HospitalInspections.org

Based on clinical record review and interview, it was determined there was no evidence the facility informed three (#3, #5 and #10) of fifteen (#1-5 and #11-20) patients of their patient rights. Failure to inform the patients of their rights did not assure the patients were informed and aware of their rights to file a complaint and the names, addresses and phone numbers of who to file the complaint to. The failed practice affected Patient #3, #5 and #10. Findings follow:

A. Review of Patient #3's clinical record did not show Patient #3 was informed of his rights as a patient. During an interview with the Quality Analyst at 2:53 PM on 01/24/18 the findings were verified.

B. Review of Patient #5's clinical record did not show Patient #5 was informed of his rights as a patient. During an interview with the Quality Analyst at 12:35 AM on 01/25/18 the findings were verified.

C. Review of Patient #10's clinical record did not show Patient #10 was informed of her rights as a patient. During an interview with the Quality Analyst at 3:35 PM on 01/25/18 the findings were verified.

D. During an interview with the Quality Analyst at 3:30 PM on 01/25/18 she stated each patient's clinical record should contain a signed patient rights form.

Based on clinical record review, policy and procedure review, and interview it was determined that the facility failed to follow its own policy in that the presence or absence of an advanced directive was not documented in 15 of 15 (#1-5, #10-18 and #20) clinical records. The failed practice did not ensure facility staff was knowledgeable in the event of a medical emergency which required resuscitative efforts. The failed practice had the likelihood to affect patients # 1-5, #10-18, and #20. Findings follow:

A. Review of clinical records # 1-5, #10-18 and #20 on 01/24/18 from 12:15 PM to 3:00 PM and 01/25/18 from 9:00 AM to 1:30 PM showed no documentation of advance directives.

B. Review of the policy and procedure titled "Advanced Directives" showed "I. Admitting Process. On admission either to outpatient or inpatient status, the registrar shall ask the patient if an advance directive has been signed. A. The response shall be entered into the Advance Directive screen using the following code and the appropriate action shall be taken. B. The entered code will be printed on the face sheet."

C. During interview with the Quality Analyst on 01/25/18 at 2:00 PM, she stated the facility discovered during this survey that a previous computer upgrade in July 2017 left the advance directive field in the computer blank, which did not allow the medical staff to view current or upgraded advance directive information.

D. The above findings were verified with The Quality Analyst on 01/25/18 at 2:45 PM.

Based on policy and procedure review, clinical record review and interview, it was determined there was no evidence a Registered Nurse (RN) supervised and evaluated the nursing care for two (Patient #4, and #5) of fifteen (#1-5, #10-20) patients in that a RN failed to ensure the patients attended therapy groups as outlined on the patient care plan. Failure to ensure the patients attended therapy groups as dictated by the care plan did not allow for consistent treatment and had the potential for prolonged hospitalization. The failed practice had the potential to affect Patients #4 and #5. Findings follow:

A. Review of the policy and procedure titled "Geriatric and Adult Psychiatric Programs" received from the Program Director for Behavioral Health Unit at 3:25 PM on 01/24/18 showed Group Activities would be provided at 10:15 AM and 3:00 PM on the Geriatric Unit and 9:30 AM and 1:30 PM on the Adult Psychiatric Unit Monday through Friday and a minimum of one hour on Saturday and Sunday. Review of the above policy and procedure also showed weekend programming would be implemented by the weekend staff.

B. Review of the clinical record for Patient #4 showed no evidence Patient #4 attended Group Therapy or refused to go for two (07/08/17 and 07/09/17) of seven (07/07/17 through 07/12/17) days. During an interview with the Clinical Analyst at 8:55 AM on 01/25/18 the findings were verified.

C. Review of the clinical record for Patient #5 showed no evidence Patient #5 attended Group Therapy or refused to go per the policy and procedure in A for three (09/07/17, 09/10/17, and 09/12/17) of nine (09/07/17 through 09/14/17) days. During an interview with the Clinical Analyst at 10:48 AM on 01/25/18 the findings were verified.


38994

Based on clinical record review it was determined a Registered Nurse (RN) failed to supervise and evaluate the nursing care in that one of one (#14) patient's clinical record did not contain documentation daily dressing changes were performed as ordered by the Physician. Failure to perform daily dressing changes as ordered did not give the Physician the information necessary to make clinical decisions. The failed practice affected Patient #14. Findings follow:

A. Review of Patient #14's clinical record showed a Physician Order dated 12/31/17 for daily dressing changes to left knee. Review of patient #14's clinical record show dressing changes were not performed on 23 (12/26/17, 12/28/17, 12/19/17, 12/31/17, 01/01/18 through 01/05/18, 01/07/18 through 01/12/18, and 01/15/18 through 01/23/18) out of 31 (12/26/17 through 01/25/18) days.

B. The above findings were verified by RN # 3 on 01/25/18 at 1:35 PM.

Based on review of policy and procedure and clinical records, it was determined the facility failed to ensure a nursing care plan was developed and kept current for one (#10) of fifteen (#1-15) patients. Failure to develop a nursing care plan within eight hours of admission as per policy did not allow the nurses to be aware of the care needed, how it was to be accomplished and the best methods, approaches, goals and changes needed to ensure the best nursing care and results for the patient. The failed practice affected Patient #10. Findings follow:

A. Review of the policy and procedure titled "Plan of Care" received from the Chief Quality Officer at 9:50 AM on 01/24/18 showed the nursing care plan was to be developed and completed within eight hours of admission.

B. Review of the clinical record for Patient #10 showed an admission date and time of 01/23/18 at 7:25 PM. Review of the clinical record did not show a care plan was developed. During an interview with the Quality Analyst at 3:35 PM on 01/25/18 the findings were verified.