HospitalInspections.org

Based on review of the rules and regulations, medical record review and interview the governing body failed to ensure the anesthesiologist assumed responsibility for the care provided to the patient by completing a timely post-anesthesia evaluation for 1 of 3 (Patient #1) sampled surgery patients.

The findings include:

1. Review of the hospital's 'Unified Medical Staff Bylaws" with a board approved date of "January 25, 2022 revealed, "..."Surgery And/Or Invasive or Interventional Procedures"...Post-anesthesia Evaluation...Any patient who receives general or regional anesthesia or deep sedation/analgesia shall have a post-anesthesia evaluation completed and documented no later than 48 hours after surgery or procedure requiring anesthesia services..."

2. Medical record review revealed that Patient #1 was admitted on 4/4/2022 for an outpatient procedure which uses an implantable device that sends electrical signals to trigger the body's own natural blood flow regulation system to control high blood pressure (Barostim). This outpatient is performed while the the patient is under the influence of anesthesia.

Review of the Anesthesia Postprocedural Evaluation revealed, "...Anesthesia event on 4/6/2022...There were no known complication for this encounter...4/11/22 8:37 AM..." This was electronically signed 5 days after the surgery which should have been no later that 48 hours after the surgery.

In a interview on 6/28/2022 at 11:25 AM in the Director Quality Director Office the Risk Manager was asked what is the time frame for signing the post procedure evaluation on Patient #1 should it have been completed and signed within 48 hours of surgery. The Risk Manager stated, "...Yes..."

Based on policy review, medical record review and interview, the hospital failed to ensure an advance directive status was accurate for 1 of 11 patients (Patient #4) reviewed for advance directives and the hospital failed to ensure patients received care in a safe setting by following through on mandatory education for a patient who fell with injury for 1 of 11 (Patient #5) sampled patients and the hospital failed to ensure that an elopement was treated as an elopement instead of leaving against medical advise for one (1) of one (1) (Patient #11) patients reviewed for elopement and the hospital failed to per hospital policy that a restraint order was issued by a physician for one (1) of one (1) (Patient #4) patients reviewed and the hospital failed to ensure assessment were done timely and accurately for one (1) of one (1) (Patient #4) sampled patients reviewed and the hospital failed to ensure Physician that were authorized to order restraints receive education regarding the hospital policy for one (1) of one (1) sampled patients.

The findings include:

1. Review of the hospital's policy "Medical Record Content/Documentation Guidelines" with a revision date of "4/21" revealed, "...There is evidence in the medical record that advance directives have been addressed. In the absence of actual advance directive, the patient's wishes are documented in the patient's medical record...Do Not resuscitate [DNR] orders are accompanied by documentation in the medical record stating when the decision was made and who was involved in the decision making process...Other documentation required is accomplished in accordance with the facility's DNR policy..."

Review of the hospital's policy "Advance Directives" with a reviewed date of "4/11" revealed, "...To inform adult inpatients of their rights to make decisions concerning their medical care, including their right to accept or refuse treatment and their right to make advance directives...The Living will allows the patient the options of 1) appointing another individual to act on their behalf when the patient can no longer make decisions and 2) specifying treatments that the patient does or does not want to receive..."

2. Patient #4 presented to the Emergency Room with complaints of Altered Mental Status and Extremity Weakness on 6/1/2022.

The advanced directive section has not been addressed in Patient #4's medical record.

The Emergency Department (ED) Timeline on 6/1/2022 at 7:37 PM revealed Daughter #2 had information on Patient #4 and wanted an update.

The admission history and physical on 6/1/2022 revealed Patient #4 presented with a Altered Mental Status and was a full code. The physician discussed with Patient #4 the advance care plan and code status and the decision maker was listed in the medical record.

The ED Timeline on 6/1/2022 revealed the Power of Attorney (POA) was the son. (which was really the Grandson).

The Daily Medicine Progress note on 6/2/2022 revealed the DNR [Do Not Resituate] status was discussed with the patient's Granddaughter (which was really Patient #4's grand Daughter-in-law).

Physician's order dated 6/2/2022 revealed Patient #4 was a DNR.

The nursing notes on 6/3/2022 revealed Patient #4 grand Daughter-in-law and Grandson were asked to bring the paperwork to the hospital so the contact information could be updated.

The nursing notes on 6/4/2022 revealed the family brought in the POA and Daughter #1 was added as the contact and first regarding decisions for Patient #4.

The Occupational Therapy Evaluation on 6/6/2022 at 11:12 PM revealed in the chart Daughter #2 was her primary caretaker.

Interview on 8/26/2022 beginning at 10:12 AM the Risk Manager (RM) stated Advance Directives are not required documentation in the Medical Record of course if would be optimum.
Refer to A132.

3. Review of the hospital's policy "Code Purple - Elopement Patient Absent Without Leave" with a last revision date of "3/21" revealed, "...The Security Department, in conjunction with the nursing staff and all employees, are alert and provide an immediate response in the event of a reported patient absent without official leave..."

Review of the hospital's policy "Refusal of Treatment Policy" with a last revision date of "1/06/14" revealed, "...leaving the hospital against medical advice...Notifies physician of patient/authorized representative intent...Physician/Designee...Discusses with patient/authorized representative need for treatment and risks of not receiving...Documents discussion in medical record...Completes Attachment C...Witnesses signature of patient/authorized representative..."

Patient #5 was admitted on 6/27/2022 with diagnoses of Urinary Tract Infection and Laceration Without Foreign Body Of Other Part Of Head and Unspecified Place In Hospital As The Place Of Occurrence Of The External Cause.

The ED [Emergency Department] Provider notes on 6/27/2022 at 6:25 PM revealed Patient #5 had a history of dementia came by ambulance because of generalized weakness, worsening confusion, and episode of vomiting. The patient just sustained a fall while in the waiting room and had to have a laceration repair to her Left eyebrow and received a hematoma to the Left hand. The patient was already in the room before the son found this out. The son was notified at 6:20 PM and taken to the room.

Review of the video footage in the ED on 6/27/2022 beginning at 3:49 PM Patient #5 was in the ambulance bay on a gurney, transferred from the gurney, to the wheelchair, brought to the lobby and put across from the ED triage desk. Patient #5 got up and tripped on the pedal of the wheelchair and falls face forward. Patient #5 was helped up by two unidentified people and a employee. Patient #5 was helped back to the wheelchair and taken to Room [named number] at 6:13 PM.
Refer to A-144.

4. Patient #11 presented to the ER on 8/11/2022 with Shortness of Breath.

The Security event log on 8/17/2022 revealed an Elopement of a missing adult.

In an e-mail correspondence on 9/9/2022 the Risk Manager (RM) provided this surveyor with a copy of the security event log.

The Facesheet for "Discharge Information" on 8/18/2022 at 2:08 AM revealed Patient #11 left against medical advice.

The nursing progress notes on 8/18/2022 at 1:28 AM revealed nurse entered Patient #11's room around 12:00 AM and she was not present. Code Purple was activated. The Physician on call was notified along with Patient #11's husband. Patient did not return.

Interview on 9/2/2022 beginning at 1:13 PM the Risk Manager (RM) was asked who was notified about Patient #11 elopement when she could not be located. The RM stated, "...Patient #11's husband her doctor..." The RM was asked if the patient was found and if this elopement was reported to the police. The RM stated Patient #11 was not found and the police was not notified.

In an e-mail correspondence on 9/12/2022 the Risk Manager stated that on Patient #11's admission of 8/11/2022 the patient eloped.
Refer to A144.

5. The hospital's policy "Restraint Of The Non-Violent/Non- Self Destructive Patient" with a review/revision date of "7/20" revealed, "... [Named] Hospital does not accept orders for restraints by other Licensed Independent Practitioners (such as Nurse Practitioners, Physician Assistants)..."

Patient #4 presented to the Emergency Room with complaints of Altered Mental Status and Extremity Weakness on 6/1/2022.

Physician's telephone order dated 6/9/22 at 9:30 PM revealed an order for Restraints non-violent or non-self destructive...ordering provider was by Nurse Practitioner (NP) #1.

In an e-mail correspondence dated 8/24/2022 at 3:38 PM the Risk Manager was asked it states in the restraint policy that the facility cannot accept an order for restraints by Licensed Independent Practitioners. The Risk Manager stated, "...With policy in place at that time, yes..."
Refer to A168.

6. Review of the hospital's policy "Restraint Of The Non-Violent/Non- Self Destructive Patient" with a review/revision date of "7/20" revealed, "... family involvement in the treatment of restraints. Patient and significant others should be educated before the restraints are applied along with all attempts made of notification. Observation, assessments and reassessments should occur every hour and every two hours. If the documentation is not complete based on the patient's condition, the needs, reason, clinical judgement is documented.

Review of the hospital's policy "Medical Record Content/Documentation Guidelines" with a revision date of "4/21" revealed records should be complete, accurate and timely to maintain the best possible, health records.

Review of the facility's hospital policy "Documentation Policy" with a revision date of "3/21" revealed, "...Electronic and paper documentation of care, treatment and services is documented at or near the time it occurs. The exception is emergency=, non-routine circumstances (ie [example], Code Blue)...Post charting is not recommended and is done only when necessary. Post Charting is documentation of an entry after completion of the clinician's shift (ie [example], next day, next shift, worked, next week..."

Review of the hospital's policy "Sitter Guidelines: with a effective date of "12/19" revealed, "...To establish guidelines...for patient sitters...sitters provide direct one to one continuous observation with the purpose of promoting a safe environment..."

Patient #4 presented to the Emergency Room with complaints of Altered Mental Status and Extremity Weakness on 6/1/2022.

Physician's order dated 6/9/22 at 9:30 PM revealed an order for restraints non-violent or non-self-destructive.

The flowsheet beginning on 6/9/2022 - 6/10/2022 revealed one hour restraint monitoring documentation did not occur.

The flowsheet beginning on 6/9/2-22 - 6/10/22 revealed the two hour restraint monitoring documentation was incomplete.

The restraint flowsheet on 6/9/2022 at 9:30 PM revealed that Patient #4 declined notification for family but was disoriented and confused.

Review of the flowsheet "Restraint Order"on 6/9/2022 at 10:00 PM revealed section "Education Family Notification" the charge nurse was notified. This was a post-charted entry made on the next day next shift at 6/10/2022 at 7:20 PM.

Review of the nursing progress note on 6/9/2022 at 9:30 PM documented part of Patient #4 assessment for being put in restraints. The charge nurse notified the house supervisor. This was a post charged entry made on the next day next shift.

The restraint flowsheet on 6/10/2022 at 3:37 PM revealed the restraints were discontinued but there was no assessment documented for the restraints to be discontinued.

The discharge note on 6/10/2022 at 3:42 PM revealed Patient's #4 daughter was upset about not being notified that Patient #4 was in restraints and was demanding that they be remove and that she be discharged back to the Assisted Living Facilty and that the physician order a sitter because of fall risk.

Physician's order dated 6/10/2022 at 4:56 PM revealed a order for a sitter.

The nursing flowsheet on 6/10/2022 at 5:08 PM under the section "Provider Notification/Communication" revealed, "...Sitter order. Notified Charge Nurse..."

Interview on 6/29/2022 beginning at 8:39 AM the daughter was not made aware of her mother being put into restraints until about 3:00 PM on the day next day.

Interview on 6/29/2022 beginning at 12:03 PM the Risk Manager stated, "...Our policy states that we will make every attempt to notify the family but we do not have to make contact per our restraint policy..."

Interview on 6/29/2022 beginning at 12:22 PM the Nurse Manager (NM) stated I first spoke to the daughter about her mother being put in restraints and not being notified and that she should have been notified. On the contact list there were multi family members listed and it was late and we didn't know who to contact, it was late, but we didn't know who to contact. This is when the daughter's escalation began. Daughter #1 told me that she expected her mother home today (6/10/2022)..."

In an e-mail correspondence on 8/24/2022 at 3:38 PM the Risk Manager was asked did Patient #4 have a sitter after the restraints were discontinued. The Risk Manager stated, "...Patient's #4 Registered Nurse (RN) discovered...an order for sitter...and that a sitter was never assigned..."
Refer to A174.

7. Review of the hospital's policy "Restraint Of The Non-Violent/Non- Self Destructive Patient" with a review/revision date of "7/20" revealed, "...Physician Training and Education...Physician authorized to order restraints receive education regarding the hospital policy entitled: Restraint of the Non-violent/Non-Self destructive Patient..."

2. Medical record review revealed Patient #4 was admitted on 6/1/2022 with an diagnosis of Mental Status Change, Extreme Weakness and COVID.

The restraint flowsheet on 6/10/2022 at 3:37 PM revealed the restraints were discontinued but there was no assessment documented for the restraints to be discontinued.

Review of the discharge note on 6/10/2022 at 3:42 PM revealed, "...Patient was placed in restraints overnight for her own protection as well as staff's protection. Patient's daughter...demanded removal of restraints...patient will need a sitter due fall risk in the setting of Dementia and Sundowning..."

A physician's order dated 6/10/2022 at 4:56 PM revealed a order for a sitter.

The nursing flowsheet on 6/10/2022 at 5:08 PM under the section "Provider Notification/Communication" revealed, "...Sitter order. Notified Charge Nurse..."

