HospitalInspections.org

Based on the manner and degree of standard level deficiencies referenced to the Condition, it was determined the Condition of Participation §482.13, PATIENT RIGHTS, was out of compliance.

A-0144 The patient has the right to receive care in a safe setting. Based on observations, interviews and record review, the facility failed to ensure at-risk patients were monitored and cared for according to facility policy and physician orders in two of two patient records reviewed for at-risk patients (Patients #7 and #9) and one of one observations for patients requiring a 1:1 Patient Safety Attendant (Patient #9). Additionally, the facility failed to ensure an action plan was implemented to prevent re-occurrence in one of one safety events reviewed involving a patient requiring monitoring for alcohol withdrawal (Patient #7).

A-0131 The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient's rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. Based on interviews and document review, the facility failed to ensure patients with limited English proficiency were able to make informed decisions regarding their care in 1 of 3 medical records reviewed for patients with limited English proficiency (Patient #3). Specifically, the facility failed to provide oral and written language assistance services according to facility policy. The facility further failed to ensure general consents were completed according to facility protocol in 3 of 13 medical records reviewed (Patients #5, #10 and #11).

Based on interviews and record review, the facility failed to ensure patients with limited English proficiency were able to make informed decisions regarding their care in 1 of 3 medical records reviewed for patients with limited English proficiency (Patient #3). Specifically, the facility failed to provide oral and written language assistance services according to facility policy. The facility further failed to ensure general consents were completed according to facility protocol in 3 of 13 medical records reviewed (Patient #5, #10 and #11).

Findings include:

Facility policies:

The Limited English, Accommodating Patients With Limited English Proficiency read, Definitions: Effective Communication is communication sufficient to provide the individual with limited English proficiency the same level of services received by individuals who are not limited in English proficiency. LEP "limited English proficiency" is a patient's self-assessed ability to speak English less than "very well" and encompasses individuals who do not speak English as the primary (or preferred) language and who have limited ability to read, write, speak or understand English. Language Assistance Services are oral and written language services needed to assist individuals with LEP to communicate effectively with staff.

Identification of Persons who may be LEP: As soon as facility becomes aware of language and communication needs of a person with LEP, staff will use the form "Notice of Language Assistance Services" to inform such persons of service and determine what language services may be needed. If language services are declined, staff will then use the "Waiver of Language Assistance" to document the refusal. The forms "Notice of Language Assistance Services" and "Waive of Language Assistance" will be included in the patient's medical record.

Area staff are responsible for obtaining a qualified interpreter when needed to ensure effective communication. Family members or friends will not be used for language assistance except when the individual specifically requests that the accompanying adult interpreter facilitate communication and reliance on that adult is appropriate under the circumstances.

Any and all contacts with interpreting agencies must be documented in patient records. The staff member will document in the medical record that assistance has been provided, offered or refused.

The Informed Consent to or Refusal of Medical Treatment by Patient or Substitute Decision Maker policy read, all patients shall have the right to participate actively in decisions regarding the patient's care and to receive the information necessary to enable informed consent to or refusal or a particular treatment, surgery, procedure or plan of care. To obtain informed consent, the physician informs the patient or appropriate decision maker, in language geared to the level of understanding of the patient or decision maker, of the patient's medical status and diagnosis, and an explanation of the consequences if no treatment is pursued.

The Conditions of Admission and Consent for Outpatient Care document read, Consent to Treatment: I consent to the procedures that may be performed during this hospitalization, including but not limited to emergency treatment, diagnostic procedures, medical nursing or surgical treatment, or hospital services rendered as ordered by the Physician. Release of Information: I authorize my healthcare information to be disclosed for purposes of communicating results, findings and care decisions. I consent to Providers using and disclosing healthcare information about me for purposes of treatment, payment and healthcare operations. Acknowledgement of Notice of Patient Rights and Responsibilities: I have been furnished with a Statement of Patient Rights and Responsibilities, ensuring that I am treated with respect and dignity and without discrimination or distinction.

1. The facility failed to provide available language assistance services, including interpreter services and informed consent documents in the patient's primary language, in order to ensure patients with limited English proficiency were able to participate in and make informed decisions regarding their care.

a. Patient #3's medical record was reviewed. Review of the history and physical (H&P) completed on 8/2/19 at 7:59 p.m. revealed Patient #3 was admitted for a worsening great toe infection and osteomyelitis (an inflammation of the bone due to infection). The H&P noted Patient #3 was Spanish-speaking only.

i. Review of the medical record revealed inconsistent utilization and documentation of language assistance services during physician interactions with Patient #3 and family members.

As examples:

On 10/15/19 a hospitalist progress note documented Patient #3 was reporting chest pain and dyspnea (difficult or labored breathing). The note documented cardiology was consulted and planned to start a heparin (a blood-thinner medication used to prevent blood clots) drip and take the patient for a heart catheterization (the insertion of a thin tube called a catheter into a chamber or vessel of the heart) the following day. The patient and daughter were updated of the findings and plan.

On 10/27/19 a nephrology progress note documented the daughter at bedside spoke some English and wanted to make sure water "comes off."

On 10/30/19 a hospitalist progress note documented Patient #3 was Spanish-speaking only. The physician discussed with the daughter at bedside who helped to translate.

On 11/1/19 a hospitalist progress note documented the physician appreciated podiatry's impression whether the foot was salvageable, and cited "High Medical Complexity." The note documented the plan of care was discussed with the patient.

On 11/2/19 a hospitalist progress note documented Patient #3 reported shortness of breath and nausea, and denied chest pain.

On 11/7/19 a nephrology progress note documented the patient was Spanish-speaking. The note read, the patient refused to stay and was leaving AMA, and understood the risks including life-threatening complications.

There was no documentation in these physician notes of how the provider communicated with Patient #3 and family members, or whether interpretation services were utilized or offered, in order to ensure the patient and family understood her health status and plan of care.

ii. The medical record further revealed multiple instances in which informed consent for medical procedures was not completed in the patient's primary language and without evidence of interpretation services being utilized.

As example:

On 10/15/19 at 5:00 p.m. a consent form in English was completed by Physician #21 for a left heart catheterization.

On 10/17/19 at 1:45 p.m. a consent form in English was completed for a blood transfusion.

On 10/22/19 at 8:10 a.m. a consent form in English was completed for an angiography (an imaging procedure to visualize the inside of blood vessels or chambers of the heart).

On 10/30/19 at 3:00 p.m. a consent form in English was completed for a second angiography.

