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Based on record review, interview and policy and procedure review the hospital failed to provide documentation that patient's rights received upon admission for 4 of 10 records reviewed (patients #2, 8, 9, and 10). Failure to provide patient's rights upon admission put all patients at risk for being uniformed of their rights for safe care, being free from all forms of abuse, decisions making for all healthcare concerns, privacy, confidentiality, the right to refuse care and voicing their concerns about the care they receive.

Findings include:

- Record review on 1/30/17 revealed patient #2, #9, and #10's medical record lacked documentation of patient's rights received upon admission. The medical record for patient #8 revealed the receipt of patient rights was signed upon discharge.

Interview on 1/30/17 at 5:30 PM, Quality and Regulatory Coordinator Staff A and Informatics (the science of processing data for storage and retrieval; information science) Registered Nurse (RN) Staff X verified the records for patient's #2, 8, 9, and 10 failed to provide documentation of patient's rights upon admission and patient # 8 signed patient rights upon discharge. Staff A stated sometimes they are not able to give the patient's rights prior to admission and attempts are made to meet with the patients during their stay at the hospital. Attempts were made for patient #9 and 10 and staff were not able to connect with the patient.

- Policy and Procedure review on 2/1/17 revealed policy "Patient Rights and Responsibilities" states ...administration strives to promote hospital compliance with regulations and laws pertaining to patient's rights ...patient education - patients and/or families are educated about basic patient rights in the following manner: written information containing a copy of patients' rights is provided upon admission. If the patient is a minor or incapacitated, the rights are communicated through a patient, guardian or designated representative ...associates assist with the education process and to answer questions about patient rights, including rights regarding advanced directives and the process for complaint resolution.

Based on interview, record review, policy review and document review the hospital failed to show evidence the nursing staff complied with hospital policies regarding skin and wound care assessments and treatments for 4 of 20 patient's records reviewed (patient #11, # 13, #16, and #17). Failure to ensure nursing staff completed skin and wound assessment and care put all patients at risk for unsafe and ineffective wound care management.

Findings include:

- Patient #11's record review on 2/1/17 revealed an admission date of 1/10/17 to an Intensive Care Unit with a diagnosis of Coumadin Toxicity (excess amounts of the anticoagulant drug Coumadin in the bloodstream either casued by overdose or drug interactions). The initial nursing assessment on 1/10/17 failed to provide documentation of a Braden score (a scale used to predict pressure sore risk by examining six categories; sensory perception, moisture, mobility, activity, nutrition, friction and shear. Very High Risk: Total Score 9 or less; High Risk: Total Score 10-12; Moderate Risk: Total Score 13-14; Mild Risk: Total Score 15-18; No Risk: Total Score 19-23).

- Patient #13's record review on 2/1/17 revealed an admission date of 12/19/16 due to a left hip fracture. The medical record lacked documentation of any skin/wound issues on the initial assessment. The first documentation of skin issues on the nursing assessment appeared two days later on 12/21/16. Nursing staff documented an opened area on the coccyx (tailbone) and cream applied. There were no changes in the documentation for the coccyx on 12/22/16 and 12/23/16. On 12/24/16, the nursing assessment revealed documentation of a pressure ulcer and bordered foam dressing applied to the coccyx. On 12/25/16, nursing staff described the coccyx wound as erythema (superficial reddening of the skin) and no dressing applied. On 12/26/16, nursing staff described the wound as flat pink tear and a bordered foam dressing applied. Nursing staff documentation on 12/27/16 and 12/28/16 was the same as 12/26/16. On 12/29/16, nursing staff documentation described the wound as flat, erythema and the dressing was removed. On 12/30/16, nursing staff documented the wound was red,. Finally, on 12/31/16, nursing staff documented a pink pressure ulcer over a bony prominence and cream was to be applied. The record lacked documentation of any other assessment of this pink pressure ulcer described on 12/31/16 before the patient discharged on 1/2/17. Nursing assessments of the coccyx wound were inconsistent and the medical record lacked evidence that nursing staff consulted the Wound Care Nurse to care for Patient #13's pressure ulcers.


