HospitalInspections.org

Based on record review and interview the facility failed to ensure that informed medical consent was properly executed in a timely manner for 1 (P2) of 10 patients reviewed. This failed practice could lead to patients not being informed of his or her health status and denies the patient there right to be involved in their treatment.

The findings are:

A. Record review of Policy Titled: "Consents". Approved Date: 05/02/2022. Effective Date: 05/02/2022. Document Number 5979.5. States Item 1.2: "The patient does not waive the right to control what shall be done to his/her body or property when he/she seeks medical care. Any unauthorized examination, diagnostic test, or treatment of a patient constitutes a technical battery. Therefore, the consent - except under emergency conditions - of the patient or patient's legal representative must be obtained prior to [bolded in policy] the rendition of medical care".

B. Record review of P2's electronic medical record face sheet shows an admission date and time of 02/25/2022 at 06:41 PM.

C. Record review of P2's electronic medical record Medical/Financial Consent shows a signature by patient and witness at date and time of 02/26/2022 at 1600 (4:00 pm), this is 21 hours after admission.

D. On 07/01/2022 at approximately 10 am, in an interview with S(Staff) #11, Nurse Manager, confirmed: "It was a weekend, they didn't have an evening clerk on this day. Sometimes they have a hard time getting consent."

E. On 07/01/2022 at approximately 10 am, in an interview with S#7 Regulation Division Director, when asked about what the facility policy states and about obtaining consent 22 hours after admission, stated: " There's not a time frame for obtaining consent, I couldn't find a time frame in consent policy. The intent is to get it as soon as possible."

Based on record review and interview the facility failed to provide a Quality Assurance Performance Improvement (QAPI) that includes measurable improvement in indicators for which there is evidence that it will improve health outcomes through measurement, analysis, tracking and other aspects of performance that assess processes of care, facility services and operations. This failed practice can lead to repeat incidence of adverse events or incidents and can lead to ongoing patient harm.

The findings are:

A. Record review of QAPI Council Minutes for 2021 and 2022. In minutes for May 2021 under Risk category, it states "Grievances, Unanticipated deaths and Adverse events/near misses are discussed." Minutes for June 2021 under Risk category state "Grievances, Unanticipated deaths and Adverse events/near misses are discussed but under section labeled: Action/Follow-up steps as determined by Quality Council it states, "Goals have not yet been set." In minutes for July 2021 under Risk category, it states No grievances, No unanticipated deaths in May. The only information documented : There were 19 adverse events that included: 7 falls, 1 AMA (Against Medical Advice), and 11 others. In minutes for February 2022 through May 2022 in the Risk category it lists the number of events for the month and under discussion category, it states, " No discussion necessary." The minutes show no discussion of the issues of concern or ongoing plan for dealing with issues.

B. Record review of facility's "2022 Quality Assurance Process Improvement Plan" dated 2022 states under section IV Approach: The facility will utilize a Plan-Do-Study-Act process utilizing section V. Methodology 1. Sources of Data: The [facility] collects data from a variety of sources including, but not necessarily limited to, the following: Patient/Family/Visitors (patient satisfaction survey, comment cards, complaints, and suggestions) The data for the person served include the characteristics of the person and are collected at a) beginning of service. b) appropriate intervals. c) end of services and d) point in time following the service)."

C. Record review of Medical Executive Committee Minutes dated 02/28/22 shows agenda item #5 Quality Council (report) Agenda has no mention of Grievance/Complaints, Incidents or Adverse Events noted and there are no minutes for the meeting present. On Minutes dated 03/28/22 #5 Quality Council (report), Agenda has no mention of Grievance/Complaints, Incidents or Adverse Events noted. On the minutes for this meeting under Patient Safety Event Reporting states 24 incidents; 5 near missed, 0 unsafe conditions. The Trideo (Incident Reporting System) reporting events have gone up. Parent corporation have a "Zero Harm" initiative is in full swing. No other mention of this in the meeting.

D. Record review of facility's policy titled, "Grievance Procedure,(Facility Name)" effective date 01/25/22 confirms in section #6 "Procedure" section 6.15 confirms, "The grievance is incorporated in the [facility] QAPI (Quality Assurance Performance Improvement) process."

E. On 06/30/22 at 3:00 pm during interview with S(Staff) 1 (Director of Quality/Risk) who confirmed, "We have identified the lack of documentation in QAPI minutes as an area of improvement. We bring up numbers of grievances as a talking point but we don't discuss anything in detail due to the sensitivity and staff involved."