Interview on 6/29/2022 beginning at 8:39 AM Daughter #1 stated, "...She was not made aware of her mother being put into restraints until about 3:00 PM on 6/10/2022 until I spoke with Physician #3 who told her that Patient #4 could not be discharged for 48 hours after the restraints were released..."

Interview on 6/29/2022 beginning at 12:22 PM the Nurse Manager (NM) stated, "...I first spoke to Daughter #1 it was about her mother being put in restraints...and I apologized and told her that she should have notified her about her mother being put in restraints...Physician #3 notified Daughter #1 about not being able to be discharged due to the 48 hour policy for restraints..."

Interview on 6/30/2022 beginning at 11:05 AM the Risk Manager was asked if Physician #3 had received training in restraints. The Risk Manager stated, "...No..."
Refer to A175.

Based on facility policy, medical record review, and interview, the facility failed to ensure patients' right to formulate an advance directive and to have hospital staff who provide care in the hospital that comply with the provision of healthcare when the individual is incapacitated for 1 of 11 (Patient #4) patients sampled for advance directives.

The findings include:

1. Review of the hospital's policy "Medical Record Content/Documentation Guidelines" with a revision date of "4/21" revealed, "...To initiate, facilitate and promote the attainment of high quality content of health records...To maintain, as best possible, health records which are complete, accurate, timely, comprehensive, and consistent and which reflect sound, documentation practices...To promote communication between health care providers...An adequate written/electronic medical record is maintained for every patient assessed or treated at the facility...A patient's medical record is complete when...Evidence of known advance directives...A Discharge Summary is recorded at the time of discharge...discharge summary contains...Care, treatment and services provided...Final Diagnosis, procedures and complications...Medical Record entries are legible, complete, dated, timed and authenticated in...electronic form by the person responsible for providing or evaluating the service as defined by hospital policy...Timing applies to all medical record entries...patient assessments...There is evidence in the medical record that advance directives have been addressed. In the absence of actual advance directive, the patient's wishes are documented in the patient's medical record...Do Not resuscitate [DNR] orders are accompanied by documentation in the medical record stating when the decision was made and who was involved in the decision making process...Other documentation required is accomplished in accordance with the facility's DNR policy..."

Review of the hospital's policy "Advance Directives" with a review date of "4/11" revealed, "...To inform adult inpatients of their rights to make decisions concerning their medical care, including their right to accept or refuse treatment and their right to make advance directives...The Living will allows the patient the options of 1) appointing another individual to act on their behalf when the patient can no longer make decisions and 2) specifying treatments that the patient does or does not want to receive...Oral statement by the declarant to the attending physician, which are made a part of the medical record by the attending physician...Durable Power of Attorney for Health Care (DPOA)...The DPOA commonly appoints an individual to make decisions for the patient when the patient is no longer able to do so. The DPOA also commonly states the patient's wishes with regard to specific types of treatment the patient does or does not want to receive..."

2. Medical record review revealed Patient #4 was admitted on 6/1/2022 with an diagnosis of Altered Mental Status, Extremity Weakness and COVID.

Review of the medical record revealed no documentation advance directives had been addressed.

Review of the ED [Emergency Department] Timeline on 6/1/2022 at 7:37 PM revealed, "...pts [patient's] daughter #2 has information on patient and would like an update as well..."

The admission history and physical on 6/1/2022 at 10:43 PM revealed Patient #4 presented with a Altered Mental Status and was a full code. The physician discussed with Patient #4 the advance care plan and code status and the decision maker was listed in the medical record.

Review of the ED Timeline on 6/1/2022 at 4:58 AM revealed, "...POA [Power of Attorney] son (phone number) Daughter-n-law (phone number)..." However, the person listed as the son was really the grandson to Patient #4.

Review of the Daily Medicine Progress note on 6/2/2022 at 11:53 AM revealed, " ...Discussed in detail with patient's granddaughter (which was really Patient #4's granddaughter-in-law), discussed code status DNR [Do Not Resuscitate]..."

A physician's order dated 6/2/2022 at 3:30 PM revealed an DNR order.

Review of the nursing notes on 6/3/2022 at 9:00 AM revealed, "...Patients grand-daughter in law and grandson called upset that "nurses are calling Daughter #2" reports Daughter #2 is not capable to making decisions for patient as she has a POA for herself. Reports POA of patient is actually her other daughter #1. This writer instructed family to please bring paperwork to the hospital so we can update the contact information..."

Review of the nursing notes on 6/4/2022 at 1:26 AM revealed, "...Patient AAO [Awake, Alert, and Oriented] to self only with garbled speech. Family brought in POA paperwork and daughter #1 added as point of contact and family requested she be contacted first regarding decisions for patient ..."

Review of the nursing notes on 6/4/2022 at 3:39 PM revealed, "...Pt...needs IV access. RN called to obtain consent for midline, daughter #1 stated she would not like for mother to have a midline or any type of IV access..."

Review of the nursing notes on 6/4/2022 at 3:39 PM revealed, "...Pt is receiving remdesivir and needs IV access. RN called to obtain consent for midline, daughter #1 stated she would not like for mother to have a midline or any type of IV access..."

Review of the daily medicine progress notes on 6/5/2022 at 2:30 PM revealed, "...Afebrile, pulled out IV and family does not want another IV inserted, dc [discontinue] remdesivir..."

Review of the Occupational Therapy Evaluation on 6/6/2022 at 11:12 PM revealed, "...Per chart her daughter #2 is her primary caretaker..."

Review of the Patient Education for Advance Care Planning (In Progress) on 6/9/2022 at 6:29 PM...revealed in the Learning progress Summary...Patient...Needs Reinforcement..."

Review of the daily medicine progress notes on 6/10/2022 at 2:18 PM revealed, "...Patient lives at a assisted living facility, case management working on transfer back once medically stable...Patient confused today, in soft restraints, refusing to take medication, thinks she is being poisoned..."

In an interview on 6/29/2022 beginning at 12:22 PM in the Quality Director Office the Nurse Manager (NM) stated, "...I first spoke to Daughter #1 about her mother being put in restraints at 9:30 PM on the night before (6/9/2022) and I apologized and told we were in the wrong and that she should have notified her about her mother being put in restraints...There were multi family members on the contact list and it was late but we didn't know who to contact and then...Physician #4 notified daughter #1 about not being able to be discharged Patient #4 due to the 48 hour policy for Restraints...this started the escalation with Daughter #1...Our director of RT [Respiratory Therapy] gave us a lender tank so we sent her home (Assisted Living Facility) with one of our oxygen tanks, till she could get oxygen set up at home..."

In an interview on 8/26/2022 beginning at 10:12 AM the Risk Manager (RM) stated, "...Advance Directives are not required documentation in the Medical Record of course if would be optimum..."

In an interview on 8/26/2022 beginning at 2:46 PM in the Quality Director Office the RM was asked if she was aware that the Power of Attorney on record for Patient #4 was not a Power of Attorney for Healthcare but of finance. The RM stated, "...Yes." The RM was asked if she was aware that the granddaughter-in-law was the one the physician discussed the Do No Resuscitate order with. The RM stated, "...Yes...but at that time...in the chart it stated that the grandson was the Power of Attorney and he was probably there when the physician was discussing the Do No Reinstate order. The RM was asked does it state in the chart that the grandson was present. The RM stated, "...No...only the granddaughter-in-law..." The RM was asked in the chart it actually states at that time the Power of Attorney was the son (but the son turned out to be the grandson) The RM stated, "...Yes that is true..."

Based on policy review, medical record review, video review and interview the hospital failed to ensure patients received care in a safe setting for one (1) of one (1) (Patient #5) sampled patients who sustained a fall with a laceration repair while being cared for by the hospital and failed to ensure a patient received high-quality, safe and professional care for one (1) of (1) (Patient #11) sampled patients who eloped.

The findings include:

1. Review of the hospital's policy "Code Purple - Elopement Patient Absent Without Leave" with a last revision date of "3/21" revealed, "...To provide a rapid response whenever a Patient is absent without official leave (AWOL) ...The Security Department, in conjunction with the nursing staff and all employees, are alert and provide an immediate response in the event of a reported patient absent without official leave ...Emergency Preparation Plan for CODE PURPLE ...What circumstances warrant a full implementation of this plan?...Protocols/Criteria to Initiate: A CODE PURPLE can be implemented/initiated when any of the following criteria are identified (or at the caregiver's discretion) ...Previous Elopement ...Patients who meet any one of these criteria will be provided a purple gown to help with identification of elopement risk. If a patient is seen in common areas wearing a PURPLE GOWN then security is to be notified immediately ...Procedure ...Nursing Personnel, Reporting Unit ...Will observe/consider the following ...Patient missing from area or unit without staff's knowledge of patient's alternative location ..."

Review of the hospital's policy "Refusal of Treatment Policy" with a last revision date of "1/06/14" revealed, "...[Named] Hospital recognizes that competent adult patients generally have the right to refuse treatment, including leaving the hospital against medical advice (AMA)...Procedure... Responsible Party...Staff Nurse...Steps...Notifies physician of patient/authorized representative intent...Physician/Designee...Discusses with patient/authorized representative need for treatment and risks of not receiving...Documents discussion in medical record...Notifies Nursing Administrative Supervisor/Designee...Documents...refusal in medical record...Completes Attachment C ("Patient's Refusal/Declination of Examination, Treatment or Transfer")...Signs Attachment C...Physician/Staff Nurse...Witnesses signature of patient/authorized representative...If patient/authorized representative also refuses or is unable to sign Attachment C, signs back of Attachment C in appropriate space...If patient/authorized representative also refuses to sign "Patient's Release Form," writes "Refused to Sign" and signs and dates this statement..."

2. Medical record review revealed that Patient #5 was admitted on 6/27/2022 with diagnoses of Urinary Tract Infection and Laceration Without Foreign Body Of Other Part Of Head and Unspecified Place In Hospital As The Place Of Occurrence Of The External Cause.

Review of the ED [Emergency Department] Provider notes on 6/27/2022 at 6:25 PM revealed, "...94 -year old with history of dementia, hypertension, diabetes presents via EMS due to generalized weakness, worsening confusion, and episode of vomiting. During my initial evaluation the patient just sustained a fall while in the waiting room. She states her head hurt and had some left arm and hand pain. She states she is unsure why she originally came, but knew she was supposed to be waiting to meet someone here. Was unable to obtain further history from the patient. Did obtain further history from her daughter and son after their arrival to the ED...Today her confusion is significantly worsened, and the patient began experiencing nausea and had 1 episode of emesis. After the symptoms worsen EMS was called for transfer of patient to the emergency department...They state at baseline the patient is often oriented to place and herself, but does have some confusion secondary to her dementia...Head...Approx [approximately] 2 cm [centimeter] linear laceration present superior to L [left] eyebrow...Musculoskeletal...(swelling present over ulnar aspect of L [left] hand) and tenderness (ttp [Thrombocytopenia, Thrombotic Thrombocytopenis Purpura] of L [left] hand, L [left] shoulder, L [left] humerus) present...Oriented to self, place. Confused regarding time, situation..Laceration length (cm) [centimeter] 3...number of sutures 4...patient describing back pain after the fall...Patient now complaining of mid to lower upper arm pain. Has associated tenderness to palpation. Will add on x-ray to further evaluate for potential humeral fracture...Patient's left forehead laceration has been irrigated, repaired...obtain further history from the daughter and son after arriving to the room at 6:18 PM she was moved to room 19. The patient was already in the room before the son found this out. The son was notified at 6:20 PM and taken to the room. Documented at 8:50 PM...Nurse...took him to the room..."

Review of the video footage in the ED on 6/27/2022 beginning at 3:49 PM Patient #5 is brought into the ambulance bay on a gurney...at 4:14 PM she is transferred from the gurney to the wheelchair and brought out to the lobby and put across from the ED triage desk...at 4:37 PM a nurse or tech comes to get her and takes her back for an assessment by the ED staff...4:58 PM returned to the ED waiting room and the Patient was placed in the wheelchair across from the nurses desk...5:52 PM Patient #5 gets up out of the wheelchair on her own and goes to the nurses desk and then down the hall to the bathroom by herself...she return back from the bathroom to the wheelchair at 6:03 PM...at 6:12 PM Patient #5 gets up from the wheelchair and hangs her right foot on the foot pedal of the wheelchairs and falls face down on the floor...2 unidentified people in the ED waiting room come to her aid and start helping her get up out of the floor and as an Employee is making her way toward Patient #5 to help get her out of the floor and sits her back down in the wheelchair and then 2 employees take her by wheelchair back to Room 19 at 6:13 PM..."

Review of the grievance report on 6/29/2022 at 1:30 PM revealed, "...Patient's son called risk management to express concerns related to the care his mother received in the Emergency Room on Monday 6/27/2022. Patient was brought into the ED around 4:00 PM via EMS for worsening confusion and weakness. Patient has dementia, and while patient was admitted via ambulance entrance, the family was asked to report to the front desk. At the front desk the son and daughter were both told that they could no go back and sit with their mom until she was placed in a room. They were given a number to call and told they could check on her every 15 minutes for updates, at some point between patient arriving to the ED at 4:00 PM and 6:15 PM, patient was placed in a wheel chair and taken to the waiting room, and left alone...during this time the patient attempted to get up on her own and fell out of the wheelchair and hit her head and hurt her wrist. patient required stitches per the son. Family is very upset that they were not told that she was in the waiting room, when they called to check on her. Family was also very upset that they were not called when she fell, when family arrived to the patient's room in the ED, they found their mother covered in blood. They are also upset that she was left alone with severe dementia and report that if they had beeen told she was in the waiting room, they would have been happy to sit with her. Patient's son would like someone to follow up with him, he explanation...spoke with Mr. Adams to make him aware an investigation had been opened, 7/1: extension letter mailed. Son has asked for additional documents..."