Review of the informed consents revealed no evidence interpretation services were utilized or offered to ensure Patient #3 understood the forms and procedures referenced.

b. On 1/20/20 at 12:01 p.m., an interview was conducted with Physician #20. Physician #20 stated when a patient was identified as primarily Spanish-speaking, any staff member who spoke Spanish or any family member who spoke English could provide interpretation. She stated she would have staff or family interpret discussions with patients because it was easier than using the virtual interpretation services.

Physician #20 stated she did not document in the medical record when she used interpretation services, or how she communicated with a patient who did not primarily speak English. She stated she did use consent forms in a different language if needed, and she would have a nurse, staff member or family member interpret the discussion of the consent form. She stated she did not recall having used interpreter services during the time she cared for Patient #3.

Physician #20 stated interpretation was important when treating patients with limited English proficiency because it ensured the correct history and diagnosis were obtained. She further stated if patients or family members did not understand the care they received, they might go home from the hospital and not follow the instructions they were given.

Physician #20 stated she did not recall having recently received education or training regarding use of language assistance services.

c. On 1/20/20 at 12:58 p.m., an interview was conducted with Physician #21. Physician #21 reviewed the surgical consent completed for Patient #3 on 10/15/19 and acknowledged he was the physician who completed this consent. He stated if a patient's primary language was Spanish, providers should make an effort to get the consent signed in Spanish, and stated a patient who does not speak English should not sign a consent in English. He stated the consent form completed for Patient #3 was available in Spanish and he did not know why the Spanish-language form was not used.

Physician #20 stated it was important to complete informed consent so a patient understood what was going on with them and the results of any testing done. He stated it was also important to ensure a patient understood the procedure, why it was needed, and the risks and benefits associated with the procedure.

Physician #20 stated he had not received education or training regarding language assistance services in the past two years. He stated he wished physicians received more education and resources regarding caring for patients with limited English proficiency.

d. On 1/20/20 at 2:13 p.m., an interview was conducted with Patient Access Manager (Manager) #22. Manager #22 stated video interpretation was available for patients in the emergency department and main hospital. She stated video interpretation was the best resource to interview patients, discuss consents and inform patients of their rights.

Manager #22 stated staff should always use a certified interpreter because family may not be able to interpret the medical language used by a doctor or in a consent form. She stated if a patient preferred for a family member to interpret, they would sign the language assistance waiver.

e. On 1/20/20 at 9:51 a.m., an interview was conducted with Manager #23. He stated he reviewed the informed consent forms completed for Patient #3, and he was unable to provide evidence the physicians utilized interpretation services when completing consents in English.

Manager #23 stated physicians had not been included in any recent education or training regarding language assistance services for patients with limited English proficiency.

2. The facility failed to ensure admission consents and documentation informing patients of their rights was completed according to facility protocol.

a. The medical records for Patients #5, #10 and #11 were reviewed.

Patient #5 was admitted on 10/4/19 for postpartum hemorrhage.
Patient #10 was admitted on 12/13/19 for labor and delivery via Caesarean-section.
Patient #11 was admitted on 10/8/19 for newborn feeding concerns and failure to thrive.

The medical records revealed no evidence general consents for admission were completed or signed, and did not reveal documentation of any efforts to obtain consent for admission and treatment.

b. On 1/20/20 at 2:13 p.m., an interview was conducted with Patient Access Manager (Manager) #22. Manager #22 stated every patient signed a general consent form for admission and outpatient care. She stated the form explained importation information to the patient including patient rights and responsibilities, consent to treatment, the facility financial agreement, and consent to professional services.

Manager #22 stated the form was usually completed in the emergency department when a patient was first admitted. She stated if a patient could not sign consents immediately then facility staff were responsible for seeing the patient at a later time to review and sign the forms.

Manager #22 stated it was important to complete general consents with patients because consent allowed the facility to legally treat the patient. She stated if consents were not completed with every patient the facility was not in compliance with the requirements for informed consent.

c. On 1/20/20 at 4:13 p.m., an interview was conducted with Manager of Quality and Regulatory Compliance (Manager) #23. Manager #23 stated there was no evidence of general consents having been completed for Patients #5, #10 or #11.

Based on observations, interviews and record review, the facility failed to ensure at-risk patients were monitored and treated according to facility policy and physician orders in two of two patient records reviewed for at-risk patients and one of one observations for patients requiring a 1:1 Patient Safety Attendant (Patient #7 and #9). Additionally, the facility failed to ensure an action plan was implemented to prevent re-occurrence in one of one safety events reviewed involving a patient requiring monitoring for alcohol withdrawal (Patient #7).

Findings include:

Facility Policy:

The At Risk Patients policy read, Definitions: At Risk Patient: Patient has been placed on a mental health or drug/ alcohol (ETOH) emergency commitment; Patient suffering from acute drug/ ETOH intoxication or withdrawal; Patient's behavior presents a danger to self or others; Patient's presentation and/or history indicates the need for further safety assessment. Patient Assist: The utilization of a security officer or safety attendant to protect a patient from harming themselves or others. Policy: These guidelines are intended to help clinical staff implement appropriate interventions to reduce the risk of patients harming themselves or others when they recognize an "At Risk Patient." Any patient on a Patient Assist is the direct responsibility of the assigned RN.

The security officer or safety attendant assigned to a Patient Assist is required to stay at the door of the room, or as close as possible without causing an adverse effect on the patient. Security officers or safety attendants assigned to patients on the medical floors will typically be inside the room and will maintain a distance from the patient that promotes their safety and the safety of the patient. The security officer or safety attendant will keep the patient in line-of-sight. When the patient is being monitored by a safety attendant, safety attendant documentation needs to be completed, including the Safety Attendant Flowsheet.

All At Risk Patients will have their belongings inventoried by the admitting RN and a second staff member. The belongings will be secured and any items deemed unsafe will be made inaccessible to the patient. Remove all items identified as potentially injurious from the patient's room. All reasonable efforts will be made to remove the following items not necessary for ongoing patient care, including but not limited to: medications, intoxicating beverages or substances, breakables, sharps, appliances with electrical cords, items that can be used to strangle such as cords, rope, dental floss, yarn, belts, extra tubing, and trash can liners, matches and lighters, any non-essential items. Searches of belongings and person shall be documented by the clinical staff in the patient's medical record.

The Safety Attendant policy read, 1:1 Patient Safety Attendant (PSA) - An individual assigned and responsible for participation in the care of a patient requiring continuous observation at the bedside with a focus on patient safety. Protective observation is provided for patients who meet certain behavioral, environmental, or medical criteria. The PSA will document continuous observation on the Protective Observation Tool. The patient is in direct view of the safety attendant at all times. The patient is continually visualized by the PSA at the bedside. Document observed safety check every 15 minutes on Protective Observation Tool.

