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Based on interview, observation, and record review the facility failed to meet the Condition of Participation (CoP) for Patient Rights by failing to protect and promote patient rights as evidenced by the following:

A. The facility failed to comply with the requirements of the grievance process. See Tag 123.

B. The facility failed to involve family members in the development and implementation of the care plan for 1 (P#1) of 12 patient records reviewed. See Tag 130.

Based on interview, observation, and record review the facility failed to meet the Condition of Participation (CoP) for Nursing Services by failing to have an adequate number of licensed, registered nurses, failing to supervise nursing care, and failing to develop and keep current a nursing care plan for each patient as evidenced by the following:

A. The facility failed to have an adequate number of licensed registered nurses to provide nursing care when needed to meet the immediate needs of any patient. See Tag 392.

B. The facility failed to supervise and evaluate the nursing care for 2 of 12 patient records reviewed. See Tag 395.

C. The facility failed to ensure that the nursing staff develops and keeps current a nursing care plan for each patient for 3 of 12 patient records reviewed. See Tag 396

Based on record review and interview the facility failed to comply with the requirements of the grievance process. This failed practice has potential to provide inadequate information to a complainant in an untimely manner. The findings are:

A. Record Review of the Complaint /Grievance event report for P# 1 revealed the date of the event was 4/23/2019 and the root cause analysis date listed was 07/16/2019.

B. Record Review of the facility Policy A.1.02 Patient-Family Grievances (06/2019) confirmed the facility is required to submit the results of the grievance investigative process to the conplainant in a timely manner.

C. Record Review of Response to Grievance Letter from the facility states "the Nasal Gastric tube (NGT - A tube that is passed through the nose and down into the stomach) was successfully replaced."

D. On 07/15/19 at 1:10 pm during interview, S#1 Chief Clinical Officer stated "x-ray confirmed NGT was coiled in back of throat."

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Based on interview and record review the facility failed to involve family members in the development and implementation of the care plan (POC) for 1 (P#1) of 12 patient records reviewed. This deficient practice has the potential to result in care that does not meet the medical needs of the patient.
Findings are:

A. Record review of P#1's "Admission Orders" dated 03/22/19, revealed orders for Physical therapy (PT) and Occupational Therapy (OT) for evaluation and treatment.

B. Record review of P#1's "Nursing Plan of Care" (POC) dated 03/25/19 and updated as of 04/15/19, revealed "Encourage early ambulation, dangling legs, up in chair, and ambulation. Encourage patient to perform ADL's (activities of daily living) independently. Intervene when patient unable to perform. Consult OT (occupational therapy) for bathing/grooming/dressing/toileting/hygiene." In addition, the POC revealed "Consult speech therapy (ST)" (in the altered nutrition section of the POC) for "feeding deficit."

C. Record review of P#1's POC revealed there was no evidence of documentation of a PT, OT or ST intervention in the POC.

D. On 7/18/19 at 10:00 am during interview, the complainant, stated "I do not remember speaking with a Physical Therapist. They [name of facility staff] only got her out of bed once. "I had to get her (Speech Therapist) a couple of times, I asked if she could try ice chips or something (P#1)" and "she (P#1) was eating solid foods at home (prior to the initial hospitalization)." The complainant confirmed he was not involved in the planning of the nutritional or therapy needs of the patient.

E. On 7/17/19 at 2:00 pm during interview with S#1 (Chief Clinical Officer), confirmed they were unable to provide any Physical Therapy (PT) or Occupational Therapy (OT) notes for P#1. S#1 also confirmed that there was no documentation that PT or OT participated in the development of the POC for P#1.

F. Record review of [name of facility] policy "Interdisciplinary Care Plan" dated 02/20/19 revealed, "Overall progress of patient's condition will be discussed by each discipline, as appropriate, in patient care conference. New or revised problems and goals rising from the discussions will be incorporated in the care plan."

