HospitalInspections.org

Based on interview and record review, the facility failed to ensure a medical doctor co-signed and assumed full responsibility for the H&P, when a patient was admitted by a mid-level practitioner for 4 (#s 6, 7, 8, and 9) of 4 sampled patients. Findings include:

1. Review of patient #6's medical record showed an admission date and H&P completed on 4/7/22, by staff member V. The H&P was not co-signed for approval and the responsibility of the patient care was not assumed by the MD/DO.

2. Review of patient #7's medical record showed an admission date and H&P completed on 4/8/22, by staff member V. The H&P was not co-signed for approval and the responsibility of the patient care was not assumed by the MD/DO.

3. Review of patient #8's medical record showed an admission date and H&P completed on 4/6/22, by staff member V. The H&P was not co-signed for approval and the responsibility of the patient care was not assumed by the MD/DO.

4. Review of patient #9's medical record showed an admission date and H&P completed on 4/1/22, by staff member W. The H&P was not co-signed for approval and the responsibility of the patient care was not assumed by the MD/DO.

During an interview on 4/13/22 at 3:28 p.m., staff member N stated mid-level practitioners were granted the privilege to admit patients. Staff member N stated he was unaware a MD/DO was responsible to review and co-sign the H&P completed by mid-level practitioners when patients were admitted.

During an interview on 4/14/22 at 10:40 a.m., staff member D stated the facility did not have a policy that required a MD/DO to co-sign the admission H&P completed by mid-level practitioners.

Review of the facility's Medical Staff ByLaws did not specify a MD/DO needed to co-sign an admission H&P completed by a mid-level practitioner and assume full responsibility for the H&P for the patient.

Based on interview and record review, the facility failed to have a process for ensuring the implementation of additional precautions to mitigate the spread of COVID-19 for facility staff with COVID-19 vaccine exemptions. Findings include:

Review of the facility's policy, titled COVID Vaccination as a Condition of Employment, approval/effective date 1/24/22, showed:

- ..."D. Exemptions and Accommodations, ...

- ...2. In granting accommodations or exemptions, [facility] will ensure that it minimizes the risk of transmission of COVID-19 to at-risk individuals, in keeping with its obligation to protect the health and safety of patients. ..."

- The policy and procedure did not show any additional precautions for staff that were unvaccinated.

During an interview on 4/12/22 at 10:42 a.m., staff member B stated additional precautions were not in place for unvaccinated/exempt employees.

During an interview on 4/12/22 at 11:59 a.m., staff member R stated she had an exemption for the COVID-19 vaccine. Staff member R stated she did not follow any additional precautions because she had not received the vaccine. Staff member R stated the personal protective equipment she wore at work was the same as vaccinated staff.

Based on observation and interview, the facility failed to protect all patients' health information and privacy from the public by placing transfer status and code status on the outside of the patients' rooms. Findings include:

During an observation on 4/12/22 at 8:55 a.m., all patient rooms showed the transfer status placed on the outside of the door.

During an observation on 4/12/22 at 10:42 a.m., patient #s 11, 20 and 21 had 6 inch red stop signs on their doors, with 'Do Not Resuscitate' written on the red stop sign.

During an interview on 4/12/22 at 3:42 p.m. staff members B and C stated the transfer and code status were on the patients' room doors for communication to all staff. Staff member C stated she would assist residents with transfers, and to ensure patient safety, she would want to know their transfer status.

Based on observation, interview, and record review, the facility failed to develop a comprehensive care plan for 2 (#s 18 and 20) of 5 sampled patients. Findings include:

During an observation on 4/12/22 at 11:55 a.m., patient #20 was eating lunch in the dining room. The patient had no teeth, and was eating pureed foods out of coffee cups. She was sitting in a wheelchair.

Review of patient #20's care plan showed:
"Resident at risk for weight loss due to potential for aspiration."
Interventions included:
"Staff will monitor resident during meals
Staff will ensure resident eats all her meals
Staff will assist resident to the dining room for meals"

Patient #20's care plan, dated 1/5/22, did not show the patient was on a pureed diet, had no teeth, did not describe the level of assistance she required to eat her meals, or the assistance she needed to go to the dining room. The care plan did not include the level of assistance required for her activities of daily living, her communication, or cognitive status.

Review of Patient #18's care plan, dated 1/5/22, showed 2 areas of concern - at risk for hypo/hyperglycemia, and a history of manipulative behaviors. The care plan did not include what her manipulative behaviors were with interventions for staff, and did not show the level of assistance the patient required for her activities of daily living.

During an interview on 4/14/22 at 8:35 a.m., staff member F stated she was responsible for care plan meetings and developing the care plans. She stated she was new to the position, and realized the care plans were not comprehensive and did not show the patients' needs.