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812 GORMAN AVENUE

ELKINS, WV 26241

PATIENT RIGHTS

Tag No.: A0115

Based on observation, clinical record review, document review and interview it was revealed the facility failed to do fall risk assessments as directed by policy and procedure, and individualize care plans to prevent falls. (See tag A 144.)

A. An Immediate Jeopardy (IJ) to Patient Rights was called on 10/12/21 at 3:15 p.m. because the facility failed to assess all patients for fall risk, individualize their care plans to reflect their current risk and put procedures in place to prevent falls. One (1) patient fell and sustained an inguinal hematoma. The facility failed to post patient's fall risk indicators (signs) in line of sight for patients on COVID isolation.

B. Serious injury, serious harm, serious impairment or death: Patients who experience falls are at risk for serious injury, harm, impairment or death. One (1) patient who fell became unstable and died.

C. Need for immediate action: The facility needs to take steps to prevent falls in patients, as they can result in serious injury, harm, impairment or death.

D. An Immediate Plan of Correction was received by the State agency Program Manager. The facility re-educated all nursing staff prior to their next shift on fall risk and monitoring telemetry and change of conditions with notification to the physician and fall risk being placed in site of eyes at patient door. It was accepted and the facility abated the IJ on 10/12/21 at 8:45 p.m.

PATIENT RIGHTS: CARE IN SAFE SETTING

Tag No.: A0144

Based on observation, clinical record review, document review and interview it was revealed the facility failed to protect and promote patient's rights to be free from falls. The facility did not do a falls risk reassessment on one (1) out of one (1) patient who fell (patient #1). The facility did not assess fall risk every shift and ensure fall care plans were current for five (5) out of ten (10) patients (patient #1, 5, 6, 7 and 8). The facility did not create individualized falls risk care plans for ten (10) out of ten (10) patients (patients #1 through 10). Falls place all patients at risk for serious harm, serious injury, serious impairment, or death.

Findings include:

Observation was conducted on 10/11/21 at 8:40 a.m. on Unit Two North (2N) with the Interim Director of Patient Services (IDPS). Four (4) patients (patients #5, 6, 7 and 8) were on enhanced respiratory isolation (isolation that requires the room door being closed, special filtering of the room air and the wearing of full personal protective equipment (PPE) by anyone entering the room). None of these patients had signs indicating their fall risk in line of sight of staff.

Review of patient #1's clinical record revealed he/she was admitted with a diagnosis of COVID-19. On 10/4/21 he/she had no fall risk assessment. On 10/5/21 at 7:42 p.m. his/her fall risk assessment reflected a moderate fall risk. His/her care plan was not individualized to include moderate fall risk. On 10/5/21 at 9:23 a.m. he/she fell. A Computed Axial Topography scan (CAT scan--a medical imaging technique used in radiology to get detailed images of the body non-invasively for medical purposes) done after the fall revealed he/she had an inguinal hematoma measuring 24.1 x 8.4 x 9.0 centimeters in dimension. No reassessment of his/her fall risk was done after the fall. No changes were made in his/her care plan after the fall.

Review of patient #5's clinical record revealed he/she was admitted with a diagnosis of COVID-19 and dehydration. His/her fall risk was high. The care plan was not individualized to include high fall risk.

Review of patient #6's clinical record revealed he/she was admitted with a diagnosis of COVID-19 pneumonia. His/her fall risk was high. The care plan was not individualized to include high fall risk.

Review of patient #7's clinical record revealed he/she was admitted with a diagnosis of COVID-19. He/she was a high fall risk. The care plan was not individualized to include high fall risk.

Review of patient #8's clinical record revealed he/she was admitted with a diagnosis of COVID-19 and altered mental status. He/she was a high fall risk. The care plan was not individualized to include high fall risk.

Review of a document titled, "POLICY DESCRIPTION: FALL PREVENTION," revised 5/21, revealed in part: "Each adult and pediatric patient will be assessed, on admission and as needed such as status change or change in patient condition for level of risk for falls by a nurse. The RN (registered nurse) will then start an individualized care plan with the appropriate interventions according to the fall risk score...An individualized plan of care will be developed using interventions assigned to risk score for both adult and pediatric patients. This plan of care will be evaluated every shift and as needed.... Each high fall risk and moderate fall risk patient will have the "logo patient fall" tag placed at line of vision..."