The Alcohol Research Foundation Clinical Institute Withdrawal Assessment (CIWA) and Alcohol Withdrawal Monitoring Flow Sheet read, Total score and refer to Alcohol Withdrawal Orders for assessment parameters and medication orders. For last CIWA score 0-4, monitor every 4 hours while awake. For last CIWA score 5-10, monitor every 4 hours. For last CIWA score 11-19, monitor every 2 hours. For last CIWA score 20 or greater, monitor every 1 hour.

The physician order for Lorazepam Tab (Ativan Tab) and Lorazepam Inj (Ativan Inj) Administration Criteria read, PRN Reason: Withdrawal Symptoms. CIWA-Ar Level and dose to give: Less than 5- Give no dose. Level 5 - 8- Give 1mg PO (1st choice) or IV (2nd choice) every 2 hours PRN. Level 9 - 11- Give 2mg PO or IV every 2 hours PRN. Level 12 or greater- 4mg IV every 1 hour PRN. After 2 consecutive doses of 4mg and CIWA-Ar still 12 or greater- Give 6mg IV every 30 minutes PRN. After 3 consecutive doses of 6 MG and CIWA-Ar isn't 8 or less notify MD for further orders.

The Error and Incident Reporting- Quality Improvement policy read, The purpose of this policy is to detect, document, investigate, evaluate, correct, and prevent errors. Internal occurrence report forms are completed by staff to document errors that have occurred in any phase of patient testing. The error may then be further investigated with details documented in the Risk Management Notification Module. These are then referred to any manager whose department was impacted by the error as well as the facility Risk Manager. Corrective actions are taken to improve processes when necessary to reduce the frequency of such errors. Under the direction of the Risk Manager and hospital administration, any error that has caused a serious adverse effect to a patient will be investigated by a multidisciplinary team using Root Cause Analysis. Strategies will be developed to prevent reoccurrence of the event.

1. Facility staff failed to ensure a safe environment for an at risk patient on a mental health hold was monitored according to facility policies and protocols.

a. On 1/15/20 at 5:05 a.m. an interview was conducted with the Medical/Surgical Charge Nurse (Charge RN) #17. Charge RN #17 stated Patient #9 was considered an at risk patient as she was on a mental health hold and required a Patient Safety Attendant (PSA).

b. An observation was conducted on 1/15/20 at 5:40 a.m. of Patient #9. Observations revealed Certified Nursing Assistant (CNA) #16, who was the PSA assigned to monitor Patient #9, located outside the second door to the patient's room. The patient was not initially in view of CNA #16 from where he was located. There were no lights on in the hallway, the ante room and the patient's room. Patient #9 was not visible to the surveyor until the patient moved towards the foot of the bed in the room.

When asked, CNA #16 stated he was watching the patient for "self-harm". According to the Protective Observation Tool used by CNA #16 to document safety checks and observations of the patient, the documented precautions were "Suicide" and "Other- Patient Safety."

Observations of the inside of Patient #9's room revealed the following items: a phone with cords, monitor cords, pants with draw-strings on the patient and in the room, pencils, a call light with cords, shoes with shoe strings on the patient, computer cords, and bed cords. These items were found during surveyor observation, even though staff interviews reported the patient was previously searched "last night." According to the At Risk Patient policy, these items would be considered "potentially injurious" to an at risk patient.

The Protective Observation Tool for Patient #9 was reviewed at 5:45 a.m. Review revealed CNA #16 was not documenting patient observations and safety checks in real time, and had documented observations which had not yet occurred. The Observation Tool had already been completed for the observations due to occur at 6:00 a.m. and 6:15 a.m. CNA #16 did not respond when asked why those observations had already been completed.

c. Review of Patient #9's medical record revealed an At Risk Patient Environmental Checklist was completed on 1/14/20. The checklist documented the patient was identified as High Risk and 1:1 Patient Safety Attendant required.

The checklist read, "Nursing staff or security staff shall search and remove/ secure items deemed hazardous per facility's search policy, please check all that apply." The checklist item "Ligature risks, including tubing, wires/ string, cords" was marked "Yes." However, the observation of Patient #9's room on 1/15/20 revealed multiple items consistent with the definition of a ligature risk remained in the patient's room.

d. On 1/15/20 at 8:39 a.m. an interview was conducted with the Medical/Surgical Nurse Manager (Manager) #12 who was present during the observations conducted for Patient #9 and the surveyor. Manager #12 stated charge nurses were responsible for doing shift audits and safe room checks for at risk patients. She stated Patient #9 required 1:1 monitoring for hallucinations, erratic behavior, and wandering. She stated it was the nurse's responsibility to ensure the patient was safe.

Manager #12 stated during the observation of Patient #9 she reviewed the Protective Observation Tool which had been completed. She stated she was concerned the observations had been pre-marked on the tool. Manager #12 stated the expectation was for observations to be documented in real-time, and the purpose of the observation tool was to document what was happening in the moment.

Manager #12 stated the expectations for a CNA who was acting as a patient safety attendant were to be alert and have eyes on the patient at all times and verified this had not occurred during the observation of Patient #9.

Manager #18 stated when a patient was on precautions for suicide, the patient's room must be free of ligature risks including machines with cords. She stated the safety attendant should be within arm's reach of a patient on precautions for suicide. Manager #12 stated if the safety attendant for Patient #9 believed the patient was on precautions for suicide, she would question why there were items considered ligature risks in the patient's room. Manger #12 was unsure why this had not occurred for Patient #9.

2. Facility staff did not monitor, re-evaluate, or provide ordered medications per facility protocols and physician orders for an at-risk patient who experienced alcohol withdrawal.

a. A Patient Event Record for Patient #7 entered on 8/4/19 at 7:01 a.m. and appended at 7:29 a.m. by Registered Nurse (RN) #2 was reviewed. The record revealed on 8/3/19 at 11:00 p.m. RN #2 notified Physician #3 of concerns with Patient #7, which included unsafe mobile events, disorientation, setting off the bed alarm, pulling out IVs, and unsteadiness. The report read, orders were received from Physician #3 for an enclosure bed, and Patient #7 was safely transferred to a Posey bed (an enclosed hospital bed designed to help provide a safe environment for patients at risk for fall or unassisted bed exit).

