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Based on record review and interview, the facility failed to protect the rights of Patient #1 by not recognizing and responding to a grievance and follow a process for prompt resolution for family members who complained about quality of care for 1 of 1 patients (Patient #A).


Findings included:


Record review of Patient #A's medical chart showed a multidisciplinary note entry on 1/12/24 at 17:17 (5:17 pm) made by RN-Staff #10. The note showed that family members had called by phone and complained about bruises seen on the patient. They wanted to find out the reason why the bruises were present. RN-Staff #10 described the patient as having bruises to right arm, left shoulder, right and left thighs, and right lower abdomen. Also present in the chart were pictures of these bruises, taken on 1/12/24. These pictures were of the right and left shoulders, right and left inner thighs, lower abdomen, and right hand.

Record review of nursing progress notes showed an entry made on 1/17/24 at 15:46. It stated that the patient's family was very upset about the patient's observed actions and were still worried about bruises they had observed on the patient. The notes explained that the family was concerned that the patient was being over medicated and sedated and were concerned about the reasons for the patient's bruises. The patient was not able to verbalize what had happened with regards to the bruises, and the nursing notes further stated that the patient was unaware of the bruises.

Further review of nursing notes and other interdisciplinary notes failed to show any follow up communication made with the family member who had made their complaints known to nursing staff about Patient #A.

Record review of facility's Grievance Report log failed to show any entries concerning Patient #A.

In an interview on 1/31/24 at 9:00 am, CEO-Staff #1 and DON-Staff #2 acknowledged that the facility never followed through with a grievance process to resolve issues of complaints received from Patient #A's family members.

Based on observation, and interview the facility failed to maintain patient shower stalls as shown by the presence of shower stalls with flaked paint, wall board and /or tile in rooms for 7 of 10 rooms observed (#s 103, 105, 106, 107 ,108, 110 and 111).

During the initial tour at 10: 30 am with Staff #1 Chief Executive Officer (CEO) the room of a patient (E) who was in the dayroom and left a trail of water and wet footprints in the dayroom was entered (#106). The wall in the shower stall just below the showerhead was chipped and missing paint and portion of the baseboard in the bathroom was missing.

Other observations during the tour were:
Room 111 - The wall in the shower stall just below the showerhead was chipped and missing paint.

Room 110 - The wall in the shower stall just below the showerhead was chipped and missing paint.

Room 108 - The lower wall on the side of the shower stall just shower was gouged with an approximate 4x4x 0.25-inch portion missing chipped and missing. The wall below, abutting the baseboards were also chipped. The baseboards were pulling away from the wall.

Room - 107 The entire length of wall in the shower stall just below the showerhead was bubbled up to approximately 6 inches above the shower enclosure and approximately a third of the way down the outer shower wall next to the shower enclosure. Paint was chipped and missing in various spots. There were previously patched areas visible that had bubbled and were eroding.

Room 106 - The wall in the shower stall just below the showerhead was chipped and missing paint and portion of the baseboard was missing.

Room 105 - The wall in the shower stall just below the showerhead was chipped and missing paint and portion of the baseboard was missing.

Room 103 - The wall adjacent to the shower had baseboard missing.
When interviewed 1/30/24 at 10:15 am Staff #1 confirmed the showers needed repair. Staff #1 stated the facility had identified which showers needed repair had a contract for repair. Staff #1 provided a form titled TE- KD Contractors INC, Wallcovering, Painting, Special Coatings. The business signature on the form was by Robert Moore dated 11/28/23.

When interviewed 1/31/24 at 11:50 am via phone, Robert Moore from TE-KD Contractors stated the form he signed for Oceans Healthcare Pasadena on 11/28/13 was a "bid for general painting" and had nothing to do with patient bathrooms. He stated his company exclusively does painting and not construction or repairs. He added he was unaware of the facility bathroom issues.

Based on record review and interview the facility failed to ensure a registered nurse supervised and evaluated the nursing care, based on the patient's condition for 1 of 1 patient (A) reviewed with injuries.

Policies:
Assessment Process Inpatient: Policy Number AS-01 Revised 02/01/2020

Policy: An Intake Screening and Assessment, Nursing Admission Assessment, Psychosocial Assessment, Recreation/Leisure Assessment, Psychiatric Evaluation, and a History & Physical Evaluation are preformed on all inpatient admissions in order to effectively identify patient symptomology and formulate an individualized treatment plan specific to the patient's presenting problems.

*The policy does not address nursing assessments after the initial admission assessment.

