HospitalInspections.org

Based on record review and interview, staff failed to follow facility policy regarding patient rights as evidenced by 1 of 1 patient complaint (Patient #1).

Findings include:

The facility policy titled, "Patient Rights and Responsibilities," #SNG-P-15, dated 9/1/2018, was reviewed on 12/3/2018 at 1:26 PM. The policy revealed in part, "2. Respect and Dignity: The patient has the right to receive considerate, respectful care at all times and under all circumstances with the highest regard for his/her personal dignity."

The facility policy titled, "Patient Bill of Rights, #SNG-P-8, dated 9/1/2018, was reviewed on 12/3/2018 at 1:31 PM. The policy revealed in part, "Privacy and Confidentiality: Personal Privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meeting of family and patient/resident groups, but this does not require the facility to provide a private room...Quality of Life Dignity: The facility must promote and care for patient's/residents in a manner and in an environment that maintains or enhances each patient's/residents dignity and respect in full recognition of his or her individuality."

A review of the facility's complaint file on 12/3/2018 at 1:30 PM revealed that Patient #1's family expressed concerns on 11/15/2018 regarding communication and information regarding criteria for admission, options for discharge, and potential financial obligations relayed in the emergency department by Nurse Practitioner D on 11/10/2018 to Patient #1 while family members were present.

A record review was conducted on Patient #1's closed medical record on 12/4/2018 at 7:40 AM accompanied by Emergency Department Manager C. A progress note written by a Registered Nurse on 11/15/2018 at 11:30 AM revealed, "[Patient #1] expressed [gender] concern regarding financial matter in going to a facility and that [gender] was informed before to pay $800. This was not presented to [gender] clearly that resulted to [gender] not amenable with the discharge plan."

On 11/15/2018 at 12:00 PM, a care conference note written by Director of Nursing B revealed, "This writer and [Case Manager E] met with family to discuss patients care during stay. They are concerned that pt (patient) has given up because [gender] is going to a nursing home and that [gender] will have to sell [gender] house, as presented to [gender] in the ED (emergency department)."

During an interview with Director of Nursing B on 12/3/2018 at 2:30 PM regarding these concerns, Director B stated, "I had a discussion with the family...The hospitalist (Nurse Practitioner D) was unsure of [Patient #1's] admission criteria and if we could keep [Patient #1]. It ended up as we could admit [Patient #1] but if [Patient #1] needed further care and can't pay, [Patient #1] may lose [Patient #1's] house."

Director B also stated that Director B had a, "stern discussion with the hospitalist about the approach to families/patients with long term care needs."

An interview with Case Manager E was conducted on 12/4/2018 at 1:38 PM. Case Manager E stated that Nurse Practitioner D stopped Case Manager E in the hallway and asked what was going on. Case Manager E relayed the concerns of Patient #1's family to Nurse Practitioner E who stated, "I bent over backwards for this family for a patient who's not as sick as the patient in the next room and they are still not happy." There was no documentation in the medical record regarding the conversation.

These findings were discussed at exit interview on 12/4/2018 at 3:00 PM with Director of Nursing B, Emergency Room Manager C, and Chief Administrating Officer I. Regarding the conversation in the hallway regarding Patient #1's care and concerns, Director B agreed that the hallway is not an appropriate place to have a conversation about patients.

Based on record review and interview, staff failed to conduct pain assessments/reassessments per facility policy in 7 out of 10 medical records reviewed (Patient #1, 2, 3, 7, 8, 9, and 10).

Findings include:

The facility policy titled, "Pain Management Policy," # KT2N6QC5SZE5-3-1616, dated 10/23/2018, was reviewed on 12/3/2018 at 1:30 PM. The policy revealed in part, "Ongoing assessment/reassessment a. Assessments are completed with any patient report of pain, following a pain-producing event, after any intervention targeted to reduce pain and upon discharge. An evaluation of a patient's pain response(s) to pain interventions must be documented in the EHR (electronic health record). Pain reassessments should occur once a sufficient time as elapsed for the treatment to be effective, following drug and non-drug treatments...In the acute care in-patients will be assessed for pain and documented in the EHR at a minimum of every 8 hours. If pain is present, assessments will be documented every 4 hours...Patients experiencing severe, rapidly changing pain and patients exhibiting any signs of drowsiness or sedation will be reassessed sooner and more frequently until pain is managed and without evidence of sedation."

A medical record review was conducted on Patient #2's closed medical record on 12/3/2018 at 3:20 PM accompanied by Emergency Department Manager C, who confirmed the following findings: Patient #2 was an inpatient at the facility from 10/18/2018-10/20/2018 with a primary diagnosis of urinary tract infection. On 10/19/2018 Patient #2 received 2 Tylenol for back and generalized pain at 4:30 PM. There was no pain reassessment documented and no further pain assessments documented after 4:30 PM on 10/19/2018. Per interview on 12/3/2018 at 3:30 PM with Manager C regarding frequency of pain assessment documentation, Manager C stated, "The policy is at least once a shift."