Review of a document titled, "POLICY DESCRIPTION: FALL RESPONSE," revised 10/18, revealed in part: "A patient's plan of care following any fall will be modified to include additional checks of monitoring the patient's status for several days."

During the tour on 10/11/21 at 8:40 a.m. the IDPS acknowledged patients #5, 6, 7 and 8 were in COVID isolation and there were no fall risk signs in line of sight of staff. He/she acknowledged having a line of site fall risk sign was a policy that was not being followed.

An interview was conducted on 10/12/21 at 2:35 p.m. with the Quality Risk Manager and the Vice President and Chief Nursing Officer (VP CNO). The VP CNO acknowledged the care plans used for all patients in the facility on all units are not individualized for each patient. The care plans are only individualized in the RN's assessments each shift and sometimes those assessments are missed. Sometimes the charting does not reflect individualization of the care plans.

A phone interview was conducted with RN #2 on 10/12/21 from 1:45 p.m. to 2:08 p.m. He/she stated patient #1 was a high fall risk when he/she took over his/her care on 10/5/21 at 7:00 a.m. He/she was getting stronger and wasn't as much of a fall risk. He/she heard a noise from his/her room and went in to check on him/her. He/she attempted to stand after he/she started to leave the room to get help to take him/her to the bathroom and he/she fell. After he/she was lifted back into the bed by four (4) staff members, he/she told him/her that he/she was not allowed to get out of bed without help and he/she put his/her alarm on. He/she did not reassess his/her fall risk. He/she did not update his/her care plan. The policy is for fall risk to be reassessed with changes in patient condition.

NURSING SERVICES

Tag No.: A0385

Based on clinical record review, document review and interview it was revealed the facility failed to provide nursing supervision of care, resulting in a patient being pulseless for nine (9) minutes before cardiopulmonary resuscitation (CPR) was started and the patient expired. This occurred in one (1) out of ten (10) patients reviewed (patient #1). (See tags A 386, A 396 and A 398.)

A. An Immediate Jeopardy (IJ) to Nursing Services was called on 10/12/21 at 3:15 p.m. because the facility failed to provide CPR to patient #1 after telemetry showed she/he was pulseless. Patient #1 was pulseless for nine (9) minutes before a nurse going into his room to hang blood tubing found her/him unresponsive, pulseless and not breathing and began CPR.

B. Serious injury, serious harm, serious impairment or death: Patient #1 died.

C. Need for immediate action: Action needs to be taken to ensure any patient whose heart stops beating and/or stops breathing is given CPR immediately to improve chances for continued life.

D. An Immediate Plan of Correction was received by the State agency Program Manager. The facility re-educated all nursing staff prior to their next shift on fall risk and monitoring telemetry and change of conditions with notification to the physician and fall risk being placed in site of eyes at patient door. It was accepted and the facility abated the IJ on 10/12/21 at 8:45 p.m.

ORGANIZATION OF NURSING SERVICES

Tag No.: A0386

Based on review of clinical records, document review and interview it was revealed the Vice President and Chief Nursing Officer (VP CNO--one person) failed to ensure policy and procedures for care planning and prevention of falls were followed. He/she failed to ensure telemetry technicians were documenting tracking of patient telemetry readings and notifying nursing staff of changes in readings. He/she failed to detect there was a nine (9) minute lag between the time a patient's telemetry showed he/she became pulseless and when Cardiopulmonary Resuscitation (CPR) was started on him/her when reviewing his/her care after he/she died (patient #1).

Findings include:

Observation was conducted on 10/11/21 at 8:40 a.m. on Unit Two North (2N) with the Interim Director of Patient Services (IDPS). Four (4) patients (patients #5, 6, 7 and 8) were on enhanced respiratory isolation (isolation that requires the room door being closed, special filtering of the room air and the wearing of full personal protective equipment (PPE) by anyone entering the room). None of these patients had signs indicating their fall risk in line of sight of staff.

