yellow arm band physically placed on the patient, yellow magnet placed in the patient's room, fall risk potential for injury on the patient's plan of care.

The Nursing Activity Flow Records for Patient #2 were also reviewed for the period of time 05/03/13 - 05/09/13. The flow records are evidence that specific standards for a patient, including "activity" and "safety", were met. One of the activity standards included turning and repositioning the patient every two hours, and one of the safety standards included ensuring the patient's bed alarm was on. The flow records are completed at the end of each nursing and/or nursing assistant shift, with eight or 12 hours being a normal shift.

Nursing Activity Flow Records dated 05/03/13 at 4:41 AM and 11:22 AM revealed the activity and safety standards for Patient #2 had been met. The next Nursing Activity Flow Record was completed at 3:45 AM on 05/04/13, approximately 16 hours later, and lacked evidence staff completed the activity or safety standard checks.

Review of a nursing note written on 05/04/13 at 1:20 AM revealed the following recorded information:

"Pt found lying down near her doorway face down. Pt responds to verbal stimuli with moaning. Alert to person only. Hematoma noted to left side of her forehead. PERRLA, 2mm. Bleeding noted to left hand with one open area. Bleeding controlled. Pt returned back to bed." Physician paged.

A stat CT (computed tomography)) scan of the head/brain was ordered on 05/04/13 at 1:49 AM. Results of the scan were documented as "1. New thin parafalcine acute subdural hematoma and areas of possible subarachnoid hemorrhage around the right frontal lobe."

After Patient #2's fall, at 1:54 AM on 05/04/13 a nursing note indicated "bed alarm activated." And again at 2:07 AM "bed alarm is on."

At 3:30 AM on 05/04/13 the Staff Q, the medicine physician, wrote a progress note indicating Patient #2 was assessed after the fall. At that time Staff Q documented Patient #2 was alert and oriented times three with no neurological deficits. Following assessment, the plan for Patient #2 was ICU (intensive care unit) monitoring and repeat CT scan of the head/brain in 36 hours.

At 3:55 AM a nursing note revealed that Patient #2's daughter was "called at this time to notify" of patient's transfer to the ICU. Patient #2 was subsequently transferred to the ICU on 05/04/13 at 4:30 AM.

Once in the ICU, a nursing note written on 05/04/13 at 5:00AM revealed Patient #2 was attempting to "crawl out of bed" and again at 5:20 AM Patient #2 was attempting to "crawl over siderails of the bed". Patient #2 was described as agitated and verbally abusive to staff. At 5:25 AM the nurse documented an order for soft bilateral wrist and vest restraint was obtained. The bilateral soft wrist restraints were applied at that time. Staff then completed the required Restraint/Protective Device Patient Assessment form and completed required two hour checks.

The restraints were then removed on 05/04/13 at 12:30PM, at which time the daughter was noted to be at the bedside. The Internal Medicine physician, Staff R, documented a progress note on 05/04/13 at 12:10PM. At that time the physician documented he/she spoke to the daughter about vision changes Patient #2 was experiencing and the need for restraints.

The Nursing Activity Flow Records for 05/05/13 revealed the activity and safety standards were met at 5:00AM, but at 5:00PM staff failed to document the activity and safety standards were met.

On 05/05/13 at 7:32 PM Patient #2 was then transferred from ICU back to the hospital's step-down telemetry unit. Upon arrival to the floor at 7:50 PM the bed was noted to be in low/locked position per a nursing note. A nursing note documented on 05/06/13 at 8:10PM revealed the bed alarm was also in place.

The next Nursing Activity Flow Record was completed on 05/06/13 at 8:00PM, approximately 27 hours after the previous one (05/05/13 at 5:00 PM), at which time the activity and safety standards were documented as met. A nursing note dated 05/07/13 at 10:30AM revealed the patient's call light was in reach and bed was in the low and locked position.

Review of a neurosurgery progress note written on 05/07/13 at 10:35AM revealed "pt had a fall last night" per nurse's report. Physical exam revealed Patient #2 was "alert, irritable, flat affect, poor eye contact. Patient with very limited verbal communication. Uncooperative."

