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Based on clinical document review, facility documents and staff interview, it was determined that the Governing Body failed to provide a safe care setting for the facility's patient population. As evidenced by the lack of monitoring of the coffee machine temperatures on the patient care units by dietary. The lack of the Quality Assessment Performance Improvement Program developing, implementing and maintaining an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program for monitoring the coffee machines. The lack of the Nursing department to appropriately assess a Mentally Retarded Patient with several co-morbidities and implementing an appropriate plan of care for the safe delivery of care for the patient.
Due to the lack of involvement from these entities, 1(#2) of 10 sampled patients sustained a 3rd degree burn from hot coffee provided by the facility's Nursing staff and placed the remaining patient population in danger of sustaining similar injuries.
Based on these findings the Condition of Participation for Governing is out of compliance.

Based on clinical record review, facility document review, staff interview, and policy review, it was determined the facility failed to protect the Patients Rights related to, notification of rights, investigation of a verbal grievance and resolution , participation in a plan of care, informed consent, notification of admission and ensuring care in a safe setting. As evidence by:

1. Failure of the facility to ensure the guardian for a Mentally Retarded patient was informed of the patients rights prior to the initiation of treatment. (refer to A-0117)

2. Failure of the facility to review, investigate, and resolve each patient's grievance within a reasonable time frame (refer to A-0122)

3. Failure of the facility to communicate the resolution for a verbal grievance and provide the person filing the verbal grievance with a written notice of its decision, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process and the date of completion. (refer to A-0123).

4. Failure of the facility to involve the guardian of 1(#2) of 10 sampled patients in the development and implementation of the patient's plan of care, ensuring the plan of care meets the patient's psychological and medical needs.(refer to A-130)

5. Failure of the facility to obtain a legal consent from the guardian for 1(#2) of 10 sampled patients, ensuring the guardian was able to make "informed" decisions regarding the patients care. (refer to A-0131)

6. Failure of the facility to follow the policy to notify the guardian of 1(#2) of 10 sampled patients, of the patients admission in a timely manner. (refer to A-0133)

7. Failure of the facility to ensure a safe care setting for 1 (#2) of 10 sampled patients and potentially the current patient population. To ensure a safe and therapeutic care setting for any patient that presents to the facility.( refer to A-0144)

Due to the cumulative effect of these systemic problems, the Condition of Participation for Patient Rights was determined to be out of compliance.

Based on clinical record review, staff interview and policy review, it was determined the facility failed to inform the guardian for 1(#2) of 10 sampled patients of the patients rights.

Findings included:

1. A review of the admission assessment, Emergency Department (ED) Physicians record dated 5/7/11 at 9:16 a.m., revealed "Additional review of systems unobtainable due to patient's impaired ability to communicate". Further review of the ED Physicians assessment revealed the patient has a past medical history of Mental Retardation.

2. A review of the patient's clinical record revealed a document dated 6/19/2006 appointing a Guardian for the patient.

3. A review of the patient's "Right's and Responsibility"documentation dated 5/7/11, revealed the patient's signature acknowledging they had received a copy of the document. Further review of the clinical record failed to reveal that the guardian was notified of the patient's rights.

Interview on 7/12/11 at approximately 2:00 p.m. with the Risk Manager confirmed the guardian advocate had not been notified.

A review of the facility's policy, " Patient Rights and Responsibilities", policy # RI-2, revised 1/09, page 2 of 3, " the right of the patient's designated representative to exercise rights on behalf of the patient."

Based on facility document review, staff interview and policy review it was determined the facility failed to respond to a telephone grievance made by guardian of 1 (#2) of 10 sampled patients

Findings Include:

An Interview was conducted on 7/12/11 at approximately 5:00 p.m.,with the Risk Manager. The Risk Manager stated patient #2's guardian had "left a message on the Risk Manager voice mail". The Risk Manager was unsure as to what the date was when she received the voicemail but stated it was the day before another State Agency had completed their investigation regarding the patient. A review of facility records revealed a State Agency had completed their investigation on 5/12/11 regarding a burn injury to patient #2. The Risk manager stated she did not respond to the voice mail.

