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Based on observation, interview, and clinical record review, the facility failed to ensure the patient (or their representative) was provided informed consent for treatment (A131), each patient (or their representative) was provided with information on advance directives, patients were not restrained as part of a fall prevention program (A154), each patient had less restrictive methods used prior to placing them in restraints (A165), restraints were applied as ordered (A168), and when placed in restraints were monitored according to hospital policy (A175). The cumulative effect of these systemic practices resulted in the agency's inability to ensure that patient's rights were protected. This affected eight of 12 patients reviewed with a census of 204 patients. (Patients #1, #2, #3, #4, #6, #8, #9, and #12)

Based on clinical record review and interview, the facility failed to ensure an informed consent was obtained from each patient or their designated representative. This affected Patient #1, #4, and #6. The sample size was 12 and the facility's census was 204 patients.

Findings:

The clinical record review in its electronic form for Patient #6 was completed on 03/01/13. The clinical record review revealed a history and physical dated 02/22/13 at 8:30 A.M. that stated the patient was 83 years old and had a chief complaint of abdominal and back pain. The history and physical stated he/she was "somewhat" confused. The history and physical stated the patient was unable to walk and had a poor appetite.

A physician's admission note dated 02/21/13 3:37 P.M. that stated the patient was unable to provide a clinical history of him/herself, that it had to be obtained from a sibling, and that he/she was confused but was able to recognize his/her name.

There was no documentationthe patient or the sibling signed a consent to be admitted to the facility.

Further review of the medial record revealed nursing documentation the patient was assessed as legally blind and that the patient was confused.

An informed consent for a cystoscopy and ureteroscopy signed by the physician on 02/25/13 and at the line where the patient signs, a scribble.

On 03/01/13 at 3:00 P.M. Staff stated the scribble looked like the signature of the confused, blind patient, and was unable to locate a signed consent for admission.




31597


The clinical record review for Patient #1 was completed on 03/02/13. The patient was admitted to the facility on 02/24/13 with a diagnosis of possible seizure activity, altered mental status, and chronic obstructive pulmonary disease. The consent to hospital care form listed the patient was unable to sign due to clinical reasons. On 02/26/13 at 10:40 AM, a registered nurse documented the patient's wife was at the bedside. There was no documentation the registered nurse obtained consent from the wife. As of 03/02/13, the hospital had not obtained consent from the patient or patient's family.

The clinical record review for Patient # 4 was completed on 03/01/13. The 84 year old patient was admitted to the facility on 02/12/13 with a diagnosis of change in mental status. The clinical record had a consent to hospital care signed by the patient with no date specified. The clinical record had consent to hospital care signed by a person on the patient's signature line on 02/12/13. The unidentified person's relationship to the patient was not listed and the reason the patient was unable to consent was not specified on the document.

On 03/01/13, the findings were reviewed with Staff F and confirmed.

Based on interview and clinical record review, the facility failed to ensure Patient #8, #9, and #12 (or their representative) received information regarding advance directives. The sample size was 12 patients, the census was 204 patients.

Findings:

The clinical record review in its electronic form for Patient #8 was completed on 03/01/13. The clinical record review revealed an emergency department provider note signed on 02/19/13 at 2:29 P.M. that stated the 66 year old patient was suicidal and threw herself from the wheelchair onto the floor at the nursing home.

Nursing documentation at 02/20/13 at 11:56 P.M. stated exploring the patient's advance directive-whether he/she had them or wanted to formulate them-was deferred.

Six days into the patient's length of stay, there was no documentation that this was done.

On 02/28/13 in an afternoon interview, Staff Nurse N confirmed information on the patient's advance directive-whether he/she had them or whether he/she wanted to formulate them-had not yet been addressed in the clinical record.

The clinical record review in its electronic form for Patient #9 was completed on 03/01/13. The clinical record review revealed a behavioral history and physical signed on 02/20/13 that stated the 84 year old patient was admitted to the facility with a chief complaint of confusion and not eating for several days.

There was no documentation the topic of advance directives was discussed with the patient or family as to-whether he/she had them or wanted to formulate them.

On 02/28/13 in an afternoon interview, Staff Nurse N confirmed information on the patient's advance directive-whether he/she had them or whether he/she and/or family wanted to formulate them-had not been addressed in the clinical record.

