HospitalInspections.org

Based upon interview and record review the facility failed to protect the rights of 1 of 10 patients (Patient (Pt.) # 6) to be free from neglect in a sample of 10 reviews and failed to protect all patients in the Intensive Care Unit (ICU) by allowing an employee under investigation for neglect to continue to work in the ICU after the misconduct was discovered.

Findings include:

The Facility failed to protect Pt. # 6 from neglect when oral cares for patients on a ventilator were falsely documented but not completed. See A0145.

The facility failed to protect all patients in the ICU by allowing an employee under investigation for neglect to continue to work in the ICU after the misconduct was discovered. See A0145.

Based on Record Review and Interview the Facility failed to protect 1 of 10 patients (Patient (Pt.) # 6) from neglect in a sample of 10 reviews when oral cares for patients on a ventilator were falsely documented but not completed and failed to protect all patients in the ICU by allowing an employee under investigation for misconduct continue to work in the ICU on 09/27/2021, 10/01/2021, 10/02/2021, 10/03/2021, 10/06/2021, 10/07/2021 and 10/10/2021.

Findings Include:

The facility policy number 731, titled, "Caregiver Misconduct Reporting," dated 09/27/2017 stated, "Neglect: means an intentional omission or intentional course of conduct by a caregiver....that is contrary to the entity's policies and procedures....Neglect is the intentional carelessness, negligence, or disregard of policy or care plan, which causes or could be reasonably expected to cause pain, injury or death.....Immediately upon learning of an incident of alleged misconduct, the manager shall take whatever steps are necessary to ensure that patients are protected from subsequent episodes of misconduct while [facility]investigates the matter."


On 09/24/2021 at 9:26 AM an email was sent to Registered Nurse (RN) Supervisor I and RN Manager H from RN T, informing them of the falsification of documented oral cares that were documented as completed when they were not completed by RN G from 9/20/2021 through 9/23/2021 [for Patient # 6 and an unidentified Pt]. The email stated, "Hi [name], I know you are already aware of the issue that occurred this week with (name of RN G). I was told to reach out and explain everything that occurred since this issue put our patients at risk and BOTH of these patients had to be put on antibiotics in the last 24 hours d/t +(due to positive) sputum cultures in both of them, which could have been caused by little to no oral care provided by (name of RN G0 during the week, which I tracked in order to have enough proof to confront her about this issue. Prior to (name of RN G) leaving for FMLA (Family Medical Leave) I noticed that the oral kits I put out and replace on night shift were not being used or replaced.....these are all patients on ventilators. The patients that I took report from her/him from didn't seem to have good oral care provided through out the day. Their mouths and secretions had not seemed to be taken care of well when I would take over for night shift (after a few days in a row exchanging patients you just tell it wasn't being done), and again, the oral kits didn't seem to be used in the room. Her/His charting is very good, and according to his/her charting everything is always done, exactly on time and how it should be done. This worries me because other things that she charts doesn't always look either...(name of RN G) and I exchanged two patients....from Monday 9/20 to Wednesday 9/22. Both COVID patients, on ventilators that aren't doing great. ....On 9/21 I returned that night...when I walked into 270s room....there were still 10 oral care kits left (which means no oral care kits were used for the entire 12 hours shift)...270 .....started spiking higher fevers this day and his ET (Endotracheal) secretions started to increase....09/22/ PM I returned to work....and 6 oral care kits ....in room 269 had not been used. This patient had been prone all day, and the chux (a disposable pad) underneath the foam pad was soaked all the way through to the pillow case and pillow, and it smelled horrible...So after report I had a conversation with (name of RN G) about this issue.......She/he then said to me, "I'm sorry for lying." and admitted that she/he had not been doing oral cares in the rooms."

In an interview on 02/02/22 at 9:45 AM with RN Interim ICU Manager H when asked about this self report and what internal investigation was completed, RN Manager H stated, "I don't recall the exact date, when it was brought to my attention. I met with (name of RN G) on 10/12/21 to discuss the events of the email on 9/23/2021. (Name of RN G) said, "I lied, I wasn't doing the things I did and copied things forward." I reached out to Human Resources (HR) and would get back to (name of RN G). We reviewed the policy on expected behaviors and reached out to HR and determined needed to be a termination." When asked if there was documentation of the investigation or of the conversations with HR or Risk, RN Manager H stated, "There is no documentation of the conversations, other than the email conversation and (name of RN G) admitting to falsifying the documentation. (Name of RN G) was termed on 10/13/2021."

In an interview on 02/01/2022 at 10 AM with RN Intensive Care Unit (ICU) Supervisor I, when asked about what follow up or investigation that was done following this incident, RN Supervisor I stated, "I'm not sure of the follow up. I knew a nurse had followed (name of RN G) and sent an email that oral care was completed, but it wasn't completed, had charted yes, but didn't do it." When asked what is the expectation with oral care and vented patients, RN Supervisor I stated, "It is part of the documented learning and the vent bundle order set. People are trained one to one in the unit and now an educator works with new staff to ensure competencies. Verbal follow up happens at huddles morning and night discussing oral care and how to avoid infection, but no documentation of that."