A review of the Grievance log failed to reveal any documentation of a verbal Grievance.

A review of the facility policy, " Patient Grievance Policy", policy# RI-4, revised 11/10, page 2-3 of 6, revealed paragraph A (1) Receipt of a verbal complaint is to be addressed promptly by the staff present, (2) The patient complaint should be immediately documented stating facts of the complaint and the resolution provided.
Further review of the policy page 3, paragraph B (1) Grievances made about situations endangering the patient, given the seriousness of the allegations and potential harm to patients, require immediate investigation and review.

Based on staff interview, policy review and facility document review it was determined the facility failed to provide the steps taken on behalf of the patient to investigate the grievance process and date of completion for 1(#2) of 10 sampled patients

Findings included:

An Interview was conducted on 7/12/11 at approximately 5:00 p.m., with the Risk Manager. The Risk Manager stated patient #2's guardian had "left a message on the Risk Manager voice mail". The Risk Manager was unsure as to what the date was when she received the voicemail but stated it was the day before another State Agency had completed their investigation regarding the patient. A review of facility records revealed a State Agency had completed their investigation on 5/12/11 regarding a burn injury to patient #2. The Risk manager stated she did not respond to the voice mail.

Review of the facility's documentation did not reveal evidence of the patient's guardian's being notified of a resolution of the grievance.

A review of the facility's policy, "Patient Grievance Policy", policy #RI-4, revised 11/10, page 3 of 6, paragraph B (2), " Grievances require a written notice (response) to the patient (or representative) within seven (7) days. The written response will contain the name of the hospital contact person and identify the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process and date of completion".

Based on clinical record review, staff interview and policy review, it was determined the facility failed to include the patient's guardian in the development and implementation of the plan of care in 1 (#2) of 10 sampled patients.

Findings include:

(1) A review of the facility's policy," Nursing Staff Role in Patient and Family Teaching", policy # NS-43, revised 1/09, revealed the purpose of the policy is "to facilitate patient and family understanding of the disease process, interventions and care".
Further review of the policy, section titled Procedure, paragraph (1) revealed nursing staff is responsible to "utilize the admission assessment to identify any patient education needs" and paragraph (2) review the findings from the assessment with the physician, patient and patient's family to determine a plan of action to meet the patient's education needs in relation to the prescribed medical treatment and care".

(2) A review of the patient #2's clinical record revealed no evidence of the guardian of the patient being notified or included in the development and implementation of the plan of care.

(3) An interview was conducted on 7/14/11 at 3:00 p.m., with the Risk Manager. When questioned whether the patient's guardian had been contacted concerning the patient she answered "no".

Based on clinical record review, staff interview and review of policy, it was determined the facility failed to honor the patients right for her guardian to make informed decisions on her behalf for 1 (#2) of 10 sampled patients, regarding her medical care.

Findings included :

1. A review of patient #2's Emergency Department physician's documentation dated 5/7/11 at 9:16 a.m., "Additional review of systems unobtainable due to patient's impaired ability to communicate". Further review revealed the patient had a past medical history of Mental Retardation.

2. A review of patient #2's clinical record revealed a legal document appointing a guardian for the patient dated 6/19/2006.

3. A review of the conditions of treatment and admission form revealed the patient #2's signature dated 5/7/11 for consent to hospital care and treatment. There was no evidence of the guardian consent for treatment.

4. A review of the clinical record for patient #2 revealed no evidence of informing the patient's guardian of decisions regarding the patient's care.

5. A review of the facility's policy "Informed Consent", policy # RI-64, revised 1/10 revealed on page 2 of 6 paragraph titled " Participants in the consent process: When patients are unable to participate in the consent process and there is a legally authorized representative empowered to make such decisions, it is important to obtain the authorization from such individual."
Further review of the policy page 4 of 6, paragraph for "Persons under Guardianship, Legal guardian must sign consent forms for persons under legal custody."