The clinical record review in its electronic form for Patient #12 was completed on 03/01/13. The clinical record review revealed 60 year old patient was admitted to the facility on 02/22/13 with a chief complaint of depression.

The clinical record review in its electronic form stated on 02/22/13 at 11:36 A.M. that the patient did not have advance directives, but was interested in them.

At the time the review of the clinical record in its electronic form was completed-and six days into the patient's length of stay-the clinical record did not reflect that the topic of advance directives was discussed with the patient.

In an interview the afternoon of 02/28/13 Staff A confirmed the record did not reflect where the topic of advance directives was discussed again with the patient.

Based on clinical record review, interview and policy review, the facility failed to ensure restraints were not used per policy for the prevention of falls for three (Patient #1, #3 and #4) of 12 clinical records reviewed. The census was 204 patients.

Findings include:

The clinical record review for Patient #1 was completed on 03/02/13. The patient was admitted to the facility on 02/24/13 with a diagnosis of possible seizure activity, altered mental status, and chronic obstructive pulmonary disease. On 2/26/13 at 3:00 PM, a licensed practical nurse documented bilateral wrist and mitts in place due to patient trying to get out of bed without assistance.

On 02/28/13, the facility's policy Use of Restraint or Seclusion was reviewed. The policy stated the routine use of restraints for the prevention of falls is prohibited.

On 02/28/13 Staff D was interviewed. Staff D stated the facility does not normally use restraints to prevent falls.

The clinical record for Patient #3 was reviewed on 03/01/13. The patient was admitted to the facility on 02/09/13 with a diagnosis of a femoral neck fracture. On 2/24/13 at 5:46 AM, a physician wrote an order for soft wrist restraints to protect the patient's physical safety. On 02/24/13 at 10:23 PM, a nurse documented the restraints were in use due to the patient was attempting to remove a nasogastric tube and attempting to get out of bed.

On 02/24/13 at 5:00 AM, a nurse documented a continued need for restraints. The nurse documented alternative interventions attempted prior to the use of restraints as placing the bed in a low/locked position and placing the call light within the patient's reach. Less restricitve interventions to protect the nasogstric tube such as arm splints or mitts without wrist restraints, were not documented.

The clinical record review for Patient # 4 was completed on 03/01/13. The 84 year old patient was admitted to the facility on 02/12/13 with a diagnosis of change in mental status. The patient had a past clinical history of stroke (the rapid loss of brain function due to disturbance in the blood supply to the brain), atrial fibrillation (irregular heart beat) and was on Coumadin (used to prevent heart attacks, strokes, and blood clots in veins and arteries) therapy. On 02/12/13 at 6:00 PM, a physician ordered pulse ox checks every four hours. On 02/12/13 at 5:59 PM, a physician ordered oxygen two liters per minute and pneumatic compression devices (PCD's) to be worn continuously except for bathing and skin assessment and periods of ambulation. The clinical record had documentation the patient was not wearing the ordered oxygen on 02/13/13 at 7:00 PM through 02/14/13 at 6:00 PM. On 02/13/13 at 11:00 PM, a nurse documented the patient was attempting to climb out of bed and the staff moved the patient closer to the nurse's station. At 11:00 PM, the nurse documented the patient was very confused and agitated. The nurse wrote the patient was crying out for shoes and refused to stay in bed. At 12:00 AM, the nurse documented the patient was very restless, yelling and climbing out of bed. At 1:00 AM, the nurse documented the patient was still restless and a nursing assistant was sitting with the patient. On 02/14/13 at 2:45 AM, a physician ordered bilateral wrist restraints. The physician documented in the progress noted the patient was wandering the floors and noted he/she ordered bilateral soft restraints for the patient's safety. The nursing staff did not place the ordered oxygen on the patient or obtain a pulse ox reading per orders prior to placing the patient in restraints on 02/14/13.

The findings were reviewed with Staff F on 03/01/13 and confirmed.

Based on clinical record review, policy and observation, the facility failed to ensure the nursing staff identifed a mitt as a restraint for one (Patient #2) of 12 clinical records reviewed. The census was 204 patients.