In an interview on 6/27/2022 at 4:06 PM, in the Quality Director's Office with the Registered Nurse (RN) #10 (that worked triage that day) and the Emergency Department Manager. RN #11 stated, "...Patient #5 arrived by ambulance and she was put in a wheelchair in front of the nurses station...Patient #5 was put in the Wheelchair because she was assessed and was stable 100% she could walk and talk ...The contract I had with her she was in the triage room bathroom and I assisted her back to the waiting room in the wheelchair...when she was in the restroom she was able to stand up and sit down on her own and verbalize any needs or wants that she had. I was at the triage desk I hear her go OOOOO and she had fell...I don't know if she had tripped which caused her to fall. Three nurses ran to her assistance and helped her back to the chair...she had a laceration to her left brow and she never lost conscious...we took her to room 19 that was it for me...The standard process is for the ambulance nurse to get their vital signs and screens them if they are stable...and only stable patients can be brought to the waiting room if we are full. On that day we were full in the back (all of the exam rooms and halls were full of patients) census for that day was 195 when Patient #5 arrived we had 89 patients and 31 plus patients in the waiting room and halls...We are unsure who the person talked to or spoke to every 15 minutes that is not a standard process for us..."

In a telephone interview on 7/7/2022 beginning at 10:29 AM the complainant stated, "...One of the main reasons we took Patient #6 to the Emergency Room (ER) was because she was confused, and I have a copy of the ambulance report and it states on the report that she is a 94 year old woman with a diagnosis of Dementia and that when they responded she was confused. My mother was transported by ambulance and my sister and I followed behind the ambulance and on arrival to the ER my sister when in to the front desk and talked to a man that gave her a phone number an told her to call every 15 to 20 minutes to check on our mother's status and that we could not go back there in the hall where she was at due to the COVID restrictions...and that one of us could sit in the waiting room...but because it was so very crowded we decided to sit on the bench outside of the ER ...on about the 4th or 5th call the person that answered the phone stated I don't see her anywhere...Oh wait she is in room 19 so I go back to room 19 and there is my mother (Patient #6) with blood everywhere head busted open and her had with a terrible bruise and hematoma on her hand...That is when I found out they had put her in a wheelchair and took her out in the waiting room by herself no one called and told us so one of us could have been with her and she got up out of the wheelchair and tripped and they still didn't call us...I called to find out she was in room 19. I asked to speak to the charge nurse and about 4 hours later I got to talk to a charge nurse that was on the 2nd shift this incident happened on the 1st shift...She told me that she would be notifying risk management and that was also a lie ...I called Risk Management to report it and this lady named Amy told me she didn't know anything about the incident...she lied to me also because she asked me if I cared it she when to visit my mother in the hospital I told her no my sister was with her and she stated no one came to visit my mother from risk management...Also this lady who identified herself as the Assistant Manager (AM) of the ER called me on Friday and do you know what her first question to me was...What did you think about the care your mother got in the ED...REALLY...What the hell do you think I thought...she never asked me the first time How my mother was...That should have been her first question she asked...she did tell me they were heavily investigating the incident..."

In a interview in the Quality Director's Office on 7/27/2022 beginning a 1:00 PM with Risk Manager #2 stated, "...It was not a problem for them (son and daughter) to be with Patient #5 in the waiting room. There was a communication problem in between the ambulance bay and the front desk or hall room. They (the son and daughter) was given a number to call and check on her every 15 minutes and instead of going to the waiting room they (son and daughter) went to the picnic table in the back. The phone number they were given was the east side ambulance area and that is a high acuity area and it is not known who was answering that phone. It was a misunderstanding they should have be notified that their mother was in a room. One side makes an assumption and then the other side makes an assumption. ER Managers are meeting with registration for the Er to see how they can work that problem out..."

Review of the Emergency Room August 2022 Staff Meeting revealed, "...Patient Communication/Experience...Discussed what should be communicated to patients and their families (no example)...Discussed patient visitation (All patients are allowed a visitor, including in the hallway) (no example)...Discussed appropriate time to update family during traumatic event ( as soon as patient is stable) (no example)..."

Review of the Staff Meeting Roster for 8/23/2022 revealed 20 employee's signatures. Review of the Staff Meeting Roster for 8/25/2022 revealed 17 employee's signatures.

Received in an email on 9/13/2022 at 12:28 PM from the Risk Manager revealed, "...Attached are the last of the staff required to review the education for ED communications both nursing and admissions..." This surveyor received a total of 31 "Staff Meeting Minutes Attestation".

The Emergency Room department list revealed a total of 82 employees. A total of 68 staff on the department list received this inservice. This is not 100%.

Review of the Huddle Notes on 8/16-18/2022 revealed, "...Whenever a family member of [or] friend of a patient is asking for information pertaining to their loved one. Notify the clinical staff immediately (nurse) so that they can give the proper appropriate response. We are not to give out any information of any kind..."

Review of the Huddle Sign in on Tuesday 8/16/2022 revealed 10 employee's signatures.

Received in an email on 9/13/2022 at 12:28 PM from the Risk Manager revealed, "...Attached are the last of the staff required to review the education for ED communications both nursing and admissions..." This surveyor received a total of 5 acknowledgements with this email for the Admission department.

The admission department for the Emergency Room listed a total of 27 employees. A total of 15 employees for the admission department listed received this mandatory inservice. This is not 100%.

In a interview on 9/1/2022 beginning at 10:15 AM the Risk Manager stated, "...This was a mandatory staff meeting..."

3. Medical record review revealed that Patient #11 was admitted on 8/11/2022 with a diagnosis of Shortness of Breath.

Review of the Security event log "End Of Summary Report" on 8/17/2022 revealed under task description...Elopement (Adult...Patient) (Missing Adult)..."

In an e-mail correspondence on 9/9/2022 the Risk Manager (RM) stated, "...Attached is the security event log which is how they document occurrences..."

Review of the Facesheet on under the section of "Discharge Information" on 8/18/2022 at 2:08 AM revealed, "...Disposition: Left Against Medical Advice...Discharge Destination...None..."

Review of the discharge note with a date of service of 8/18/2022 at 2:08 AM and a creation time of 8/29/2022 at 8:41 AM revealed, "...Patient #11 is a 53 y. [year] o. [old] female who was admitted for acute exacerbation of combined systolic and diastolic dysfunction...She had a known history of leaving AMA [Against Medical Advice] and medical nonadherence on previous admits...Hospice team was also consulted given poor prognosis, unfortunately patient was not a candidate or home with hospice..."

Review of the Admission History and Physician on 8/11/2022 at 10:23 PM revealed, "...female with past medical history significant for congestive heart failure and diabetes mellitus who presents to the ED with shortness of breath...Last records show the patient was hospitalized 12/9/2022 - 12/10/21 and 12/11/2021 - 12/13/21 leaving AMA both admissions..."

Review of the Psychiatry consult note on 8/12/2022 at 1:34 PM revealed, "...I am asked to see regarding possible depression. She stated that she has been chronically depressed and has a poor response to numerous antidepressants. She denies any suicidal ideations. She does recognize that her CHF [Congestive Heart Failure] is progressive and severe and she wishes no heroic measures...Married she states that her husband is an alcoholic. She has 2 grown children who live out of state...She relates that her family understand the terminal nature of her illness and are prepared...She reports a tendency to chronic low mood and poor response to multiple medications. She denies any history of upswings. She is not confused. She has no psychotic symptoms...She shows good insight and judgement...Assessment...Dysthymia [A mild but long-term form of depression]...She declines any antidepressants..."

Review of the Daily Medicine Progress note on 8/12/2022 at 3:59 PM revealed, "...Assessment and Plan...h [history]/o [of] leaving AMA [Against Medical Advice] on previous admits...H [history]/o [of] depression...Generalized deconditioning...not on RX [prescriptions] and has not followed up per the patient due to lack of insurance, lack of financial means and support...asked Psych to see...patient is determined to "go Home and die with dignity and no pain", "let the heart failure take over the body"..."

Review of the Daily Medicine Progress note on 8/13/2022 at 3:18 PM revealed, "...Unilateral R [right] medical thigh swelling/mass...pt was under impression that this is "edema", but it does not appear to be the case...Poor dentition, tooth ache...Cocaine use = denies chronic use; states that a friend gave her some for free to help with toothache...pt would like placement with hospice; not a candidate for GIP [General Inpatient hospice] no insurance, so no SNF would take; states that she can't go home because husband is an alcoholic and cannot take care of her...patient will most likely go Home with charity HH vs hospice..."

Review of the Daily Medicine Progress note on 8/14/2022 at 2:12 PM revealed, "...very emotionally labile, but able to redirect and calm down...easily tears up on exam..."

Review of the Daily Medicine Progress note on 8/15/2022 at 8:05 PM revealed, "...Still appears to have some feeling of hopelessness abut the near future - notes that her EF [Ejection Fraction - how much blood the left ventricle pumps out with each contraction] is already quite poor and functional status is quite poor as well..."

Review of the Hospice nursing progress notes on 8/15/2022 at 6:57 PM revealed, '...Patient called me this afternoon and requested to meet me in am to discuss many things...."

Review of the Hospice nursing progress notes on 8/15/2022 at 7:41 PM revealed, "...Very difficult situation. Spoke with patient, case management and physician. Patient can go home with hospice but their are many issues of safety. Patient doesn't have a bank account and not able to access husbands bank account. Unsure if able to get social security statements for hospice house..."

Review of the nursing progress notes on 8/18/2022 at 1:28 AM revealed, "...Aprrox [approximately] 12:00 AM this nurse entered patient's room and patient was not present. this searched unit and was unable to locate pt. Charge nurse was notified and a Code Purple was activated. House Supervisor notified of event. security unable to located patient. Physician on call for Team Health notified of incident. Pt has not yet returned at this time. Notified Sidney Harvard (spouse) listed contact on chart that patient left hospital without consulting with the Doctor or staff..."

In an interview on 9/2/2022 beginning at 1:13 PM the Risk Manager (RM) was asked who was notified about Patient #11 elopement. The RM stated, "...Her husband and her doctor..." The RM was asked where Patient #11 was found. The RM stated, "...Patient #11 was not found she had left like this on several occasions AMA [Against Medical Advice]. The RM was asked again so the Patient was not found. The RM stated she was picked up on a camera by security. The RM was asked where the police called. The RM stated, "...No..."

In an e-mail correspondence with the Risk Manager was asked to provide the Form C for Patient #11 leaving AMA. The Risk Manager stated, "...Visit 08-11-2022, the patient eloped. Does not require a Form C..."

Based on review of hospital policy, medical record review and interviews the facility failed to obtain a physican's order for the use of physical restraints for 1 of 1 (Patient #4) sampled patients surveyed for restraints.

The findings include:

1. Review of the hospital's policy "Restraint Of The Non-Violent/Non- Self Destructive Patient" with a review/revision date of "7/20" revealed, "...Family involvement in the treatment is attempted and documented as appropriate. The use of restraint is in accordance with a physician order responsible for the care of the patient. [Named] Hospital does not accept orders for restraints by other Licensed Independent Practitioners (such as Nurse Practitioners, Physician Assistants...An appropriately trained Registered Nurse (RN) may initiate restraints...Consult with the patient's family and significant others concerning the individualized means of calming and reassuring the patient...Monitoring and Observation...Visual observation of the patient occurs a minimum of every 1 hour or more frequently based on the patient's condition and includes...Patient position and comfort ...Restraint device properly applied...Assessment and reassessment of the individual in restraint occurs a minimum of every 2 hours or more frequently based on the patient's condition and included the following...Patient/Family Or Significant Other Education...When possible the patient and /or significant are notified and educated before the restraints is [are] placed on the patient. The education includes: the potential need for restraints along with criteria for release. Explain to the patient and/or significant other that restraint will be discontinued as soon as change in the patient condition allows...Criteria For Restraint Release...The RN assesses the patient prior to release from restraint. The criteria for release is specified by the physician and documented in the medical record ...Documentation includes ...The circumstances that led to restraint including a description of the patient's behavior...Information provided by the family about restraint...Physician notification-including attending and consulting as appropriate...Criteria for release...physician evaluation of the patient, assessment, reassessment and on-going monitoring...Notification of the patient's family, as appropriate including all attempts made...If a component of the assessment, reassessment, monitoring is not completed based on the patient's condition, the needs, reason, clinical judgement or rational is documented...Physician Training and Education...Physician authorized to order restraints receive education regarding the hospital policy entitled: Restraint of the Non-violent/Non-Self destructive Patient..."

2. Medical record review revealed Patient #4 was admitted on 6/1/2022 with an diagnosis of Altered Mental Status, Extremity Weakness and COVID.