6. An interview was conducted on 7/14/11 at 3:00 p.m., with the Risk Manager. When questioned whether the patient's guardian had been contacted concerning the patient she answered "no".

Based on clinical record review, policy review and staff interview it was determined the facility failed to notify the patient's guardian of her admission for 1 (#2) of 10 sampled patients.

Findings include:

(1) A review of the emergency department (ED) records for patient #2 revealed the patient presented to the ED on 5/7/11 at 9:14 a.m., for complaints of "swelling to left side of face and bottom lip."The patient was admitted to the facility at 1:38 p.m.

(2) A review of patient #2's clinical record revealed a legal document appointing a guardian for the patient dated 6/19/2006.

(3) A review of the 24 hour nursing flow sheet for patient #2, from the date of admission 5/7/11 at 3:10 p.m. through 5/09/11 revealed no evidence of informing the patient's guardian of admission. Further review of the patient's clinical record revealed the initial contact with the patient's guardian was the day before discharge, 48 hours after admission.

(4) A review of the facility's policy, "Patient Rights and Responsibilities", policy # RI-2, revised 1/09, revealed the patient has the right to "have a family member or representative notified promptly of admission to the facility."

(5) An interview was conducted on 7/14/11 at 3:00 p.m., with the Risk Manager. When questioned whether the patient's guardian had been contacted concerning the patient she answered "no".

Based on clinical record review, staff interview, facility documents, and review of policies it was determined the facility failed to provide a safe patient care setting for 1 (#2) of 10 sampled patients. The continued use of this practice has resulted in 1 patient injury and places the current patient population at risk for more injuries to occur.

Findings include:

(1.) A review of patient #2's, Nursing flow sheet dated 5/8/11 at 9:00 a.m., revealed, "the patient spilled hot coffee on self. A burn was noticed to the upper center chest". A review of the Physician's assessment and plan in the progress note dated 5/8/11, noted the patient had a 3rd degree burn. The continued review of the Physician's progress note dated 5/9/11 by a 2nd Physician also revealed a 3rd degree burn to right upper chest.


(2.) A review of the event report dated 5/8/11 at 9:10 a.m., revealed the admission diagnosis of "Facial Cellulitis". An entry under Objective stated "patient spilled coffee on chest". The timeline of events revealed at 9:15 a.m., the Physician was notified and Silvadene cream was applied and at 9:40 a.m. the Supervisor was notified. The Risk Manager Designee was notified on 5/9/11 at 10:00 a.m. There was no documentation the Guardian of the patient was notified. A entry was documented eight (8) days after the event occurred, on 5/16/11 by the Risk Manager Designee which stated, "Investigated per Risk Manager, will remind nursing staff to ensure safety of hot beverages to patients in next news letter." Disposition- no further action needed.
Further review of the documentation did not reveal any further investigation was conducted by the facility on why and how the patient was burned by hot coffee. There was no documentation of notifying the patients Guardian. There was no documentation on any immediate safeguards put in place for the patient population.

(3.) A review of the Quality Assurance Performance Improvement documenting for dietary services did not reveal any evidence of tracking and trending of the coffee temperature brewed on the nursing units served to patients.

(4.) An Interview was conducted on 7/12/11 at approximately 2:30 p.m. with the Patient Care Technician (PCT) that was involved with patient # 2. The PCT stated the patient had repeatedly requested a cup of coffee. The PCT went to the nursing unit's pantry and obtained a 12 ounces cup of coffee from the coffee machine.
The PCT returned to the patient's room and placed the cup of coffee on the overbed tray. The PCT then left the patient's room. The PCT stated she just got outside the door and down the hall when she was told by another staff person the patient has spilled coffee on her and needed assistance. The PCT gathered towels, ice and cloth for the ice and went into to patient's room. The PCT noticed a bright red burn like area on the patient's chest approximately 5.5 in diameter. The PCT stated she placed the cool cloth on the area and then placed the ice in a cloth on the area.