- Record review on 2/1/17 revealed patient #16 was admitted with a fractured femur on 1/27/2017. Nursing Staff found two pressure ulcers on admission - one in the middle of the patient's back midline and one on the coccyx. Nursing staff obtained an order for Wound Care Nurse consultation on 1/28/2017. Nursing staff documented a Braden score of 13 on admission and the MUST (Malnutrition Universal Screening Tool) score was 2 (High risk for nutritional deficiency). Nursing staff documented the nutrition intake as poor appetite. Nursing staff ordered a nutrition consult on 1/31/2017. The patient was discharged back to the nursing facility on 1/31/2017. The medical record lacked evidence that the Wound Care Nurse assessed the patient prior to discharge (consult placed 3 days prior) and that a nutrition consult was completed prior to their discharge.

- Record review on 2/1/17 revealed patient #17 was admitted to the cardio-thoracic intensive care unit on 12/28/2016 and transferred to 8 SE on 12/30/16. The nursing staff completed an initial skin assessment on 12/28/2016 and nursing staff documented that a boarder foam dressing was on the right lower arm. The Braden score on admission was 14. The medical record lacked evidence nursing staff documented that a pressure ulcer was present on admission. Nursing staff documented a boarder foam dressing to the right arm on 12/29/2016. On 12/30/2016 at 11:00 AM, nursing staff documented that the coccyx was red and a cream ordered. On 12/31/2016 at 9:15 AM, nursing staff documentation indicated a boarder foam dressing was applied to the coccyx and the left arm. Nursing staff ordered a Wound and Skin Consult on 12/31/2016. The order said it did not require a physician's signature. On 1/1/2017, nursing staff described the coccyx as pink and cream applied and that a boarder foam dressing was on both the right and left arm. On 1/2/2017, nursing staff documentation described the coccyx as pink/purple. There was no evidence in the medical record the Wound Care Consultant assessed the wounds and there was no evidence a nutrition assessment was completed. The patient discharged back to the nursing facility on 1/2/2017.

Interview on 1/31/17 at 8:30 AM, Interim Supervisor RN Staff B, stated if a pressure ulcer is found by the staff nurse and if the Braden score is less than 18 they are to initiate a wound and skin consult and wound consultants notify the physician.

Interview on 1/31/17 at 1:26 PM, Wound Care RN Staff O, The staff will call the physician for orders and the wound care team will give their recommendations to the physician for approval. The nurses will follow through with the wound care each shift as ordered.

Interview on 2/1/2017 at 12:20 PM, Quality and Regulatory Readiness Coordinator, Staff A spoke with unknown person on the telephone and reported the Wound Care Consultant cancelled the order because there was no physician signature and the nurse did not give specifics on the wound for Patient #17.

- Record review on 2/1/17 revealed patient #18 was admitted to the floor on 1/4/2017 with fractured right femur. The Braden score on admission was 16. Nursing staff documented on admission there were no pressure ulcers. The patient had surgery on 1/5/2017 for prosthetic hip replacement. Nursing staff documented the patient had a poor appetite, difficulty swallowing and was on a pureed diet. On 1/7/2017 the patient's blood Albumin level was 2.0 and total protein was 4.7 (both are blood tests that indicate nutritional health and both were low). The MUST score was not completed. There was no evidence nursing staff initiated a nutritional consult. On 1/9/2017, the day of discharge, nursing staff documented that the right heel was red and had a blister. The inter agency transfer and discharge instructions did not mention the red heel or blister. There was no evidence nursing staff initiated the Pressure Ulcer Prevention care plan. There was no evidence nursing staff notified the doctor of the red heel and blister prior to the patient's discharge.

Interview on 2/1/2017 at 12:45, Informatics Specialist RN Staff J said a MUST score of 2 means the patient is at a high nutritional risk and should trigger a Nutritional Consult.