A physician's telephone order dated 6/9/22 at 9:30 PM revealed an order for Restraints non-violent or non-self destructive...ordering provider was authorized by Nurse Practitioner (NP) #1...Rationale: Interference with Medical Devices or Treatment Patient Safety, Restraint Type Soft Wrist ...Bilaterally Left Right Discontinuation Criteria Not Clinically Justified ..."

In an e-mail correspondence dated 8/24/2022 at 3:38 PM the Risk Manager was asked it states in your restraint policy that the hospital does not accept orders for restraints by other Licensed Independent Practitioners (such as Nurse Practitioners, Physician Assistant)...This restraint order was placed by Nurse Practitioner #1. Should this order have been by a physician. The Risk Manager stated, "...With policy in place at that time, yes..."

Based on policy review, medical record review and interview, the hospital failed to ensure a patient was monitored and re-evaluated by nursing staff to determine the earliest possible time to discontinue restraints for 1 of 1 (Patient #4) sampled patients.

The findings include:

1. Review of the hospital's policy "Restraint Of The Non-Violent/Non- Self Destructive Patient" with a review/revision date of "7/20" revealed, "...Family involvement in the treatment is attempted and documented as appropriate. The use of restraint is in accordance with a physician order responsible for the care of the patient. [Named] Hospital does not accept orders for restraints by other Licensed Independent Practitioners (such as Nurse Practitioners, Physician Assistants...An appropriately trained Registered Nurse (RN) may initiate restraints...Consult with the patient's family and significant others concerning the individualized means of calming and reassuring the patient...Monitoring and Observation...Visual observation of the patient occurs a minimum of every 1 hour or more frequently based on the patient's condition and includes...Patient position and comfort ...Restraint device properly applied...Assessment and reassessment of the individual in restraint occurs a minimum of every 2 hours or more frequently based on the patient's condition and included the following...Patient/Family Or Significant Other Education...When possible the patient and /or significant are notified and educated before the restraints is [are] placed on the patient. The education includes: the potential need for restraints along with criteria for release. Explain to the patient and/or significant other that restraint will be discontinued as soon as change in the patient condition allows...Criteria For Restraint Release...The RN assesses the patient prior to release from restraint. The criteria for release is specified by the physician and documented in the medical record...Documentation includes...The circumstances that led to restraint including a description of the patient's behavior...Information provided by the family about restraint...Physician notification-including attending and consulting as appropriate...Criteria for release...physician evaluation of the patient, assessment, reassessment and on-going monitoring...Notification of the patient's family, as appropriate including all attempts made...If a component of the assessment, reassessment, monitoring is not completed based on the patient's condition, the needs, reason, clinical judgement or rational is documented...Physician Training and Education...Physician authorized to order restraints receive education regarding the hospital policy entitled: Restraint of the Non-violent/Non-Self destructive Patient..."

Review of the hospital's policy "Medical Record Content/Documentation Guidelines" with a revision date of "4/21" revealed, "...To initiate, facilitate and promote the attainment of high quality content of health records...To maintain, as best possible, health records which are complete, accurate, timely, comprehensive, and consistent and which reflect sound, documentation practices...To promote communication between health care providers ...An adequate written/electronic medical record is maintained for every patient assessed or treated at the facility...A patient's medical record is complete when...Evidence of known advance directives...A Discharge Summary is recorded at the time of discharge...discharge summary contains ...Care, treatment and services provided...Final Diagnosis, procedures and complications...Medical Record entries are legible, complete, dated, timed and authenticated in...electronic form by the person responsible for providing or evaluating the service as defined by hospital policy...Timing applies to all medical record entries...patient assessments...There is evidence in the medical record that advance directives have been addressed. In the absence of actual advance directive, the patient's wishes are documented in the patient's medical record...Do Not resuscitate (DNR) orders are accompanied by documentation in the medical record stating when the decision was made and who was involved in the decision making process...Other documentation required is accomplished in accordance with the facility's DNR policy..."

Review of the facility's hospital policy "Documentation Policy" with a revision date of "3/21" revealed, "...Documentation demonstrates the patient care process, from assessment and planning care to interventions and evaluation...Electronic and paper documentation of care, treatment and services is documented at or near the time it occurs. The exception is emergency=, non-routine circumstances (ie [example], Code Blue)...Post charting is not recommended and is done only when necessary. Post Charting is documentation of an entry after completion of the clinician's shift (ie [example], next day, next shift, worked, next week..."

Review of the hospital's policy "Sitter Guidelines: with a effective date of "12/19" revealed, "...To establish guidelines for the utilization and functioning of patient sitters. sitters provide direct one to one continuous observation with the purpose of promoting a safe environment...If a licensed provider orders a patient sitter, the registered nurse performs an assessment prior to implementation....Identify patient need for one to one continuous observation based on registered nurse assessment including...High risk for fall; unable to follow safety instructions and/or alternatives are unsuccessful..."

2. Medical record review revealed Patient #4 was admitted on 6/1/2022 with an diagnosis of Altered Mental Status, Extremity Weakness and COVID.

A telephone physician's order on 6/9/22 at 9:30 PM revealed an order for restraints non-violent or non-self-destructive. With the rationale of interference with Medical Devices or Treatment Patient Safety. The restraint type would be Soft Wrist bilaterally for the left and right wrist.

The restraint flowsheet beginning on 6/9/2022 - 6/10/2022 revealed the restraint one hour monitoring was documented as every two hours.

The restraint flowsheet beginning on 6/9/2-22 - 6/10/22 revealed the restraint two hour monitoring assessments were incomplete for the 6/10/2022 10:08 AM, 12:23 PM and 2:33 PM assessments.

Review of the restraint flowsheet on 6/9/2022 at 9:30 PM revealed an note that stated, "...Patient declined notification for family notification...patient was disoriented x 4 Level of Consciousness was confused..."

Review of the flowsheet under "Restraint Order" on 6/9/2022 at 10:00 PM revealed, "...Education Family Notification...notified charge nurse..." This note was created on 6/10/2022 at 7:20 PM. Patient #4 was put into restraints on 6/9/2022 at 9:30 PM. This is considered post-charting the entry was made on the next day on the next shift.

Review of the nursing progress note on 6/9/2022 at 9:30 PM revealed, "...Patient constantly attempts to get out of bed she completely disrobes and has all her wires wrapped around her body. Placed bed alarm on and attached oxygen and probe back on patient. She consistently does this every 10 min. She is very confused and unsafe to prevent any harm the doctor was notified to request restraints. Notified the charge nurse to determine who to notify because once retrieved there was a list of people to notify. Per charge nurse notify her and she will notify house supervisor. This note was created on 6/10/2022 at 7:07 PM. Patient #4 was put into restraints on 6/9/2022 at 9:30 PM. This is considered post-charting the entry was made on the next day on the next shift.

Review of the nursing flowsheet on 6/10/2022 at 3:16 PM section "Provider Notification/Communication"...Comment...revealed, " ...Daughter #1 wants to speak to the MD...Wants the patient home today ..."

Review of the nursing flowsheet on 6/10/2022 at 3:19 PM section "Provider Notification/Communication" revealed, "...Asked if the restraints need to be D/C [discontinued] and evaluate the patient..."

Review of the restraint flowsheet on 6/10/2022 at 3:37 PM revealed that the bilateral soft restraints were discontinued but there was no documentation for the assessment for the discontinue criteria of Patient #4 restraints.

Review of the discharge note on 6/10/2022 at 3:42 PM revealed, "...Patient was placed in restraints overnight for her own protection as well as staff's protection. Patient's daughter was very upset about not being notified about this and demanded removal of restraints. She requested to talk to risk management about this. I provided her with the main number where she can be transferred to risk management or the charge nurse. I have talked to patient's nurse and case management. restraints have been removed, patient will need a sitter due fall risk in the setting of Dementia and Sundowning..."

A physician's order dated 6/10/2022 at 4:56 PM revealed a order for a sitter "...Frequency: Routine Until Discontinued 6/10/22 4:57 PM - Until..." The order was discontinued on 6/10/2022 at 10:25 PM [Patient Discharge].

Review of the nursing flowsheet on 6/210/2022 at 5:08 PM under the section "Provider Notification/Communication"...Comment...Sitter order. Notified Charge Nurse..."

Review of the flowsheet on 6/10/2022 at 8:08 AM " revealed an Fall Risk Assessment with a Fall Risk Score of 45 (High Risk Fall Precautions = Scores of 14 or greater) also in the section Enhanced Safety Measures is documented in a comment "...Restraints applied properly..." This is the last Fall Assessment for 6/10/2022. When a sitter is order per hospital policy a fall risk assessment should be done. This fall risk assessment was done in the last fall assessment documented.

In an telephone interview on 6/29/2022 beginning at 8:39 AM Daughter #1 stated, "...She was not made aware of her mother being put into restraints until about 3:00 PM on the day of 6/10/2022 when Daughter #1 spoke with Physician #4 who told her that Patient #4 could not be discharged for 48 hours after the restraints were released..."

In an interview on 6/29/2022 beginning at 12:03 PM in the Quality Director Office with the Risk Manager stated, "...It is in our policy that we will make every attempt to notify the family but we do not have to make contact per our restraint policy..."

In an interview on 6/29/2022 beginning at 12:22 PM in the Quality Director Office the Nurse Manager (NM) stated, "...When I first spoke to Daughter #1 it was about her mother being put in restraints on 6/9/2022 at 9:30 PM. I apologized and told her we were in the wrong and that she should have notified her about her mother being put in restraints...There were multi family members on the contact list and it was late but we didn't know who to contact and then the physican Physician #3 notified Daughter #1 about not being able to be discharged due to the 48 hour policy for restraints...this started the escalation with Daughter #1...Daughter #1 told me that she expected her mother home today (6/10/2022)...Our director of RT [Respiratory Therapy] gave us a lender tank so we sent her home with one of our oxygen tanks, till she could get oxygen set up at home...the Case Manager would have been the person to set up Home Health which would be [Named] Home Health and she also had some PT [Physical Therapy] and OT [Occupation Therapy] set up for Patient #4.

In an interview on 6/29/2022 beginning at 1:43 PM in the Quality Director office with the Administrative Director the Administrative Director stated, "...The NM called me and explain what had gone on with Patient #4 she had told me about the restraints and the Patient was supposed to be discharged that day and everything had been arranged and she was going to be transported back by ambulance back to the Assisted Living facility and we were letting her borrow one of our oxygen tanks..."

In an e-mail correspondence on 8/24/2022 at 3:38 PM with the Risk Manager, the Risk Manager was asked who was the sitter that stayed with Patient #4 after the restraints were discontinued. The Risk Manager stated, "...Discussions with Patient's #4 primary Registered Nurse (RN) discovered that the physician placed an order for sitter in case one was needed and that a sitter was never assigned. This RN also states that she and the PCA (Patient Care Assistance) #1 were in and out of the patients room every 30 minutes to an hour to redirect patient to not pull tubes and/or to replace the O2. The sitter order was eventually DC'd [discontinued]. The Risk Manager was asked is there documentation to support that a sitter was not assigned and that the RN, Patient Care Tech and PCT #1 were in and out of the room every 30 minutes to an hour to redirect the patient. The Risk Manager stated, "...No." The Risk Manager was asked would the restraints have been discontinued that day if the daughter was not requesting Patient #4 to be discharged that day. The Risk Manager stated, "...Removing a patient from restraints as soon as possible and when appropriate is always a goal of the staff. In this case, the chart does not reflect a removal of restraints due to a discharge..."

Based on policy review, facility document review, medical record review and interview, the facility failed to ensure patients with restraints were monitored by trained physician at at interval determined by hospital policy.

The findings include:

1. Review of the hospital's policy "Restraint Of The Non-Violent/Non- Self Destructive Patient" with a review/revision date of "7/20" revealed, "...Family involvement in the treatment is attempted and documented as appropriate. The use of restraint is in accordance with a physician order responsible for the care of the patient. [Named] Hospital does not accept orders for restraints by other Licensed Independent Practitioners (such as Nurse Practitioners, Physician Assistants...An appropriately trained Registered Nurse (RN) may initiate restraints...Consult with the patient's family and significant others concerning the individualized means of calming and reassuring the patient...Monitoring and Observation...Visual observation of the patient occurs a minimum of every 1 hour or more frequently based on the patient's condition and includes...Patient position and comfort ...Restraint device properly applied...Assessment and reassessment of the individual in restraint occurs a minimum of every 2 hours or more frequently based on the patient's condition and included the following...Patient/Family Or Significant Other Education...When possible the patient and /or significant are notified and educated before the restraints is [are] placed on the patient. The education includes: the potential need for restraints along with criteria for release. Explain to the patient and/or significant other that restraint will be discontinued as soon as change in the patient condition allows...Criteria For Restraint Release...The RN assesses the patient prior to release from restraint. The criteria for release is specified by the physician and documented in the medical record...Documentation includes...The circumstances that led to restraint including a description of the patient's behavior...Information provided by the family about restraint...Physician notification-including attending and consulting as appropriate...Criteria for release...physician evaluation of the patient, assessment, reassessment and on-going monitoring...Notification of the patient's family, as appropriate including all attempts made...If a component of the assessment, reassessment, monitoring is not completed based on the patient's condition, the needs, reason, clinical judgement or rational is documented...Physician Training and Education...Physician authorized to order restraints receive education regarding the hospital policy entitled: Restraint of the Non-violent/Non-Self destructive Patient..."