(5). An Interview was conducted on 7/12/11 at approximately 1:45 p.m. the attending physician of patient #2. The Physician confirmed the patient sustained a 3rd degree burn to the chest area.

(6.) An Interview with the Risk Manager on 5/12/11 stated there was an investigation on file. The Risk Manager presented this surveyor with an Event Report dated 5/8/11. The Risk Manger was documented as notified on 5/9/11 at 10:00 a.m. The Risk Manager Designee was noted to document on 5/16/11 to investigate per the Risk Manager. There no evidence of details of the investigation completed. Further review the event report documentation revealed the Risk Manager Designee "will remind nursing staff to ensure safety of hot beverages to patients in the next news letter".
The disposition of the Event Report was documented as no further action needed dated 5/16/11.

(7.) A review of the facility's policy for "Patient Rights and Responsibilities", policy # RI-2, revised 1/09, revealed the patient has the right to " Personal Safety".

Based on clinical document review, facility documents and staff interview, it was determined that the facility failed to develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program for the monitoring of the coffee machine temperatures on the patient care units. Due to the failure to monitor these, 1(#2) of 10 sampled patients sustained a 3rd degree burn from hot coffee provided by the facility's Nursing staff and placed the remaining patient population in danger of sustaining similar injuries. Due to the lack of monitoring by the Quality Assessment Performance Improvement Program and the Governing Body, the Condition of Participation for Quality Assessment Performance Improvement was found to be out of compliance.

Based on document review and staff interview, it was determined that the facility failed to track and trend quality indicators related to temperature monitoring of coffee machines in the patient care areas and failed to evaluate incidents reported through the facility's Risk Manage Program. This practice results in the failure to take action to improve safe care of the patients and place them at risk for serious harm.

Findings include:

(1.) A review of patient #2's Emergency Department physician's documentation dated 5/7/11 at 9:16 a.m., " Additional review of systems unobtainable due to patient's impaired ability to communicate". Further review revealed the patient had a past medical history of Mental Retardation.

(2.) A review of patient #2's Nursing flow sheet dated 5/8/11 at 9:00 a.m., revealed the patient had spilled hot coffee on herself and sustained a burn to her upper center chest. A review of the Physician's progress note dated 5/8/11 revealed the patient was noted to have a 3rd degree burn. A continued review of the Physician's progress note dated 5/9/11 by a 2nd Physician revealed the patient sustained a 3rd degree burn to right upper chest.


(3) A review of the event report dated 5/8/11 at 9:10 a.m., revealed an admission diagnosis of "Facial Cellulitis". An entry under Objective stated the "patient spilled coffee on chest". The timeline of events revealed at 9:15 a.m., the Physician was notified and Silvadene cream was applied and at 9:40 a.m. the Supervisor was notified. The Risk Manager Designee was notified on 5/9/11 at 10:00 a.m. There was no documentation the Guardian of the patient was notified. A entry was documented eight(8) days after the event occurred, on 5/16/11 by the Risk Manager Designee which stated, " Investigated per Risk Manager, will remind nursing staff to ensure safety of hot beverages to patients in next news letter." Disposition- no further action needed.
Further review of the documentation did not reveal any further investigation was conducted by the facility or why and how the patient was burned by hot coffee. There was no documentation of notifying the patients Guardian. There was no documentation on any immediate safeguards put in place for the patient population.

(4) A review of the Quality Assurance Performance Improvement documentation for dietary services failed to reveal any evidence of tracking and trending of the coffee machine temperatures of coffee brewed on the nursing units served to patients.

(5) An interview was conducted on 7/12/11 at approximately 2:30 p.m. with the Patient Care Technician (PCT) that was involved with patient # 2. The PCT stated the patient had repeatedly requested a cup of coffee. The PCT went to the nursing unit's pantry and obtained a 12 ounces cup of coffee from the coffee machine.
The PCT returned to the patient's room and placed the cup of coffee on the overbed tray and left the patient's room. The PCT revealed that she had just gotten outside the door and down the hall when she was told by another staff person the patient had spilled the coffee on herself and needed assistance. The PCT gathered towels, ice and cloth for the ice and went into to patient's room. The PCT noticed a bright red burn like area on the patient's chest approximately 5.5 inches in diameter. The PCT revealed she placed the cool cloth on the area and then placed the ice in a cloth on the area.