Staff S, a second physician, also wrote a progress note on 05/07/13 (time unknown) entitled "Fall Assessment." This physician indicated he/she was called by the nurse to assess Patient #2. At that time Patient #2 denied hitting his/her head and losing consciousness.

Per a documented nursing note Patient #2's "daughter called, updated with current condition and POC" at 12:49 PM on 05/07/13. There were no documented nursing notes detailing when Patient #2 had fallen again or that the family was notified.

The next documented activity standard check (per Nursing Activity Flow Record) was on 05/07/13 at 1:25 PM, but staff failed to document the safety standard check was completed.


The next activity and safety standard checks was not completed until 05/08/13 at 2:18PM, approximately 24 hours after the previous one. Per the nursing notes the bed was locked and in the low position on 05/08/13 at 9:00 PM and on 05/09/13 at 4:05 AM.

The last documented activity and safety standard check was on 05/09/13 at 5:40 PM, approximately 27 hours after the previous one (05/08/13 at 2:18 PM). Patient #2 was then discharged to home with care of family on 05/09/13 at 5:40 PM.



On 08/15/13, Patient #2 was admitted again to the hospital's step-down telemetry unit with diagnoses of abdominal pain and weakness and the nursing admission assessment was completed at 11:09PM. Patient #2 was alert and oriented at the time and review of the nurse's musculoskeletal assessment revealed Patient #2 reported experiencing muscular weakness/paralysis, gait changes, and decreased ability to complete activities of daily living (ADL). Patient #2 also reported experiencing two or more falls at home in the past month, and Patient #2's gait was documented as unsteady on admission.


Review of the safety assessment revealed Patient #2 was identified as a "Risk for Falls" with a total Fall Risk Score of 7. Once again the Falls Prevention Protocol for Patient #2 was initiated at that time.

The Nursing Activity Flow Records for Patient #2 were then reviewed for the period of time 08/15/13-09/17/13. The first documented activity flow record was on 08/16/13 at 2:08 PM, approximately 14 hours after Patient #2 was admitted and revealed the activity and safety standards were met. The next flow record was completed on 08/16/13 at 11:05 PM and revealed the activity and safety standards were met.

At 11:48 AM Patient #2 was noted to be resting in bed. A nurse was noted to be in Patient #2's room again at 2:00 PM and 4:15 PM.

At 8:00 PM on 08/16/13 a nursing note revealed Patient #2 was calling out and "found lying across bed, unable to sit up." Patient #2 was then re-oriented. At 8:30 PM and 9:00 PM nursing notes revealed Patient #2 was receiving peritoneal dialysis.

At 11:05 PM on 08/16/14 review of a nursing note revealed the following information: "staff nurse heard calling for help. several staff members to room, states he heard noise from room, finding patient laying on floor, flat on back. pts eyes open but not talking now, pupils checked. left 2 mm, not seeing reaction, right 2 mm sluggish. after 90 sec or so, pt moving head and talking, able to state name and that" he/she "was up going to bathroom. able to move extremities. denies pain in extremities, back or buttocks. does c/o head hurting. abrasion, with scant bleeding noted with mild edema noted right side of occipital area. able to stand pt to walk back to bed, weak but able to be weight baring. vitals obtained, neuro checks done. bed alarm on."

A physician progress note was written at 10:39 PM on 08/16/13. The physician indicated he/she was paged to assess Patient #2 at 10:15 PM, following the fall. Patient #2 complained of a headache at that time and didn't recall falling. Patient #2 was described as confused but alert and oriented times three. Red area noted on "posterior head" and bilateral knee abrasions. Cranial nerves II-XII were intact. Following physical assessment, the physician ordered a CT of the head and neurological checks and vital signs every four hours.

At 10:55 PM the nurse wrote Patient #2's daughter returned the telephone call and was informed of Patient #2's fall. At 11:40 PM Patient #2 was then taken for the CT scan.

Impression following that CT scan was: 1) "bifrontal left larger than right hemorrhagic contusion" and 2) "small bilateral subdural hematomas with no significant shift or hydrocephalus."