2. Medical record review revealed Patient #4 was admitted on 6/1/2022 with an diagnosis of Altered Mental Status, Extreme Weakness and COVID.

Review of the nursing flowsheet section "Provider Notification/Communication"...Comment...on 6/10/2022 at 3:16 PM revealed, " ...Daughter #1 wants to speak to the MD...Wants the patient home today ..."

Review of the nursing flowsheet on 6/10/2022 at 3:19 PM section "Provider Notification/Communication" revealed, "...Asked if the restraints need to be D/C [discontinued] and evaluate the patient..."

Review of the restraint flowsheet on 6/10/2022 at 3:37 PM revealed that the bilateral soft restraints were discontinued but there was no documentation for the assessment for the discontinue criteria of Patient #4 restraints.

Review of the discharge note on 6/10/2022 at 3:42 PM revealed, "...Patient was placed in restraints overnight for her own protection as well as staff's protection. Patient's daughter was very upset about not being notified about this and demanded removal of restraints. She requested to talk to risk management about this. I provided her with the main number where she can be transferred to risk management or the charge nurse. I have talked to patient's nurse and case management. restraints have been removed, patient will need a sitter due fall risk in the setting of Dementia and Sundowning..."

A physician's order dated 6/10/2022 at 4:56 PM revealed a order for a sitter "...Frequency: Routine Until Discontinued 6/10/22 4:57 PM - Until..." The order was discontinued on 6/10/2022 at 10:25 PM [Patient Discharge].

Review of the nursing flowsheet on 6/10/2022 at 5:08 PM under the section "Provider Notification/Communication"...Comment...Sitter order. Notified Charge Nurse..."

In an telephone interview on 6/29/2022 beginning at 8:39 AM Daughter #1 stated, "...She was not made aware of her mother being put into restraints until about 3:00 PM on the day of 6/10/2022 when Daughter #1 spoke with Physician #3 who told her that Patient #4 could not be discharged for 48 hours after the restraints were released..."

In an interview on 6/29/2022 beginning at 12:22 PM in the Quality Director Office the Nurse Manager (NM) stated, "...When I first spoke to Daughter #1 it was about her mother being put in restraints on 6/9/2022 at 9:30 PM. I apologized and told her we were in the wrong and that she should have notified her about her mother being put in restraints...There were multi family members on the contact list and it was late but we didn't know who to contact and then the physican Physician #3 notified Daughter #1 about not being able to be discharged due to the 48 hour policy for restraints...this started the escalation with Daughter #1...Daughter #1 told me that she expected her mother home today (6/10/2022)...Our director of RT [Respiratory Therapy] gave us a lender tank so we sent her home with one of our oxygen tanks, till she could get oxygen set up at home...the Case Manager would have been the person to set up Home Health which would be [Named] Home Health and she also had some PT [Physical Therapy] and OT [Occupation Therapy] set up for Patient #4.

In an interview on 6/30/2022 beginning at 11:05 AM in the Quality Director Office the Risk Manager was asked for verification that Physician #3 had received training in restraints. The Risk Manager stated, "...No we only train our [Named] hospital physicians in restraints..."

Based on policy review, document review, record review and interview, the hospital failed to ensure nursing services met the needs of all patients and conducted ongoing assessments of patients and each patient's current care plan reflected the goals and nursing care to be provided to meet the patients' needs ensure all patients for 6 of 11 (Patient #1, #3, #4, #6, #7 and #8) sampled patients.

The findings include:

1. Review of the "Pain Management Guidelines" policy with a revision date of "1/21" revealed, "...A comprehensive pain assessment is conducted as appropriate to the patient's condition and the scope of care, treatment and services provided...Pain assessment includes...A pain intensity rating scale appropriate for the patient...location...Quality...Onset...Duration...Aggravating/relieving factors...Relieving medication...When medication orders for pain management include levels of pain ...1 - 3 Mild Pain ...4 - 6 Moderate Pain ...7 - 10 Severe Pain ...Notify physician to obtain new order(s) when medication for pain management does not align with patient reported pain level...The nurse continues to intervene until an acceptable level of pain is obtained...Document pain assessment, interventions and reassessment in the medical record..."

Review of the hospital's policy "Assessment/Reassessment Policy" with a last review/revision date of "12/20" revealed, " ...Reassessment occurs ...at regular intervals ...to evaluate the patient's response to care, treatment, and services...The Registered Nurse creates an initial plan for care, treatment and services appropriate to the patient's specific assessed needs and revises or maintains the plan based on the patient's response..."

2. Patient #1 was admitted on 4/4/2022 for an outpatient procedure.
After the procedure, Patient #1 experienced nausea and vomiting. There was no documentation the patient was discharged with a prescription for medication for nausea and vomiting. On 4/7/2022, a nurse placed a follow-up call to check Patient #1's status since the procedure on 4/6/2022. The patient reported pain at the site and nausea and vomiting continued. Patient #1 said she had contacted the doctors office and they were calling in a medication for nausea and vomiting.
While Patient #1 was in the hospital for the outpatient procedure, pain assessments were performed. The pain assessments were not complete and did not include any type of intervention.
Upon returning home after the outpatient procedure, Patient #1 found the IV sheath still in her arm.

3. Patient #3 presented to the Emergency Room on 4/4/2022 with chief complaints of Altered Mental Status and Extremity Weakness. During hospitalization, Patient #3 periodically took pain medications. Pain assessessments were performed but they were incomplete, either with no documentation of pain score, no documentation of the location, quality, onset, duration or any type of intervention or a pain goal; no documentation of pain reassessments after pain medication given.
Patient #3 was ordered to have a scan that medication to be given based on the patient's actual weight. Nursing services only recorded weight as a stated weight.
Patient #3 had a physician's order for medication to be titrated to help control high blood pressure. The physician's orders were not followed to lower the blood pressure. The patient also had a physician's order for neuro checks every two hours but were not completed as ordered every two hours.

4. Patient #4 presented to the Emergency Department on 6/1/2022 with chief complaints of Altered Mental Status and Extremity Weakness.
Physician's order dated 6/9/22 revealed an order for restraints non-violent or non-self-destructive. There was no documenation the family was notified Patient #4's condition required the use of restraints. 5. Patient #6 presented to the Emergency Room on 7/5/2022 with complaints of generalized weakness, worsening confusion and episodes of vomiting. Patient #6 complained of pain. Review revealed documentation of the patient's pain level with no assessment for the effectiveness of interventions that were put in place. The medical record revealed no documentation of an order for pain medication or documentation the physician was notified of the pain level.

6. Patient #7 was admitted on 5/13/2022 with 2 months of worsening lower extremities weakness. The patient had orders for pain medication. Review of pain assessments revealed they were either incomplete, no documentation of any intervention implemented at the time of the assessment, or no reassessment for the effectiveness of the medication administered.

7. Patient #8 was presented to the Emergency Room on 8/4/2022 with complaints of pain in the right thigh after a fall today. The patient was hospitalized from 8/4/2022 to 8/17/2022. Review of daily nursing assessments for "sacrum skin" and for "heels" revealed no presence of a pressure ulcer to the sacrum and no deep tissue injury to the heels. The patient was discharged to Skilled Nursing Facility #1 (SNF) with no diagnosis of any type pressure areas or injury.
The admission assessment at SNF #1 revealed a Stage II to the left and right buttock and a DTI to the left heel.
Review of Patient #8's flowsheets for positioning revealed the patient was in a supine position for 12 days. A physician's order for intake and output (I&O) dated 8/9/2022 was for "strick I&O". There was no intakes recorded for 7 days and no output recorded for 4 days.
Refer to A-395.

8. Review of the "Interdisciplinary Patient Plan of Care and Daily Goals/Priority List Guidelines" policy with a review/revision date of "9/19" revealed, " ...The patient plan of care is reviewed and interventions documented ongoing throughout stay through integrated participation of all disciplines..."

Review of the hospital's policy "Assessment/Reassessment Policy" with a last review/revision date of "12/20" revealed, "...Reassessment occurs...at regular intervals...The Registered Nurse creates an initial plan for care, treatment and services appropriate to the patient's specific assessed needs and revises or maintains the plan based on the patient's response. Planning for care, treatment and services is individualized to meet the patient's unique needs and circumstances ..."

9. Medical record review revealed that Patient #1 was admitted on 4/4/2022 for an outpatient procedure.

Review of Patient's #1 current care plan dated 4/6/2022 revealed, "...Goal: Optimal Comfort and Wellbeing ..." revealed no Risk identified, no problem identified and the Outcome Optimal Comfort and Wellbeing was ongoing, progressing..." There was no documentation of treatments or interventions to prevent Patient #1's nausea and pain issues.

10. Medical Record revealed Patient #3 was admitted to the hospital on 4/4/2022 with a diagnosis of Cerebral Vascular Accident.

Review of Patient #3's current care plan dated 4/4/2022 revealed, "...Problem: Adult Inpatient Plan of Care - Goal: Optimal Comfort and Wellbeing - Interventions to monitor pain and promote comfort...Problem: Cerebral Tissue Perfusion (Stroke...Goal: Optimal Cerebral Tissue Perfusion - Interventions to protect and optimize cerebral perfusion..." There was no documentation or treatments or interventions for Patient #3's blood pressure, neuro check and pain.

11. Patient #4 presented to the Emergency Room on 6/1/2022 with chief complaints of Altered Mental Status and Extremity Weakness.
Physician's order on 6/2/2022 at 5:38 PM revealed an order for isolation.
Patient #4's care plan dated 6/2/2022 revealed no care plan for enhanced respiratory precautions.

12. Patient #6 presented to the Emergency Room on 7/5/2022 with complaints of generalized weakness, worsening confusion and episodes of vomiting.

Patient #6's care plan dated 7/6/2022 revealed there was no documentation of treatments or interventions for Patient #6 pain control.
Physician order on 7/6/2022 at 7:43 AM revealed an order for Isolation.
Patient #6's care plan dated 7/6/2022 revealed no care plan isolation.

13. Patient #7 was admitted on 5/13/2022 with 2 months of worsening lower extremities weakness.

Patient #7 care plan dated 5/13/2022 revealed no care plan was developed

14. Patient #8 presented to the Emergency Department on 8/4/2022 with complaints of pain in right thigh after a fall today. The patient was discharged from the hospital 8/17/2022. Daily skin assessments documented no ulcers, no injuries to the skin. Review of documentation from SNF #1 revealed upon admission, Patient #8 had stage II pressure ulcers to right and left buttocks as well as a DTI to the left heel.

Patient #8's care plan dated 8/5/2022 revealed there was no documentation to treatments or interventions for Patient #8 pressure injury.
Refer to A-396.

Based on medical record review, policy review and interview, nursing services failed to supervise and evaluate the nursing care for 6 of 11 (Patients #1, 3, 4, 6, 7 and 8) sampled patients who received care at the hospital when they failed to ensure nausea medication was administered for Patient #1; failed to ensure nursing services took steps to manage and assess patients' pain and reassessed pain levels after the administration of pain medication for Patient #1, #6 and #7; failed to ensure nursing service discontinue the IV sheath upon discharge for Patient #1; failed to ensure nursing services followed physician orders to control blood pressure for Patient #3; failed to ensure restraints were applied to Patient #4 after ordered by appropriate licensed provider; failed to ensure nursing services followed physician orders for neuro checks for Patient #3; the hospital failed to ensure nursing services performed skin assessments, developed and implemented measures to prevent the development of preventable pressure injuries and failed to identify actual skin breakdown until tissue injury occurred for Patient # 8 who developed hospital acquired pressure injuries; failed to document actual weight; failed to document oral input and output to ensure patient's needs were met for Patient #3 and #8.

The findings include:

1. Review of the "Pain Management Guidelines" policy with a revision date of "1/21" revealed, "...The patient's right to pain medication is recognized, respected, and supported. The patient/family/caregiver has responsibilities and is involved in the development of an individualized plan of care for managing pain...A comprehensive pain assessment is conducted as appropriate to the patient's condition and the scope of care, treatment and services provided ...Patients are screened for pain at the point of entry to the facility ...Each complete patient assessment per patient care area policy ...Pain assessment includes ...A pain intensity rating scale appropriate for the patient population ...location ...Quality ...Onset ...Duration ...Aggravating/relieving factors...Relieving medication...A pain goal is developed related to function and activities of daily living. The patient is involved in developing realistic expectations and goals that are understood by the patient for the degree, duration and reduction of pain...When medication orders for pain management include levels of pain ...1 - 3 Mild Pain ...4 - 6 Moderate Pain ...7 - 10 Severe Pain ...Notify physician to obtain new order(s) when medication for pain management does not align with patient reported pain level...Reassessment of intervention effectiveness occurs based on type/route of medication, method of pain management...The reassessment is documented. The nurse continues to intervene until an acceptable level of pain is obtained as determined collaboratively by the patient, family or caregiver...Document pain assessment, interventions and reassessment in the medical record...However, the lesser potent medication can be administered based on patient preference when ordered by the physician ...Reassessment of intervention effectiveness occurs based on the type/route of medication, method of pain management, and as patient condition requires. The reassessment is documented ...Documented pain assessment, interventions, and reassessment in the medical record..."