Review of patient #1's clinical record revealed he/she was admitted on 9/20/21 with a diagnosis of COVID 19. His/her care plan listed low risk, moderate risk, and high risk for falls. It was not individualized to his/her fall risk level (high). His/her care plan did not change at any time during his/her hospitalization. On 10/5/21 patient #1 fell. His/her fall risk prior to the fall was moderate. A computed tomography scan (CAT scan--a medical imaging technique used in radiology to get detailed images of the body non-invasively for medical purposes) was done which showed he/she had developed an inguinal hematoma (blood clot) measuring 24.1 x 8.4 x 9.0 centimeters in dimension. He/she had difficulty with hypotension following the fall and persistent abdominal pain. No fall-risk reassessment was done after the fall to indicate his/her risk was increased to high fall risk nor was his/her care plan updated to direct monitoring of his/her condition more frequently. He/she received plasma, had lab work done and was scheduled to receive an infusion of packed red blood cells. He/she signed a consent for the transfusion on which his/her signature was noted to be significantly deteriorated from previous documents he/she signed during his/her hospital stay. (The signature trailed from the signature line downward across the entire text on the page). The physician was not notified. The care plan was not changed to reflect this deterioration in condition. On 10/5/21 at 11:30 a.m., his/her telemetry showed he/she was pulseless. This change in condition was not acknowledged by the patient's registered nurse (RN), the charge RN or any member of the healthcare team. Patient #1 was found unresponsive by RN #1 at 11:39 a.m. when he/she entered the room to hang blood tubing. Patient #1 was pulseless and was not breathing. CPR was started and continued until 12:29 p.m. at which time he/she was pronounced dead. The death certificate listed primary cause of death as hypovolemic shock with sequentially listed conditions leading to the cause of death as acute hemorrhage and fall (occurring "hours" before death). COVID 19, hypoxia, diabetes and hypertension were listed as underlying causes present "years" before death.

Review of patient #5's clinical record revealed he/she was admitted with a diagnosis of COVID-19 and dehydration. His/her fall risk was high. The care plan was not individualized to include high fall risk.

Review of patient #6's clinical record revealed he/she was admitted with a diagnosis of COVID-19 pneumonia. His/her fall risk was high. The care plan was not individualized to include high fall risk.

Review of patient #7's clinical record revealed he/she was admitted with a diagnosis of COVID-19. He/she was a high fall risk. The care plan was not individualized to include high fall risk.

Review of patient #8's clinical record revealed he/she was admitted with a diagnosis of COVID-19 and altered mental status. He/she was a high fall risk. The care plan was not individualized to include high fall risk.

Review of a document titled, "POLICY DESCRIPTION: FALL PREVENTION," revised 5/21, revealed in part: "Each adult and pediatric patient will be assessed, on admission and as needed such as status change or change in patient condition for level of risk for falls by a nurse. The RN will then start an individualized care plan with the appropriate interventions according to the fall risk score...An individualized plan of care will be developed using interventions assigned to risk score for both adult and pediatric patients. This plan of care will be evaluated every shift and as needed.... Each high fall risk and moderate fall risk patient will have the "logo patient fall" tag placed at line of vision..."

Review of a document titled, "POLICY DESCRIPTION: FALL RESPONSE," revised 10/18, revealed in part: "A patient's plan of care following any fall will be modified to include additional checks of monitoring the patient's status for several days."

During the tour on 10/11/21 at 8:40 a.m. the IDPS acknowledged patients #5, 6, 7 and 8 were in COVID isolation and there were no fall risk signs in line of sight of staff. He/she acknowledged having a line of site fall risk sign was a policy that was not being followed.

A phone interview was conducted with RN #2 on 10/12/21 from 1:45 p.m. to 2:08 p.m. He/she stated patient #1 was a high fall risk when he/she took over his/her care on 10/5/21 at 7:00 a.m. He/she was getting stronger and wasn't as much of a fall risk. He/she heard a noise from his/her room and went in to check on him/her. He/she attempted to stand after he/she started to leave the room to get help to take him/her to the bathroom and he/she fell. After he/she was lifted back into the bed by four (4) staff members, he/she told him/her that he/she was not allowed to get out of bed without help and he/she put his/her alarm on. He/she did not reassess his/her fall risk. He/she did not update his/her care plan. The policy is for fall risk to be reassessed with changes in patient condition.

An interview was conducted on 10/12/21 at 2:35 p.m. with the Quality Risk Manager (QRM) and the VP CNO. The VP CNO acknowledged the care plans used for all patients in the facility on all units are not individualized for each patient. The care plans are only individualized in the RN's assessments each shift and sometimes those assessments are missed. Sometimes the charting does not reflect individualization of the care plans.