- Document review on 1/30/17 at 5:35 PM revealed the hospital received a Joint Commission Complaint on November 23, 2016 and this document was the corrective action plan. Corresponding documents were provided on 1/31/2017 at 1:00 PM titled PREVENTING PRESSURE INJURIES, a training module that was implemented as a result of the Joint Commission complaint and a document title Patient Safety Alert, Preventing pressure Injuries, December 2016. This document was described as a "huddle tool" and the information is shared with nursing staff during the daily safety huddles on each unit. The huddle tool is in the SBAR format. SBAR is an acronym for Situation, Background, Assessment and Recommendation; a technique that can be used to facilitate prompt and appropriate communication. The corrective action plan measures to be performed were as follows: to document if a pressure ulcer wound is present upon admission, to complete the skin assessment within 24 hours of admission and if the Braden scale is 18 or less it requires astute observation and implementation of immediate prevention measures.

Policy titled Wound and Skin reviewed on 2/1/2017 at 8:55 AM directed: ..."Perform a sin and risk assessment (Braden Scale) on admission, daily or when there are changes in the patient's status."... ..."Patients with a total score of 15-18 or less are considered to be "at risk" for developing pressure ulcers. A score of 13-14 + moderate risk, 10-12 + high risk and 9 or below + very high risk. " ... "individuals with existing pressure ulcers should have a dietary referral" ..."Assess actual wound/ulcers on admission, or when observed for the first time, at each dressing change, and/or as status of the wound changes"... ..."Notify the physician of the following: occurrence of actual skin breakdown"...
Interview on 2/1/17 at 9:10 AM. Clinical Ambassador Staff AA stated when staff log into "My Learning" they see a "to do" list. All clinical staff have been assigned the Preventing Pressure Injuries module. Once they complete the module it will show up in their transcript.
Interview on 2/2/17 at 7:50 AM, Quality and Regulatory Readiness Coordinator Staff A explained the education pamphlet included the Patient Safety Alert SBAR, Preventing Pressure Injuries education module assigned to nursing associates and Pressure Injury Prevention Points. At 10:05 AM Staff A explained "Preventing Pressure Injuries" learning module was assigned to 1214 nursing associates throughout all Via Christi campuses on 1/27/2017, 310 associates have completed the module as of 2/2/2017 at 10:05 AM. The staff have 60 days to complete the module.
Interview on 2/2/17 at 9:41 AM, Clinical Ambassador Staff AA stated it is an expectation that staff will mark yes or no on the initial skin assessment if a pressure ulcer was present on admission. This field was made mandatory in January. A team will go around and check documentation in a Prevalence study quarterly.

Based on record review, interview and document review the hospital failed to ensure a physician signature on a History and Physical (H&P) within 24 hours after admission for 1 of 10 records reviewed (patient #10). Failure of a physician to sign an H & P within 24 hours of admission put all patients at risk for receiving unsafe care related to past history, medications, allergies, current symptoms, social and mental issues and cultural issues.

Findings include:

- Patient #10's record review on 1/30/17 revealed an admisssion date of 6/24/16 and discharge date of 6/29/16. The physician signed the H & P on 7/6/16 (12 days after admission).

Interview on 1/30/17 at 5:30 PM Quality and Regulatory Coordinator Staff A and Informatic (the science of processing data for storage and retrieval; information science) Registered Nurse (RN) Staff X verified the physician signature on the H & P for patient # 10 was dated 7/6/16.

- Document review on 1/31/17 revealed document "Patient Record Guidelines" states ...the H&P shall in all cases, be performed and a report thereof dictated or written within twenty-four (24) hours after admission of the patient and prior to surgery/procedure. The H&P is the responsibility of the attending physician.

- Document review on 1/31/17 revealed document "Medical Staff Bylaws" states ...history and physical examination report ...the provider must sign, date and time this entry prior to surgery and within 24 hours after admission.