Review of the hospital's policy "Assessment/Reassessment Policy" with a last review/revision date of "12/20" revealed, " ...A registered nurse (RN) completes a head to toe assessment...upon receiving a patient post operatively/post procedure (not including diagnostics such as chest xray, MRI, ultrasound, etc.)Reassessment occurs ...at regular intervals ...to evaluate the patient's response to care, treatment, and services ...to respond to a change in status and/or diagnosis or condition ...to meet time intervals determined by the course of the care, treatment, and services for the patient ...The Registered Nurse creates an initial plan for care, treatment and services appropriate to the patient's specific assessed needs and revises or maintains the plan based on the patient's response. Planning for care, treatment and services is individualized to meet the patient's unique needs and circumstances ..."

2. Medical record review revealed that Patient #1 was admitted on 4/4/2022 for an outpatient procedure (implantation of a carotid baroreceptor stimulator (Barostim).

(a) Review of Patient #1's record revealed the following of the patient's complaint of nausea:
A physician's order dated 4/6/2022 at 2:03 PM revealed an order for Zofran injection 4 mg [miligrams] every 30 minutes as needed Route IV [Intravenous] the reason nausea or vomiting.

Review of the nursing flowsheet on 4/6/2022 revealed that Patient #1 complained of nausea at 6:17 PM, nausea and was vomiting at 6:21 PM, and was still complaining of nausea at 6:23 PM.

Review of the After Visit Summary on 4/6/2022 did not revealed any prescription for nausea medication for home use.

Review of Nurse Navigator note on 4/7/2022 at 12:39 PM revealed "...Called pt [patient] to see how she is feeling after Barostim [procedure in which a device is implanted that decreases blood pressure in patients who are resistant to medications in the treatment of hypertension] yesterday. Pt reports pain at the site and n [nausea)/v (vomiting) - unable to keep any water down without throwing up. Per Physician #2, sent in 4 mg [milligram] SL [sublingually, under the tongue) Zofran. Told pt [patient] to call if she's not feeling better tomorrow, pt verbalized understanding..."

Review of the flowsheet "Check-in/updates" for post procedure recovery on 4/7/2022 at 2:47 PM revealed, RN #8 asked Patient #1 "...Have you had any nausea or vomiting...She contacted the doctor and they are calling something in for her..."

(b) Review of pain assessments for Patient #1 revealed the following:
Review of the nursing flowsheet on 4/6/2022 at 2:10 PM, revealed a pain assessment with a pain score of 7. The pain assessment did not include the location, quality, onset, duration or any type of intervention.

Review of the nursing flowsheet on 4/6/2022 at 2:15 PM, revealed a pain assessment with a pain score of 7. The pain assessment did not include the location, quality, onset, duration or any type of intervention.

Review of the nursing flowsheet on 4/6/2022 at 2:20 PM, revealed a pain assessment with a pain score of 7. The pain assessment did not include the location, quality, onset, duration or any type of intervention.

Review of the nursing flowsheet at 2:46 PM, revealed a pain medication was administered to Patient #1 but not documented on the Medication Administration Sheet. There was no pain assessment for this administration of pain medication.

Review of the pain assessment at 4/6/2022 at 2:26 PM, 2:32 PM, 2:56 PM and 3:01 PM revealed a pain score of 3. The pain assessment did not include the location, quality, onset, duration or any type of intervention.

In an e-mail correspondence on 7/15/2022 at 2:35 PM the Risk Manager stated, "...Per policy, reassessment of pain for effectiveness of intervention should occur. Patient may request to try acetaminophen for pain.

(c) Review of medical record regarding removal of IV for Patient #1 revealed the following:
Review of the flowsheet on 4/6/2022 at 6:11 PM under the section for IV [intravenous] properties revealed, "...Peripheral IV 4/6/2022...Right Forearm...Removal date: 4/6/2022 at 6:11 PM...Removal Time: 5:30...Site Assessment Clean; Dry; Intact 4/6/2022 at 6:10 PM...Line Status Saline locked at 4/6/2022 6:10 PM...Dressing Type Tegaderm at 4/6/2022 at 6:10 PM...Dressing Appearance Clean; Dry; Intact; No drainage...at 4/6/2022 6:10 PM..."

In an interview on 6/27/2022 beginning at 1:11 PM RN #6 stated, "...The Post Op nurse is responsible for making sure the IV is taken out before the patient goes home. RN #6 was asked when the IV is taken out of the patient's arm is that documented anywhere. RN #6 stated, "...There are several places it could be documented. RN #6 was asked should the removal of the IV be documented. RN #6 stated, "...It should be documented that the IV was removed..."

Interview on 6/27/2022 beginning at 1:45 PM in the Quality Director Office with RN #2 stated, "...I did not know till two days later that I had left the IV in the patient's arm. When the post operative phone call was made to check on the patient the next day the patient told that she still had her IV in her arm. I failed to take the IV out of her arm..."

In an telephone interview with the Patient #1 on t/11/2022 beginning at 10:34 AM Patient 1 stated, "...Upon arriving home I noticed I had the IV Sheath still in my arm. Nurse #2 said the reason for not taking the IV out was because I had long sleeves on.... I complained to Nurse #2 that my arm was in significant pain where the IV was located at. I was told it would be removed. It was never removed. I once again complained before I left that my arm was still hurting significantly. Nothing was done. I told the medical staff numerous times I was in significant pain from the IV..."

3. Medical Record revealed Patient #3 was admitted to the hospital on 4/4/2022 with a diagnosis of Cerebral Vascular Accident.

(a) Review of Patient #3's complaint of pain and pain assessments revealed the following:
A physician's order dated 4/4/2022 at 6:56 PM revealed an order for Acetaminophen 650 mg [milligrams] by mouth every 4 hours as needed.

On 4/6/2022 at 10:28 AM a pain assessment was performed on Patient #3 which revealed no documentation of a pain score.

Review of Patient #3's Medication Administration Record (MAR) on 4/6/2022 at 10:30 AM revealed Tylenol 650 mg [milligrams] was administered by mouth. There was no documentation Patient #3 was reassessed for the effectiveness of this pain medication.

On 4/6/2022 at 10:32 AM a pain assessment was performed on Patient #3 at which time Patient #3 rated her pain at a level of 10 or severe pain. The pain assessment did not include the location, quality, onset, duration or any type of intervention or a pain goal.

On 4/6/2022 at 4:26 PM a pain assessment was performed on Patient #3 at which time Patient #3 rated her pain at a level of 10 or severe pain. The pain assessment did not include the location, quality, onset, duration or any type of intervention or a pain goal.

Review of the Patient #3's MAR on 4/6/2022 at 4:26 PM revealed Tylenol 650 mg was administered by mouth. There was no documentation Patient #3 was reassessed for the effectiveness of this pain medication

Review of Patient #3's MAR on 4/6/2022 at 8:32 PM revealed Tylenol 650 mg was administered by mouth. There was no pain assessment documented for the administration of the Tylenol 650 mg. There was no documentation the patient was reassessed for the effectiveness of this pain medication.

On 4/7/2022 at 3:02 AM a pain assessment was performed on Patient #3 at which time Patient #3 rated her pain at a level of 8 or severe pain. The pain assessment did not include the location, quality, onset, duration or any type of intervention or a pain goal. There were no interventions documented for Patient #3 pain level of 8 or severe pain.

On 4/7/2022 at 3:04 AM a pain assessment was performed on Patient #3 at which time Patient #3 rated her pain at a level of 8 or severe pain. The pain assessment did not include the location, quality, onset, duration or any type of intervention or a pain goal. There were no interventions documented for Patient #3 pain level of 8 or severe pain.

Review of Patient #3's MAR on 4/7/2022 at 4:15 AM revealed Tylenol 650 mg was administered. There was no pain assessment performed for the administration of this pain medication. There was no documentation the patient was reassessed for the effectiveness of this pain medication.

Review of the discharge summary on 4/7/2022 revealed, " ...However today she reports she hurt all night until I ordered Fioricet this AM and now greatly improved..."

In an e-mail correspondence on 7/15/2022 at 2:35 PM the Risk Manager stated, "...Per policy, reassessment of pain for effectiveness of intervention should occur..."

(b) Review of physician's order for Patient #3 to be weighed prior to Computerized Tomography (CT) scan revealed the following:
Review of the physician's orders dated 4/4/2022 at 3:29 PM revealed, "...Weight patient...Order Comments SHOULD BE DONE PRIOR TO CT SCAN FOR RAPID DOSING OF ALTEPLASE..."

Review of the ED [Emergency Department] to Hosp [Hospital]-Admission on 4/4/2022 at 4:54 PM revealed, "...Height and Weight...Weight 213 lb [pounds]...Weight Method: Stated..."

Review of the physician's orders on 4/6/2022 at 6:02 AM revealed, "...Weight patient...Order Comments SHOULD BE DONE PRIOR TO CT SCAN FOR RAPID DOSING OF ALTEPLASE..."

Review of the medical record did not revealed Patient #3 had been weighted on 4/6/2022.

In an e-mail correspondence on 7/15/2022 at 2:35 PM the Risk Manager was asked the following: Concerning Patient #3 her weight was documented as a stated weight should Patient #3 weight been an actual weight instead of a stated weight; also there were two orders (one on the 4/4/22 and one 4/6/2022) for Patient #3 to be weighted; on 4/4/2022 documented stated weight 213, 4/6/2022 no weight is recorded. but I do not see a weight for 4/6/2022. The Risk Manager stated, "...Actual weights are preferred. No further weights taken during stay per record review..."

(c) Review of Patient #3's orders revealed the following to be implemented if blood pressure is elevated:
Review of the physician orders on 4/4/2022 at 4:20 PM revealed an order for Clevidipine titrated as needed initiate infusion at 1 mg milligram]/hr [hour] titrate up or down by double rate every 5 minutes for BP [Blood Pressure] > [greater than] = [or equal to] 15 mm HG [millimeters of mercury] of goal. If BP within 15 mm Hg of goal titrate by 2 mg/hr every 5 minutes until goal reached. Monitoring parameter SBP [Systolic Blood Pressure] ...Maintain SBP to < [less than] = [or equal too] 180 mmH ...Usual max [maximum] 21 mg/hr..."

A physician's order dated 4/4/2022 at 6:56 PM revealed, "...Hydralazine (Apresoline) injection 10 - 20 mg [miligrams] every 4 hours PRN [as needed] IV [Intravenous]...Side effects Low blood pressure, headache, dizziness..."

A physician's order dated 4/4/2022 at 6:56 PM notify physician (High BP [Blood Pressure)... if BP doesn't meet target of SBP [Systolic Blood Pressure] 180 within 30 minutes after appropriate treatment as ordered..."

On 4/5/2022 at 4:52 AM blood pressure reading was 192/86. Review of the Medication Administration Record revealed two (2) orders for elevated systolic Blood Pressure that were not given to Patient #3 with a blood pressure reading of 192/86. Physician's orders were not followed to notify physician if blood pressures did not meet target of systolic blood pressure 180.

On 4/5/2022 at 5:34 AM blood pressure reading was 205/100. Review of the Medication Administration Record revealed two (2) orders for elevated systolic Blood Pressure that were not given to Patient #3 with a blood pressure reading of 205/100. Physician's orders were not followed to notify physician if blood pressures did not meet target of systolic blood pressure 180.

Review of the Neurology consult on 4/6/2022 at 6:20 AM revealed " ...Immediate Plan Hold Hydralazine ...Neurochecks every 2 hours x 4 hours then every 4 hours...BP [blood pressure] treatment for SBP > [greater than] 180...Labetalol (normodyne) 10-20 mg [miligrams] IV [Intravenous] push (slowly): 10-20 mg IV every 10 minutes PRN [as needed] until BP in target OR maximum 300 mg OR Heart Rate < [less than] 50/[beats] min [minute]...Chief Complaint...All information obtained from the patient's nurse at bedside, medical record and patient herself...Throughout the night, patient had been hypertensive. Given hydralazine which cause the patient to become agitated, crying, had trouble speaking. Apparently, she does have some language difficulties from prior event however She got significantly worse after hydralazine effusion...Stoke code activated. Overall examination is unremarkable with the exception of stuttering and mild aphasia however she is able to identify every object and follow commands without difficulties. No focal motor weakness. No involuntary movements either..."

On 4/7/2022 at 8:15 AM blood pressure reading was 239/100. Review of the Medication Administration Record revealed one (1) orders for elevated systolic Blood Pressure that were not given to Patient #3 with a blood pressure reading of 239/100. Physician's orders were not followed to notify physician if blood pressures did not meet target of systolic blood pressure 180.

In an e-mail correspondence on 7/15/2022 at 2:35 PM the Risk Manager was asked when Patient #3 systolic blood pressure was above 180 there were physicians order for Patient #3 to be treated and receive interventions were these interventions done. The Risk Manager stated, " ...Record review indicated BP [Blood Pressure] > [greater than] 180 receive interventions. This was not completed..."

(d) Review of Patient #3's record revealed the following about neurological (neuro) checks:
Review of the ED [Emergency Department] to Hosp [Hospital]-Admission on 4/4/2022 at 3:29 PM revealed, "...Orders Placed Neuro Checks Every 2 Hours..."