5. An interview was conducted on 7/12/11 at approximately 1:45 p.m. with the attending physician of patient #2. The Physician confirmed the patient sustained a 3rd degree burn to the chest area.

6. An interview was conducted with the Risk Manager on 7/12/11 who stated there was an investigation on file. The surveyor was presented with an Event report dated 5/8/11. A review of the event report revealed the Risk Manager was notified on 5/9/11 at 10:00 a.m., and a investigation was documented by the Risk Manager Designee on 5/16/11, eight (8) days after the event occurred. There were no further evidence of the details of the investigation. Further review of the event report documentation revealed the Risk Manager Designee will "remind nursing staff to ensure safety of hot beverages to patients in the next news letter."
The disposition of the Event Report was documented as no further action needed dated 5/16/11.

Further interview with the Risk Manager revealed the coffee pots located on the patient's care area were still in service on 7/12/11.

Based on clinical document review, facility documents, policy review and staff interviews, it was determined that the Nursing department failed to appropriately assess a Mentally Retarded Patient with several co-morbidities and failed to implement an appropriate plan of care for the safe delivery of care for 1 (#2) of 10 sampled patients.
Based on these findings the Condition of Participation for Nursing is out of compliance.

Based on document review and staff interview it was determined the facility failed to ensure the Registered Nurse supervised the safe delivery of nursing care for 1 (#2) of 10 sampled patients.

Findings include:

(1.) A review of patient #2's Emergency Department physician's documentation dated 5/7/11 at 9:16 a.m., " Additional review of systems unobtainable due to patient's impaired ability to communicate". Further review revealed the patient had a past medical history of Mental Retardation.

(2) A review of the nursing admission assessment dated 5/7/11 at 3:10 p.m. revealed the patient to have diabetes, epilepsy, seizures, cerebral palsy and mental retardation. A review of the nurses assessment of the patient's functional screen revealed the patient was total dependent for self care, had occasional accidents with excretory function, use of assistive devices on ambulation, and oriented to self only. The screening scoring was documented as a 12 for the patient. A review of the rehabilitation screening in the nursing assessment on 5/7/11 indicates for score of 7-13 that rehabilitation screening is indicated. Further review of the nursing assessment revealed a physical therapy screen request was marked with yes and no on the document. A review of the patient's orders in meditech revealed a physical therapy request was not obtained. A review of the assessment of orientation to environment revealed the patient needs frequent review due to mental retardation.

(3) A review of the Physician's History and Physical for patient #2 dated 5/7/11 at 3:32 p.m. revealed the patient presented with a Chief Complaint of facial swelling to the Emergency Department complaining of swelling to the left side of her face and bottom lip. A review of the physician examination revealed "left-sided facial swelling noticed from the left lower eyelid involving the entire left sided cheek".

(4) A review patient #2's clinical record revealed a document sent by the Residential facility documenting the patient was to have soft foods only please, tends to take too large bite and will choke.

(5) A review of patient #2's Nursing flow sheet dated 5/8/11 at 9:00 a.m., revealed the patient had spilled hot coffee on herself and sustained a burn to her upper center chest. A review of the Physician's progress note dated 5/8/11 revealed the patient was noted to have a 3rd degree burn. A continued review of the Physician's progress note dated 5/9/11 by a 2nd Physician revealed the patient sustained a 3rd degree burn to right upper chest.

