HospitalInspections.org

Based on interviews and record reviews it was determined that the facility staff failed to notify the physician and/or family about a decline in a patient's condition for 1 of 21 sampled patients (Patient #10).

The findings include:

The facility staff failed to notify Patient #10's physician and family about a decline in the patient's condition. No documentation was found to indicate that Patient #10's physician and family were included in decision making when the patient experienced a decline in condition.

Patient #10 was admitted to the facility with respiratory distress and pneumonia. Patient #10 had a "Do Not Resuscitate" form signed in the patient's clinical record. No physician order for comfort care or hospice care was found in Patient #10's clinical record.

On 9/6/10 at 10:00 PM, a respiratory therapist documented that Patient #10 was 'alert' and 'unresponsive'; the respiratory therapist also documented that he or she was unable to obtain a heart rate for the patient. Respiratory documentation prior to this aforementioned entry only had the patient documented as 'alert' and always had a heart rate documented (ranging from 60 to 100 beats per minute).

Nursing documentation indicated:
- Patient #10's restraints were removed on 9/6/10 at 4:30 PM because the patient was unresponsive.
- Patient #10's blood pressure was documented as 66/33 on 9/6/10 at 10:30 PM and the charge nurse was notified.
- Patient #10's blood pressure was documented as 60/32 on 9/7/10 at 1:35 AM.
- Patient #10 was found without respirations and pulse on 9/7/10 at 2:15 AM; the patient was pronounced dead by a facility staff member.

Review of Patient #10's clinical record failed to reveal evidence that the patient's family or physician was made aware of the aforementioned changes in condition. No documentation was revealed to indicate that Patient #10's physician provided staff with guidance and/or orders to direct care related to these changes in condition.

During an interview with the facility chief nursing officer (CNO) on 6/1/12 at 12:50, the failure to include the physician and family in the patient's care when this change in condition occurred was discussed. The CNO reported that documented evidence, of physician and/or family notification of Patient #10's decline, was not found. The CNO stated that she believed that the physician and family were notified but that no documentation exists to 'prove it'. The CNO acknowledged that a "Do Not Resuscitate" form does not mean comfort care; the CNO stated that an order for comfort care should have been obtained.

The failure of the facility staff to involve Patient #10's physician and/or family in the patient's care as evident by not notifying the physician and/or family of a change in condition was discussed for a final time with the facility's chief financial officer (the interim chief executive officer was not present during the survey), CNO, and Risk Manager during a survey team meeting on 6/1/12 at 1:35 PM.

Based on interviews and record review, it was determined that the facility staff failed to have patient restraint orders renewed in a timely manner for 2 of 4 sampled patients who had restraints ordered (Patient #21 and Patient #8).

The findings include:

1. The facility staff failed to renew Patient #21's restraint order every 24 hours as directed in the facility's restraint policy.

The following information was found in a facility policy entitled, 'Restraint Use', under the heading of 'Implementation of Restraints for Medical/Surgical Reasons': "Continued use of restraints beyond 24 hours is authorized by the physician by renewing the original order or issuing a new order" and "The renewal or new order is issued no less than once each calendar day and is based on the physician's face to face examination."

Review of Patient #21's clinical record reveal that bilateral soft wrist restraints were ordered for 24 hours on 5/18/12 at 1:00 PM. The next order for restraints was dated 5/20/12 (this order was not timed).

The facility's chief nursing officer (CNO) was interviewed on 5/31/12 at 1:45 PM; the CNO was asked about the absence of a renewal restraint order on 5/19/12 for Patient #21. The CNO stated the 5/19/12 renewal restraint order was missed.

The failure of the facility staff to obtain a renewal restraint order for Patient #21 was discussed for a final time, with the facility's chief financial officer (the interim chief executive officer was not present during the survey), CNO, and Risk Manager, during a survey team meeting on 6/1/12 at 1:35 PM.

2. The facility staff failed to renew Patient #8's restraint order every 24 hours as directed in the facility's restraint policy.

The following information was found in a facility policy entitled, 'Restraint Use', under the heading of 'Implementation of Restraints for Medical/Surgical Reasons': "Continued use of restraints beyond 24 hours is authorized by the physician by renewing the original order or issuing a new order" and "The renewal or new order is issued no less than once each calendar day and is based on the physician's face to face examination."

Review of Patient #8's clinical record revealed that a right soft wrist restraint was ordered on 2/17/11 at 6:30 PM; a renewal order for this restraint was not found. Documentation indicated that the right soft wrist restraint was used for Patient #8 consistently until it was removed on 2/19/11 at 2:00 AM. During an interview on 6/1/12 at 1:20 PM, the facility chief nursing officer (CNO) reported that a renewal order for Patient #8's restraint was missed.

The failure of the facility staff to obtain a renewal restraint order for Patient #8 was discussed for a final time with the facility's chief financial officer (the interim chief executive officer was not present during the survey), CNO, and Risk Manager during a survey team meeting on 6/1/12 at 1:35 PM.

Based on review of Life Safety Code survey report of the Life Safety survey conducted July 11, 2012, it was determined the hopsital did need meet the standard for Life Safety from fire.

Findings:

Please refer to LSC survey report of July 11, 2012.

Based on observation, record review, and interview, it was determined that the facility staff failed to maintain 1 of 3 elevators in a safe condition.

The findings include:

The facility staff failed to maintain an elevator, which was commonly used by staff to transport patients, in a safe condition.

On 5/31/12 at 12:20 PM, with the facility's chief nursing officer (CNO) present, one of the facility's elevators was noted to have a bent piece of metal with multiple sharp edges on the moving door. This elevator was labeled for employee use but the CNO reported that patients were transported by staff in wheelchairs and stretches using this elevator. The elevator was noted to be in a location that was accessible to the public; there were no locked doors preventing patients and visitors from using this elevator. Later in the day on 5/31/12, the sharp areas of the protruding piece of metal, on the elevator, were noted to be covered with tape.

The survey team was provided with a letter written by the facility staff to the elevator company dated 5/31/12. The letter included the following information: "During an inspection ... (a surveyor) sited that the edge of the stainless door on car 1 (employee elevator) is protruding. This is the same door that your company repaired some time ago. As I told you then, the way that the door was originally repaired would not last long-term."

The aforementioned observation of the elevator was discussed for a final time with the facility's chief financial officer (the interim chief executive officer was not present during the survey), CNO, and Risk Manager during a survey team meeting on 6/1/12 at 1:35 PM.