A physician's orders dated 4/4/2022 at 6:56 PM revealed an order for Neuro checks every 4 hours at 8:00 PM until specified.

A physician's telephone order dated 4/6/2022 at 6:11 AM revealed an order for Neuro checks every 2 hours.

A physician's orders dated 4/6/2022 at 6:11 AM revealed Neuro checks every 4 hours at 8:00 PM until specified.
Timeline for neuro checks are as follows:
4/4/2022 at 6:13 PM
4/5/2022 at 10:38 PM
4/6/2022 at 12:30 AM
4/6/2022 at 8:10 AM
4/6/2022 at 10:00 AM
4/6/2022 at 8:00 PM
4/7/2022 at 2:00 AM

In an e-mail correspondence on 7/15/2022 at 2:35 PM the Risk Manager stated, "...Explanation Record reviewed. Neuro checks not completed q [every] 2 (two) hours..."

4. Medical record review revealed Patient #4 was admitted on 6/1/2022 with an diagnosis of COVID. The patient presented to the Emergency Department (ED) with chief complaints of Altered Mental Status and Extremity Weakness.

A telephone physician's order dated 6/9/22 at 9:30 PM revealed an order for restraints non-violent or non-self-destructive. With the rationale of interference with Medical Devices or Treatment Patient Safety. The restraint type would be Soft Wrist bilaterally for the left and right wrist.

The restraint flowsheet beginning on 6/9/2022 - 6/10/2022 revealed the restraint one hour monitoring was documented as every two hours.

The restraint flowsheet beginning on 6/9/2-22 - 6/10/22 revealed the restraint two hour monitoring assessments were incomplete for the 6/10/2022 10:08 AM, 12:23 PM and 2:33 PM assessments.

Review of the restraint flowsheet on 6/9/2022 at 9:30 PM revealed an note that stated, "...Patient declined notification for family notification...patient was disoriented x 4 Level of Consciousness was confused..."

Review of the flowsheet under "Restraint Order" on 6/9/2022 at 10:00 PM revealed, "...Education Family Notification...notified charge nurse..." This note was created on 6/10/2022 at 7:20 PM. Patient #4 was put into restraints on 6/9/2022 at 9:30 PM. This is considered post-charting the entry was made on the next day on the next shift.

Review of the nursing progress note on 6/9/2022 at 9:30 PM revealed, "...Patient constantly attempts to get out of bed she completely disrobes and has all her wires wrapped around her body. Placed bed alarm on and attached oxygen and probe back on patient. She consistently does this every 10 min. She is very confused and unsafe to prevent any harm the doctor was notified to request restraints. Notified the charge nurse to determine who to notify because once retrieved there was a list of people to notify. Per charge nurse notify her and she will notify house supervisor. This note was created on 6/10/2022 at 7:07 PM. Patient #4 was put into restraints on 6/9/2022 at 9:30 PM. This is considered post-charting the entry was made on the next day on the next shift.

Review of the nursing flowsheet under the section Provider Notification/Communication Other (Comment) on 6/10/2022 at 3:16 PM revealed, " ...Daughter #1 wants to speak to the MD Refused IV access for the patient. Wants the patient home today..."

In an telephone interview on 6/29/2022 beginning at 8:39 AM Daughter #1 stated, "...She was not made aware of her mother being put into restraints until about 3:00 PM on the day of 6/10/2022 when Daughter #1 spoke with Physician #4 who told her that Patient #4 could not be discharged for 48 hours after the restraints were released..."

In an interview on 6/29/2022 beginning at 12:03 PM in the Quality Director Office with the Risk Manager stated, "...It is in our policy that we will make every attempt to notify the family but we do not have to make contact per our restraint policy..."

In an interview on 6/29/2022 beginning at 12:22 PM in the Quality Director Office the Registered Nurse (RN) #12 stated, "...I first spoke to Daughter #1 was about her mother being put in restraints on 6/9/2022 at 9:30 PM. I applied and told we were in the wrong and that she should have notified her about her mother being put in restraints...There were multi family members on the contact list and it was late but we didn't know who to contact and then the physican Physician #4 notified Daughter #1 about not being able to be discharged due to the 48 hour policy for restraints...this started the escalation with Daughter #1...Daughter #1 told me that she expected her mother home today (6/10/2022)...Our director of RT [Respiratory Therapy] gave us a lender tank so we sent her home with one of our oxygen tanks, till she could get oxygen set up at home..."

In an interview on 6/29/2022 beginning at 1:43 PM in the Quality Director office the Administrative Director the stated, "...the RN #12 called me and explain what had gone on with Patient #4 she had told me about the restraints and the patient was supposed to be discharged that day and everything had been arranged and she was going to be transported by ambulance back to the Assisted Living facility and we were letting her borrow one of our oxygen tanks..."

Review of the nursing flowsheet under the section Provider Notification/Communication Other (Comment) on 6/10/2022 at 3:19 PM revealed, " ...Asked if the restraints need to be D/C [discontinued] and evaluate the patient ..."

Review of the nursing flowsheet under the section Provider Notification/Communication Other (Comment) on 6/10/2022 at 5:08 PM Sitter order. Notified Charge Nurse ..."

Review of the discharge note on 6/10/2022 at 3:42 PM revealed, "...Patient was placed in restraints overnight for her own protection as well as staff's protection. Patient's daughter was very upset about not being notified about this and demanded removal of restraints. She requested to talk to risk management about this. I provided her with the main number where she can be transferred to risk management or the charge nurse. I have talked to patient's nurse and case management. restraints have been removed, patient will need a sitter due fall risk in the setting of Dementia and Sundowning..."

A physician's order dated 6/10/2022 at 4:56 PM revealed a order for a sitter "...Routine Until Discontinued..." The order was discontinued on 6/10/2022 at 10:25 PM [Patient Discharge].

Review of the flowsheet on 6/10/2022 at 8:08 AM " revealed an Fall Risk Assessment with a Fall Risk Score of 45 (High Risk Fall Precautions = Scores of 14 or greater) also in the section Enhanced Safety Measures is documented in a comment "...Restraints applied properly..." This is the last Fall Assessment for 6/10/2022.

Review of the flowsheet on 6/10/2022 at 3:37 PM revealed that the bilateral soft restraints were discontinued but there was no documentation assessment for discontinuation.

Review of the nursing flowsheet under the section "Provider Notification/Communication"...Comment...on 6/10/2022 at 5:08 PM Sitter order. Notified Charge Nurse..."

In an e-mail correspondence on 8/24/2022 at 3:38 PM with the Risk Manager, the Risk Manager was asked who was the sitter that stayed with Patient #4 after the restraints were discontinued. The Risk Manager stated, "...Discussions with Patient #4's primary RN discovered that the physician placed an order for sitter in case one was needed and that a sitter was never assigned. This RN also states that she and the PCA #1, were in and out of the patients room every 30 minutes to an hour to redirect patient to not pull tubes and/or to replace the O2. The sitter order was eventually DC'd [discontinued]. The Risk Manager was asked is there documentation to support that a sitter was not assigned and that the RN, Patient Care Tech and PCT #1 were in and out of the room every 30 minutes to an hour to redirect the patient. The Risk Manager stated, "...No." The Risk Manager was asked would the restraints have been discontinued that day if the daughter was not requesting her mother was to be discharged that day. The Risk Manager stated, "...Removing a patient from restraints as soon as possible and when appropriate is always a goal of the staff. In this case, the chart does not reflect a removal of restraints due to a discharge..."

Review of the Social Work Note on 6/10/2022 at 5:05 PM revealed, "...SW [Social Worker] received returned phone call from the Assisted Living facility and she stated the pt's furniture has been moved and provided new apartment #21. No report is needed. SW spoke w [with]/ the [named ] Ambulance, pt is labeled-"ready for pick up" pt is now 3rd in line..."

5. Medical record review revealed that Patient #6 was admitted on 7/5/2022 with a diagnoses of Pulmonary Embolus, Elevated Troponin, COVID 19 and Hyperglycemia.

(a) Review of Patient #6's complaint of pain and pain assessments revealed the following:
On 7/5/2022 at 10:57 PM a pain assessment was performed on Patient #6 at which time Patient #6 rated her pain at a level of 4 or moderate pain. The pain management interventions at this time were a quiet environment facilitated. There was no documentation of the effectiveness of the interventions that were put in place. There was no physician's order at this time for pain medication or any documentation to confirm the physician was notified of Patient #6's pain level.

On 7/6/2022 at 3:45 AM a pain assessment was performed on Patient #6 at which time Patient #6 rated her pain at a level of 10 or severe pain, The pain assessment revealed the pain location was generalized in the anterior chest with nonverbal indicators of pain by Patient #6 displaying grimacing and restless; sleep pattern change, pain management interventions quiet environment facilitated There was no documentation of the effectiveness of the interventions that were put into place. There was no physician's order at this time for pain medication or any documentation to confirm the physician was notified of Patient #6's pain level.

On 7/6/2022 at 4:16 AM a pain assessment was performed on Patient #6 at which time Patient #6 rated her pain at a level of 10 or mild pain. The pain assessment revealed the pain location was generalized in the chest with nonverbal indicators of pain by Patient #6 displaying grimacing. The pain management interventions revealed pillow support was provided, the patient's position was adjusted, a quiet environment was facilitated, unnecessary movement minimized. There was no documentation of the effectiveness of the interventions that were put into place. There was a note in the pain assessment that stated, "...Will be paging MD at this time...(it was dated and timed with this date 7/6/2022 at 4:17 AM)..."

On 7/6/2022 at 8:35 AM a pain assessment was performed on Patient #6 at which time Patient #6 rated her pain at a level of 8 or severe pain (in comments called attending for orders) the location anterior chest. No interventions documented. There was no physician's order at this time for pain medication.

On 7/6/2022 at 12:00 PM a pain assessment was performed on Patient #6 at which time Patient #6 rated her pain at a level of 6 or moderate pain (in comments it stated, "no changes from previous assessment". Patient #6's location of pain was in the anterior chest with no interventions documented. There was no physician's order at this time for pain medication.

On 7/6/2022 at 4:24 PM a pain assessment was performed on Patient #6 at which time Patient #6 rated her pain at a level of 7 or moderate pain (in comments it stated, "no changes from previous assessment". Patient #6's location of pain was the anterior chest with no interventions documented. There was no physician's order at this time for pain medication.

A physician's order dated 7/6/2022 at 6:23 PM revealed an order for Tylenol 1,000 mg tablet every 4 hours PRN [as needed] reasons Mild Pain (1-3). When ordered for pain and PRN [as needed], may give for higher pain score upon patient request.

Review of Patient #6's Medication Administration Record (MAR) on 7/6/2022 at 6:35 PM revealed a dose of 1,000 mg [miligrams] of Tylenol was administered. There was no pain assessment documented. There was no assessment for the effectiveness of this pain medication.

Patient #6 started complaining of pain on 7/5/2022 beginning at 10:57 PM and continued to complain of pain throughout the night of 7/5/2022 and the next day 7/6/2022. Patient #6 did not receive a physician's order for pain medication until 7/6/2022 at 6:23 PM. Patient #6 received her first administration of pain medication on 7/6/2022 at 6:35 PM.

6. Medical record review revealed that Patient #7 was admitted on 5/13/2022 with a diagnosis of Generalized Weakness.

(a) Review of Patient #7's pain and pain assessments revealed the following:
A physician's order dated 5/14/2022 revealed an order for Tylenol 325 mg [milligram] take two tablets (650 mg) by mouth every 4 hours as needed.

A physician's order dated 5/14/2022 revealed an order for Norco 5-325 mg [milligram] take one tablet by mouth every 4 hours as needed for moderate pain (4-6).

A physician's order dated 5/21/2022 revealed an order of Percocet 5-325 mg give 1-2 tablet by mouth every 4 hours as needed for mild pain (4-6).

A physician's order dated 5/21/22 revealed an order for Dilaudid injection 0.5 mg every 10 minutes as needed for severe pain (7-10) maximum cummulation dose 2 mg every 2 hours.

A physician's order dated 6/16/22 revealed an order for Tylenol 650 mg 2 tablets for mild pain (1-3) every 4 hours as needed.

On 5/13/2022 at 3:34 PM a pain assessment was performed on Patient #7 at which time Patient #7 rated her pain at a level of 2 or mild pain. The pain assessment did not include the location, quality, onset, duration or any type of intervention or a pain goal.

On 5/15/2022 at 8:08 AM a pain assessment was performed on Patient #7 at which time Patient #7 rated her pain at a level of 4 or moderate pain.

Review of the Medication Administration Record (MAR) dated 5/15/22 at 8:11 AM Norco 5-325 mg [milligram] tablet was administered for pain. There was no pain assessment documented for the administration of this pain medication and there was no documented reassessment for the effectiveness of the pain medication.

Review of the MAR on 5/15/22 at 3:01 PM Norco 5-325 mg [milligram] tablet was administered for a pain score of 5 or moderate pain. There was no documented reassessment for the effectiveness of this pain medication.

Review of the MAR on 5/16/22 at 3:56 PM Norco 5-325 mg [milligram] tablet was administered. There was no pain assessment documented for the administration of this pain medication and there was no documented reassessment for the effectiveness of this pain medication.