Based on record review, interview and document review the hospital failed to properly execute informed consent forms at admission for 4 of 10 records reviewed (patients #2, 8, 9 and 10). Failure to ensure informed consent forms are signed at admission puts all patients at risk for a lack of shared decision making concerning their healthcare decisions for treatments, tests, surgeries, legal and ethical issues and patient rights.

Findings include:

- Record review on 1/30/17 revealed an informed consent failed to be signed at admission for patients #2, #8, #9, and #10. Hospital staff were able to obtain an informed consent for patient #8 upon discharge.

Interview on 1/30/17 at 5:30 PM, Quality and Regulatory Coordinator Staff A and Informatics (the science of processing data for storage and retrieval; information science) Registered Nurse (RN) Staff X verified the records for patient's #2, 9, and 10 failed to provide documentation of an informed consent upon admission and patient #8 failed to provide documentation of an informed consent upon admission, but were able to obtain upon discharge. Staff A stated sometimes they are not able to complete the informed consent upon admission and attempts are made to complete the forms during their stay at the hospital. Staff A indicated attempts were made to obtain consent for admission for patient # 9 and #10 but staff were unable.

- Document review on 1/31/17 of "Patient Record Guidelines" stated ...Informed Consent ...Medical records must include evidence of appropriate informed consent. Patients have the right to be reasonably informed about their condition and proposed treatment in order to make informed decisions concerning their care and treatment. Documentation of this informed consent will be identified in the medical record.

Based on record review, interview and document review the hospital failed to ensure documentation of a discharge summary in 1 of 10 records reviewed (patient #7) and failed to provide an attending physician signature on the discharge summary for 1 of 10 records reviewed (patient #8). Failure for the physician to sign the discharge summary and provide a discharge summary puts all patients at risk for receiving unsafe care regarding medications, treatments, wounds, nutrition and other healthcare issues when transitioning home or to another facility.

Findings include:

- Patient #7's record review on 1/30/17 lacked evidence of a discharge summary and Patient #8's record review showed a discharge summary dictated by a resident that failed to be signed by the attending physician.

Interview on 1/30/17 at 5:30 PM, Quality and Regulatory Coordinator Staff A and Informatics (the science of processing data for storage and retrieval; information science) Registered Nurse (RN) Staff X verified the records for patient #7 failed to provide documentation of a discharge summary and patient #8 showed a discharge summary dictated by a resident and failed to be signed by the attending physician. Staff A stated these were missed and will be followed up on.

- Documentation review on 1/31/17 of document "Patient Record Guidelines: states ...Discharge summaries must be completed within seven (7) days of the patient's discharge ...the discharge summary provides information to other healthcare providers to facilitate the transition of care and ensure the coordination and continuity of healthcare services for patients ...the attending physician may delegate the completion of the medical record to a resident or an allied health practitioner. This does not abrogate the responsibility of medical record completion of the attending.

Based on observation, interview and policy and procedure review the Via Christi Hospital failed to ensure infection control measures when a staff member (RN Staff L) failed to dispose of personal protective equipment (PPE) properly, by finding blood on the floor (approximately 1 tablespoon) and in a trash can in a patient ' s waiting room area and when staff (Patient Care Technician (PCT) Staff M) failed to handle glucose monitoring equipment properly in a patients room with contact precautions (apply to specified patients known or suspected to be infected or colonized with microorganisms that can be transmitted by direct or indirect contact). Failure to follow and perform infection control measures put all patients, staff and visitors at risk for acquiring infections, diseases and exposure to pathogens.

Findings include:

- Observation on 1/31/17 at 11:33 AM revealed Registered Nurse (RN) Staff L cleaning a transfer board in a droplet precaution (droplet transmission involves contact of the conjunctivae or the mucous membranes of the nose or mouth of a susceptible person with large-particle droplets containing microorganisms generated from a person who has a clinical disease or is a carrier of the disease) patient ' s room. Staff L had on gloves and a mask as required personal protective equipment (PPE) for droplet precautions. Staff L took the transfer board out of the patient ' s room and across the hall into the clean utility room while still wearing the mask. Staff L went back into the patient ' s room still wearing the mask, completed cleaning the patient area and again left the room wearing the same mask and then proceeded down another hallway to the medication room. Staff L then removed the mask in the medication room with other staff present.