Findings include:

The clinical record for Patient #2 was reviewed on 03/01/13. The patient was admitted to the facility on 02/19/13 with a diagnosis of change in mental status. On 02/20/13 at 9:15 AM, a physician ordered the application of hand mitts. On 2/21/13 at 7:30 AM, a registered nurse documented the hand mitts were not tied down and not a restraint per the facility ' s policy. An order to continue the use of restraints was not obtained by the nursing staff on 02/21/13.

On 02/28/13, the facility ' s policy Use of restraint or seclusion was reviewed. The policy stated if mitts are so bulky the patient ' s ability to use their hands is significantly reduced, the mitts are considered a restraint.

On 3/1/13, Staff E demonstrated the use of the facility ' s mitt. Staff E was unable hold a bottle of water with the mitt restraint in place.

Based on clinical record review, interview and policy review, the facility failed to ensure the least restrictive intervention to ensure patient safety was used for two (Patient #1 and #3) of 12 clinical records reviewed. The census was 204 patients.

Findings include:

The clinical record review for Patient #1 was completed on 03/02/13. The patient was admitted to the facility on 02/24/13 with a diagnosis of possible seizure activity, altered mental status, and chronic obstructive pulmonary disease. On 2/26/13 at 3:00 PM, a licensed practical nurse documented bilateral wrist and mitts in place due to patient trying to get out of bed without assistance.

On 02/28/13, the facility ' s policy Use of Restraint or Seclusion was reviewed. The policy stated the routine use of restraints for the prevention of falls is prohibited.


On 02/28/13 Staff D was interviewed. Staff D stated the facility does not normally use restraints to prevent falls.

The clinical record for Patient #3 was reviewed on 03/01/13. The patient was admitted to the facility on 02/09/13 with a diagnosis of a femoral neck fracture. On 2/24/13 at 5:46 AM, a physician wrote an order for soft wrist restraints to protect the patient ' s physical safety. On 02/24/13 at 10:23 PM, a nurse documented the restraints were in use due to the patient was attempting to remove a nasogastric tube and attempting to get out of bed.

On 02/24/13 at 5:00 AM, a nurse documented a continued need for restraints. The nurse documented alternative interventions attempted prior to the use of restraints as placing the bed in a low/locked position and placing the call light within the patient ' s reach.
Less restricitve interventions to protect the nasogstric tube such as arm splints, were not documented.

Based on clinical record review, policy and observation, the facility failed to enure physician orders were obtained for restraint usage for one (Patient #2) of 12 clinical records reviewed.

Findings include:

The clinical record for Patient #2 was reviewed on 03/01/13. The patient was admitted to the facility on 02/19/13 with a diagnosis of change in mental status. On 02/20/13 at 9:15 AM, a physician ordered the application of hand mitts. On 2/21/13 at 7:30 AM, a registered nurse documented the hand mitts were not tied down and not a restraint per the facility's policy. An order to continue the use of restraints was not obtained by the nursing staff on 02/21/13.

On 02/28/13, the facility's policy Use of restraint or seclusion was reviewed. The policy stated if mitts are so bulky the patient's ability to use their hands is significantly reduced, the mitts are considered a restraint.

On 3/1/13, Staff E demonstrated the use of the facility ' s mitt. Staff E was unable hold a bottle of water with the mitt restraint in place. The mitt was bulky

Based on clinical record review, interview and policy review, the facility failed to ensure patients who were restrained were monitored per policy for one (Patient #1) of 12 clinical records reviewed. The sample size was 204 patients.

Findings include:

The clinical record review for Patient #1 was completed on 03/02/13. The patient was admitted to the facility on 02/24/13 with a diagnosis of possible seizure activity, altered mental status, and chronic obstructive pulmonary disease. On 2/26/13 at 3:00 PM, a licensed practical nurse documented bilateral wrist and mitts in place due to patient trying to get out of bed without assistance. A nurse documented a need for the continued use of restraints on 02/26/13 at 10:00 AM. A nurse documented a need for the continued use of restraints on 2/27/13 at 8:00 AM. The time lapse between the documentation of the continued need for restraints was 26 hours. A nurse documented the continued need for restraints on 02/24/13 at 5:00 PM. The next documented need for continued need of restraints was 02/25/13 at 8:00 am and on 02/25/13 at 6:00 PM. The time period between the documentation of continued need of restraints was greater than eight hours.

On 02/28/13, during a tour of the four west nursing unit, Patient #1 was observed with bilateral wrist restraints.

