HospitalInspections.org

Based on record review and interview with staff, 2 of 7 outpatient records did not have documentation of advance directives.
Findings include:
Electronic record review with staff on 1/12/10 found there was no documentation in Patients' #29 and #33 record documenting whether the patient has an advanced directive. Staff reported the "Health Screening" form is completed by the patient and the assigned clinician should review for completeness. The portion of the questionnaire asking whether the patient has an advance directive was left blank. Interview at 2:50 P.M. with the manager and staff confirmed documentation of advance directive was not done as evidenced by the incomplete forms.

Based on observation, record review and interview with staff, the facility failed to ensure the patient's right to be free of neglect when the policy and procedures for identifying, protecting and completing a thorough investigation was not done.
Findings include:
A complaint investigation was done during the validation survey on 1/14/10.
On 12/28/09 at 2:10 P.M., the patient's adult daughter contacted the Department of Health, Office of Health Care Assurance to register a complaint regarding this facility. The patient's daughter reported that on 12/28/09 her mother was transferred to another unit, she left her mother's bedside at about 3:30 P.M. and when she returned between 6:30 P.M. and 7:00 P.M. she attempted to use the call light. She did not receive a response and approached a nurse aide (complainant was able to provide the name of the nurse aide) and was told that he/she "unplugged" it as her mother was calling too often. The complainant approached the Charge Nurse and Evening Supervisor who the complainant reported appeared to be in agreement with the nurse aide's action. The complainant also reported the facility's "Patient Advocate" was contacted.
Observation on 1/13/10 at 11:05 A.M. with the Unit Manager and the nurse aide that was identified by the complaint was done. Observed the unit's call light is a cord that is plugged into an outlet in the wall. The staff demonstrated that when the call light is unplugged it will sound an alarm and they questioned how the call light was unplugged. The nurse aide also noted that there is also another connection that has to be made for the system to be operational.
During the observation tour, the nurse aide was interviewed regarding the event. The nurse aide reported the complainant asked the patient in the other bed to press the call light. When the nurse aide responded, the complainant approached the nurse aide to report her mother's call light was not working. The nurse aide confirmed that the call light was not plugged in when she/he responded to the complainant's concern. The nurse aide could not recall the time of the event. The nurse aide also reported that the patient called every "5 seconds" and was "confused," calling for a change of personal brief when it was just changed.
Electronic record review was done on the mornings of 1/13/10 and 1/14/10 with facility staff. The patient was admitted to the facility on 12/24/09 with history of multiple cerebrovascular accidents with left sided weakness, dysarthria, and dysphagia (g-tube feeding). The flow sheet dated 12/24/09 notes patient requires help for bathing, feeding, getting dressed, toileting, walking, and going up and down stairs. The Patient Summary notes patient is at high risk for falls. A nursing progress note dated 12/27/09 notes patient has "slurred speech difficult to understand" and indicated she had pain by pointing to left lower extremity and left shoulder. The patient had a care plan to address pain.
The Patient Advocate was interviewed on 1/13/10 at 9:45 A.M. and on 1/14/09 at 10:10 A.M. the Patient Advocate (PA) and his/her manager were interviewed by the survey team. The PA clarified that the event occurred on 12/27/09. The PA reported the complainant was interviewed by the PA via telephone on the morning of 12/28/09. The PA stated the complainant reported that her mother's call light was not working as it was not plugged in and staff informed her that the call light was disconnected as her mother called so much. Per the PA, the complainant commented that the staff gave an "attitude." The complainant was also able to identify the charge nurses by name and reported to the PA that she thought the nurse aide (identified by name) unplugged the call light.
The PA referred the complaint to the unit nurse manager on 12/28/09 for follow up. The PA reported that the nurse manager communicated that the staff had mentioned the event to him/her and the unit nurse manager was not sure how the call light cord became unplugged.
The facility's policy and procedures dated 5/15/07 entitled "Abuse/Harm or Neglect of Patients: Reporting and Intervention" was reviewed with the PA and Unit Manager. The facility's definition of neglect includes "Failure to exercise that degree of care toward a dependent person which a reasonable person with responsibility of a care giver would exercise." The Unit Manager acknowledged that an allegation of neglect was not identified by their unit and when allegations of abuse/neglect are identified another unit will investigate. The Unit Manager also reported that the determination of whether there is an allegation of abuse/neglect is deferred to the patient care unit manager and the patient care unit manager did not identify the incident as an allegation of neglect.
The section 5.4.2 Alleged Abuse/Harm or Neglect by an Employee was also reviewed with the PA and Unit Manager that states the following: "5.4.2.2. The unit or Department Manager may suspend the employee immediately, pending investigation..." The Unit Manager confirmed the alleged perpetrator continues to work and confirmed he/she was at work on 1/13/10 and recognized the need to protect other patients during the investigation.
The Unit Manager reported the incident is in the process of being investigated as a complaint not an allegation of neglect; therefore, a thorough investigation has not been done.

Based on observation, record review, and staff interview, the facility failed to ensure a care plan was developed for the use of restraint or seclusion for Patient #3.