The record further read, at 2:30 a.m. RN #2 heard Patient #7 scream from his room, and upon entering the room RN #2 smelled smoke and burning plastic. RN #2 found Patient #7 hanging head first out of the Posey bed, with his head on the ground and his arms out. RN #2 saw a lighter in Patient #7's hand, even though Patient #7 had been searched previously by security. The record read, Patient #7 sustained a skin tear, first degree burn, and hit his head. Physician #3 was notified and orders were received for soft wrist restraints in addition to the Posey bed.

b. Patient #7's medical record was reviewed. Review of the history and physical (H&P) completed on 8/2/19 at 7:59 p.m. revealed Patient #7 was admitted for acute chest pain and alcohol withdrawal. The assessment and plan read, CIWA (Clinical Institute Withdrawal Assessment, a scale used for assessment and management of alcohol withdrawal) protocol would be initiated for alcohol withdrawal.

The attending physician placed an order for CIWA monitoring on 8/2/19 at 3:49 a.m. The physician placed additional orders for intravenous (IV) and oral Lorazepam (a sedative medication used to treat drug and alcohol withdrawal, also referred to as Ativan) with specific Administration Criteria on 8/2/19 at 4:00 a.m.

A scanned Alcohol and Withdrawal Monitoring Flow Sheet, completed by the Registered Nurse (RN) assigned to care for Patient #7, was reviewed. The flow sheet documented Patient #7's CIWA scores and administrations of medication between 4:00 a.m. on 8/2/19 and 6:00 a.m. on 8/4/20.

i. The flow sheet revealed multiple instances in which Patient #7 was not assessed in the appropriate time frames based on the patient's documented CIWA scores.

According to the CIWA protocol, for a score of 11-19 the patient should have been monitored and re-evaluated every two hours for vital signs, nausea and vomiting, sweats and any disturbances, tremors, orientation, anxiety, headaches and agitation.

On 8/3/19 at 9:30 a.m. RN #1 documented Patient #7 had a CIWA score of 11. Patient #7 was not re-evaluated until three hours later at 12:37 p.m. when RN #1 documented the score for Patient #7 remained at 11. The next evaluation did not occur until three hours and 23 minutes later at 4:00 p.m. when RN #1 documented the score for Patient #7 remained at 11 with no improvement.

On 8/3/19 at 6:00 p.m. RN #1 documented Patient #7 had a score of 11. Patient #7 was not re-evaluated until three hours later at 9:00 p.m.

According to the CIWA protocol, for a score of 20 or greater, the patient should have been monitored and re-evaluated every hour.

At 9:00 p.m. RN #2 documented Patient #7 had a CIWA score of 20. Patient #7 was not re-evaluated until two hours later on 8/4/19 at 12:00 a.m. when RN #2 documented the score for Patient #7 increased to 23. The next two evaluations did not occur until two hours later at 2:00 a.m, when RN #2 documented Patient #7's score was 21, and subsequently 1.5 hours later at 3:30 a.m., when RN #2 documented Patient #7's score was 19.

ii. The flow sheet further revealed multiple instances in which Patient #7 was not given the appropriate amount of medication based on the patient's documented CIWA scores and per physician orders.

On 8/3/19 at 9:00 p.m., when RN #2 documented Patient #7 had a CIWA score of 20 the patient was given 2 mg of IV Ativan. At 10:00 p.m., when RN #2 documented the score for Patient #7 increased to 21 the patient was again given 2 mg of IV Ativan. According to physician orders, the patient should have received 4 mg of IV Ativan on both of these occasions for a CIWA score of 12 or greater.

At 12:00 a.m. when RN #2 documented Patient #7 had a score of 23, and again at 2:00 a.m. when RN #2 documented the score was 21 the patient was given 4 mg of IV Ativan. At 3:30 a.m. when RN #2 documented Patient #7's score was 19 the patient was given 2 mg of IV Ativan. According to physician orders, the patient should have received 6 mg of IV Ativan on all of these occasions for a CIWA score remaining greater than 12.

Had Patient #7 received the correct amounts of medication during this time frame without improvement in his CIWA scores, the physician orders would have called for the nurse to notify the physician for further orders. Review of Patient #7's medical record revealed no evidence the RN contacted the physician to report the patient's elevated CIWA scores.

iii. Review of nursing documentation entered revealed additional evidence Patient #7 exhibited escalating symptoms related to alcohol withdrawal, and was not demonstrating improvement in response to administered medications.

A nurse note entered by RN #1 at 7:00 p.m. revealed Patient #7 was experiencing confusion, and was up and dressed in his street clothes. RN #1 documented the patient removed his telemetry monitoring, stated he was going home, and stated he was told he was going home. RN #1 documented when she informed Patient #7 he was not yet discharged he admitted his thinking may have been "muddled."

A Restraint Documentation entered by RN #2 at 11:11 p.m. revealed Patient #7 was displaying symptoms of agitation, altered consciousness, and confusion, and required the initiation of an enclosure restraint device at 11:06 p.m. The clinical justification for initiation of the restraint was documented as unsafe mobile attempts and attempts to remove a device.

On 8/4/19 at 6:46 a.m. Physician #3 entered an addendum to a clinical note. The addendum read, the patient had to be placed in a Posey bed due to unsafe mobile attempts. The physician documented per update by the RN, the patient was found later after she smelled smoke. Physician #3 documented Patient #7 had a lighter on him, lit the Posey bed on fire and crawled out through the hole he made. The patient fell out and hit his head on the floor as he was exiting head first.

The note entered by Physician #3 did not indicate he had been notified of Patient #7's elevated CIWA scores at the time this event occurred.

c. On 1/14/20 at 3:43 p.m. an interview was conducted with RN #13. RN #13 stated the CIWA scoring and assessment were based on a patient's symptoms and the scores determined how much medication to give to a patient experiencing alcohol withdrawal. She stated nurses assessed patients for symptoms of anxiety, hallucinations, and nausea or vomiting.

RN #13 stated nurses assessed patients every four hours if the patient was not scoring or requiring medication, and would assess more frequently depending on the score and amount of medication the patient required. She stated the nurse would refer to the physician order in the Electronic Medication Administration Record (EMAR) to determine the appropriate medication dosage and frequency.

RN #13 stated if a patient's withdrawal symptoms were not controlled, it was part of the CIWA protocol to notify the physician and discuss a possible transfer to the intensive care unit (ICU). RN #13 stated it was important to notify the physician when a patient's withdrawal symptoms were not managed on the medical-surgical unit because the ICU could provide an increased level of medication the patient may need.