Patient #2 was transferred to the Intensive Care Unit (ICU) on 08/17/13 at 01:40 AM. The next documented Nursing Activity Flow Record was on 08/18/13 at 06:40 AM, while Patient #2 was in the ICU. There were no documented Nursing Activity Flow Records for 08/17/13.

A repeat CT scan was then done on 08/17/13 at 06:13 AM. Impression following this scan was 1) "no substantial change in bifrontal hemorrhagic contusions, 2) thin subdural hematomas along the left cerebral hemisphere and the right temporoparietal region have shown minimal change" and 3) there is a nondisplaced calvarial fracture through the parietal bones."

Review of a progress note written by Internal Medicine (IM) on 08/16/13 at 08:00 AM, indicates they were called to assess Patient #2 status post "fall last night." Patient #2 was yelling at the time of assessment. IM wrote "cerebral bleed" secondary to recurrent falls.

On 08/18/13 at 07:45 AM, Neurosurgery documented in progress note a plan that included "frontal contusion" and right frontal subdural hematoma status post fall on hospital day two. No surgical intervention needed at that time.

The next activity and safety standard check was documented on 08/18/13 at 1:40 PM and at 8:30 PM Patient #2 was transferred from ICU back to the step-down telemetry unit. Staff documented another activity and safety standard check on 08/19/13 at 1:37 PM, approximately 24 hours after the previous check. Activity and safety standards were met and documented again at 6:17 PM. The next check was on 08/20/13 at 1:47 PM, approximately 19 hours later, and staff failed to document safety standards were met.

A third CT of the head was done on 08/21/13 at 9:47 AM. and revealed the following: 1) "evolution and slight distribution of mixed density bilateral subdural hematomas which overall are stable in thickness", 2) "slight increase in prominence of predominantly low density left frontal extra-axial collection" and 3) "hemorrhagic contusions in the inferior frontal lobes are not significantly changed."

The following Nursing Activity Flow Records were inconsistently documented during the remainder of Patient #2's hospitalization, until Patient #2 was discharged on 09/17/13:

08/22/13 at 11:07AM - activity and safety standard done approximately 29 hours since the last activity and safety check at 05:30AM on 08/21/13.
08/23/13 at 12:31 PM - safety standard undocumented, activity done approximately 17 hours after last check from 08/22/13 at 6:58 PM - activity and safety done.
09/02/13 at 12:49AM - activity and safety done, approximately 19 hours since the previous check.
09/02/13 at 9:55 PM - activity and safety done, approximately 21 hours since the previous check.
09/06/13 at 1:23 PM - activity and safety done, approximately 17 hours since the previous check on 09/05/13 at 8:33 PM - activity and safety done.
09/07/13 at 3:18 PM - activity and safety done, approximately 15 hours since the previous check on 09/06/13 at 9:55 PM - activity and safety done.
09/08/14 at 1:40PM - activity and safety done, approximately 16 hours since the previous check at 09/07/13 at 9:41 PM - activity and safety done.
09/09/13 at 2:50 PM - no documented safety check, approximately 19 hours since the previous activity check at 09/08/13 at 8:02 PM - activity and safety done.
09/10/13 at 1:44 PM - activity and safety done, approximately 25 hours since the previous check.
09/11/13 at 1:55 PM - activity and safety done, approximately 16 hours since the previous check at 09/10/13 at 9:49 PM - activity and safety done.
09/13/13 at 1:29 PM- activity and safety done, approximately 16 hours since previous check on 09/12/13 at 9:43 PM.
09/14/13 at 2:07 PM - activity and safety done, approximately 16 hours since previous check, last done on 9:28 PM on 09/13/14.
09/15/13 at 8:16 PM- activity and safety done, approximately 24 hours since the previous check.

The Director of the Eight Floor (Staff F) stated on 02/11/14 at 3:10 PM the Activity Standards include turning and repositioning the patient at least every two hours if not performing independently.


