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Based on medical record review, staff interview, and policy review, the hospital failed to ensure that each patient admitted to the hospital received a copy of their patient rights and had a signed consent for treatment for 3 of 16 patients reviewed (Patient # 6, 7, and 16). The hospital's failure to ensure that patients receive and understand their Patient Rights put all patients at risk for not understanding their rights to information about their care, their privacy, participation in the planning of their care, and the safety, protection and their comfort during their admission to the hospital.

The findings include:

- Patient # 6's medical record reviewed on 8/9/2016 revealed the patient was admitted to the Hospital on 8/7/2016 with a diagnosis of severe sepsis (life threatening condition as a result of infection causing the body to damage tissues and organs). The medical record lacked evidence the patient or the patient's representative received a copy of the patient rights or the patient or the patient's representative consented to treatment at the Hospital.

- Patient #7's medical record reviewed on 8/9/2016 revealed the patient was admitted to the Hospital on 8/6/2016 with a diagnosis of sepsis (life threatening condition as a result of infection causing the body to damage tissues and organs). The medical record lacked evidence the patient or the patient's representative received a copy of the patient rights or the patient or the patient's representative consented to treatment at the Hospital.

- Patient # 16's medical record review on 8/9/2016 revealed the patient was admitted to the Hospital on 8/7/2016 with a diagnosis of sepsis (life threatening condition as a result of infection causing the body to damage tissues and organs) and pneumonia (inflammatory condition of the lung). The medical record lacked evidence the patient or the patient's representative received a copy of the patient rights or the patient or patient's representative consented to treatment at the Hospital.

Policy titled "Procedure for Registration Forms and Signatures" reviewed on 8/9/2016 at 3:00 PM directed " ...obtains signatures on all registration forms, form the patient or legally authorized individual, prior to or during the registration process or within a reasonable time frame based upon the patient circumstance ...and ...Reasonable attempts will be made for follow up on signatures not obtained during the registration process ... and ... A physician or licensed clinical person should document a medical reason why the patient is unable to provide a signature within the medical record ... and ... If a signature is not received from the patient or telephone consent from an authorized person, no treatment should be rendered unless it is an emergency ... "

Based on observation, medical record review and staff interview the hospital failed to ensure patient safety was met in that the nursing staff failed to provide ongoing nursing assessments and activation of safety devices and alerts for 6 of 32 patients sampled (Patients #1, #17, #18, #19, #20, and #21). Failure by nursing staff to provide ongoing assessments and activation of safety devices and alerts had the potential to increase the risk of patient falls. The facility failed to ensure nursing staff followed physician orders for the removal of a Foley catheter (removal of a tube placed in the bladder to collect urine) for one of 32 patient's sampled (Patient #1). This failure had the potential to place patients at an increased risk for infections.

The findings include:


- Patient #1's medical record reviewed on 8/8/2016 revealed the patient was admitted on 6/2/2016 and discharged on 6/7/2016 with a diagnosis of a sigmoid stricture (bowel obstruction). After the surgical procedure the patient was taken to 8T (tower) room 4-810. The medical record revealed the nursing staff failed to round on the patient at least every two hours on 6/4/2016 and 6/5/2016. Nursing assessment documentation revealed the bed alarm was not recorded as "on" during the evening shift and night shift of 6/4/2016. The medical record revealed the patient fell in their room at approximately 5:45 AM the morning of 6/5/16.

Patient #1 interviewed on 8/8/2016 at 1:30 PM revealed they had fallen in the early morning of 6/5/2016 after being woken up by a beeping IV machine. Patient #1 stated they tried to use the call light but no one came. The patient indicated they were instructed to use the hospital telephone at night, but the telephone in their room was on a high shelf in the corner of the room away from their bed. The patient confirmed the bed alarm was not turned on as no alarm sounded when they got out of bed. The patient revealed no nurses had been to their room for hours before they fell.

- Patient #1's record also revealed an order was placed on 6/2/2016 at 5:54 PM to discontinue the Foley catheter at 10:00 AM on 6/3/2016. A second order to discontinue the Foley catheter was placed on 6/4/2016 directing staff to remove the Foley catheter at 10:15 AM. Nursing documentation revealed the Foley catheter was not removed until 6/4/2016 at 7:00 PM. Failure of the nursing staff to remove the foley catheter as directed placed the patient at a higher risk for a urinary tract infection.

- Patient #17's medical record reviewed on 8/10/2016 revealed the patient fell on 3/1/2016 at 3:50 AM on the 8T unit fall report. Fall recorded in medical record by RN Staff F. Documentation stated patient #17 was found on the floor by nurse assistant. Documentation noted that patient stated s/he did not fall but sat on floor because s/he was tired of waiting for someone to comne to take her to the bathroom and did not want to pee the bed. RN Staff F documented non-skid socks were put on patient #17 by RN Staff F but patient #17 had removed them. Documentation states the patient refused to have bed alarm set and that patient was non-compliant with fall risk safety education. Documentation stated that patient was wearing a "fall risk" wrist band and a fall risk sign was at the door. Post fall assessment documentation stated patient did not hit head.

- Patient #18's medical record reviewed on 8/10/2016 revealed the patient fell on 4/26/2016 at 7:00 AM on the 8T unit fall report. Fall recorded in medical record by Staff RN G. Documentation stated patient #18 was found on floor, leaning on door rail at 8:30 AM and was recorded at 8:39 AM. Shift assessment on 4/25/2016 at 9:30 PM revealed bed alarm was not set. Documentation after the fall revealed patient #18 had non slip socks on, but was unclear if socks were in place before the fall. Following the fall, documentation revealed bed alarm was set and fall risk arm band was in place. Post fall assessment documentation stated it was unknown if patient #18 hit head. The medical record failed to indicate the bed alarm was on prior to the patients fall.