Documentation: Policy Number NSG-02 Revised 01/01/2023

Policy: Inpatient nursing personnel document the patient's progress every 12-hour shift, incorporating the elements of the nursing process and patient's treatment goals and progress within the patient's medical record.

Daily:
The Registered Nurse (RN) documents or reviews the LPN/LVN documentation on the Nursing Shift Assessment a minimum of once per shift.
1. All notes must be related to the patient's problems on th treatment plan.

Routine:
RN and or Licensed Practical Nurse/Licensed Vocational Nurse (LPN/LVN) documents all extraordinary occurrences and special needs (i.e., falls, etc.) in the multidisciplinary progress notes and documents any notifications or issues reported to the physician or non-physician provider (NPP), as applicable. The daily nurse note is only for daily assessment and expected occurrences.

Discharge:
The nurse completes a thorough discharge note in the multidisciplinary progress notes on discharge which includes the following information:
*Time of discharge
*Mode patient is discharged (via EMS, Patient family, Van transport etc.)
*Patient's physical/emotional status at time of discharge [skin assessment complete at time of discharge, patient stable at discharge, current behavior at discharge]

Initial Nursing Assessment of patient #A by Registered Nurse (RN) #7 dated 1/8/24 documented Skin No rashes, No Bruises.

Record Review of patient #A's Admission History and Physical by Nurse Practitioner (NP) #14 dated 1/9/24 at 07:37 am documented Skin No rashes, No Bruises.

RN Progress note of patient #A by RN #7 dated 1/12/24 from 7 am to 7 pm, 7 pm to 7 am documented skin as having bruising to right arm. Left shoulder, right thigh, and right abdominal fold. Pictures were taken and uploaded into the patient record.

RN Progress note of patient #A by RN #15 dated 1/13/24 from 7 am to 7 pm documented Skin No Wounds, No Bruises, Skin Color Normal. There was no documentation of bruises, location (s), number, descriptions or measurements of size, any edema present.

RN Progress note of patient #A by RN #16 dated 1/13/24 from 7 pm to 7 am documented - Bruises. There was no documentation of location (s), number, descriptions or measurements of size, color, any edema present.

RN Progress note of patient #14 by RN #19 dated 1/14/24 from 7 am to 7 pm documented Skin No Wounds, No Bruises, Skin Color Normal. There was no documentation of bruises, location (s), number, descriptions or measurements of size, any edema present. Note indicated decreased skin turgor.

RN Progress note of patient #A by RN #16 dated 1/14/24 from 7 pm to 7 am documented Skin No Wounds, No Bruises, Skin Color Normal. There was no documentation of bruises, location (s), number, descriptions or measurements of size, any edema present.

RN Progress note of patient #A by RN #16 dated 1/15/24 from 7 am to 7 pm documented No Skin Issues, Skin Color Normal. There was no documentation of bruises, location (s), number, descriptions or measurements of size, any edema present.

RN Progress note of patient #A by RN #17 dated 1/15/24 from 7 pm to 7 am documented Skin Normal, intact, no bruises, Skin Color Normal. There was no documentation of bruises, location (s), number, descriptions or measurements of size, any edema present.

RN Progress note of patient #A by RN #11 dated 1/16/24 from 7 am to 7 pm documented Skin Normal, Intact, no bruises, Skin Color Normal. There was no documentation of bruises, location (s), number, descriptions or measurements of size, any edema present.

RN Progress note of patient #A by RN #11 dated 1/17/24 from 7 am to 7 pm documented No Skin Issues, bruises on hands. There was no documentation of bruises, location (s), number, descriptions or measurements of size, any edema present.

Patient discharged to hospital HCA Hospital 1/18/24 at approximately 16:00 for decreased alertness and altered mental status.

Nursing note 1/11/24 by RN #10 read that Patient #A was very confused, and several times refused to allow a change of a brief soiled with a bowel movement (BM). That on 1/11/24 Patient #A had a soiled brief, was very combative and was throwing feces at staff and other patients as well as smearing it on walls and other surfaces. It indicated four staff were required to restrain her to get her changed and cleaned. Emergency medication was given.

When interviewed 1/31/24 at 1:00 pm RN #18 stated the protocol was to leave skin assessment up to the provider. He stated that was the performance improvement.

On 1/31/24 photos of patient #As bruises taken 1/12/31 were reviewed with RN #2 Director of Nursing. Photos displayed deep purple bruising to the right inner thigh. lower abdominal area, left upper arm and right upper shoulder.

When interviewed 1/31/24 RN #2 at 1:20 pm RN #2 Director of Nursing was asked if the bruises should be described in the nurses notes. She could see that would be helpful.