RN #13 stated it was important to keep patients experiencing alcohol withdrawal comfortable and safe, as these patients could hallucinate, attempt to get out of bed, or display unsteadiness.

d. On 1/14/20 at 4:39 p.m. an interview was conducted with the Medical/Surgical Charge Nurse (Charge RN) #15. Charge RN #15 stated the CIWA protocol was used to score a patient's signs and symptoms of withdrawal, and would indicate how much medication should be administered. She stated if a patient required two administrations of 4 mg or 6 mg of Ativan, there were specific instructions in the EMAR for the physician to be contacted and the patient required a higher level of care.

e. On 1/15/20 at 5:05 a.m. an interview was conducted with the night-shift Medical/Surgical Charge Nurse (Charge RN) #17. Charge RN #17 stated the CIWA protocol was in place to determine how much Ativan to give based on a patient's symptoms. She stated Ativan was administered to patients for alcohol withdrawal because it calmed the patient and helped with withdrawal symptoms and seizures.

Charge RN #17 stated if a patient's CIWA scores were high enough on three assessments, the patient would advance to a higher level of care because the patient may need a different medication if Ativan was not helping, and the patient's withdrawal symptoms may need to be managed more closely. She stated the risks of alcohol withdrawal included behaviors which could harm the patient, disorientation, seizures and death.

f. On 1/15/20 at 8:39 a.m. an interview was conducted with the Medical/Surgical Nurse Manager (Manager) #12. Managers #12 reviewed the medical record and Alcohol Withdrawal Monitoring Flow Sheet for Patient #7.

Managers #12 and #18 stated on 8/3/19 at 9:30 a.m. when Patient #7 had a CIWA score of 11 the patient should have been monitored every two hours. Managers #12 and #18 stated she was concerned the patient was not re-evaluated for up to three hours because the nurse did not follow the physician's orders. Manager #12 stated it was important to follow physician orders for Ativan and alcohol withdrawal monitoring because it ensured patient safety and prevented further escalation of a patient's symptoms.

Manager #12 stated at 9:00 p.m. when Patient #7's CIWA score increased to 20 the patient should have been re-evaluated every hour and the amount of medication given should have increased to 4 mg of Ativan. She stated she could see from the medical record 4 mg of Ativan was the ordered dose for this score, but was not the amount administered.

Manager #12 stated at 12:00 a.m., when Patient #7 had a CIWA score of 23, the amount of medication given should have increased to 6 mg of Ativan. She stated by this point the physician should have been notified. She stated a CIWA score of 23 was high enough to be concerning. Manager #12 was unable to locate evidence in Patient #7's medical record the nurse notified the physician of the patient's increasing CIWA scores.

Manager #12 stated the safety concerns related to alcohol withdrawal which needed to be monitored were impulsive behaviors, seizures, injuries, and abnormal heart rhythms which could become lethal.

g. On 1/20/20 at 12:31 p.m. an interview was conducted with Physician #3. Physician #3 stated the two most important elements of the CIWA protocol were the administration of oral and IV Ativan, which were given based on the patient's CIWA score as assessed by the nurse. Physician #3 stated he did not typically see the scores documented by the nurse for a patient, and stated a physician treating a patient for alcohol withdrawal would use the EMAR to monitor the amount of Ativan administered in a 24 hour period. The physician would use this information to determine whether a patient's symptoms withdrawal symptoms were controlled.

Physician #3 reviewed Patient #7's Alcohol Withdrawal Monitoring Flow Sheet completed by RN #1 and RN #2. Physician #3 stated the scores and medications documented for Patient #7 were not correct according to the CIWA protocol, and specifically administering 2 mg of Ativan for a score of 21 was not correct. He stated he could immediately see the amounts of medication given to the patient were not correct, because at one time the patient received 2 mg of Ativan for a score of 21 and at a later time received 4 mg of Ativan for the same score of 21.

Physician #3 stated the amounts of medication administered to Patient #7 were relatively low and would indicate the patient's symptoms were controlled. However Physician #3 stated upon review of the CIWA scores documented for Patient #7, he would be concerned the patient's symptoms were actually not controlled.

Physician #3 stated he would expect to be notified by the nurse of the scores documented for Patient #7, and stated he was surprised the physician caring for Patient #7 on the night of 8/3/19 and morning of 8/4/19 was not contacted. He stated there was no excuse for giving a patient less medication than the amount ordered, or for failing to notify a physician of the patient's scores.

Physician #7 stated prior to this interview he was not aware of the scores documented on the monitoring flow sheet for Patient #7 and further stated the patient's hospital course made more sense to him after reviewing the monitoring flow sheet and the patient's documented CIWA scores. He stated the behaviors Patient #7 exhibited, including unsafe mobile events, agitation, and attempting to get out of bed, were associated with the patient withdrawing. He stated the patient become more agitated and needed to be put into a Posey bed likely occurred because his CIWA scores and withdrawal symptoms were untreated.

3. The facility failed to ensure an action plan was implemented to prevent reoccurrence of a safety event involving a serious adverse effect to an at risk patient.

a. A Patient Event Record for Patient #7 entered on 8/4/19 at 7:01 a.m. and appended at 7:29 a.m. by Registered Nurse (RN) #2 was reviewed. The record revealed on 8/3/19 at 11:00 p.m. RN #2 notified Physician #3 of concerns with Patient #7, which included unsafe mobile events, disorientation, setting off the bed alarm, pulling out IVs, and unsteadiness. The report read, orders were received from Physician #3 for an enclosure bed, and Patient #7 was safely transferred to a Posey bed.

The record further read, at 2:30 a.m. RN #2 heard Patient #7 scream from his room, and upon entering the room RN #2 smelled smoke and burning plastic. RN #2 found Patient #7 hanging head first out of the Posey bed, with his head on the ground and his arms out. RN #2 saw a lighter in Patient #7's hand, despite having been searched previously by security. The record read, Patient #7 sustained a skin tear, first degree burn, and hit his head. Physician #3 was notified and orders were received for soft wrist restraints in addition to the Posey bed.

Follow-up documentation for the patient event was reviewed. The event was classified as a Sentinel Event because it involved fire, flame or smoke. A manager note entered by Director of Patient Safety (Director) #19 read, will need to conduct RCA (Root Cause Analysis)- event sentinel in nature.

b. The Summary of Root Cause Analysis, completed on 8/16/19 by the Clinical Patient Safety and Quality Committee of the Board, was reviewed. The Identified Root Cause read, the patient was not placed on the At Risk Protocol for alcohol withdrawal upon admission to the unit, and personal belongings and clothing were not checked for unsafe items. A second Identified Root Cause read, security did not conduct a search of the patient's clothing.