The facility ' s documentation of Use of Restraint or Seclusion-RN/LPN was reviewed on 02/28/13. The form stated the nurse will document the continued need for restraints every eight hours.

Based on observation, interview, and policy review, the facility failed to ensure each patient had relevant nursing plans of care for activity and to prevent skin impairment, each patient had their skin assessed for high risk of skin impairment (396), and each patient had their physician's orders followed for the application of pneumatic compression devices to prevent blood clots, for the application of oxygen, and the collection of stool specimens, and each patient had reason for placement of a urinary catheter (A395). This affected Patient #1, #3, #4, #8, #10, and #11. The sample size was 12 patients, and the census was 204 patients.

Based on clinical record review and policy review, the facility failed to ensure nursing followed physician orders for maintaing a nasogastric tube and have reasons for inserting a urinary catheter in Patient #1, apply pneumatic compression devices to Patient #3, #4, and #8 as ordered to prevent blood clots to the legs, apply oxygen to Patient #4 as ordered, send stool specimens as ordered for Patient #11, perform a skin risk assessment for Patient #8, and turn Patient #10 who had a pressure sore. The sample size was 12 patients, and the census was 204 patients.

Findings include:

The clinical record review in its electronic form for Patient #8 was completed on 03/01/13. The clinical record review revealed an emergency department provider note signed on 02/19/13 at 2:29 P.M. that stated the 66 year old patient was suicidal and threw herself from her/his wheelchair onto the floor at the nursing home.

On 02/28/12 during a tour on 02/28/13 at 10:10 A.M. of the geripsychiatric unit where Patient #8 was staying, the patient was observed up in a chair without pneumatic compression devices applied-a form of medical equipment that prevent blood clots from forming in the legs.

A physician's order dated 02/22/13 stated the patient was to have pneumatic compression devices, but did not give a frequency.

There was no documentation to reveal where the patient's skin was assessed for risk of breakdown.

On the morning of 02/28/13 in an interview, Staff Nurse A confirmed the record did not contain a skin risk assessment.

Review of the facility's policy, Care of the Patient with Skin Breakdown Care and Pressure Ulcer Prevention, revised 01/13, stated patient's skin was to be assessed on admission and at least daily.

The clinical record review in its electronic form for Patient #11 revealed the 91-year-old patient was admitted to the facility on 02/23/13. A history and physical dictated on 02/24/13 at 8:24 A.M. stated the patient's chief complaint was fatigue and hypotension. The history and physical stated the patient was assessed as anemic.

A physician's order dated 02/23/13 at 5:10 P.M. revealed orders for stool specimens to test for occult blood. The clinical record review revealed on 02/24/13 at 11:00 A.M. and on 02/25/13 at 11:00 P.M. the patient had large tarry stools. The record review did not reveal where the stools were sent to the laboratory.

In the afternoon of 02/28/13 in an interview, Nurse Manager 1 confirmed the stool had not been sent.

The clinical record review for Patient #10 in its electronic form was completed on 03/01/13. The clinical record review revealed the 82 year old patient presented to the emergency department on 02/27/13 at 9:28 A.M. for chief complaint of right hand numbness and chest pain.

A nursing note dated 02/28/13 at 8:00 A.M. stated the patient had a red pressure sore two by two centimeters wide and long, and 4.5 centimeters deep on the right side of her/his bottom. On 02/27/13 at 5:00 P.M. the patient's skin was assessed as being at high risk. The record stated the patient was placed on her/his left side. The record failed to have documentation to indicate where he/she was turned until 02/28/13 at 7:00 A.M.

In the afternoon of 02/28/13 in an interview, Nurse Manager 1 confirmed there wasn't documentation to indicate the patient had been turned during the night.