(6) An interview was conducted on 7/12/11 at approximately 2:30 p.m. with the Patient Care Technician (PCT) that was involved with patient # 2. The PCT stated the patient had repeatedly requested a cup of coffee. The PCT went to the nursing unit's pantry and obtained a 12 ounces cup of coffee from the coffee machine.
The PCT returned to the patient's room and placed the cup of coffee on the overbed tray and left the patient's room. The PCT revealed that she had just gotten outside the door and down the hall when she was told by another staff person the patient had spilled the coffee on herself and needed assistance. The PCT gathered towels, ice and cloth for the ice and went into to patient's room. The PCT noticed a bright red burn like area on the patient's chest approximately 5.5 inches in diameter. The PCT revealed she placed the cool cloth on the area and then placed the ice in a cloth on the area.

Based on clinical record review and policy review it was determined the facility failed to implement an appropriate nursing care plan for 1(#2) of 10 sampled patients.

Findings include:

(1) A review of the Physician's History and Physical for patient #2 dated 5/7/11 at 3:32 p.m. revealed the patient presented with a Chief Complaint of facial swelling to the Emergency Department complaining of swelling to the left side of her face and bottom lip. A review of the physician examination revealed "left-sided facial swelling noticed from the left lower eyelid involving the entire left sided cheek". The patient's past medical history revealed cataracts, cerebral palsy, depression, Parkinson, seizure disorder, hyperlipidemia, metal retardation, diabetes mellitus, and schizophrenia.

(2) A review patient #2's clinical record revealed a document sent by the Residential facility documenting the patient was to have soft foods only please, tends to take too large bite and will choke.

(3) A review of the Emergency Room Fax Report for transport to the Medical Unit on 5/7/11 revealed under physical assessment ( will include only findings outside of normal limits) patient is mentally retarded and has cerebral palsy. Further review of the document revealed the recommendation for precautions were, skin, fall and seizure.

(4) A review of the Nursing Admission Assessment documentation for patient #2, dated 5/7/11 at 3:10 p.m., revealed the patient has a history of diabetes,epilepsy, seizures, cerebral palsy, schizophrenia, and mental retardation.
(a) A review of the functional screen completed for the patient stated the patient was totally dependent for self care, had occasional accidents with excretory function, uses assistive devices on ambulation, and is oriented to self only. The screening scoring was documented as a "12" for the patient. A review of rehabilitation screening in the nursing assessment on 5/7/11 indicates for score of 7-13 a rehabilitation screening is indicated. Further review of the nursing assessment revealed a physical therapy screen request was marked with yes and no on the document. A review of patient's orders in meditech revealed a physical therapy request was not obtained.
(b) A review of the assessment of orientation to environment revealed the patient needs frequent review due to mental retardation.
(c)A review of the Level of Consciousness on neurosensory assessment revealed the patient was alert and oriented to place and the patient was mentally retarded.
(d)The speech assessment was marked clear. The assessment did not address the swallowing and chewing that would indicate a speech therapy request.
(e) A review of the nutritional assessment revealed diabetes and difficulty swallowing/chewing. The assessment was documented as "no" to any abnormal findings.
(f)The bladder assessment revealed the patient was incontinent at times.
(g) The integumentary assessment indicated the patients face was red and swollen on the person diagram.

(5) The review of the interdisciplinary patient plan of care is based on the patient assessment. The plan of care documentation for the nursing problem of nutrition was not address by the nursing staff during the patients stay at the hospital. A review of the Interdisciplinary patient education documentation revealed the patient was educated on activity level and the readiness to Learn was noted to mental impaired and patients response was no indication of learning.

(6) A review of the patient plan of care initiated on admission revealed no documentation of a problem with nutrition, patient mobility, knowledge deficit and discharge planning. The plan of care documented the patient was at risk for falls.

(7) A review of the facility's policy," Nursing Staff Role in Patient and Family Teaching", policy # NS-43, revised 1/09, revealed the purpose of the policy is "to facilitate patient and family understanding of the disease process, interventions and care".
Further review of the policy, section titled Procedure, paragraph (1) revealed nursing staff is responsible to " utilize the admission assessment to identify any patient education needs" and paragraph (2) review the findings from the assessment with the physician , patient and patient's family to determine a plan of action to meet the patient's education needs in relation to the prescribed medical treatment and care".



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