Based on record review and interview the facility failed to ensure that a Registered Nurse (RN) was evaluating the care for each patient upon admission for 2 (P2 and P3) of 10 patients charts reviewed. This failed practice could likely lead to patients not receiving a skilled assessment by a Registered Nurse.

The findings are:

A. Record review of Policy Titled: "Assessment, Initial and Ongoing" Approved Date: 02/17/2022. Effective Date: 02/17/2022. Document Number 5971.4. States Item 3: "The Registered Nurse may delegate the data collection aspects of the assessment to other qualified nursing staff members, however, the Registered Nurse is responsible for assessment and care planning to include initiation of discharge planning."

B. Record review of P(patient)2 electronic health record Admission Assessment dated 02/25/2022 at 2003 (8:03 pm) shows S(staff)26, Licensed Practical Nurse, completing the admission assessment with no Registered Nurse sign off delegated.

C. Record review of P(patient)3 electronic health record Admission Assessment dated 03/18/2022 at 2153 (9:53 pm) shows S(staff)26, Licensed Practical Nurse, completing the admission assessment with no Registered Nurse sign off delegated.

D. On 6/30/2022 at approximately 10 am, in an interview with S(staff)11, Nurse Manager, confirmed "An RN (Registered Nurse) is supposed to sign off on the LPN (Licensed Practical Nurse) assessment."

Based on record review and interview the facility failed to ensure that necessary information to monitor the patient's condition is included in the patient's record and failed to provide interventions for bowel management for 2 (P4 and P7) of 10 (P1-P10) patients records reviewed. This deficient practice is likely to lead to significant patient harm by not adequately monitoring a patients bowel status which could lead to bowel obstruction and eventually death.

The findings are:

Patient 4:
A. Record review of Comprehensive Flowsheet for P4 for dates of admission (04/12/2022 to 04/25/2022) shows no bowel movement tracked on the following days: 4/12/22, 4/15/22, 4/16/22, 4/17/22, 4/18/22, 4/20/22, 4/21/22, 4/22/22, 4/23/22, and 4/24/22.

B. Record review of Medication Administration Record (MAR) for P4 for dates of admission (4/12/2022 to 04/25/2022) shows the following order: Senna (medication to treat constipation) 2 tablets nightly PRN (as needed) for constipation. MAR shows that Senna was not given, nor offered during entire length of stay. No other medications to treat constipation were administered or ordered.

C. Record review of P4 face sheet shows admission diagnosis as "Partial Small Bowel Obstruction"

D. On 6/30/2022 at approximately 11 am, in an interview with S(staff)8, Chief Medical Officer, when asked about P4 going 4 days (4/15/22, 4/16/22, 4/17/22, 4/18/22) and then another 4 days (4/20/22, 4/21/22, 4/22/22, 4/23/22) with no bowel movement and being admitted for a small bowel obstruction, stated "He probably hadn't eaten much, I imagine he was completely empty, I wouldn't be alarmed if he didn't complain of GI [gastrointestinal] issues. Maybe he had a colonoscopy and was empty." Medical chart does not indicate if a colonoscopy was performed prior to admission to the facility.

Patient 7:
E. Record review of Comprehensive Flowsheet for P7 for dates of admission (05/04/2022 to 05/13/2022) shows no bowel movement tracked on the following days: 5/4/22, 5/6/22, 5/7/22, 5/8/22, 5/9/22, 5/10/22, 5/11/22 and 5/12/22.

F. Record review of Medication Administration Record for P7 for dates of admission shows following order:
a. Bisacodyl suppository 10 mg (milligrams) (medication to treat constipation) every 48 hours PRN (as needed) for constipation. Record shows that Bisacodyl was not given, nor offered during entire length of stay.
b. Polyethylene Glycol 17g (grams) (medication to treat constipation) daily PRN for constipation. Record shows that Polyethylene Glycol was not given, nor offered during entire length of stay.
c. Senna (medication to treat constipation) 1 tablet 2 times daily PRN (as needed) for constipation. Record shows that Senna was not given, nor offered during entire length of stay.

G. On 6/30/2022 at approximately 10:30 am, in an interview with S11, Nurse Manager, confirms that bowel tracking and intervention did not take place according to nursing standards and ordered medications were not administered because bowel tracking did not take place.