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Based on document review, observation and interview, it was determine the Hospital failed to protect each patient's rights by failing to report, review and analyze incidents to ensure patients were cared for in a safe environment. Therefore, the Condition of Participation, 42 CFR 482.13, Patient's Rights was not met.

Findings include:

1. The Hospital failed to report, review and analyze incidents to ensure patients were cared for in a safe environment. See A-0144

Based on document review, observation and interview, it was determined for 1 of 1 (Pt #1) patient record reviewed with a hospital acquired injury, the Hospital failed to report, review and analyze incidents to ensure patients were cared for in a safe environment. This has the potential to affect all patients who receive care by the Hospital, with a current census of 20 inpatients.

Findings include:

1. Pt #1 Start of Care (SOC): 5/14/22
Diagnosis: Encephalopathy. The record was reviewed throughout the survey on 6/7/22 and 6/8/22. The record noted on 5/14/2022, Pt #1 was admitted to room 176 (video surveillance cameras) unable to ambulate due to osteoarthritis and contractured bilateral legs. The record noted Pt #1 was initially obtunded and non-verbal, although Pt #1 would complain of generalized pain and/or aches in bilateral legs. On 5/21/22 at approximately 10:59 PM, Pt #1 was moaning and crying out in pain in the left leg and rated the pain as an 8 (pain scale 0 (no pain) to 10 (worst pain). The physician was notified and pain medication was ordered and administered. The record noted Pt #1 continued to complain of severe pain in the left leg and on 5/22/22 an x-ray was conducted which noted an acute fracture of the left distal femur. The primary care physician and the house supervisor were notified and an orthopedic physician was consulted. The orthopedic consult was conducted on 5/23/22 and a knee immobilizer was ordered with no other treatment recommendations.

2. The Adverse Event log was reviewed on 6/7/22 at approximately 11:00 AM. The Adverse Event log lacked documentation of Pt #1's hospital acquired left distal femur fracture.

3. Two video recordings (no sound, date or time on the recording) titled "Med Surg Room 176 20220514_000000 (dated 5/14/22) and Med Surg Room 176 20220521_002634 (dated 5/21/22)" of Pt #1's hospitalization in room 176 was reviewed on 6/8/22 at approximately 3:15 PM.
a) Between 5/14/22 and 5/21/22 Pt #1 was observed to be bedbound, lethargic, drowsy, bilateral legs were contracted at the knee joint (right leg was handcuffed to the bed due to being an inmate) and dependent for all cares. The recording dated 5/21/22 at 1 minute (min) 4 seconds (secs), Pt #1 was observed to be incontinent of stool and 3 employees cleaned, rolled side to side, change the bed linen, aggressively lifted/slid the patient up in the bed and covered his/her face with the sheet. It was observed that one employee donned a facemask around his/her neck and the other employee cleaned up stool, obtained new linens, changed the linens on the bed and take the linen bag out of the room without changing gloves or conducting hand hygiene. Pt#1 was then observed to be restless and agitated, rocking back and forth, reaching out into the air with arms. The recording at 12 min 37 sec was observed to have an employee enter the room and pulled Pt #1's left leg and Pt #1 sat up and grabbed the left leg and appeared to scream. Pt #1 was observed to be flailing, reaching out to legs and in distress, although legs were covered with a sheet until 29 min and 16 sec when the sheet was removed and the left leg was observed to be turned inward and was lying flat on the bed.
b) The video dated 5/14/22 was observed at 36 min 05 sec a food tray was brought into room 176 and placed on the bedside table; at 37 min 05 sec a new food tray was brought and the first one removed; at 37 min 10 sec the second food tray was removed without either of the meals being consumed or staff feeding assistance offered. At 37 min 19 sec Pt #1 was observed to be lying naked in the bed with the room door open. At 37 min 33 sec, 37 min 42 sec, 37 min 45 sec and at 38 min 02 sec staff were observed without donning masks.

4. During an interview on 6/8/22 at approximately 12:00 PM, the Director of Regulatory Services (E#2) verbally agreed Pt #1's hospital acquired injury had not been reported as an adverse event and should have been. E#2 verbally agreed the Hospital did not conduct an investigation of the incident and should have been.

5. During the exit conference on 6/8/22 at approximately 4:30 PM, the Chief Executive Officer (E#7), the Vice President of Nursing (E#1) and E#2 reviewed the video recording. E#1 stated pieces of the video were reviewed prior to the exit and verbally agreed with the breech in infection control practices. E#1 and E#2 verbally agreed there was an acute change in Pt #1's condition which ultimately resulted in the fractured distal femur. E#1, E#2 and E#7 verbally agreed the incident should have been reported and an investigation should have been conducted.