The Risk Reduction Strategies read, Interim Director of 5 South (Medical/ Surgical Unit) was to pilot a checklist and handoff for nursing to utilize for at risk patients. The checklist was created and vetted by 9/30/19, and the pilot was determined unsuccessful according to the Chief Nursing Officer.

A second Risk Reduction Strategy read, the Program Manager of Security was to review expectations with the team regarding conducting room and belongings searches. The training was documented as having been due and completed 8/30/19. 100% compliance with safety checks was to be monitored by auditing through 11/3/19.

The Summary of Root Cause Analysis did not indicate Patient #7's medical record was reviewed as part of the investigation. It did not identify lapses in compliance with CIWA monitoring protocol or medication orders as relevant findings or root causes for the patient event.

c. Document review and interviews revealed the facility did not ensure the Risk Reduction Strategies identified in the RCA were implemented.

i. On 1/14/20 at 5:25 p.m. an interview was conducted with Director #19. Director #19 stated the action plan identified as part of the RCA was to create a handoff for nurses to utilize when caring for at risk patients. She stated the handoff was piloted but was determined to be unsuccessful, and the subsequent action plan was to conduct drills with security regarding searches of at risk patients. Director #19 was unable to provide any documentation the actions from the RCA had been completed to include any drills had been completed.

Director #19 stated security did a staff training in follow-up to Patient #7's event, and security was also to provide auditing of safety checklists completed for patients. Director #19 stated she did not have evidence of staff training or auditing conducted by security.

Director #19 stated a bulletin was sent to HSS (the security agency contracted with the facility) as part of the action plan identified by the RCA. A Security Training Bulletin dated September 19 was provided, which outlined security responsibilities during the search of a psychiatric patient. There was no documentation regarding which staff received or reviewed the bulletin.

ii. On 1/15/20 at 8:39 a.m. an interview was conducted with the Medical/Surgical Nurse Manager (Manager) #12. RN Manager #12 stated she believed the previous nurse manager participated in conversations regarding the patient safety event involving Patient #7, but she had not received any report from the previous manager regarding this event.

Manager #12 stated she was aware of the concerns and action plans identified as part of the RCA, but did not have documentation regarding her implementation of the action plans. She stated the primary opportunity identified for nursing related to collection of patient belongings for at risk patients. Manager #12 stated the action plan was to create an at risk/ high risk tool for nursing to utilize when caring for at risk patients, but the tool was quickly determined to be unsuccessful. Manager #12 stated there had been no other action plans identified and could not state what was in place to prevent a similar incident which had occurred with Patient #7 from occurring again at the facility.

d. Document reviews and interviews revealed the investigation and RCA for the patient safety event did not identify lapses in compliance with the CIWA protocol as a contributing factor to the patient safety event, and as such did not implement measures to prevent reoccurrence of these lapses.

i. Interviews revealed staff had not received any recent education or training regarding the CIWA monitoring protocol and administration of medications ordered for alcohol withdrawal.

During an interview conducted on 1/14/20 at 4:08 p.m. RN #14 stated she could not recall having been provided with training or education specific to the CIWA protocol. During an interview conducted on 1/14/20 at 4:39 p.m. Charge RN #15 stated staff had not received any recent education or training specific to the CIWA protocol, nor could she remember the last time staff had received education on this topic.

Review of documentation of nursing huddles from 8/1/19 to 1/13/20 for the Medical-Surgical Unit revealed no evidence of discussion or education related to CIWA protocol monitoring or medications.

ii. During the interview on 1/14/20, Director #19 stated she interviewed the nurse involved in the patient safety event, and she and the nurse manager had reviewed the medical record for Patient #7. She stated processes for CIWA monitoring appeared to have been followed appropriately. She stated concerns regarding compliance with the CIWA protocol were not identified as part of the RCA, nor were any process changes implemented regarding CIWA monitoring in response to the RCA.

iii. During the interview conducted on 1/15/20, Manager #12 stated she had not interviewed any staff regarding the event involving Patient #7. She stated prior to this interview she had not reviewed the medical record for Patient #7.

iv. On 1/20/20 at 12:31 p.m. an interview was conducted with Physician #3. Physician #3 stated he had not have the opportunity to review the medical record for Patient #7. He stated as chief of medical staff he was very aware of the safety event related to Patient #7, and stated the event was reviewed by leadership, department heads, and the nurse leader on the medical-surgical unit.

Physician #3 stated prior to this interview he had not reviewed the CIWA scores documented on the Alcohol Withdrawal Monitoring Flow Sheet for Patient #7. He stated he was not aware of the lapses in compliance with CIWA monitoring and administration of ordered medications which occurred prior to the safety event involving Patient #7.

Based on the manner and degree of standard level deficiencies referenced to the Condition, it was determined the Condition of Participation §482.23, NURSING SERVICES, was out of compliance.

A-0392 The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for bedside care of any patient.

Based on interviews and document reviews, the facility failed to ensure there was an adequate number of nursing staff to meet the needs of patients. Specifically, nursing staff did not respond to patient call lights in a timely manner in 2 of 2 patient call light logs reviewed (Patients #3 and #6). Nursing staff failed to ensure patients were offered hygiene care according to unit standards in 1 of 11 adult patient medical records reviewed (Patient #6).

A-0395 A registered nurse must supervise and evaluate the nursing care for each patient.

Based on interviews and document reviews, nursing staff failed to evaluate patients' wounds in a consistent manner according to standards of practice in one of three medical records reviewed for wound care (Patient #3).

Based on interviews and document reviews, the facility failed to ensure there was an adequate number of nursing staff to meet the needs of patients. Specifically, nursing staff did not respond to patient call lights in a timely manner in 2 of 2 patient call light logs reviewed (Patients #3 and #6). Nursing staff failed to ensure patients were offered hygiene care according to unit standards in 1 of 11 adult patient medical records reviewed (Patient #6).

Findings include:

Facility policy:

The Scope of Service -Medical/Surgical read, the unit is staffed based on each shift's patient census and patient acuity.

The Scope of Service -Telemetry read, a charge nurse is responsible for, and supervises the care delivered each shift. Minimum staffing for the unit consists of 2 Registered Nurses (RN) on duty. Additional staff will be added based on an increase on the census and according to patient care needs. Patient care is provided as a partnership, patient-focused care model using the established staffing matrix. The Director is ultimately responsible for staffing the unit appropriately for census, acuity and patient needs.