31597


The clinical record review for Patient #1 was completed on 03/02/13. The patient was admitted to the facility on 02/24/13 with a diagnosis of possible seizure activity, altered mental status, and chronic obstructive pulmonary disease. The clinical record contained an order to insert a Foley catheter (a thin, sterile tube inserted into your bladder to drain urine) if needed on 02/24/13 at 5:37 PM. The order did not specify what constituted the medical need for the Foley catheter. The clinical record had documentation of incontinence care being provided on 02/24/13 at 1:17 PM. On 02/24/13 at 9:40 PM, a nurse documented the patient was pulling at the Foley, intravenous catheter site and attempting to get out of the bed. The nurse placed the patient in bilateral mitt restraints. The clinical record did not have documentation of when the Foley catheter was inserted or the reason for the insertion of the Foley catheter. The clinical record contained an order for a nasogastric tube (tube that is passed through the nose and down through the nasopharynx and esophagus into the stomach) on 02/23/13 at 10:45 AM. The clinical record did not contain an order to discontinue the nasogastric tube. On 02/26/13 at 2:13 PM, a licensed practical nurse documented he/she removed the patient's nasogastric tube.

A tour of the four west nursing unit was conducted on 02/28/13. Patient #1 was observed without a nasogastric tube.

On 03/02/13, the findings were reviewed with Staff F and confirmed.

On 3/01/13, the facility's policy Urinary Catheter, Indwelling, Care of the Patient was reviewed. The policy stated to not use urinary catheters for the management of incontinence.

On 03/01/13, the job description for a licensed practical nurse (LPN) was reviewed. The job description stated the LPN works under the direction of a registered nurse or physician. The clinical record did not contain evidence of a physician or registered nurse instructing the LPN to remove the nasogastric tube

The clinical record review for Patient #3 was completed on 03/01/13. The 83 year old patient was admitted to the facility on 02/09/13 with a diagnosis of a femoral neck fracture (hip fracture). The patient developed a deep vein thrombosis (the formation of a blood clot (thrombus) in a deep vein, predominantly in the legs) on 02/16/13. The patient was ordered pneumatic compression devices (PCD's) (inflatable compression sleeves and a characteristic pressure modulation in order to reduce risk of deep vein thrombosis) for the prevention of blood clots. The clinical record had evidence of the patient wearing the PCD's on 2/22/13 at 12:00 PM, 2/25/13 at 12:00 AM and on 02/27/13 at 10:00 AM. The clinical record did not have evidence of the PCD's used on 02/24/13 or 02/26/13.

During an interview on 03/01/13, Staff F stated the use of pneumatic compression devices should be documented at a minimum of every eight hours while the nurses are assessing the patients.

The clinical record review for Patient # 4 was completed on 03/01/13. The 84 year old patient was admitted to the facility on 02/12/13 with a diagnosis of change in mental status. The patient had a past clinical history of stroke (the rapid loss of brain function due to disturbance in the blood supply to the brain), atrial fibrillation (irregular heart beat) and was on Coumadin (used to prevent heart attacks, strokes, and blood clots in veins and arteries) therapy. On 02/12/13 at 6:00 PM, a physician ordered pulse ox checks every four hours. On 02/12/13 at 5:59 PM, a physician ordered oxygen two liters per minute and pneumatic compression devices (PCD's) to be worn continuously except for bathing and skin assessment and periods of ambulation. The clinical record had documentation the patient was not wearing the ordered oxygen on 02/13/13 at 7:00 PM through 02/14/13 at 6:00 PM. On 02/13/13 at 11:00 PM, a nurse documented the patient was attempting to climb out of bed and the staff moved the patient closer to the nurse's station. At 11:00 PM, the nurse documented the patient was very confused and agitated. The nurse wrote the patient was crying out for shoes and refused to stay in bed. At 12:00 AM, the nurse documented the patient was very restless, yelling and climbing out of bed. At 1:00 AM, the nurse documented the patient was still restless and a nursing assistant was sitting with the patient. On 02/14/13 at 2:45 AM, a physician ordered bilateral wrist restraints. The physician documented in the progress noted the patient was wandering the floors and noted he/she ordered bilateral soft restraints for the patient's safety. The nursing staff did not place the ordered oxygen on the patient or obtain a pulse ox reading per orders prior to placing the patient in restraints on 02/14/13. The clinical record did not contain evidence of the PCD's being applied to the patient during the patient's admission at the facility.

The findings were reviewed with Staff F on 03/01/13 and confirmed.

Based on interview, clinical record review, and policy review, the facility failed to develop care plans for Patient #7 to address risk of skin impairment, edema, sleep/wake cycle, or when he/she was allowed to ambulate. The sample size was 12 patients, and the census was 204 patients.