A Root Cause Analysis (RCA) was completed on 10/08/2021 regarding [Pt. #6, identified in the RCA as Pt. #1] death, identified as a probable ventilator-associated pneumonia (PVAP) investigation, stated, "Patient admitted to facility 9/8 with covid pneumonia, had worsening 02 (oxygen) needs and was intubated on 9/19 in the ICU. Patient had Pseudomonas (bacteria) cultured in blood and sputum on 9/23/2021 and at that this time did not qualify for a PVAP, but as a bacterial pneumonia. Patient condition worsened and increased antibiotics were prescribed, as all normal flora were absent on subsequent cultures. MDRO (Multi drug resistant organism) strain of pseudomonas emerged and patient expired on 10/12/2021. No other psuedomonos was cultured in the unit and all Hand Hygiene and TBP (Trach bundle protocols) audits were completed to standard. Action items: Discuss with all staff members in person at huddles/team meetings, Hand Hygiene with assessment....continual monitoring of hand hygiene and transmission based precaution tracers."

On 02/01/2022 at 10:45 AM reviewed RN G schedule which revealed RN G remained on the schedule after the supervisor was aware of the incident involving the falsification in the documentation of cares being provided. RN G worked 9/27/2021, 10/1/2021, 10/2/2021,10/3/2021, 10/6/2021, 10/7/2021 and 10/10/2021. This was confirmed by Director of Nurses (DON) C in interview on 02/01/2022 at 10:45 AM.

In an interview on 02/01/2022 at 11:40 AM with Risk Manager J, when asked what the process was for dealing with an allegation of caregiver misconduct, Risk Manager J stated, "We have a process, when I'm notified of care or concern...then pull in Human Resources (HR), if the employee is scheduled, we talk about what to do with that employee while the incident is being investigated. We get the right people at the table, guide the investigation and get statements. I don't understand why (name of RN G) wasn't pulled from the schedule, I wouldn't have known about this until mid October. We weren't brought in at the front end, not sure why. Part of the delay was on my end and then we were brought in late."

In an interview on 02/02/2022 at 8:05 AM with Regulatory Manager B when asked if there was an incident report or follow up on the internal investigation, Manager B stated, "There is no other documentation of the internal investigation between HR and Risk until the self report was completed on 10/21/2021, no incident report was completed for the event in September."

In an interview on 02/02/2022 at 9:15 AM with Risk Manager J, when asked about the facility misconduct policy, Manager J stated, "Correct, the manager has 24 hours to report, this should have been escalated right away. Dependent on what it is, could put the patient at harm and we need to contain that right away."

In an interview on 02/17/2022 at 8:40 AM with Regulatory Manager B, when asked what education was done following this incident, Manager B stated, "No education was done with managers at that time regarding reporting requirements. We are currently in the process of creating education for managers." When asked what policy changes were made to the Caregiver Misconduct policy, Manager B stated, " The policy was up for review, and no content changes were made to the policy during this review cycle. This review was not a connected action in follow up to our report of caregiver misconduct."

Based on record review and interview, the facility failed to ensure that a documentation system is in place to determine the vaccination (and/or exemption) status for COVID-19 for all staff who are employed at the facility in 1 of 4 staff categories (contracted independent providers).

Finding include:

A review of facility policy titled, "COVID-19 Illness Prevention" #3101 last revision date 09/22/2021 revealed, "The COVID-19 vaccine will be required for all ThedaCare team members and providers, as well as anyone who works inside facilities including independent affiliated providers and medical staff members, contractors, volunteers and students. Full vaccination is required by November 22, 2021, meaning the complete two-dose series for Pfizer or Moderna, or one dose for Johnson & Johnson. Limited exemptions for specific medical or religious reasons will be considered...ThedaCare requires that, in the absence of granted medical or religious exemption, team members and other staff receive the COVID-19 vaccine. ThedaCare will communicate to team members and other staff the availability and requirements for vaccination. If you receive the COVID-19 vaccination outside a ThedaCare work environment, you are required to provide proof of vaccination to your leader of Employee Health."

During an interview with Senior Vice President of Operations I stated, "I am very confident due to conversations during meetings, the hospital staff including medical staff is over 95% with the vaccine compliance policy however we just don't have a process in place to account for the documentation of the independent medical providers." Senior Vice President of Operations I stated, the facility is in the midst of creating a system to maintain the physicians' status with vaccinations."

During a review of facility documentation of COVID-19 vaccination, there were 2,033 confirmed, Employees, Independent Providers, Privileged Providers and Students total. There was 1,681 total staff with confirmed documentation of completion of the vaccination or approved exemptions (83%).

During a review of facility documentation of COVID-19 vaccination, there was 413 independent medical providers that come into the hospital, however the facility only received confirmed documentation that 61 of the providers have documented that they have received the COVID-19 vaccination.