An interview was conducted on 10/12/21 at 2:55 p.m. with the QRM and the VP CNO. The VP CNO acknowledged documentation maintained by the telemetry technicians does not reflect notification of nursing staff when a change in heart rhythm occurs. The VP CNO also acknowledged there was no evidence in the nursing notes that notification had been received from the telemetry department. The VP CNO acknowledged documentation and notification to reflect telemetry monitor changes needs to be improved and that nine (9) minutes lag time between patient #1 (who was on telemetry) going pulseless and CPR being started was unacceptable.

NURSING CARE PLAN

Tag No.: A0396

Based on clinical record review, document review and interview it was revealed the nursing staff failed to ensure each patient had an individualized fall risk care plan in place to prevent falls. This failure occurred in ten (10) out of ten (10) patients (patients #1 through 10). This failure creates the potential for serious harm, injury, impairment, or death to all patients from falls. One (1) of ten (10) patients reviewed died after a fall (patient #1).

Findings include:

Review of patient #1's clinical record revealed he/she was admitted on 9/20/21 with a diagnosis of COVID 19. His/her care plan listed low risk, moderate risk, and high risk for falls. It was not individualized to his/her fall risk level (high). His/her care plan did not change at any time during his/her hospitalization. On 10/5/21 patient #1 fell. His/her fall risk prior to the fall was moderate. A computed tomography scan (CAT scan--a medical imaging technique used in radiology to get detailed images of the body non-invasively for medical purposes) was done which showed he/she had developed an inguinal hematoma (blood clot) measuring 24.1 x 8.4 x 9.0 centimeters in dimension. He/she had difficulty with hypotension following the fall and persistent abdominal pain. No fall-risk reassessment was done after the fall to indicate his/her risk was increased to high fall risk nor was his/her care plan updated to direct monitoring of his/her condition more frequently. He/she received plasma, had lab work done and was scheduled to receive an infusion of packed red blood cells. He/she signed a consent for the transfusion on which his/her signature was noted to be significantly deteriorated from previous documents he/she signed during his/her hospital stay. (The signature trailed from the signature line downward across the entire text on the page). The physician was not notified. The care plan was not changed to reflect this deterioration in condition. On 10/5/21 at 11:30 a.m., his/her telemetry showed he/she was pulseless. This change in condition was not acknowledged by the patient's registered nurse (RN), the charge RN or any member of the healthcare team. Patient #1 was found unresponsive by RN #1 at 11:39 a.m. when he/she entered the room to hang blood tubing. Patient #1 was pulseless and was not breathing. CPR was started and continued until 12:29 p.m. at which time he/she was pronounced dead. The death certificate listed primary cause of death as hypovolemic shock with sequentially listed conditions leading to the cause of death as acute hemorrhage and fall (occurring "hours" before death). COVID 19, hypoxia, diabetes and hypertension were listed as underlying causes present "years" before death.

Review of patient #5's clinical record revealed he/she was admitted with a diagnosis of COVID-19 and dehydration. His/her fall risk was high. The care plan was not individualized to include high fall risk.

Review of patient #6's clinical record revealed he/she was admitted with a diagnosis of COVID-19 pneumonia. His/her fall risk was high. The care plan was not individualized to include high fall risk.

Review of patient #7's clinical record revealed he/she was admitted with a diagnosis of COVID-19. He/she was a high fall risk. The care plan was not individualized to include high fall risk.

Review of patient #8's clinical record revealed he/she was admitted with a diagnosis of COVID-19 and altered mental status. He/she was a high fall risk. The care plan was not individualized to include high fall risk.

Review of a document titled, "POLICY DESCRIPTION: FALL PREVENTION," revised 5/21, revealed in part: "Each adult and pediatric patient will be assessed, on admission and as needed such as status change or change in patient condition for level of risk for falls by a nurse. The RN will then start an individualized care plan with the appropriate interventions according to the fall risk score...An individualized plan of care will be developed using interventions assigned to risk score for both adult and pediatric patients. This plan of care will be evaluated every shift and as needed.... Each high fall risk and moderate fall risk patient will have the "logo patient fall" tag placed at line of vision..."

Review of a document titled, "POLICY DESCRIPTION: FALL RESPONSE," revised 10/18, revealed in part: "A patient's plan of care following any fall will be modified to include additional checks of monitoring the patient's status for several days."

