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Based on document review and interview the facility failed to ensure evidence of a patients safety related to a patient injury without investigation in one (1) instance. (Patient # 9)


The cumulative effects of the above resulted in the facility inability to promote patient rights in a safe setting.

Based on document review and interview the facility failed to ensure evidence of a patients safety related to a patient injury without investigation in one (1) instance. (Patient # 9)

Findings include:

1. The hospital policy titled, Patient Abuse and Neglect, PolicyStat ID 13034136, indicated all patients have the right to be free from abuse or neglect as well as the fear of being abused or neglected. Allegations or information indicating that abuse or neglect may have occurred would be thoroughly and promptly investigated with appropriate action taken. All hospital employees have an obligation to protect patients, prevent abuse or neglect from occurring, and to report any and all information concerning occurrences where abuse or neglect may have occurred. If there is an allegation or indication of physical injury, the hospital shall seek appropriate medical attention. This policy was last revised in 01/2023.

2. The hospital policy titled, Patient Rights and Responsibilities, PolicyStat ID 13517670, indicated the patient had the right to receive an appropriate assessment and care in a safe setting free from physical abuse. This policy was last revised in 09/2021.

3. Review of the Incident Log dated 06/01/2023 to 08/17/2023, lacked any incidents related to patient # 9.

4. Review of patient # 9's medical record (MR), indicated the patient was a 77 y/o (year/old) admitted to the hospital on 08/02/2023 with a diagnosis of unspecified dementia, urinary retention, and hypertension. Review of the patient MR initial skin assessment dated 08/03/2023 indicated the patient had bruises/scratches to both forearms. Daily Nursing Assessments dated 08/08/2023 at 6:00 pm by S # 4 (Licensed Practical Nurse-LPN), indicated "brui (line through) error discoloration noted to bilateral eyes", and on 08/10/2023 at 6:00 pm by S # 4, note indicated bruises (fading) noted to face. The MR lacked any skin assessment documentation related to bilateral eye bruising or cause of facial bruising.

5. Review of patient # 9's MR from H # 3 (Acute Care Hospital) dated 08/13/2023 at 5:52 am, indicated upon conducting a physical examination of the patient - noted bilateral mild periorbital ecchymosis which appeared over twenty-four (24) hours old.

6. In interview on 08/21/2023 at approximately 11:30 am with staff member S # 3 (Behavioral Health Assistant-BHA), confirmed the patient didn't have bruises around his/her eyes when he/she was transferred from the 200 unit to the 100 unit. He/she indicated they were off work and when they came back he/she had the bruised eyes.

7. In interview on 08/21/2023 at approximately 3:30 pm with staff member S # 4 (Licensed Practical Nurse-LPN), confirmed no investigation was conducted related to the patient facial bruising.

Based on document review and interview, the facility failed to electronically document details and actions taken with a patient in an incident report (IR) in one (1) instance. (patient # 9).

Findings include:

1. The facility policy titled, "Incident Reports", PolicyStat ID 13033981, indicated an incident was defined as any event which was not consistent with the routine operation of the hospital and that adversely affects or threatens to affect the well-being of the patient. An incident report should be completed in the system by the end of the shift in which the incident occurred but no later than twenty-four (24) hours from the time of the event occurred. Incident Reports should include details of the incident and what actions were taken. This policy was last revised in 01/2023.

2. Review of the facilities IR log dated June 01, 2023 to August 17, 2023 for all three units (100, 200 & 300) lacked any documentation related to patient # 9's emergent medical send out on 08/13/2023 at approximately 5:13 am.

3. Review of the facilities Nursing Education 2023 documentation, indicated all incidents (send outs) must have an incident report completed.

4. Review of patient # 9's MR, indicated the patient was a 77 y/o (year/old) admitted to the hospital on 08/02/2023 with a diagnosis of unspecified dementia, urinary retention, and hypertension. Review of the patient medical record (MR) Daily Nursing Assessment dated 08/13/2023 at approximately 5:00 am by S # 11 (Registered Nurse), indicated patient # 9 was found unresponsive. His/her vital signs were taken - blood pressure was undetected, blood sugar 176, pulse 140, oxygen level 77% on room air, temperature 100.5, and his/her respirations were four (4). Patient was placed on oxygen and 911 was called.

