HospitalInspections.org

Based on record review and interview, the hospital failed to inform 1 of 4 patient's (Patient #2) family representative, in that, Patient #2's family representative was not contacted prior to Patient #2's tracheostomy surgery on 04/24/14 as requested by the family member.

Findings included:

Patient #2's "Nursing Intraoperative Record" and corresponding medical records reflected no notification of the family regarding Patient #2's tracheostomy surgery on 04/24/14.

Patient #2's nurse (Nurse #12) on 04/24/14 stated in an interview on 09/03/14 at 11:18 he spoke with the Operating Room nurse (Nurse #29) when she came to get Patient #2 for surgery, and told Nurse #29 the family representative wanted to be notified prior to Patient #2's surgery. Nurse #29 told Nurse #12 she would take care of contacting the family representative. When Nurse #12 recovered Patient #2 after the procedure, the family representative was "visibly upset" because no one had notified the family prior to the surgery.

Based on observation, record review, and interviews, the facility failed to identify the use of a mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely, in that, 1 of 2 patient's record (Patient #7's) documented the use of a lapbelt and bilateral mittens without an order, a face to face assessemt and nurse rounding for safety.

Findings included:

The 5/30/14 through 6/05/14 physicians' orders for Patient #7 reflected no restraint orders.

The 5/31/14 progress note for Patient #7 reflected, "The patient has had the police called several times due to wandering on busy streets, not obeying traffic signs and getting lost...talks to himself and will tell wild stories about how he met the President and that he had lunch with him..."

The 6/01/14 progress note for Patient #7 reflected, "disoriented x 4...(nurse)" and "patient in restraints this morning...(physician)."

The 6/02/14 progress note for Patient #7 reflected, "DC (discontinue) restraint..."

The 6/02/14 "Neuropsychological/Psychological Consult" (NPC) indicated, "recently displayed symptoms of delirium and agitation..."

The 6/03/14 NPC indicated, "results suggest deficits in Executive Functioning, Visuospatial Functioning, Delayed Memory, Attention, and Language...does not possess the ability to make decisions in the best interest of his own safety, well-being, and welfare. His neuropsychological deficits will likely make self-care post-discharge difficult, given his difficulty formulating and executing well-thought out plans. Further, his memory impairments will act as an additional barrier to self-care...benefit from regular supervision to ensure adherence to his medication as well as ensuring his physical safety..."

During an interview and demonstration of the mittens and lap belt on 9/03/14 ending at 1:45 PM, Personnel #19 and Personnel #1 showed the surveyor a sample of the mittens and lap belt used with Patient #7. Personnel #19 explained the mittens velcor strap is placed around the wrist. The mittens have a large, foam pad larger than a hand and about 3 inches thick. Personnel #19 said the lab belt is secured to the bed and then around the patient's body. The lapbelt has velcor and a pinch clamp. Personnel #19 said the leadership's education of the staff since 2012 had included that the lap belt and this type of mitten was not considered restraints and so, it was not necessary for a nurse to have orders, nurse rounding and a face to face assessment when using these devices. The surveyor stated, "this patient is documented to be confused and disoriented which may prevent him from being able to remove these devices, if he needed to. This may mean in this situation these devices restraints on this patient." Personnel #1 agreed.

During a telephone interview on 9/03/14 ending at 2:33 PM, Personnel #22 was asked about the documentation which included the lap belt and mittens on Patient #7. Personnel #22 stated, "the patient had them on when she started her shift (on 6/01/14) at 1:00 PM." Personnel #22 was asked about a restraint order, a face to face assessment and nurse rounding for restraints on the patient. Personnel #22 said these were not considered a restraint because the patient "can take them off, if they need to." Personnel #22 said these were not documented as restraints.

The 4/30/14 "Restraints/Seclusion" policy required, "the intent of this policy is to provide guidance to all district employees regarding improper use of patient restraints...Nonviolent restraint...Orders must be reviewed daily...Nonviolent restraint documentation reviewed tool...Completed at every shift...Orders written daily...RN assesses and documents...on initiation of restraint...at the beginning of shift...Every 2 hours while restrained..."

Based on record review and interview, the hospital failed to identify opportunities for improvement and changes that would lead to improved health outcomes, patient safety, and quality of care for 1 of 4 patients, in that, Patient #2's ureteral conduit stents were dislodged inadvertently in the Operating Room on 04/03/14, and the occurrence was not reported to the facility's Risk, Regulatory, & Accreditation department for the identification of opportunities for improvement and changes until after the complaint by the hospital was received on 04/09/14.

Findings included:

Patient #2's Operative Report 04/03/14 by Physician (Personnel #13) reflected: "...During the cleaning of the abdominal wall, the ureteral conduit stents were dislodged..."

Patient #2's Nursing Intraoperative Record 04/03/14 by Personnel #7 reflected no reference to the inadvertent dislodgement of the ureteral conduit stents.

Patient #2's Physicians Progress Note 04/05/14 at 15:51 by Physician (Personnel #13) reflected: "Preop dx (diagnosis) inadvertent stent removal resulting in leak at anastomosis with urinary ascites. Post op same...Anastomotic leak site seen..."