Based on record review and interview the facility failed to have an adequate number of licensed registered nurses to provide nursing care when needed to meet the immediate needs of any patient. This deficient practice has the potential to result in adverse outcomes for all patients in the facility when licensed, trained personnel are not readily available. The findings are:

A. Record review of staffing sheets for April 2019 revealed, the charge RN (Registered Nurse), who works 12 hr. shifts 6am to 6 pm or 6 pm to 6 am, was assigned primary care for 4-5 patients in addition to charge nurse duties. On 04/17 (Charge Nurse (CN) assigned 5 patients on day shift and 4 patients night shift ), 04/18 (CN assigned 4 patients on day and night shift) , 04/19 (CN assigned 5 patients on day and night shift), 04/20 (CN assigned 5 patients on day and night shift) and 04/21 (CN assigned 4 patients on day and night shift).

B. On 07/18/19 at 2:00 pm during interview CEO confirmed that based on acuity for the above dates, the CN should have been assigned 3 patients, so that oversight of other assigned personnel could have been done. CEO also confirmed that staffing is based on acuity and on the dates listed above, the acuity of the patients assigned to the CN was high.

C. On 07/16/19 at 10:00 am the family of P#2 stated that "no one had been in the room for 3 hr. to turn the patient." Family member also confirmed that frequently they had to go to the desk to get a staff member to turn the patient when P#2 had been in the same position for over 2 hr. The family member also expressed concern about staff who are training in the facility performing procedures unsupervised by facility staff, "especially on the weekend".

D. Record review of an email sent by P'2s family member to the facility dated 7/23/19 revealed, "No response to monitors beeping by the bedside. While the experienced nurse may conclude that this may just be an artifact, my concern is for my daughter (P#2). She suffers from hypertension (high blood pressure). The monitor reads every two hours (blood pressure automatically recorded). That means, when the nurse reads the computer, the data indicate information that is maybe an hour and fifty-nine minutes old. If patient is not checked at bedside, she could have suffered a stroke and it would remain unobserved. Also, for a patient that might wake anytime, not checking when monitors beep is unacceptable."

E. Record review of P#1's "Nurses Notes" dated 04/21/19 at 9:30 am revealed, "audible gurgling noted" and "charge nurse notified, checked X-ray results, pt (patient) NGT (Nasal Gastric Tube - A tube that is passed through the nose and down into the stomach) not verified in stomach (correct placement would have been stomach or intestine)." Also documented is "9:40 am pt (patient) husband comes to nurse station reporting "my wife is not breathing."

F. On 07/18/19 at 9:22 am during interview, P#1's family member stated that on 04/21/19 when he entered the room, P#1 "had mucous all the way from her mouth to her chest" and "the little nurse said she wasn't breathing too good, and we had to put her feeding tube back in and it was cramped in her throat (P#1's throat)."

G. On 07/17/19 at 1:50 pm during interview, S#3 RN confirmed the charge nurse regularly was assigned 3-4 patients and sometimes had to supervise 2 or more LPNs (Licensed Practical Nurse) who were assigned patients. S#3 confirmed that the charge nurse often takes the high acuity patients. In addition, S#3 confirmed that on 04/21/19 that when asked by the LPN (Licensed Practical Nurse) to assess P#1 at approximately 9:30 am, "I was doing something, I had cups in my hands, so I went to finish that, I must have been passing meds."

H. Record review of "Position Description / Performance Evaluation Job Title Charge Nurse" undated revealed, "Assists and directs patient care given by nursing personnel shift." and "Assigns patients according to acuity, patient needs and staff capabilities."

Based on record review and interview the facility failed to supervise and evaluate the nursing care for 2 (P#s 1 and 2) of 12 patient records reviewed. This deficient practice has the potential to result in adverse outcomes including but not limited to death for patients in the facility. The findings are:

A. Record review of P#2's "Nursing Plan of Care" dated 07/02/19 and updated 07/15/19 revealed P#2's "Nursing Diagnosis Impaired Physical Mobility prolonged bedrest" and "Intervention to Turn every 2 hr."

B. On 07/16/19 at 10:00 am the family of P#2 stated that "no one had been in the room for 3 hr. to turn the patient." Family member also confirmed that frequently they had to go to the desk to get a staff member to turn the patient when P#2 had been in the same position for over 2 hr.