5. In interview dated 08/18/2023 at approximately 2:15 pm with staff member S # 4 (Licensed Practical Nurse-LPN), confirmed an Incident Report should have been completed for patient # 9 who was sent out to the Emergency Room (ER).

6. In interview dated 08/18/2023 at approximately 3:00 pm with administrative staff member A # 1 (CEO), confirmed "we missed it". An IR wasn't done for patient # 9's send out.

7. In interview dated 08/21/2023 at approximately 12:02 pm with staff member S # 8 (Registered Nurse-RN/Supervisor), confirmed yes, an IR should have been done in Wellsky (electronic reporting system).

8. In interview dated 08/21/2023 at approximately 2:45 pm with staff member S # 6 (RN), confirmed he/she had gone in patient # 9's room and heard how the patient was breathing, turned on the light, noticed the patient had vomited, and started suctioning him/her. "I believe" he/she aspirated. The patient's temperature was 105 degrees. "I thought" he/she was septic. The other RN on the unit was instructed to call 911 and to inform all the necessary people. An incident report should have been completed. We only had one (1) BHA (Behavioral Health Assistant) from 11:00 pm to 07:00 am.

Based on document review and interview the facility failed to provide an adequate number of ancillary personnel (Behavioral Health Assistants-BHA's) necessary for the provision of appropriate care to all patients as needed, and failed to ensure at least one (1) Registered Nurse (RN) was staffed on each unit/shift per policy (tag 392), failed to ensure the Director of Nursing and RN's followed patient care orders, completed weekly skin assessments per policy, obtained/documented weekly weights per policy, reported abnormal test results to the provider in a timely manner per policy, and gave an RN to RN patient report to the acute care hospital where a patient was transferred per policy (tag 395), and failed to follow a patient's nutrition care plan (tag 396).

The cumulative effects of the above resulted in the facility inability to provide nursing services in a safe manner.

Based on document review and interview, the Nursing Director failed to ensure an appropriate number of personnel were staffed to provide nursing care to all patients as needed in one (1) instance (Unit 100), and failed to ensure one (1) Registered Nurse (RN) was staffed on each unit in ten (10) instances. (100, 200 & 300 units).

Findings include:

1. The facility policy titled, "Staffing Plan", PolicyStat ID 13219046, indicated the DON shall ensure staffing plans are established, implemented, documented, and reviewed/revised as needed. The DON maintains 24-hour accountability for adequate staffing for each unit and under no circumstances shall there be less than one (1) RN on each unit, if the unit had more than one (1) patient. This policy was last revised in 02/2023. This policy was last revised in 02/2023.

2. Review of the BHA staffing schedule sheet, provided by the DON, for the 100 unit indicated the following:
a. On 08/12/2023 the patient census was 28 and there were two (2) BHA's staffed, but one (1) BHA was sent to another unit (per interview) on the midnight shift (11:00 pm to 7:00 am shift) making the unit short 2 BHA's.
b. On 08/08/2023, 08/09/2023, and 08/14/2023 midnight shift the patient census was 28 and there were three (3) Behavioral Health Assistants (BHA's) staffed.

3. Review of the Nursing Compliment Data sheet indicated the facility had 11.0 FTE's (Full Time Equivalent) positions open for BHA's. Total available equals four hundred forty (440) hours.

4. Review of the RN staffing (12-hour) schedule for the 100 unit indicated the following:
a. On 08/11/2023 the patient census was 26 and there was not an RN scheduled on either the day or night shift.
b. On 08/17/2023 the patient census was 27 and there was not an RN scheduled on the day shift.

5. Review of the RN staffing (12-hour) schedule for the 200 unit indicated the following:
a. On 08/10/2023 the patient census was 24 and there was not an RN scheduled on the day shift.
b. On 08/14/2023 the patient census was 25 and there was not an RN scheduled on the night shift.
c. On 08/16/2023 the patient census was 24 and there was not an RN scheduled on the day shift.

6. Review of the RN staffing (12-hour) schedule for the 300 unit indicated the following:
a. On 08/14/2023 the patient census was 14 and there was not an RN scheduled on the day shift.
b. On 08/17/2023 the patient census was 13 and there was not an RN scheduled on the day shift.
c. On 08/18/2023 the patient census was 14 and there was not an RN scheduled on the day shift.