1. Patient call lights were not answered in a timely manner to address the patients' needs.

a. On 1/13/20 at 9:11 a.m., an interview was conducted with Patient #6 who was receiving care on the 5th floor medical surgical unit. Patient #6 stated sometimes she waited "forever" for staff to come in to help her. When asked how long staff would take to respond to her call light, she said an hour or more. Patient #6 said she would "wait, wait, wait" when she thought staff were supposed to respond right away. Patient #6 said there might be a lack of staffing but was unsure as to why there was a delayed response to the call lights.

Review of Patient #6's call light logs from 12/25/19 through 1/13/20 showed multiple days where the patient's call light was not answered in a timely manner to address the patient's needs.

From 12/28/19 through 1/13/20, Patient #6 was in two different rooms on the Medical/Surgical unit. Review of the detailed call report log showed, on 1/3/20 a call was placed at 12:16 p.m. and responded to 75 minutes and 25 seconds later. At 6:08 p.m., a call was placed and not canceled until 54 minutes and 27 seconds time frame lapsed. On 1/4/20 at 8:16 a.m., a call was placed and not canceled until 52 minutes and 50 seconds later. Later the same day, at 10:58 a.m., another call was placed where nursing staff did not answer until almost an hour later.

Review of the patient's call report log for the second room, from 1/5/20 through 1/13/20, showed continued delays throughout the days when the call light was not answered in a timely manner.

As example,

On 1/5/20, Patient #6 used her call light at 7:01 a.m.. The call was not canceled until 25 minutes and 18 seconds later.
On 1/6/20, a call was placed at 5:57 a.m. and canceled 28 minutes and 11 seconds later.
On 1/8/20, the patient used her call light at 3:21 p.m.. The call was not canceled until 46 minutes and 36 seconds after it was placed.
On 1/9/20, there were three separate occasions when Patient #6's call light was not answered for over 25 minutes: 10:58 a.m., 3:32 a.m., and 7:02 p.m.
On 1/12/20, the patient placed a call at 11:12 a.m. The call was not answered for 42 minutes and 18 seconds.

Additionally, upon review of Patient #6's call light log while she was on the Telemetry unit, showed on 12/27/19 at 3:23 p.m., the call light was not canceled until 34 minutes and 54 seconds after the call was placed.

i. On 1/20/20 at 2:13 p.m., an interview was conducted RN #6 and RN #7.

RN #6 stated she tried to answer a patients' call light within a couple of minutes. RN #6 reviewed Patient #6's call light log, for 1/9/20, the day she was assigned to the patient. She said she did not remember that specific day but stated on some days patient call lights were "definitely" affected when there was a low number of staff. RN #6 stated a reasonable time to answer call lights was under five minutes.

RN #6 stated sometimes the unit would have 29 patients with only one CNA (certified nursing assistant) which left the RNs with a heavier workload. She said the CNAs were overloaded. RN #6 said patients would not get the best care if nursing staff could not get to them in a timely manner..

RN #6 stated she felt the Medical/Surgical unit had more short days than being adequately staffed. She said unless the call light was answered, nursing staff would not know what was going on with the patient and there could be a delay in patient care. She said a patient could be having chest pain, trying to get out of bed to go to the bathroom or the patient may need water. RN #6 stated if nursing staff did not get there quick enough, the patient could try to get out of bed without assistance and be at risk of falling.

RN #7 stated if a unit was short a CNA or if the charge nurse had patients, the resources for the nurses would be unavailable. She said this happened more often than it did in the past on both the Medical/Surgical unit and the Telemetry unit. RN #7 said even if the nurse had five patients a CAN could get pulled to provide one on one monitoring for a patient. RN #7 said she felt the units had been short staff at times over the last four months. After review of Patient #6's call light log for 1/3/20, RN #7 stated 75 minutes was a long time for a patient's call light to be answered.

According to the staffing matrix provided by the facility, for 33 patients, the Medical/Surgical unit should have one charge nurse, seven RN's and three Cans. Review of the unit's staffing assignment sheet, dated 1/3/20, showed the unit had one less RN and CAN than the matrix called for. Further, the charge nurse was assigned three patients which according to the RN interviews above, limited resources for the other nurses on the unit if help was needed.

c. Review of Patient #3's call log report, revealed on 11/4/19 and 11/5/19, the patient's call light was not answered in a timely manner. On 11/4/19 at 12:11 p.m., the patients call light was answered after a duration of 34 minutes and 21 seconds. On 11/5/19 at 1:15 a.m., the call light was canceled 24 minutes and 28 seconds after the call was placed.

Review of the Telemetry unit's staffing assignment sheet, dated 11/4/19, showed the unit had 30 patients and was staffed with one charge nurse, six RN's and two Cans. According to the staffing matrix for the unit, the Telemetry unit called for one more CAN for a census of 30.

The 11/4/19 night shift staffing assignment sheet showed the unit had a census of 28 patients with one charge nurse, five RN's and two Cans. The Telemetry unit's staffing matrix for 28 patients, called for one more RN and one additional CAN.

Both 11/4/19 day shift and night shift charge nurses were assigned patients.

d. On 1/20/20 at 12:18 p.m., RN #4 and RN #5 were interviewed. Both nurses provided care to Patient #3 during her 10/8/19 admission on the Telemetry unit.

Both RN's reviewed the 11/4/19 call light log. RN #4 stated 34 minutes was a long time for a patient call light to be answered. RN #5 stated 34 minutes was concerning because the patient may have needed something like pain medicine or assistance to the bathroom. RN #5 stated the purpose of the call light system was to inform nursing staff the patient needs something. RN #4 stated the goal was to answer a patient's call light as soon as you could.


RN #5 stated there had been days in the past where the unit was short staffed or did not have enough Cans. She said staff were stretched thin with answering all the patient call lights and providing their care.

e. Additional nursing staff who worked both the Medical/Surgical and Telemetry units were interviewed. All three nurses expressed concerns with staffing.

On 1/14/20 at 3:43 p.m., RN #13, who floated to both the Medical/Surgical and Telemetry units, stated there were times the units were short staffed. She said although the nurses would not be assigned over five patients, the charge nurse, at times,would have to take patients. She reported the Cans would be assigned more than they could handle. RN #13 said staffing like this affected the nurses' workload. RN #13 stated the Cans have told leadership about their concerns.