An interview was conducted on 10/12/21 at 2:35 p.m. with the Quality Risk Manager and the Vice President and Chief Nursing Officer (VP CNO). The VP CNO acknowledged the care plans used for all patients in the facility on all units are not individualized for each patient. The care plans are only individualized in the RN's assessments each shift and sometimes those assessments are missed. Sometimes the charting does not reflect individualization of the care plans.

A phone interview was conducted with RN #2 on 10/12/21 from 1:45 p.m. to 2:08 p.m. He/she stated patient #1 was a high fall risk when he/she took over his/her care on 10/5/21 at 7:00 a.m. He/she was getting stronger and wasn't as much of a fall risk. He/she heard a noise from his/her room and went in to check on him/her. He/she attempted to stand after he/she started to leave the room to get help to take him/her to the bathroom and he/she fell. After he/she was lifted back into the bed by four (4) staff members, he/she told him/her that he/she was not allowed to get out of bed without help and he/she put his/her alarm on. He/she did not reassess his/her fall risk. He/she did not update his/her care plan.

SUPERVISION OF CONTRACT STAFF

Tag No.: A0398

Based on clinical record review, document review and interview it was revealed the facility's nursing staff did not follow their policies and procedures for responding to and notifying the physician of a change in patient condition for one (1) out of one (1) patient reviewed (patient #1). Patient #1 fell and had changes in condition. Nursing services failed to adequately monitor the patient, notify the physician and initiate interventions. The patient expired.

Findings include:

Review of patient #1's clinical record revealed he/she was admitted on 9/20/21 with a diagnosis of COVID 19. On 10/5/21 patient #1 fell. A computed tomography scan (CAT scan--a medical imaging technique used in radiology to get detailed images of the body non-invasively for medical purposes) was done which showed he/she had developed an inguinal hematoma (blood clot) measuring 24.1 x 8.4 x 9.0 centimeters in dimension. He/she had difficulty with hypotension following the fall and persistent abdominal pain. He/she received plasma, had labwork done and was scheduled to receive an infusion of packed red blood cells. He/she signed a consent for the transfusion on which his/her signature was noted to be significantly deteriorated from previous documents he/she signed during this hospital stay. (The signature trailed from the signature line downward across the entire text on the page). The physician was not notified. On 10/5/21 at 11:30 a.m. his/her telemetry showed he/she was pulseless. This change in condition was not acknowledged by the patient's registered nurse (RN), the charge RN or any member of the healthcare team. Patient #1 was found unresponsive by RN #1 at 11:39 a.m. when she entered the room to hang blood tubing. Patient #1 was pulseless and was not breathing. Cardiopulmonary Resuscitation (CPR) was started and continued until 12:29 p.m. at which time he/she was pronounced dead. The death certificate listed the primary cause of death as hypovolemic shock with sequentially listed conditions leading to the cause of death as acute hemorrhage and fall (hours before death). COVID 19, hypoxia, diabetes and hypertension were listed as underlying factors (years before death).

Review of a document titled, "POLICY DESCRIPTION: CONTACTING OF PHYSICIANS," revised 9/19, revealed in part: "It is the responsibility of the RN/LPN (Licensed Practical Nurse) to notify the patient's physician with pertinent information regarding a change in clinical status..."

An interview was conducted with the Quality Risk Manager (QRM) on 10/12/21 at 1:37 p.m. He/she stated the telemetry monitor technologists monitor all of the telemetry on Two North (2N) where patient #1 was located. No physicians are present to monitor the telemetry. If there is a change in telemetry readings, the monitor technologist phones the RN in charge of the patient's care. If he/she cannot reach the RN, he/she next attempts to contact the Certified Nurse Assistant or someone on the patient's care team. If he/she cannot reach any of them, he/she phones the charge nurse.

A phone interview was conducted with RN #1 on 10/12/21 at 12:00 p.m. He/she stated he/she noted patient #1's signature on his/her consent to receive blood form was significantly deteriorated from previous signatures. He/she stated he/she said he/she was too weak to sign. He/she notified the charge nurse but not the physician. He/she was aware there is a policy that says the physician is to be notified of any change in the patient's condition, but he/she did not do this.

An interview was conducted with the Vice President and Chief Nursing Officer (VP CNO) and the QRM on 10/12/21 at 2:35 p.m. The VP CNO acknowledged patient #1's change in condition should have been noted and interventions taken to prevent a further deterioration of patient #1's condition. The VP CNO acknowledged a nine (9) minute lag between patient #1 becoming pulseless and nursing staff starting CPR is unacceptable.