Findings:

The clinical record review in its electronic form for Patient #7 was completed on 03/01/13. The clinical record review revealed the 88 year old patient was admitted to the facility on 09/28/12. Review of the patient's history and physical dictated on 09/28/12 was completed on 03/01/13. The review revealed the patient was brought to the facility's emergency department by his/her daughter for "wandering, not sleeping, confused, inappropriately touching the females, agitated, disrobing himself." The history and physical stated the patient's dementia was described as "severe." The patient was diagnosed with dementia with behavioral problems. The patient was admitted to the facility's geripsychiatric unit.

Documentation revealed the patient's skin was assessed each day during his/her hospitalization. At no time was skin breakdown revealed. A discharge summary dictated on 10/08/12 did not reveal documentation the patient had any skin breakdown nor development of pneumonia while in the hospital.

However, using a braden scale-a scale used to determine whether a patient is at risk for pressure sores--Patient #7 was assessed on 09/28/12 at 4:00 A.M., 9:00 A.M., and 9 P.M., and on 10/01/12 at 10:00 A.M., and on 10/02/12 at 9:00 A.M. On 09/28/12 at 4:00 A.M., 9:00 A.M., and 9 P.M. the score was 18, on 10/01/12 at 10:00 A.M. and 9:00 P.M., and on 10/02/12 at 9:00 A.M. the score was 17.

Review of the facility's policy, Care of the Patient with Skin Breakdown Care and Pressure Ulcer Prevention, revised on 01/13, was completed on 03/01/13. The review revealed patients with a score of between 6 and 18 are "at risk" for pressure sores.

The clinical record review did not reveal documentation a nursing care plan was created to address the risk of skin breakdown.

On 03/01/13 at 3:00 P.M. in an interview, Nurse Manager #1 confirmed nursing had not created a plan of care for preventing skin breakdown in spite of the high risk assessment.

The clinical record revealed the patients geographic location was documented every 15 minutes. Locations varied from his/her room, to the bathroom, to the hallway, to the day area.

The clinical record revealed a physician's order dated 09/28/12 at 4:48 P.M. that stated the patient could be up as tolerated.

The record review did not reveal documentation Patient #7 was ambulated or documentation a care plan was developed to address when, where, or how often to ambulate the patient.

On 03/01/12 at 3:00 P.M. in an interview, Nurse Manager #1 was unable to show where in the clinical record the patient was ambulated.

The record review revealed nursing notes that stated the patient had edematous bilateral lower extremities on 10/01/12 at 10:00 A.M., on 10/02/12 at 9:00 A.M. and on 6:00 P.M. The review revealed a nursing assessment dated 10/03/12 at 2:00 P.M. that stated the patient had edema but didn't say where.

The clinical record review in its electronic form did not reveal how nursing addressed the edema, nor did it contain a care plan that addressed the patient's edema.

On 03/01/12 at 3:00 P.M. in an interview, Nurse Manager #1 was unable to show where in the clinical record a care plan was created to address the patient's edema.

The clinical record review did not reveal any order for a restraint at any time or where any restraint was applied.

The clinical record review revealed from 09/28/12 to 7:00 A.M. Patient #7 was not taken to his/her room for sleep until 9:00 P.M. The record review revealed on 09/30/12 from 12:30 A.M. to 11:00 P.M. the patient was never in his/her room. The record stated the patient was either in the hallway or day area, but not in his/her bedroom.

On 10/01/12 from 7:00 A.M. to 10:00 P.M. the patient was in his/her room. Between 8:00 A.M. and 1:00 P.M. he/she was sleeping, and from 2:15 P.M. to 7:30 P.M. was sleeping.

The clinical record review revealed on 10/02/12 at 3:00 P.M. the patient was in his/her room for at least 30 minutes. The record review did not reveal a nursing plan of care that addressed the patient's sleep/wake cycle. On 10/03/12 at 4:00 P.M. the patient was discharged.

On 03/01/13 at 3:00 P.M. in an interview, Nurse Manager #1 stated he/she could not determine from the charting what the patient was doing in the hallway or day area, or whether the patient was in a wheelchair, gerichair, or regular chair. Nurse manager #1 also stated although documentation differentiated whether the patient was awake or asleep in room, there wasn't any way to determine if the patient was awake or asleep in any other area such as the hallway or day area. He/she also state there wasn't a care plan that addressed the patient's sleep/wake cycle.