On 1/14/20 at 4:08 p.m., RN #14 stated there were times the Medical/Surgical unit would need an additional CAN or one more nurse. She said sometimes agency staff could be requested but if they were not available, then the RN's would have to assist the Cans with patient care, including ADLs (activities of daily living) and hygiene care. RN #14 stated nursing staff could utilize the charge nurse for assistance if they do not have patients themselves.

On 1/14/20 at 4:39 p.m., Charge Nurse #15 was interviewed and stated since the unit was no longer using the pediatric side for overflow of patients, staffing had improved. However, she then stated, prior to the closing of the pediatric unit a few weeks prior to the survey, she had concerns about staffing. Charge Nurse #15 stated at that time, charge nurses were taking a full load of patients. Charge Nurse #15, as a charge nurse, she could be a resource to the nurses and assist with patient care but when she had patients herself and along with her other charge duties, she was unable to help.

Charge Nurse #15 stated sometimes it was a challenge to meet the demands of patient safety when assuming care of patients. She stated staffing had been brought up to leadership multiple times by nurses and Cans.

f. On 1/20/20 at 3:06 p.m., an interview was conducted with Chief Nursing Officer (CNO) #10, Medical/Surgical Nurse Manager (Manager) #12 and Telemetry Nurse Manager (Manager #11).

A review of the call light logs and unit assignments sheets, along with the corresponding matrices, was conducted for both Patient #6 and Patient #3. CNO #10 stated delayed response times on the call light logs was concerning, however, she did not feel there was a correlation with staffing. CNO #10 stated the staffing matrices were not set in stone and were inaccurate. When asked if the staffing matrices took in consideration of the charge nurse taking patients, CNO #10 stated it did not.

CNO #10 stated the typical patient to nurse ratio on the Telemetry unit was five patients to one nurse and for the Medical/Surgical unit, five or six to one. When asked if the facility could provide these guidelines, CNO #10 stated there were no facility guidelines for the ratios, but the facility was meeting the general benchmarks for the Denver market.

2. Facility failed to ensure patients' hygiene needs were met according to unit standards. .

a. On 1/13/20 at 9:11 a.m., an interview was conducted with Patient #6 who was receiving care on the Medical/Surgical unit. Patient #6 expressed concerns about nursing being understaffed. She said she just started to get washed up and her teeth brushed, although she had been in the hospital since December.

b. On 1/20/20 at 2:13 p.m., interviews were conducted with RN #6 and RN #7 who both had worked on the Medical/Surgical unit. RN #6 stated patients should be offered hygiene at least daily to prevent further infections, improve patient's sleep and to make patient's feel better during their stay.

RN #6 reviewed Patient #6's electronic medical record and provided the documentation for days the patient did receive hygiene care. However, there was no documentation to show the patient was offered a bath or shower and oral care on 12/28/19, 12/29/19, 12/30/19, 1/1/19 and 1/6/19.

c. On 1/20/20 at 12:18 p.m., two additional nurses (RN #4 & RN #5) were interviewed regarding the process for hygiene care. RN #4 stated hygiene care starts with Cans and was included in a patient's care plan. She stated RN's could also document in the medical record about hygiene or in a nurse's note. RN #4 stated the standard of care was for hygiene to be offered to patients on a daily basis, including showers, baths, peri care and assistance with oral care. She said linen change was included when hygiene was done.

Review Patient #6's nurse notes showed no evidence RN's documented hygiene care on the identified gaps above.

Based on interviews and document reviews, nursing staff failed to evaluate patients' wounds in a consistent manner according to standards of practice in one of three medical records reviewed for wound care (Patient #3).

Findings include:

Facility policy:

The Wound Care Guidelines for Nursing policy read, nursing management of wounds included: wound assessment, dressing and wound care and documentation of wound care. Wound assessment includes: location and type of wound (e.g. surgical, pressure, trauma, etc); how long the wound has been present; measurement if indicated; description of wound and current wound treatment. Wound assessment are to be documented in the Skin Assessment (admission assessment followed by shift assessments ) and include all elements noted in Wound Assessment above. Dressing changes will be documented in Nursing Notes and include type of dressing applied and any wounds products utilized.

1. Nursing staff failed to assess patients wounds in accordance with unit standards.

a. Review of Patient #3's nursing admission assessment, dated 10/8/19 at 8:11 p.m., revealed the patient had a procedure related wound located at the anterior right big toe. Nursing staff also documented an abrasion to the anterior right foot related to the patient's diabetes and two closed wounds located on the patient's left foot.

Review of Patient #3's nursing shift assessments, from 10/8/19 through 11/7/19, revealed a lack of nursing assessments on Patient #3's wounds which were identified on admission and throughout her stay.

As example,

On 10/12/19 at 2:27 a.m., the nursing shift assessment showed no evidence the patient's wound was assessed.

On 10/16/19 at 8:10 a.m., nursing staff did not document a wound assessment.

On 10/18/19 at 9:30 a.m., Patient #3's day nursing assessments lacked evidence which showed the condition of the patient's right big toe's dressing. Patient #3's had surgery on her toe eight days prior.

On 10/20/19 at 8:48 a.m. and 8:00 p.m., there was no evidence of a nursing assessment of the patient's right big toe amputation.

On 10/24/19 at 9:00 a.m., nursing staff documented the patient had no skin alterations which contradict daily physician notes.

Similar findings for lack of documented nursing wounds assessments, specifically for Patient #3's right big toe surgical wound, were found on 10/26/19, 10/27/19,10/28/19, 10/29/19, and 10/31/19.

On 11/7/19 at 12:17 p.m., the nursing shift assessment showed no evidence the patient's nurse evaluated the right big toe surgical wound. Patient #3's nurse documented the patient had no skin alterations/procedure sites which contradicted the discharge summary dated the same day.

b. On 1/20/20 at 11:36 a.m., an interview was conducted with Wound Care RN #8 and Float Pool RN (RN #9).

RN #9 stated she works multiple inpatient units and skin assessments were required every shift.
She said documented wounds trigger nursing to perform additional assessments of the patient.

RN #8 reviewed Patient #3's medical record and stated she was admitted to the hospital for an amputation. Dressing changes to the wound were done by himself or the podiatrist. RN #8 stated nursing staff should look at the dressing for any strike through (the point at which absorbed fluid reaches the outer surface or edge of a dressing).

RN #9 stated there was a place in the nursing assessment to document the skin assessment and each wound present. She stated the assessment was required to be done and then documented. RN #9 stated skin alteration assessments needed to be thorough to establish a baseline for the patient and for nursing staff to recognize any changes in the patient's condition. She said then the nurse could consult resources such as the wound nurse or notify changes to the physician.