On 5/16/22 at 8:00 PM a pain assessment was performed on Patient #7 at which time Patient #7 rated her pain at a level of 5 or moderate pain. It states pain medication was administered. Review of the MAR did not revealed any medication was administered for this date and time.

On 5/16/2022 at 8:48 PM a pain assessment was performed on Patient #7 at which time Patient #7 rated her pain at a level 5 or moderate pain. The pain assessment did not include the location, quality, onset, duration or any type of intervention or a pain goal.

Review of the MAR on 5/16/22 at 8:49 PM Norco 5-325 mg [milligram] tablet was administered. There was no documented reassessme

Based on policy review, medical record review and interview the hospital failed to ensure the nursing staff developed and/or implemented a nursing care plan which reflected individualized patient needs and the care to be provided for 6 of 11 (Patients #1, #3, #4, #6, #7 and #8) sampled patients reviewed.

The findings included:

1. Review of the "Interdisciplinary Patient Plan of Care and Daily Goals/Priority List Guidelines" policy with a review/revision date of "9/19" revealed, " ...Progress towards a minimum of one goal is reviewed by the nurse every 12 hours. The care plan progress note summarizes the overall progress toward the goal for the shift ...The patient plan of care is reviewed and interventions documented ongoing throughout stay through integrated participation of all disciplines. Problems or needs are resolved or identified as adequate for discharge throughout the hospital stay. Prior to discharge the RN [Registered Nurse] in collaboration with other disciplines addresses unresolved goals on the plan of care..."

Review of the hospital's policy "Assessment/Reassessment Policy" with a last review/revision date of "12/20" revealed, " ...Reassessment occurs ...at regular intervals ...to evaluate the patient's response to care, treatment, and services ...to respond to a change in status and/or diagnosis or condition ...to meet time intervals determined by the course of the care, treatment, and services for the patient ...The Registered Nurse creates an initial plan for care, treatment and services appropriate to the patient's specific assessed needs and revises or maintains the plan based on the patient's response. Planning for care, treatment and services is individualized to meet the patient's unique needs and circumstances ..."

2. Medical record review revealed that Patient #1 was admitted on 4/4/2022 for Barostim placement (an outpatient procedure for implantation of a device that decreases blood pressure in patients with drug treatment-resistant arterial hypertension).

Review of Patient's #1 current care plan dated 4/6/2022 revealed, "...Goal: Optimal Comfort and Wellbeing ..." revealed no Risk identified, no problem identified and the Outcome Optimal Comfort and Wellbeing was ongoing, progressing..." There was no documentation of treatments or interventions to prevent Patient #1's nausea and pain issues.

3. Medical Record revealed Patient #3 was admitted to the hospital on 4/4/2022 with a diagnosis of Cerebral Vascular Accident.

Review of Patient #3's current care plan dated 4/4/2022 revealed, "...Problem: Adult Inpatient Plan of Care - Goal: Optimal Comfort and Wellbeing - Interventions to monitor pain and promote comfort...Problem: Cerebral Tissue Perfusion (Stroke...Goal: Optimal Cerebral Tissue Perfusion - Interventions to protect and optimize cerebral perfusion..." There was no documentation or treatments or interventions for Patient #3's blood pressure, neuro check and pain.

4. Medical record review revealed Patient #4 was admitted on 6/1/2022 with an diagnosis of COVID. the ER with chief complaints of Altered Mental Status and Extremity Weakness.

A Physician's order dated 6/2/2022 at 5:38 PM revealed an order for isolation for enhanced respiratory precautions.

Review of Patient #4's current care plan dated 6/2/2022 revealed no care plan developed or implemented for enhanced respiratory precautions.

5. Medical record review revealed that Patient #6 was admitted on 7/5/2022 with a diagnoses of Pulmonary Embolus, Elevated Troponin, COVID 19 and Hyperglycemia.

Review of Patient #6's current care plan developed on 7/6/2022 revealed, "...Problem: Adult Inpatient Plan of Care...Goal: Optimal Comfort and Wellbeing - Interventions Monitor Pain and Promote Comfort..." There was no documentation of treatments or interventions for Patient #6 pain control.

A physician order dated 7/6/2022 at 7:43 AM revealed an order for Isolation for enhanced respiratory precautions.

Review of Patient #6's current care plan dated 7/6/2022 revealed no care plan developed or implemented for enhanced respiratory precautions.

6. Medical record review revealed that Patient #7 was admitted on 5/13/2022 with a diagnosis of Generalized Weakness.

Review of Patient #7's current care plan dated 5/13/2022 revealed no care plan developed or implemented for pain experienced by the patient.

7. Medical record review revealed that Patient #8 was admitted on 8/4/2022 with a diagnoses of a fracture of the right femur and a fracture of the right humerus, osteosarcoma, COVID-19 and Benign Hypertension. Past medical history of osteosarcoma HTM presents to the ED complaining of pain in right thigh onset after a fall today at 12:30 PM

Review of Patient #8's current care plan dated 8/5/2022 revealed. "...Problem: Adult Inpatient Plan of Care - Goal: Absence of Hospital-Acquired Illness or Injury - Interventions: Prevent Skin Injury...Problem: Oral Intake Inadequate Goal: Improve Oral Intake - Promote and Optimize Oral Intake...Problem: Skin Injury Risk Increased - Goal: Skin Health and Integrity - Intervention: Optimize Skin Protection and Promote and Optimize Oral Intake..." There was no documentation to treatments or interventions for Patient #8 pressure injury.

Based on hospital policy, medical record review and interview, the hospital failed to develop and implement an effective discharge plan for patients for post discharge care for 1 of 10 (Patient #10) sampled discharged patients reviewed.

The findings include:

1. Review of the hospital's policy "Discharge Planning" with a review/revision date "10/2020" revealed, "...To promote the continuity of patient care by initiating discharge planning at admission...To involve patient patients/families in developing plans to meet post-acute care needs...It a multidisciplinary process to promote the... care through referrals...community resources that focus on meeting the medical, psychosocial, educational...and social needs of patients..."

2. Patient #10 presented to the Emergency Room on 8/16/2022 with a scrotal abscess, pedal edema and hidradenitis. Patient #10 was scheduled for multiple abscess drainage with a discharge plan to send the patient home with family.
While the patient was still at the hospital, the Social worker provided a charity care form to the patient and his wife. Discharge paperwork documented instructions the patient and/or family was to call to set up continued care of the wounds after the chairty form was approved. Patient #10 received no education on how to care for the wounds or how to otain supplies for wound care.
Refer to A-813.

Based on policy review, facility document review, medical record review and interview, the facility failed to ensure the appropriate discharge planning process to identify post-hospital needs for 1 of 11 (Patient #10) sampled patients. Patient #10 was discharged without any education for wounds and how to get related supplies.

The findings included:

1. Review of the hospital's policy "Discharge Planning" with a review/revision date "10/2020" revealed, "...To promote the continuity of patient care by initiating discharge planning at admission...To utilize available information and refer patients to the appropriate community resources to meet their post-hospitalization/post-acute care needs...To involve patient patients/families in developing plans to meet post-acute care needs...To promote smooth transitions from acute care to alternative levels of care...Is a multidisciplinary process to promote the continuity of care through referrals to applicable community resources that focus on meeting the medical, psychosocial, educational...and social needs of patients..."

2. Medical record review revealed that Patient #10 was admitted on 8/16/2022 with a diagnosis of Hidradenitis Suppurativa.

Review of the General Surgery consult on 8/19/2022 revealed, "...Patient #10 is a 43 year old male with PMH [Past Medical History] of DM [Diabetes Mellitus], hidradenitis [chronic skin condition featuring lumps in areas of the body such as armpits or groin], obesity and gastroparesis presented to the ED [Emergency Department] on 8/16/22 for scrotal swelling, pedal edema and hidradenitis. Patient states the scrotal swelling started about 2 weeks ago and progressed in size and pain to where he is unable to tolerate ambulating. CT [computerized tomography] showed 3.7 cm [centimeter] abscess within left scrotum. Urology was consulted and initially recommended transfer to facility for debridement but then since abscess drained on its own and has improved induration surgical intervention was deemed not needed. However, patient has draining lesions in adjacent left groin and bilateral axilla for which general surgery has been consulted..."

Review of the Operative/Procedure note on 8/20/2022 revealed, "...Multiple abscess drainages and sinus tract unroofings/debridement of bilateral axillary and left grain infected Hidradenitis...

Review of the Social Worker Discharge Planning note on 8/17/2022 at 9:59 AM revealed, "...Services Anticipated at Discharge: none Concerns to Be Addressed...Patient would like to possibly see what HH [Home Health] options are available if appropriate. Discharge plan is to drive home with wife vs [versus] HH [Home Health]...Anticipated Discharge Disposition: home or self care, home with family..."

Review of the Social Worker Discharge Planning note on 8/17/2022 at 12:32 PM revealed, "...SW [Social Work] provided Charity form to pt [patient] and discussed with family who was at bedside..."

Review of the Case Management note on 8/24/2022 at 10:15 AM revealed, "...CM [Case Management] consulted to set up appt [appointment] for pt
[patient] w [with]/ [Named] Dermatology. Spoke w/[Named] Dermatology and the first available appt for new pts is 1/11/2023 @ 8:00 AM -[Named] office per pt and wife's request. Secure message sent to pt's attending MD [Medical Doctor], Physician #4 and he said to go ahead and make the appt. Met w/the pt and his wife and informed them of appt date and time. Info [information] placed on pt's AVS [After Visit Summary]. Cont to follow..."

Review of the Case Management note on 8/24/2022 at 2:36 PM revealed, "...Orders recv [received] from Physician #4 to set up OP [Outpatient] PTWC [Physical Therapy Wound Care] here. Orders placed. Met w [with]/the pt [patient] and his wife and stressed the importance of completing Charity App [application] ASAP [As Soon As Possible]. The contact number for [Named OP PTWC] placed on AVS [After Care Summary] Pt. instructed to contact them once he received final determination on his Charity App and an appt [appointment] can be scheduled. Contact info for [named physician] on AVS for follow up. Pt. and his wife verbalized understanding of all above.

Review of the Urology progress note on 8/24/2022 at 4:24 PM revealed, "...Anxious about discharge as there is no would care set up...Will need long term follow up and treatment for hidradenitis..."

Review of the After Visit Summary on 8/24/2022 revealed, "...Other instructions...Referral to Wound Clinic...Pt [patient] is awaiting charity application approval by [Named] Hospital. Please contact pt. to schedule an appt [appointment] once charity app approved. Pt. will call [phone number] once his app is approved...What's Next Follow up with [Named] Wound Care Pt is awaiting charity application approval by [Named] hospital. Please contact pt to schedule an appt once charity app approved..."

Review of the After Visit Summary on 8/24/2022 revealed no education for the treatment of wounds.

In a interview on 9/2/2022 beginning at 9:42 AM in the Quality Director's office with Registered Nurse (RN) Case Manager (CM) #2 and the Manager of Case Management and Social Work the CM #2 was asked what kind of wound care was ordered on discharge for Patient #10. The CM #2 stated, "...Patient #10 attending physician ordered PT [Physical Therapy] wound care. CM #2 was asked where the PT wound care was located. CM #2 stated, "...It is located on this campus. CM #2 was asked were would I find the information about the order for PT wound care. CM #2 stated, "...On the After Care Summary. CM #2 was asked when the first appointment was scheduled for the wound care. CM #2 stated, "...Patient #10's wife had not filled out the income portion on the Charity application and she was encouraged to fill the Charity application out as soon as possible and when she received notification that she had been approved to call the PT and schedule her appointment. CM #2 was asked were any supplies send home with Patient #10 for wound care. CM #2 stated, "I instructed the nurse to send some supplies for the would care home with the wife. CM #2 was asked if Patient #10's wife was to do the wound care at home until charity application had been approved. CM #2 stated, "...Yes." The CM #2 and the Manager of Case Management and Social Work was asked it states on the Financial Assistance Application that it was approved for services from 8/16/2022 to 11/27/2022; but it was not approved at the time of discharge for wound care. The Manager of Case Management and Social Work stated that date is retro active..."

In an interview on 9/2/2022 beginning at 10:01 AM in the Quality Director's office with the Risk Manager (RM) the RM stated, "...I have checked with the PTWC and Patient #10 has not called and made an appointment for his wound care.
In a telephone interview on 9/5/2022 beginning at 1:02 PM the Complainant was asked, "...Who gave you the supplies for your husband's wounds on discharge. The Complainant stated, "...A nurse came in the room and handed them to my husband. The Complainant was asked did you receive any type of education or training on how to dress Patient #10's wounds. The Complainant stated, "...No, I did not we did not know we were going home until the day we were discharged. The Complainant was asked who notified you that your charity application had been approved. The Complainant stated, "...No one are you telling me that my husband has been approved this is the first I have heard about it. The Complainant was asked you did not receive a phone call or a letter telling you that Patient #10 had been approved. The Complainant stated, "...No, we have not..."

A physician's outpatient referral dated 8/25/2022 at 7:27 AM revealed, "...An ambulatory referral to wound clinic. Pt is awaiting charity application approval by [named initials of hospital]. Please contact pt to schedule an appointment once charity application approved. Pt. will call [phone number] once his application is approved..."