9. Review of patient # 9's MR, indicated the patient was a 77 y/o (year/old) admitted to the hospital on 08/02/2023 with a diagnosis of unspecified dementia, urinary retention, and hypertension. Review of the patient medical record (MR) Daily Nursing Assessment dated 08/13/2023 at approximately 5:00 am by S # 11 (Registered Nurse), indicated patient # 9 was found unresponsive. His/her vital signs were taken - blood pressure was undetected, blood sugar 176, pulse 140, oxygen level 77% on room air, temperature 100.5, and his/her respirations were four (4).

10. Review of the MR from H # 3 (Acute Care Hospital), indicated the patient had been intubated in the ambulance due to respiratory distress with a 70% oxygen level on room air. An EKG (Electrocardiogram) resulted sinus tachycardia with no ST elevation and/or ectopy. Initial physical examination indicated the patient's pupils were two (2) mm (millimeter), minimally reactive and bilateral mild periorbital ecchymosis which appeared over 24 hours old. The patient's Lactic Acid Sepsis level was 5.2 mmol/L (millimoles/Liter) with the normal range 0.5 - 2.2 mmol/L. Final clinical impression was severe sepsis with septic shock, altered mental status, hypoxia, lactic acidosis, urinary tract infection, renal insufficiency, elevated troponin, and bilateral pulmonary infiltrates. Patient expired 08/15/2023 at approximately 1:59 am.

11. In interview dated 08/21/2023 at approximately 2:45 pm with staff member S # 6 (RN), confirmed unit 100 only had one (1) BHA from 11:00 pm to 07:00 am on midnight shift on 8/12/23.

12. In interview dated 08/21/2023 at approximately 12:02 pm with staff member S # 8 (RN/Supervisor), confirmed the 100 unit only had one (1) BHA from 11:00 pm to 7:00 am. The other BHA was sent to the 200 unit.

13. In interview on 08/21/2023 at approximately 12:20 pm with S # 7 (Licensed Practical Nurse-LPN), confirmed according to policy each unit/shift should be staffed with an RN.

14. In interview on 08/21/2023 at approximately 2:50 pm with S # 6 (RN), confirmed each unit should be staffed with an RN.

15. In interview on 08/22/2023 at approximately 5:00 pm with staff member S # 9 (RN), confirmed each unit/shift should be staffed with an RN.

Based on document review and interview, the Director of Nursing (DON) failed to ensure the nursing staff followed patient care orders in one (1) instance, failed to complete a weekly skin assessment in one (1) instance, failed to obtain a weekly weight in one (1) instance, failed to assess a patient appropriately in one (1) instance, failed to report abnormal results of a laboratory test to the provider in one (1) instance, and failed to ensure a nurse report regarding the patient's condition was called to the facility where the patient was transferred in one (1) instance. (Patient # 9)

Findings include:

1. The facility policy titled, Physician Orders/Receipt and Notation, PolicyStat ID 12197185, indicated provider orders shall be written for the medical and functional management for each patient specific to their individual needs. All provider orders should be second noted by an Registered Nurse (RN) or an Licensed Practical Nurse (LPN). This policy was last revised in 09/2020.

2. The facility policy titled, Skin Assessment, PolicyStat ID 12385990, indicated the purpose was to identify any existing or new injuries (bruises). Skin assessments should be completed one time per week. This policy was last revised in 09/2022.

3. The facility policy titled, Vital Signs and Weight, PolicyStat ID 12386461, indicated weights should be recorded weekly in the patient's medical record (MR). This policy was last revised in 09/2022.

4. The facility policy titled, Intake & Output Monitoring, PolicyStat ID 12386133, indicated to assure that each patient receives sufficient amount of fluid, to serve as an aid to the provider in establishing diagnosis, planning the treatment of the patient. Patients that have a Foley catheter require strict intake and output monitoring by an intake precaution order for best patient care, and should be recorded daily. Document when appropriate the color, consistency, and odor of the output in the nurses' notes. This policy was last revised in 09/2022.

5. The facility policy titled, Assessment/Reassessment, PolicyStat ID 12386392, indicated assessment was ongoing as appropriate throughout the hospital stay. Nursing will re-assess each patient every shift and as warranted by the patient's medical condition and document findings. This policy was last revised in 09/2022.