Review of a progress note dated 08/18/13 at 2:50 PM, Staff P, the pulmonologist, described Patient #2 as disoriented to place and time and noted Patient #2 had "bilateral frontal lobe contusions" and right subdural hematoma secondary to fall in hospital on 08/16/13.

On 08/22/13 at 06:30 AM the progressnote revealed Surgery was consulted about removing/replacing Patient #2's peritoneal dialysis catheter. The physician noted Patient #2 had "recent significant decline in overall health status, new subdural hematoma and was not considered a "good candidate" for the surgery at that time.

Neurology progress note revealed on 08/22/13 Patient #2 "arouses only momentarily on exam, looks at me then closes eyes again." Diagnoses: 1) encephalopathy, 2) subdural hematoma and 3) recent traumatic brain injury.

Per the progress note Patient #2 was then seen by Internal Medicine on 08/24/13 at 10:50 PM and described as "minimally responsive" with increased respiratory rate. Assessment revealed diagnoses of acute respiratory failure, metabolic encephalopathy and subdural hematoma with poor prognosis.

A final CT scan of the head/brain was done on 08/31/13 at 2:47 PM. Impression at that time was 1) "moderate to severe leukoencephalomalacia in the left frontal, left occipital and right temporal lobes showing no significant change." Leukoencephalomalacia refers to softening of the white matter of the brain most likely related to hemorrhaging (bleeding) in the brain.

Staff C was made aware of and confirmed the above findings following completion of the record review on 02/14/14 at 4:00PM.


By 12:00PM on 08/25/13, Patient #2 was intubated (on a ventilator to assist with breathing) and sedated in the hospital's Intensive Care Unit as evidenced by a progress note written by Internal Medicine. Patient #2 was noted to be suffering from acute respiratory failure, septic shock, pneumonia, urinary tract infection with e. coli, c. diff colitis, and free air under diaphragm.


On 08/26/13 at 06:00 AM Patient #2 was seen by surgery again. Patient #2 was noted to be critically ill, intubated and sedated. Diagnoses were noted to include acute respiratory failure, traumatic brain injury, and metabolic encephalopathy.

The progress note revealed on 08/26/13 at 10:35 AM Patient #2 was then seen and re-evaluated by Pulmonary. Patient #2 was noted to be on ventilator, unresponsive to name or touch. Patient #2's current diagnoses now included ventilator dependent respiratory failure secondary to shock and hypoventilation, septic shock, and traumatic brain injury secondary to fall on 08/16/13.


Patient #2 was seen and examined by Infectious Disease in ICU on 08/29/13 at 08:15AM. The diagnoses at this point were sepsis/respiratory failure, status post fall with subdural hematoma/traumatic brain injury per progress note.

Patient #2 was seen and examined again by Pulmonary on 08/29/13 at 11:07AM. At that time Patient #2 was described as awake but "will not acknowledge or follow commands." Patient #2 was noted to have improving respiratory failure, encephalopathy secondary to traumatic brain injury and hypoxemia from 08/25/13, and subdural hematoma secondary to fall after admission. Discussed extubation and possible re-intubation with daughter at that time.


Also on 08/30/13 at 1:00PM Patient #2 was seen by Internal Medicine. The physician wrote the assessment/plan for Patient #2 was 1) ventilator dependent respiratory failure and 2) intracranial bleed with encephalopathy.


On 09/02/13 at 10:07AM a Pulmonary progress note revealed the current plan for Patient #2's care was discussed and the family requested do not resuscitate/comfort care arrest (DNR-CCA) status for Patient #2. The family also requested no re-intubation.


09/05/13 at 09:38AM Pulmonary documented in progress note palliative care was to see Patient #2, and Patient #2 was to be transferred back to the telemetry floor. Patient #2 was subsequently seen and evaluated by palliative care at 11:05 AM at which time they noted Patient #2 would be appropriate for inpatient hospice, discussed with family.

On 09/06/13 at 10:48AM Palliative Care again saw Patient #2 and family was noted to be present. At this time family indicated they wanted a PEG tube inserted and to "pursue therapy/rehab" for Patient #2. Discharge planning was begun.