- Patient #19's medical record reviewed on 8/10/2016 revealed the patient fell on 5/7/2016 am at 4:34 AM on the 8T unit fall report. Fall recorded in medical record by Staff RN H. Nursing assessment documentation stated patient #19 was a high fall risk. High fall risk checklist was not completed. Documentation revealed the fall occurred at 1:19 AM and was recorded at 1:30 AM with an addendum made at 7:52 AM. Patient #19 was found on floor at 4:30 AM and "post fall protocol completed". Post fall assessment documentation stated patient did not hit head.


- Patient #20's medical record reviewed on 8/10/2016 revealed the patient fell on 5/24/2016 am at 6:55 AM on the 8T unit fall report. Nursing assessment performed by Staff RN H documented on 5/24/2016 at 0300 am that patient #20 was a moderate fall risk, bed was low to floor, call light was present, and the patient was restless. Ativan (for the treatment of anxiety) was given to patient #20. Documentation of the fall by RN Staff I on 5/24/2016 at 12:00 PM stated, "patient #20 fell last night".

- Patient #21's medical record reviewed on 8/10/2016 revealed the patient fell on 2/5/2016 am at 8:00 am per unit fall report. Documentation by RN Staff J on 2/4/2016 at 10:00 PM patient #21 was high fall risk. High fall risk check list was not completed. Documentation by RN Staff K on 2/5/2016 at 8:15 AM revealed patient #21 was a high fall risk, with a fall alert arm band, a specialty low bed, documentation that patient #21 was not to be left unattended. Bed alarm activation was not documented. RN Staff K documentation revealed patient #21 was found on the floor on 2/5/2016 at 8:45 AM. Post fall assessment documented by RN Staff L on 2/5/2016 at 9:10 AM stated the fall occurred at 9:00 AM and documented patient did not hit head ...."

Administrative Staff A interviewed on 8/11/2016 at 11:05 AM revealed nursing staff are educated using the StuderGroup Hourly Rounding:101 document stating " ...When Hourly Rounding is implemented effectively, a staff member visits each patient every hour during the day, and every two hours during the night. During these rounds, eight very specific behaviors are utilized that contribute to improved safety for patients and efficiency for staffing ... "

- Review of policy "Fall Prevention" directed ..."Patients will be assessed for potential to fall upon admission ...and reassessed with each shift assessment ..." Policy further directs " ...moderate fall risk will be identified with a yellow arm band and high risk for fall will be identified by a yellow arm band with high risk indicator lettering ..." Policy further directs ... " a safe environment is to be provided for every patient...and ...use properly fitting non-skid footwear, keep bed in lowest position ...bedrails up times two unless contraindicated ... " Fall Prevention policy further directs "...moderate fall risk supervise and or assist bedside sitting, personal hygiene, and toileting as appropriate ...evaluate need for activation of bed and chair alarm. High fall risk ...implement measures listed under moderate risk and activate bed alarm, remain with patient while toileting ...It is the responsibility of every employee to provide ongoing surveillance of the environment to ensure patient safety. Patient ' s fall risk and/or need for assistance with activities will be communicated between shifts during bedside report ... "

Based on medical record review and staff interview, the Hospital failed to ensure that 1 of 32 patients reviewed (Patient #2) had a current individualized nursing care plan. Failure to include an individualized nursing care plan in the medical record resulted in an incomplete nursing assessment of a patient's needs and goals for improvement of health status.

The findings include:

Patient # 2's medical record reviewed on 8/9/2016 revealed the patient was admitted to the Hospital on 8/6/2016 with cardiac arrest (stopped heart beat). The documentation revealed the standard care plan found in the chart had not been individualized to the patient's specific needs. Nursing care plan failed to show individualized patient goals and progress toward the goals.

RN Staff A interview on 8/11/2016 at 11:00 am revealed that the nursing care plan is driven by the patient problem list and the electronic medical record populates the care plan. Staff nurses have the opportunity to individualize the care plan specific to patient needs and set goals. The care plan allows the staff nurse to set active or inactive status, progress toward completion of the goal, and priority of the action.

Hospital policy titled "Nursing Documentation of Patient Stay" directed "...a plan of care will be developed on admission and reviewed and/or updated within every 12 hour shift, at a minimum by the registered nurse ..."

Based on observation, staff interview and policy review, the infection control officer failed to assure an effective and ongoing infection control program that identified potential infection control risks. The hospital failed to ensure proper hand hygiene and injection practices in the surgical and postoperative areas. This deficient practice has the potential to expose all patients to infectious diseases.

Findings Include:

Operating Room # 15 observed on 8/10/2016 at 7:51AM revealed Staff B failed to clean the IV port (a rubber septum located on IV tubing) of a needless system before injecting medication into it, and failed to don gloves before patient contact during the surgical procedure, and when manipulating IV lines.

Staff X observed on 8/10/2016 at 7:55 AM revealed them providing patient care to patient # 22 and then begin charting on a computer keyboard with his/her gloves on. Staff X failed to preform hand hygiene after removal of gloves and before providing patient care.

Staff C interviewed on 8/10/2016 at 8:00 AM, stated, "We don't have to wear gloves when administering meds only when in contact with fluids."

Policy titled, Hand Hygiene Policy reviewed at 10:45 AM on 8/10/2016 directed "...HCW's should perform hand hygiene before handling clean supplies, sterile supplies, clean linen, medications and food ..." and "...HCWs should perform hand hygiene after removing gloves and /or other personal protective equipment."