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Based on record review and interview, the hospital failed to protect and promote patient's rights by failing to obtain consent for treatment for two (Patients #5 and #7) of 13 patients.

This failed practice placed patients at risk of receiving treatment without consent and without understanding their rights and ability to participate in treatment.

Findings:

Patient #5
A review of the medical record showed an admission date of 10/10/19 and no signed consent or documentation of rationale for not obtaining consent to treat.

On 10/23/19 at 4:23 p.m., Staff S stated there was no consent in the clinical record.

Patient #7
A review of the medical record showed an expired EOD date of 02/17/19; documentation of a verbal consent on 02/17/19 and no signed consent to treat documents (8 months after verbal consent).

On 10/24/19 at 12:20 p.m., Staff S stated the EOD expired and the facility failed to obtain consents.





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Based on record review and interview, the facility failed to ensure nursing staff followed established policy and procedure for assessment and reassessment of patients for one (Patient #5) of 13 patients.

This failed practice has the likelihood to increase the risk for incomplete assessment, lengthened hospital stay, and decreased quality of care.

Findings:

A review of a policy titled "Nursing Assessments/Reassessments" showed requirements for RNs to document assessments each shift.

Patient #5
A nursing assessment dated 10/02/19 showed a wound on the coccyx. Nursing assessments on 10/11/19, 10/16/19, 10/19/19, and 10/20/19 showed skin was normal, with no documentation of a wound. A nursing assessment dated 10/13/19 showed a wound to the coccyx.

On 10/24/19 at 10:11 a.m., Staff B stated wounds were not documented on the nursing assessment.



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Based on patient record review and interview the hospital failed to ensure nursing staff maintained a nursing care plan for one (Patient #1) of 13 patients.

This failed practice has the likelihood to result in delayed recognition and/or treatment of active problems that could influence patient recovery, functional status, and quality of life.

Findings:

Patient #1

A review of a "Practitioner Order Sheet" dated 10/08/19 showed an order for safety checks every 15 minutes.

A review of the "Interdisciplinary Treatment Plan Master Sheet" (with a team conference date of 10/17/19) showed no update to reflect the order change based on the patient's change in condition.

On 10/23/19 at 1:00 p.m., Staff G stated the plan of care should have been updated with the change in condition.



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Based on record review and interview, the hospital failed to ensure completion of:
1) Patient Observation Record for four (Pts #3, #6, #10 and #11) of 13 patients and
2) Medication Administration Record for three (Pts #6, #9 and #11) of 13 patients.

This failed practice placed patients at a risk of incomplete records and inability to evaluate the effectiveness of treatment.

Findings:

Incomplete records

Patient #3 and #6
A review of the medical record for patient #3 and #6 showed no safety rounds documented on the "Patient Observation Records" dated 10/21/19 at 6:45 p.m.

Patient #10
A review of the medical record showed no safety rounds documented on the "Patient Observation Record" dated 08/05/19 at 3:15 p.m. and 08/10/19 at 2:15 p.m., 2:30 p.m. and 2:45 p.m.

Patient #11
A review of the medical record showed no safety rounds documented on the "Patient Observation Record" dated:
1) 09/09/19 at 7:00 a.m., 7:15 a.m., 7:30 a.m., and 7:45 a.m.;
2) 09/10/19 at 7:00 a.m., 7:15 a.m., 7:30 a.m., and 7:45 a.m.;
3) 09/11/19 at 3:15 p.m., 3:30 p.m., 3:45 p.m., 4:00 p.m., 4:15 p.m., 4:30 p.m., 4:45 p.m., 5:00 p.m., 5:15 p.m., 5:30 p.m., 5:45 p.m., 6:00 p.m., 6:15 p.m., 6:30 p.m., 6:45 p.m.; and
4)10/05/19 at 7:00 a.m. and 7:15 a.m.

Patient #6
A review of the Medication Administration Record showed an order dated 10/06/19 for Namenda to be given every morning. A review of the record showed no documentation of medication administration of Namenda on 10/06/19, 10/08/19, 10/10/19, 10/11/19, and 10/12/19. Documentation showed no order change and no refusal of medication by the patient.

A review of the medical record showed an order dated 10/06/19 for Anstedo to be given twice daily. A review of the record showed no documentation of medication administration of Anstedo on 10/09/19, 10/10/19, 10/11/19, and 10/12/19 at 10:00 a.m. and 2:00 p.m.

Patient #8 A review of the Medication Administration Record dated 10/15/19 (8:30 a.m.) showed no documented administration or refusal of the following medications: Zylopram, Lexapro, Protonix, Zyprexa, and Revia.
Patient #11
A review of the Medication Administration Record showed no documented administration or patient refusal of:
A.) Colace, Metoprolol, and Zyprexa on 08/25/19 and 08/27/19 at 8:00 p.m.;
B.) Lasix, Namenda, Aricept, Klor-Con, Lexapro, Plavix, Prenatal Vitamin,Probiotic, Rexulti, and Zestril on 09/04/19 at 8:30 p.m.;
C.) Namenda, on 09/14/19 at 8:30 p.m.;
D.) Cardura on 09/16/19 and 09/25/19 at 8:00 p.m.;
E.) Lasix on 09/17/19 at 8:30 p.m.; and
F.) Lipitor on 10/09/19 at 8:00 p.m.
On 10/23/19 at 3:00 p.m., Staff B stated it was facility policy that all medications given should be documented on the facility Medication Administration Record.

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Based on record review and interview, the hospital failed to ensure the attending physician reviewed and signed the history and physical for one (Patient #1) of 13 patients.

This failed practice had the likelihood to result in care that is non-therapeutic for patients admitted to the hospital.

Findings:

A review of a facility document titled "Rules and Regulations" dated 06/22/17 stated the history and physical examination must be performed by a practitioner with clinical privileges.

Patient #1
A review of a document titled "History and Physical Exam" dated 10/08/19 showed signature of a PA with no physician co-signature.

On 10/23/19 at 4:30 p.m., Staff A stated a physician was required to co-sign a History and Physical form signed by a physician assistant.

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