On 09/12/13 Palliative Care documented another progress note. Family expressed a desire to change Patient #2's code status again from DNR-CC to DNR-CCA after Patient #2's mental status was noted to be improved. Patient #2 reportedly expressed a desire to go home at that time. Discharge planning continued.

Patient #2 was last seen by Palliative Care on 09/16/13 at 4:13PM with the plan for discharge to an extended care facility with the possibility of hospice care after that. Patient #2 was described as alert when awakened, very weak and with lower extremity skin issues. The progress note on 09/17/13 by Staff Q, revealed Patient #2 was stable for discharge to extended care facility.

Staff C was made aware of and confirmed the above findings following completion of the record review on 02/14/14 at 4:00 PM.

The initial Skin/Tissue Assessment completed by nursing on 08/15/13 revealed the following wounds on admission:

#1 arms, back, shoulder, trunk and legs with red, black and pink bruising
#2 skin tear on left elbow, red in appearance and left open to air
#3 skin tear to left knee, red in appearance and left open to air
#4 skin tear to right forearm, red in appearance and left open to air
#5 bruising on coccyx, red in appearance and left open to air

The skin/tissue assessment of Patient #2 remained unchanged from the initial admission assessment until 08/16/13 at 11:10 PM. Following a fall, Patient #2 was now noted to also have abrasions on the right side of his/her head (wound #6), red and purple in color, with a scant amount of bloody drainage.

The skin/tissue assessment on 08/18/13 at 9:00 PM revealed wound #1 remained unchanged, wounds #2 and #3 were now scabbed over and remained open to air, wound #4 had an unknown clean and dry dressing in place and wound #5 (coccyx) now had a small open area measuring 0.5 centimeters (cm) by 0.5 cm. Barrier cream was applied to this wound.

Skin/Tissue Assessment on 08/19/13 at 07:30 AM revealed Barrier cream was applied and a notation revealed Patient #2 was to be turned every two hours.

Skin/Tissue Assessment on 08/19/13 at 7:47 PM revealed a new wound, wound #7 was first documented at this time. Patient #2's bilateral heels were described as reddened, "pink and mushy."

The next noted change in the Skin/Tissue Assessment was on 08/20/13 at 4:00 PM. Wounds #1-3 and 6 were left open to air for healing. Wound #4 was wrapped in kerlix (gauze) after bacitracin was applied, barrier cream was applied to wound #5 and wound #7 revealed bilateral heels were still reddened but only the right heel was noted be elevated on a pillow.

The first documented notation regarding Patient #2's wounds by a physician was on 09/05/13 at 11:05 AM by Palliative Care that identified Patient #2 had a coccyx wound. On 09/06/13 at 10:48 AM Palliative Care wrote that Patient #2's right great toe and bilateral heels were purple in color.

On 09/06/13 at 6:00 PM Pulmonary wrote in physician note that Patient #2's right great toe and first toe were cyanotic distally.

On 09/10/13 at 6:00 PM Patient #2 was seen by Medicine at which time they documented Patient #2's "right foot toe cyanotic/gangrene" with blisters and Patient #2 was also noted to have a sacral decubitus ulcer. Podiatry was consulted.

Patient #2 was then seen and examined by Pulmonary per progress note on 09/10/13 at 8:30 PM at which time they documented Patient #2's right great and first toes were "showing distal necrosis."

Podiatry then completed their first examination of Patient #2 on 09/11/13 at 08:40 AM. Assessment revealed ischemic changes to right digits and pressure ulcers to left heel and right ankle. Recommendation was for doppler study, offloading and wound protection.

Patient #2 was seen and examined by Podiatry again on 09/12/13 at 5:00 PM. Assessment revealed pressure ulcers to left heel and right ankle with eschar and necrosis/gangrene to first, second and fourth toes on right foot. The recommendation was for santyl (ointment) to eschar areas daily and silvadene (cream) to toes on right foot.

On 09/12/13 at 6:00 PM Patient #2 was seen by Medicine, who documented Patient #2 had a "unstagable sacral decubitus" and was a poor surgical candidate for debridement."