C. Record review of P#1's "Frequent Vital Signs Documentation" dated 03/24/19 revealed the patient was receiving Levophed (potent intravenous medication-given into the vein causing vasoconstriction-constriction (the constriction of blood vesses) of the blood vessels and an increase in blood pressure. It is used for severe hypotension-low blood pressure, shock or bradycardia (slow heart rate) and the medication was being titrated (measured and adjusted) by S#3.

D. Record review of S#3's (Registered Nurse) personnel file revealed no training or competency in facility required "Cardiogenic-Vasoactive Medication Administration Competency (Levophed)."

E. On 07/17/19 at 2:00 pm during interview, S#1 Chief Clinical Officer confirmed no training could be found which indicated S#3 had been trained to administer Levophed.

F. Record review of P#1's Nursing POC (Plan of Care) dated 03/25/19 and updated 04/15/19 revealed, an Intervention of "Perform hourly purposeful rounding."

G. Record review of P#1's "Nurses Notes" dated 04/20/19 revealed S #4 (Registered Nurse), assigned to care for the patient, documented "2 hr. rounds on Pt. (patient) from midnight till 6:00 am."

H. On 07/18/19 at 9:00 am during interview, RN #4 confirmed that the documentation "2 hr. round on Pt." confirmed observation by the CNA (Certified Nursing Assistant) and RN#4 did the initial assessment and returned to see the patient at 6:00 am at which time she observed P#1's feeding tube was "not in place." RN#4 confirmed she replaced the feeding tube, and did not observe P#1 every 2 hr.

I. Record review of "Nurses Notes" dated 04/21/19 revealed the feeding tube was "not placed in stomach" per xray results.

J. On 07/17/19 at 2:00 pm during interview S#1 (Chief Clinical Officer-CCO) confirmed no competency records could be found which confirmed RN#4 had been trained or observed inserting a feeding tube. CCO also confirmed RN#4 did not make hourly rounds to observe P#1 on 04/20/19 and documentation of rounding indicated the RN observed the patient (not just the CNA).

K. Record review of facility policy "Staff Competency" dated 10/17 revealed, "Initial skill checklist (sic) are completed by clinical employees and reviewed by the appropriate supervisor. Learning needs are identified and the appropriate persons present educational programs specific to employees."

L. Record review of facility "Vital Sign/Intake and Output Records" dated 04/15 revealed the document does not provide space for identification of initials or signature of person performing the vital sign checks or who transcribed the 24 hr. intake and output record (amount of fluid taken in and the amount of fluid output).

M. On 07/17/19 at 3:22 pm during interview, CCO confirmed theVital Sign/Intake and Output document does not include a space for the person who performed procedures to initialize their documentation and it would not be possible to determine who made the entries.

Based on record review the facility failed to ensure that the nursing staff develops and keeps current a nursing care plan (POC) for each patient for 3 P#'s (1, 2, and 3) of 12 patient records reviewed. This deficient practice has the potential to result in care which does not meet the needs of the patient. The findings are:

A. Record review of P#1's "Nursing Plan of Care (POC)" dated 03/25/19 and updated 04/15/19, revealed the following:
1. "Altered Nutrition Consult Dietician"
2. "Impaired skin Integrity pressure ulcer (injuries to skin and underlying tissue resulting from prolonged pressure on the skin) Consult Wound Care Nurse"

B. Record review of P#1's POC revealed no Dietician or Wound Care Specialist documentation, intervention or update in the POC.

C. Record review of P#2's POC dated 07/2/19 and updated 07/17/19 revealed the following:
1. "Impaired skin Integrity Decubitus (pressure ulcer) Consult Wound care nurse"
2. "Impaired Communication Consult Speech Therapy (ST)"

D. Record review of P#2's POC revealed no Wound Care specialist or ST documentation, intervention or update in the POC.

E. Record review of P#3's POC dated 07/09/19 and updated 07/15/19 revealed the following:
1. "Impaired Physical Mobility Consult Rehab Team"
2. "Altered Comfort/Acute Pain Instruct patient to evaluate and report effectiveness of interventions"

F. Record review of P#3's POC revealed no documentation of Rehabilitation Team intervention or update in the POC and no intervention or update in the status of the pain interventions or progress toward the goal of "free of complications related to immobility."



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