Findings include:
On the morning of 1/7/10 during the tour of the unit, observed Patient #3 coming down the hallway, partially undressed, yelling and swearing. The facility staff was following the patient and eventually was able to get him/her into a room. The patient continued to yell and swear and the surveyor and facility escorts were taken to a meeting room to continue the tour after the patient's needs were met.
Electronic record review was done with facility staff on 1/7/10 at 10:30 A.M. Patient #3 was admitted to the facility on 1/1/10 after presenting at the Emergency Department with reports by family member that the patient has become increasingly violent, hit parent in the face and out of control at home. The patient is diagnosed with autistic disorder with behavioral disturbance. The patient had a previous acute admission in May 2009.
Record review found documentation of restraint use on 1/6/10. There was a physician order for four point leather restraint. The restraint was applied at 1800 and discontinued at 1941. Staff confirmed a crisis assessment was not done during this hospitalization and that a care plan to identify interventions to prevent the use of restraints/seclusion was not developed.
Interview with staff revealed this is the patient's second admission and during the first admission, restraints/seclusion was not used. Staff reported during the previous admission, a box and weighted vest were used as the patient does not like open spaces and staff planned to get these items for present admission.

Based on observation, interviews, record reviews, and review of facility policy, the facility did not ensure that the condition of the patient who is restrained must be monitored by a physician, other licensed independent practitioner or trained staff that have completed the training criteria for 2 of 7 patients with restraints. (Patients #9, #44)
Finding includes:
1) Observation on the morning of 1/7/10 on one of the nursing units had Patient #44 lying in bed. The licensed nurse on duty pointed out the bilateral wrist restraints. Record review on that morning found the care plan and physicians orders for restraints. Simultaneous record review with a licensed nurse and a nursing manager found patient's flow sheet for 1/6/10 which revealed that there was no documentation for monitoring of the restraints at 1300 and 1500. The licensed nurse, charge nurse, and nursing manager confirmed that monitoring of restraints were to be done every 2 hours, and that this should be documented.
Review of the facility's policy and procedures for Restraint and Seclusion contained in section 3.3.2 noted that "Other monitoring activities shall be performed at least every two hours, or more frequently if indicated by the condition or behavior of the patient."
2) Electronic record review and concurrent staff interview was done on 1/8/10 at 10:10 A.M. with facility staff. Patient #9 was admitted to the facility on 12/28/09. The patient's nurse reported soft wrist restraints were initiated while the patient was in ICU as the patient made attempts to pull at tracheostomy tube. Review of the flow sheet found restraint monitoring was done on 1/7/10 at 0300, 0917, 1228 and 1544. There was a progress note by the nurse on 1/7/10 at 0743 that documented restraint usage. Unit staff reported restraint monitoring should be done every two hours. The substitute Unit Manager and staff confirmed the restraint monitoring was not done every two hours.

Based on record reviews and interview with staff, the hospital did not ensure that the nursing staff develops, implements, and keeps current a nursing care plan for 3 patients. (Patients #7, #48, and #53)
Findings include:
1) An intervention for a nursing care plan was not fully implemented for Patient #48. Record review for Patient #48 found a care plan for pressure ulcers/wound care. It noted that dressings and wound care would be done as ordered. There was a physician order on 12/29/09 for dressing change TID. However, review of the flow sheet with the patient's primary nurse on 1/8/09 found that on 12/31/09 dressing changes were done only 2x that day instead of TID.
2) Nursing care plan intervention was not implemented for Patient #53. Record review for Patient #53 found a care plan titled "Patient will have adequate nutrition". One of the interventions noted to push fluid intake to 1500 ml per day. However, the intervention was not met as fluid for 1/7/09 at 0700 to 1/8/09 at 0659 was 320 ml. On 1/8/09 at 0700 to 1/9/09 at 0659, there was only 320 ml. total intake.

3) Electronic record review was done on 1/7/10 at 2:55 P.M. and 1/8/10 at 9:10 A.M. with facility staff. Patient #7 was admitted to the facility on 11/10/09 due to altered mental state. The Nursing Initial Assessment noted patient had unplanned weight loss greater/equal to 15 pounds. Patient was referred to Dietician.
Progress note of 11/11/09 notes nutrition consult was done on 11/11/09. The patient was not in his/her room. Patient weighed 160 lbs. Dietician noted "good PO intake" and labs were unremarkable. The plan was to follow up to obtain diet/weight history and food preferences. Subsequent follow up note documents no new weight available and the plan was to continue to monitor PO and encourage good intake. The last progress note of 12/11/09 documents patient weighed 135 lbs. Assessment was that the patient meets the criteria for "moderate malnutrition" and dietician recommended adding Ensure plus to tray once a day with unit dietician to follow.
Review of the patient's care plan found that there was no plan with interventions to address the resident's weight loss. Interview with Unit Manager on 1/8/10 at 9:10 A.M. confirmed a care plan was indicated and was not done.

Based on record reviews and staff interviews, the facility failed to ensure all patient medical record entries were legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluation of the service provided for Patients #9 and #14.
Findings include:
1) Record review done with facility staff on 1/8/10 at 10:10 A.M. found Patient #9's post anesthesia report was signed and dated; however, the time was left blank. Interview with the licensed nurse confirmed this was not done.
2) Record review done on the morning of 1/7/10 noted Patient #14 was admitted to the facility on 12/27/09. Progress notes found entries with incomplete dates and not timed. Entries found notes dated "1/5, 1/6 and 1/7". Interview and concurrent record review with the nurse manager at 10:20 A.M. confirmed that the dated entries need to include the year and time as well.