On 09/15/13 Patient #2 was seen and examined by Podiatry before discharge. The following notes were documented: "dry necrotic changes again noted toes 1, 2, 4" on right foot, eschar right ankle and left heel still present but show improvement. Healing potential was noted to be poor and recommendation was to continue local wound care and monitor for signs and symptoms of infection.

The last Skin/Tissue Assessment by nursing was completed on 09/17/13 at 08:30 AM. The following documented wounds were present prior to Patient #2's discharge:

Wound #1 - arms, back, shoulders, trunk and legs with scant amount of serous drainage, wounds red and black in color, left open to air
Wound #2 - skin tear on left elbow, red and purple in color, left open to air
Wound #3 - skin tear to left knee, black in color, left open to air
Wound #4 - skin tear to right forearm with serosangiounous drainage, yellow and pink in color, left open to air
Wound #5 - pressure ulcer on coccyx, purple, pink, red, yellow and black in color, moderate amount of serosanguinous drainage, no documented dressing in place
Wound #6 - bruising to anterior chest, purple in color with serous drainage, left open to air
Wound #7 - bilateral heel pressure ulcers, purple and black in color, santyl ointment and unknown dressing in place
Wound # 8 - head, red, purple and pink in color, with two scabs left open to air

Staff C was made aware of and confirmed the above findings following completion of the record review on 02/14/14 at 4:00 PM.













29732

Based on interview, medical record review, and policy review, the facility failed to ensure nursing staff developed a plan of care for one (Patient #5) of 11 medical records reviewed and failed to ensure nursing staff updated nursing care plans for two (Patient #2 and #3) of 11 medical records reviewed. This had the potential to affect every patient admitted to the facility. The census at the time of the survey was 240.


Findings include:


1) The medical record review for Patient #5 was completed on 2/11/14 at 3:55 PM. Patient #5 was admitted to the facility on 1/25/14 with a diagnosis of cough, generalized weakness and general malaise. On 2/11/14 at 3:55 PM, the medical record did not contain a care plan for Patient #5.

The findings were shared with Staff K, a registered nurse, on 2/11/14 at 3:55 PM and confirmed.



2) The medical record review for Patient #3 was completed on 2/11/14 at 3:45 PM. Patient #3 was admitted to the facility on 2/9/14 following an unwitnessed fall. The nursing assessment was completed on 2/9/14 at 4:21 AM. The assessment revealed Patient #3 had a Braden score (a tool for predicting pressure sore risk) of 13(moderate risk), multiple abrasions and a rash at admission. The plan of care for Patient #3 failed to list skin/tissue as a problem/focus area.

On 2/14/14 at 3:03 PM, the facility's Assessment/Reassessment policy was reviewed. The policy stated information generated through the analysis of assessment data is integrated to identify and prioritize the interventions of the multidisciplinary plan of care. The plan of care is initiated by the registered nurse. The plan of care is individualized after completion of the initial admission assessment.




3) The medical record review for Patient #2 was completed on 02/14/14 at 4:00PM. Patient #2 was admitted to the facility's step-down telemetry unit on 05/01/13 with diagnoses of dizziness and near syncope (episode of fainting). The following areas were identified as "problems" or "focus" areas during the course of Patient #2's hospitalization: pain, activity intolerance, cardiac, respiratory, genitourinary and endocrine. Staff failed to indicate whether or not Patient #2 had met the expected outcomes and goals on the plan of care related to these problems prior to discharge on 05/09/13.

Patient #2 was again admitted to the step-down telemetry unit on 08/15/13 with diagnoses of abdominal pain and weakness. The following areas were identified as "problems" or "focus" areas during Patient #2's hospitalization: neurological, pain, activity intolerance, cardiac, respiratory, gastrointestinal, genitourinary, endocrine, infection, skin/tissue, musculoskeletal, and psychosocial.
Again staff failed to indicate whether or not Patient #2 had met the expected outcomes and goals on the plan of care related to these problems prior to discharge on 09/17/13.

Staff C was made aware of and confirmed these findings on 02/13/14 at 4:10 PM.






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