A medical record review was conducted on Patient #3's closed medical record on 12/3/2018 at 3:45 PM accompanied by Emergency Department Manager C, who confirmed the following findings: Patient #3 was an observation patient at the facility on 11/5/2018 (less than 24 hour stay) with a primary diagnosis of pain in the right ankle. On 11/5/2018 at 10:40 AM Patient #3 received 1.5 tablets of Percocet for pain, there was no pain reassessment documented. On 11/5/2018 at 3:02 PM Patient #3 received 1.5 tablets of Percocet for pain, there was no pain reassessment documented. Per interview with Manager C on 12/3/2018 at 4:02 PM regarding if there were pain reassessments documented, Manager C stated, "No it doesn't appear that way."

A medical record review was conducted on Patient #1's closed medical record on 12/4/2018 at 7:40 AM accompanied by Emergency Department Manager C, who confirmed the following findings: Patient #1 was an inpatient at the facility from 11/10/2018-11/15/2018 with a primary diagnosis of pain in the right hip. On 11/12/2018 at 8:43 AM Patient #1 received a scheduled dose of oxycontin extended release and reported a pain score of 7 on a 0-10 scale. At 5:09 PM on 11/12/2018 Patient #1 was given Narcan (opioid reversal agent) for appearing to be overly sedated with extreme lethargy and drowsiness. There was no pain reassessment documented until a Tylenol suppository was given at 7:53 PM, where Patient #1 was unable to describe the pain but appeared to be experiencing pain.

A medical record review was conducted on Patient #7's closed medical record on 12/4/2018 at 10:50 AM accompanied by Emergency Department Manager C, who confirmed the following findings: Patient #7 was an inpatient at the facility from 9/12/2018-9/15/2018 with a primary diagnosis of rhabdomyolysis (the breakdown of muscle tissue that leads to the release of muscle fiber contents into the blood). On 9/12/2018 there was no pain assessment documented from the PM shift.

A medical record review was conducted on Patient #8's closed medical record on 12/4/2018 at 11:23 AM accompanied by Emergency Department Manager C, who confirmed the following findings: Patient #8 was an inpatient at the facility from 9/25/2018-9/28/2018 with a primary diagnosis of heart failure and chronic kidney disease. On 9/28/2018 Patient #8 received Tylenol at 6:05 AM. There was no pain reassessment documented.

A medical record review was conducted on Patient #9's closed medical record on 12/4/2018 at 12:16 PM accompanied by Emergency Department Manager C, who confirmed the following findings: Patient #9 was an observation patient at the facility from 10/3/2018-10/5/2018 with a primary diagnosis of pyogenic arthritis (infection in a joint) and also multiple sclerosis. On 10/5/2018 Patient #5 received morphine for pain at 8:06 AM. There was no documented pain reassessment.

A medical record review was conducted on Patient #10's closed medical record on 12/4/2018 at 12:40 PM accompanied by Emergency Department Manager C, who confirmed the following findings: Patient #10 was an inpatient at the facility from 10/9/2018-10/12/2018 with a primary diagnosis of acute kidney failure. On 10/10/2018 there was no documented pain assessment for day shift. On 10/11/2018 there was no documented pain assessment for PM shift.

Based on record review and interview the staff failed to individualize goals and interventions related to pain in nursing care plans in 7 out of 10 medical records reviewed (Patient #1, 2, 5, 6, 7, 8, and 10).

Findings include:

The facility's policy titled, "Care Plans," #NSG C-63," dated 9/1/2018, was reviewed on 12/4/2018 at 10:48 AM. The policy revealed in part, "The plan of care shall be individualized based on the diagnosis, patient assessment, information from previous medical records, and information from the patient/patient's family." The policy does not define how often nursing staff are expected to document progress towards goals.

A medical record review was conducted on Patient #2's closed medical record on 12/3/2018 at 3:20 PM accompanied by Emergency Department Manager C, who confirmed the following findings: Patient #2 was an inpatient at the facility from 10/18/2018-10/20/2018 with a primary diagnosis of urinary tract infection. Patient #2 had a pain problem identified on the nursing care plan. The goal was: "Patient's pain/discomfort is manageable." Interventions were: "Assess and monitor patient's pain using appropriate pain scale. Collaborate with interdisciplinary team and initiate plan and interventions as ordered. Re-assess patient's pain level 30-60 minutes after pain management intervention.