Interview on 1/31/17 at 11:38 AM, RN Staff L stated that he/she is to wear a mask in the droplet precaution room. Staff L stated he/she was correct in wearing the mask until he/she was done with all patient care for his/her protection and then the mask could be removed. Staff L stated he/she is not aware of the policy and procedure for PPE in precaution rooms but follows what the sign outside the patient door states.

Interview on 1/31/17 at 11:35 AM, Interim Manager, RN Staff K stated the mask was to be removed before staff leave the patient's room. Staff K verified at 11:47 AM that the droplet precaution signage outside the patient's room revealed a picture and instructions to remove mask when leaving the patient room.

- Policy and Procedure review on 1/31/17 reveals policy "Droplet Precautions" stated ...use droplet precautions to reduce the risk of diseases that are spread through microorganisms (germs) transmitted by respiratory droplets ...droplet precautions are intended to prevent transmission of pathogens spread through close contact with secretions from the respiratory tract ...remove all personal protective equipment before leaving the room.

- Observation on 2/1/17 at 9:40 AM revealed blood (approximately 1 tablespoon) on the floor and blood in the trash can in a patient ' s waiting room area. Staff U was going to be interviewed in this area and upon seeing the blood asked the three therapists in the area if they knew there was blood there and one of them stated "I thought it was just ketchup" . Staff U proceeded to immediately have housekeeping clean up the blood.

Interview on 2/1/17 at 9:42 AM, RN Staff U verified the blood looked fresh and that the therapists present failed to ensure it was cleaned immediately.

- Policy and Procedure review on 2/2/17 revealed policy Standard Precautions (Universal and Body Substance Precautions) states ...Cleaning of blood or other body fluid spills: spills should be cleaned immediately or as soon as possible ...large spills (e.g. greater than 10ml or OPIM (other potentially infectious material)) should be cleaned by housekeeping and may require use of gloves, gowns, mask and eye wear.


- Observation on 1/31/17 at 11:55 AM, Patient Care Tech (PCT) Staff M performed a finger stick blood glucose (sugar) test on an unidentified patient in Room 8 of the Neurological Intensive care unit. A sign on the door indicated the patient was in contact isolation. PCT Staff M took the blood glucose monitor and test strips into the patient's room, placed on the bedside table, procedure explained to the patient and test performed. PCT staff M then removed gown at the door and carried the test strip container and blood glucose monitor out of the room and cleaned the monitor and outside of the test strip container with a Sani-Wipe (a disposable cloth moisten with a solution that kills germs).

Interview on 1/31/17 at 12:05 PM, PCT Staff M reported that they didn't know if they should take the strip out before going into the room because it might damage the strip. The glucose test strip bottle is taken into the patients rooms.

Readiness Coordinator Staff A provided a Policy titled Accu-Check Inform II Whole Blood Glucose Monitoring System and reported associates are trained in orientation to take the glucose test strip container into the patients rooms, the policy was reviewed on 1/31/2017 at 1:00 PM directed ..."6. SAFETY: A. Standard precautions are designed to protect the staff, patients and visitors from exposure to potentially infectious or harmful agents through the use of personal protective equipment and safe work habits."... ..."16. PATIENT TESTING PROCEDURE: ...a. Assemble all equipment"... ..."n. All patient care equipment taken into the room must be wiped down with disinfectant when it is taken out of room. The surface of both the meter and container of strips must remain damp in accord with the time displayed on the label of the container of wipe used. This time will vary by the composition and intended use of the type of wipe " ...

- Per CDC guidelines: "Unused supplies and medications taken to a patient's bedside during finger stick monitoring or insulin administration should not be used for another patient because of possible inadvertent contamination" .