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Based on record review and interview, the facility failed to ensure the patient or patient's legal guardian had the right to be informed about the patient's health status in order to have involvement with treatment and care planning decisions, in 1 of a total sample of 1 patients (Patient #1) with an allegation of abuse.

Findings

Facility policy "Disclosure of Unanticipated Outcomes of Care" document ID KT2N6QC5SZE-3-1981 last review date of 2/8/2019 was reviewed on 7/29/2019 at 1:00PM. The policy, in part states under 3.4 "Communication Process of Disclosure: a) no-harm or "near miss" events: conversation must occur with the patient and/or family. Conducted in a timely manner by the Provider, or other appropriate staff, as applicable, involved with the current care of the patient. The intent is to provide information and reassurance regarding the objective facts and necessary medical information as well as additional testing, monitoring or follow up cares needed to ensure safety of the patient. The discussion should include: explanation of what happened, general apology, treatment plan to monitor the patient to ensure safety."

In interview with Safety Officer F on 7/29/2019 at 1:15PM it was confirmed that the administration of the unordered Propofol bolus was considered a no-harm event by the facility. When asked if the event had been disclosed to the patient or family Safety Officer F stated "no". Further inquiry as to why the facility policy was not followed Safety Officer F stated "our administration and legal department decided not to. I think because the patient was sedated." When questioned regarding disclosure to family Safety Officer F shrugged her shoulders and stated "I don't know why that didn't happen, they decided not to."

Based on record review and interview the facility failed to ensure safety of patients in 1 (Patient #1) of a total sample of 1 patients.

Findings include:

Facility policy "Reporting Allegations of Patient Abuse, Neglect, or Misappropriation of Patient Property (Caregiver Misconduct)" document ID TM7XN2FTXHRM-3-209 last reviewed 7/26/2019 states in part under 3.1 (a) "Any Employee, Provider or Contractor who witnesses or becomes aware of alleged misconduct . . .must report the incident to a Charge Nurse, team Lead or Department Manager as soon as possible, and no later than 2 hours after the perceived misconduct was observed." RN H reported the event the next morning, therefore Nurse A continued to care for Patient 1 throughout the 12 hour shift. When the allegation was reported to the charge nurse the morning of 7/14/2019, the notification process defined in the above policy was followed and Nurse A placed on administrative leave pending results of investigation.

In interview with ICU Supervisor C on 7/29/2019 at 2:20PM he/she stated "If I had been made aware of the incident the evening it occurred I would have sent Nurse A home immediately." Facility policy also reveals in 3.1 d) "Response upon Learning of Allegation: Upon learning of alleged misconduct, (facility name) will take necessary steps to ensure that patients are protected from subsequent episode of misconduct while a determination on the matter is pending."

Based on record review and interview the facility failed to ensure that a comprehensive care plan that is individualized, and based on assessing the patient's nursing care needs, treatment goals, and admitting diagnosis', in 5 of a total sample of 10 medical records reviewed (Patient #'s 1, 4, 5, 7, 10)

Findings:
Review on 7/29/2019 at 1:45PM of Patient #1's medical record revealed a 55 year old admitted on 7/12/2019 with a diagnosis of alcohol withdrawal. Care Plan for Patient #1 revealed problem list for impaired skin integrity and anxiety. There was no care plan specifically addressing alcohol withdrawal. This was confirmed with Nurse Manager I at the time of review.

Review on 7/29/2019 at 3:58PM of Patient #4's medical record revealed a 54 year old admitted on 6/24/2019 with a diagnosis of altered mental status, pneumonitis and Methamphetamine ( an illegal, powerful, highly addictive stimulant that affects the central nervous system) abuse. Care plan for Patient #4 revealed ineffective airway clearance. There was no care plan specifically addressing potential Methamphetamine withdrawal. This was confirmed with Nurse Manager I at the time of review.

Review on 7/29/2019 at 4:08PM of Patient #5's medical record revealed a 53 year old admitted with a diagnosis of dehydration and chronic pancreatitis due to alcohol abuse. Care Plan for Patient #5 revealed problem list for altered tissue perfusion. There was no care plan specifically addressing alcohol withdrawal. This was confirmed with Nurse Manager I at the time of review.

Review on 7/29/2019 at 4:30PM of Patient #7's medical record revealed a 30 year old admitted on 4/9/2019 with a diagnosis of alcohol abuse and gastritis (inflammation of the lining of the stomach). Care plan for Patient #7 revealed no care plan addressing potential for alcohol withdrawal. This was confirmed with Nurse Manager I at the time of review.

Review on 7/29/2019 at 4:44PM of Patient #10's medical record revealed a 60 year old admitted on 5/30/2019 with a diagnosis of high blood pressure and alcohol abuse. Care plan for Patient #10 revealed no care plan addressing potential for alcohol withdrawal. This was confirmed with Nurse Manager I at the time of review.

In interview with Nurse Manager I and Safety Officer F, on 7/29/2019 at 4:45PM, Safety Officer F stated "I looked and we do not have a care plan that addresses alcohol withdrawal." Nurse Manager I stated "that is a good idea, we probably should have one."