A medical record review was conducted on Patient #1's closed medical record on 12/4/2018 at 7:40 AM accompanied by Emergency Department Manager C, who confirmed the following findings: Patient #1 was an inpatient at the facility from 11/10/2018-11/15/2018 with a primary diagnosis of pain in the right hip. Patient #1 had a pain problem identified on the nursing care plan. The goal was: "Patient's pain/discomfort is manageable." Interventions were: "Assess and monitor patient's pain using appropriate pain scale. Collaborate with interdisciplinary team and initiate plan and interventions as ordered. Re-assess patient's pain level 30-60 minutes after pain management intervention." There was no outcome documentation from nursing staff regarding progression towards pain management on 11/11/2018 or 11/12/2018.

A medical record review was conducted on Patient #5's closed medical record on 12/4/2018 at 9:28 AM accompanied by Emergency Department Manager C, who confirmed the following findings: Patient #5 was an inpatient at the facility from 9/3/2018-9/13/2018 with a primary diagnosis of pneumonia. Patient #5 had a pain problem identified on the nursing care plan. The goal was: "Patient's pain/discomfort is manageable." Interventions were: "Assess and monitor patient's pain using appropriate pain scale. Collaborate with interdisciplinary team and initiate plan and interventions as ordered. Re-assess patient's pain level 30-60 minutes after pain management intervention."

An interview was conducted with Manager C on 12/4/2018 at 9:45 AM regarding the generic nature of the goals and lack of individualization of the interventions. Manager C stated that the facility is aware of the care plan issues and have been working on addressing these issues, however as far as individualization of the goals and interventions, "They don't do it. Each patient gets documented on each shift by nursing who describe what they do, how it worked, and how the patient is progressing." This documentation is to be in the "Outcome" area in the plan of care notes.

A medical record review was conducted on Patient #6's closed medical record on 12/4/2018 at 10:04 AM accompanied by Emergency Department Manager C, who confirmed the following findings: Patient #6 was an observation patient at the facility from 9/13/2018-9/14/2018 with a primary diagnosis of gastroparesis (a condition in which the stomach cannot empty itself of food in a normal fashion. It can be caused by damage to the vagus nerve, which regulates the digestive system). Patient #6 had a pain problem identified on the nursing care plan. The goal was: "Achieve acceptable pain level," however there was no indication on the care plan what that acceptable pain level would be.

A medical record review was conducted on Patient #7's closed medical record on 12/4/2018 at 10:50 AM accompanied by Emergency Department Manager C, who confirmed the following findings: Patient #7 was an inpatient at the facility from 9/12/2018-9/15/2018 with a primary diagnosis of rhabdomyolysis (the breakdown of muscle tissue that leads to the release of muscle fiber contents into the blood). Patient #7 had a pain problem identified on the nursing care plan. The goal was: "Patient's pain/discomfort is manageable." Interventions were: "Include patient/family/caregiver indecisions related to pain management. Offer non-pharmacological pain management interventions." There was no outcome documentation from nursing staff regarding progression towards pain management.

A medical record review was conducted on Patient #8's closed medical record on 12/4/2018 at 11:23 AM accompanied by Emergency Department Manager C, who confirmed the following findings: Patient #8 was an inpatient at the facility from 9/25/2018-9/28/2018 with a primary diagnosis of heart failure and chronic kidney disease. Patient #8 had a pain problem identified on the nursing care plan. The goal was: "Patient's pain/discomfort is manageable." Interventions were: "Assess and monitor patient's pain using appropriate pain scale. Collaborate with interdisciplinary team and initiate plan and interventions as ordered. Re-assess patient's pain level 30-60 minutes after pain management intervention." There was only one day (9/26/2018) where outcome documentation regarding progression towards pain management was completed.

A medical record review was conducted on Patient #10's closed medical record on 12/4/2018 at 12:40 PM accompanied by Emergency Department Manager C, who confirmed the following findings: Patient #10 was an inpatient at the facility from 10/9/2018-10/12/2018 with a primary diagnosis of acute kidney failure and ankle pain. Patient #10 had a pain problem identified on the nursing care plan. The goal was: "Patient's pain/discomfort is manageable." Interventions were: "Assess and monitor patient's pain using appropriate pain scale. Collaborate with interdisciplinary team and initiate plan and interventions as ordered. Re-assess patient's pain level 30-60 minutes after pain management intervention." On 10/11/2018 there was no documentation from nursing staff where outcome documentation regarding progression towards pain management was completed.

During an interview with Director of Nursing B on 12/4/2018 at 3:00 PM regarding the expectation of staff documenting progress towards goals, Director B stated, "There is no regulatory guidance on how often care plans should be documented on for progress towards goals. Our policy also does not define how frequently staff should document progress towards goals...The expectation is once a shift if not daily."