Patient #2's Operative Report (Surgery #2) 04/05/14 at 16:01 by Physician (Personnel #13) reflected: " ...Emergency Procedure...Ultimately, he drained out roughly 2 L (liters) of urine due to the fact the stents were inadvertently removed by the OR staff. Obviously, anastomotic swelling was causative and causing a leak ...Roughly 4..."

Patient #2's Operative Report (Surgery #3) 04/06/14 at 10:27 Physician (Personnel #13) reflected: "Preoperative Diagnosis: Leaking from conduit after removal of ureteral conduit stents by staff inadvertently. Postoperative Diagnosis: Leaking from conduit after removal of ureteral conduit stents by staff inadvertently ...During the induction, there was some small amount of aspiration..."

During an interview on 09/03/14 at 13:25, Nurse #7 and Nurse #8 stated they did not document or report the inadvertent dislodgement of Patient #2's ureteral conduit stents that occurred on 04/03/14 as an incident.

During an interview on 09/03/14 at 14:10, Certified Surgery Tech #9 stated Patient #2 had his ureteral conduit stents dislodged inadvertently in the Operating Room on 04/03/14 and he was unaware if the occurrence had been documented.

During an interview on 09/05/14 at 10:55, Personnel #5 stated that after receiving the complaint a review of Patient #2's medical record and a discussion with Physician #13 was completed. A resolution letter was sent to the patient on 04/23/14 and a final determination letter was sent to the provider on 04/29/14.

Based on record review and interviews, the facility failed to ensure a registered nurse supervised and evaluated the nursing care for 1 of 4 patients (Patient #2), in that, Nurse #7 in the Operating Room on 04/03/14 failed to document the inadvertent dislodgement of Patient #2's ureteral conduit stents.

Findings included:

Patient #2's Operative Report on 04/03/14 by Physician #13 reflected: "...During the cleaning of the abdominal wall, the ureteral conduit stents were dislodged..."

Patient #2's Nursing Intraoperative Record by Nurse #7 on 04/03/14 reflected no documentation of the occurrence.

During an interview on 09/03/14 at 13:25 with Nurse #7 and Nurse #8, and at 14:10 with Certified Scrub Tech #9, each stated Patient #2 had his ureteral conduit stents dislodged inadvertently in the Operating Room on 04/03/14, and each confirmed there was no documentation of the occurrence.

Based on record review and interviews, the hospital failed to have an ongoing discharge plan to meet the medically-related needs consistent with hospital resources for 1 of 3 discharged patients (Patient #7). Patient #7 was discharged on 2 consecutive admissions (5/30/14 and 6/09/14) without consideration of available hospital resources and medically-related needs.

Findings included:

The 5/31/14 progress note from Patient #7's first admission reflected, "The patient has had the police called several times due to wandering on busy streets, not obeying traffic signs and getting lost..."

The 6/01/14 progress note for Patient #7 reflected, "disoriented x 4...(nurse)."

The 6/02/14 progress note for Patient #7 reflected, "family request that he be in locked dementia unit. However, funding is limited. Needs 24 hr obs @ (24 hour observation at) home..."

The 6/02/14 "Neuropsychological/Psychological Consult" (NPC) for Patient #7 indicated, "...per...treatment team, he recently displayed symptoms of delirium and agitation..." The 6/03/14 NPC for Patient #7 indicated, "results suggest deficits in Executive Functioning, Visuospatial Functioning, Delayed Memory, Attention, and Language...does not possess the ability to make decisions in the best interest of his own safety, well-being, and welfare. His neuropsychological deficits will likely make self-care post-discharge difficult, given his difficulty formulating and executing well-thought out plans. Further, his memory impairments will act as an additional barrier to self-care...benefit from regular supervision to ensure adherence to his medication as well as ensuring his physical safety..."

The Case Management notes for Patient #7 reflected, "6/04/14...Family would like nursing home...The only available dc (discharge) option at this time is to return home with family due to patient not being a candidate for funding for several months. Patient currently has Medicare Part B which does not pay for any form of placement. Daughter would like call from physician to discuss how long JPS is able to "negotiate" keeping patient here..."

The 6/05/14 nurse note for Patient #7 reflected, "DC home...wheelchair..."

The 6/09/14 "Admission History and Physical" from Patient #7's second admission reflected, "after returning from JPS 4 days ago patient has not been eating and drinking...progressive worsening and decreased mentation, functional status and failure to thrive...weak demented appearing...social worker to look into deposition and placement option..."

The 7/02/14 "Physician Discharge Summary" for Patient #7 reflected, "Lethargy...dementia, with behavioral disturbances...left clavicle and scapular body fracture...palliative care consultation...deemed not appropriate for hospice care...the patient did suffer a fall from his bed, despite being on fall precautions...resultant injury - left clavicle fracture, 4th and 5th rib and body of scapula fractures...non-operative management per orthopedics...Discharge Disposition: home..."