6. The facility policy titled, Transfer of Patient, PolicyStat ID 10623375, indicated report would be called regarding the patient's condition to the facility where the patient was being transferred. This policy was last revised in 10/2021.

7. The facility policy titled, Laboratory Process, PolicyStat ID 12197196, indicated nurses/unit clerks obtain laboratory results from the lab website and print the results. The nurse should update the provider of abnormal results as needed, including obtaining any new orders. This policy was last revised in 05/2021.

8. The facility policy titled, Critical Lab Values and Diagnostic Test Results, PolicyStat ID 12197209, indicated critical results are those values/interpretations that require medication intervention of urgent nature, or which require immediate attention or action by the provider/covering provider. This policy was last revised in 06/2021.

9. Review of patient # 9's MR, indicated the patient was a 77 y/o (year/old) admitted to the hospital on 08/02/2023 with a diagnosis of unspecified dementia, urinary retention, and hypertension. Provider Orders dated 08/04/2023 by staff member S # 13 (Registered Dietitian), indicated to weigh the patient weekly and document on the vital sign sheet. Monitor and document intake at each meal. Provider Orders dated 08/08/2023 at 2:30 pm by medical staff member MS # 2 (Nurse Practitioner-NP), indicated to discontinue the Foley catheter and at 6:00 pm, indicated if the patient doesn't have any output in eight (8) hours staff may replace the Foley catheter. Urine sample was collected on 08/11/2023 for urinalysis/urine culture. The MR lacked a weekly weight per provider order (admission weight 08/03/2023), weekly skin assessment per policy, lacked intake documentation per provider order, lacked output documentation, lacked provider notification related to an abnormal urinalysis result, and calling report to the transferring hospital. Provider order dated 08/13/2023 at 5:15 am indicated to send out to hospital due to non-responsive, tachycardia, and decreased oxygen saturation.

10. Review of patient # 9's MR from H # 3 (Acute Care Hospital), indicated on 08/13/2023 at approximately 5:55 am the patient arrived at H # 3 with no report from facility, and 8:00 am the patient had 1400 mL (milliliters) emptied from the Foley bag.

11. In interview on 08/18/2023 at approximately 2:05 pm with administrative staff member A # 2 (Registered Nurse-RN/Director of Nursing), confirmed he/she could not find any other documentation related to patient weights and/or intake/output documentation for patient # 9.

12. In interview on 08/21/2022 at approximately 2:50 pm with staff member S # 6 (Registered Nurse-RN), confirmed documenting intake and output isn't our charting. Someone at the corporate level removed it from the charting.

13. In interview on 08/21/2022 at approximately 3:30 pm with staff member S # 4 (LPN), confirmed S # 13 (Registered Dietitian) wrote the order on a white sheet and we (nurses) and the DON missed the orders. The weekly skin assessment/weight should have been completed on 08/10/2023.

14. In interview on 08/28/2023 at approximately 3:05 pm with medical staff member MS # 1 (Nurse Practitioner-NP), confirmed nursing should have called someone because we would have started an antibiotic. Anything critical like that the provider should have been notified. If the nurse would have done a proper physical assessment he/she would have been able to tell that the patient's bladder was distended. The patient had severe dementia he/she would have not been able to tell staff that he/she was in pain or uncomfortable.

Based on document review and interview the registered nurse failed to ensure the Interdisciplinary Care Plan related to Nutrition was followed in one instance. (Patient # 9)

Findings include:

1. The facility policy titled, Vital Signs and Weight, PolicyStat ID 12386461, indicated weights should be recorded weekly in the patient's medical record (MR). This policy was last revised in 09/2022.

2. Review of the MR for patient # 9 indicated the Interdisciplinary Care Plan - Problem - Nutrition - weigh patient per order - weekly. Signed and dated by S # 13 (Registered Dietitian-RD) on 08/04/2023 at 8:09 pm. Target date was 08/11/2023. The MR lacked documented weekly weight.

3. In interview on 08/18/2023 at approximately 2:05 pm with administrative staff member A # 2 (Registered Nurse-RN/Director of Nursing), confirmed the patient should have documented weekly weights and he/she could not find any additional documentation supporting the order.