The 6/09/14 through 7/03/14 Case Management Notes for Patient #7 included the following information. "...Ranking Disability Score: Moderately severe disability. Unable to attend to own bodily needs without assistance, and unable to walk unassisted...readmit within the last 30 days: Yes...Reason for readmission: No medical home; No PCP (primary care physician); Lack of payor source..." The daughter had requested help with...placement for the patient at a nursing home or hospice. The patient was not placeable due to being undocumented and unfunded. The family cannot private pay for placement or adult day care. The daughter requested charity SNF ( Skilled Nursing Facility) placement. The 6/30/14 note indicated APS (Adult Protective Services) was contacted. The 7/01/14 note reflected, "family did not respond to prior notice/intent to discharge patient. Family has stopped visits to patient...APS Case worker...discussed case w/ (with) RN CM (Registered Nurse Case Manager) on 7/01(/14)...had spoken to patient's daughter and encouraged her to resume care of her father...Reportedly (patient's daughter) insisted she could not provide 24 (hour) supervision for her father b/c (because) she works."

The record documented the need for 24/7 assistance for ADL's (activities of daily living), meals, and safety issues.

The 7/02/14 Adult Assessment" reflected, "disoriented to; time; situation; place...fall alert...total feed...incontinence...Activity...Assistance..."

The 7/02/14 "Functional Screen" reflected, "Ambulation/Transferring/Toileting...assistive equipment and person...Bathing/Dressing/Eating...assistive person..."

During an interview on 9/02/14 at 3:15 PM, Personnel #21 was asked about the appropriateness of Patient #7's discharge. Personnel #21 stated, "(Patient #7) was unfunded. It (the discharge) was not ideal."

During an interview on 9/03/14 at 8:45 AM, Personnel #18 was asked if the discharge plan was adjusted based on the daughter's pleas of not being able to care for Patient #7 at home 24/7. Personnel #18 said it was not.

During an interview on 9/03/14 at 3:45 PM, Personnel #17 was asked what options would be available today for a patient in a similar situation to Patient #7. Personnel #17 stated, "the patient would still be here or we would pay for care ongoing at an appropriate facility."

The 4/01/14 "Interdisciplinary Plan of Care Procedures" policy required, "Discharge planning...prepares the patient and family or significant other for care following an inpatient stay...Placement in an appropriate extended care facility."

The 4/30/14 "Inpatient Case Management" policy required, "services must be provided at the appropriate level of care. This requirement leads to the ongoing assessments and reassessments of the patients who may have ongoing treatment needs at the time of discharge from the hospital setting...Assessments, education, selection and making arrangements that prepares the patient and family to continue the treatment plan and an alternate level of care. The district considers the needs of the populations served, available resources, strategies and appropriate settings for the delivery of services when making care available to those who need it...Patients will be reassessed at least every three days for changing needs and changes in the plan of care will be documented."

The 10/25/12 "Patient Rights and Responsibilities" policy required, "Exercise these rights without regard to...Disability, age...Economic...Background or the source of payment for care. Access protective and advocacy services or have these services accessed on patient's behalf...Participate in planning for care after discharge...Reasonable responses to any reasonable request he/she may make for service...Reasonable continuity of care...Right to seek assistance when they have concerns about the patient's condition."

Based on record review and interview, the hospital failed to provide a discharge planning evaluation to include an evaluation of the likelihood of a patient's capacity for self-care or of the possibility of the patient being cared for in the environment from which he or she entered the hospital, in that,

A) 1 of 3 discharged patient's (patient #8's) record did not have a discharge planning evaluation for the 6/26/14 admission; and

B) 1 of 3 discharged patient's (patient # 7's) discharge evaluation did not include an evaluation of the possibility of the patient being cared for by family members in the environment from which he entered the hospital for 2 consecutive admissions (5/30/14 and 6/09/14 admissions) within 30 days of each other.

Findings Included:

A) Patient #8's record for the 6/26/14 admission did not document a discharge evaluation and/or plan.

During an interview on 9/03/14 at 8:45 AM, Personnel #18 was asked if there was a discharge evaluation and/or plan for Patient #8. Personnel #18 said there was not.

B) Patient #7's discharge evaluations for the 5/30/14 ad 6/09/14 admissions did not include an evaluation of the possibility of the patient being cared for by family members in the environment from which he or she entered the hospital.

During an interview on 9/03/14 at 8:45 AM, Personnel #18 was asked if there was an assessment of the family's ability to care for Patient #7 post discharge for either admission. Personnel #18 said there was not. Personnel #18 was asked if the discharge plan was adjusted based on the daughter's pleas of not being able to care for Patient #7 at home 24/7 due to work. Personnel #18 said it was not.

The 4/01/14 "Interdisciplinary Plan of Care Procedures" policy required, "Discharge planning...prepares the patient and family or significant other for care following an inpatient stay...Activities are initiated on admission and include: assessment of the patients and family...assessment of the patient, family and or significant others ability to learn and need for education related to post-discharge care...Placement in an appropriate extended care facility."

The 4/30/14 "Inpatient Case Management" policy required, "services must be provided at the appropriate level of care. This requirement leads to the ongoing assessments and reassessments of the patients who may have ongoing treatment needs at the time of discharge from the hospital setting..."

The 10/25/12 "Patient Rights and Responsibilities" policy required, "Right to seek assistance when they have concerns about the patient's condition."