HospitalInspections.org

Based on record review and interview the facility failed to meet the Condition of Participation (CoP) for Nursing Services by failing to comply with the requirements as evidenced by the following:

A. The facility failed to ensure that the RN (Registered Nurse) was evaluating Nursing care by failing to conduct an initial assessment and ongoing assessment of a wound and failing to utilize a facility approved treatment of a wound. Refer to 0395.

B. The facility failed to ensure that Nursing Staff develop and keep nursing care plans. Refer to 0396

Based on interview and record review the facility failed to maintain a process for patients to be informed of contact information for Department of Health (DOH) Complaints for all patients receiving treatment in the facility and failed to identify and respond to grievances for 1 (P1) of 10 patients reviewed. This failed practice can lead to patient's not being informed of the process for entering a complaint/grievance, repeat complaint issues and patient harm.

The findings are:

Contact info for DOH:

A. Record review of Patient Rights and Responsibilities dated 1/2020 located in the patient admission packet, confirmed the form does not contain DOH complaints contact number or website information with instruction on how to file a complaint online.

B. Record review of NMAC 7.1.13.8 "B. Notification: (1) Incident reporting: Any person may report an incident to the bureau by utilizing the DHI (Department of Health Improvement) toll free complaint hotline at 1-800-752-8649. Any consumer, employee, family member or legal guardian may also report an incident to the bureau directly or through the Licensed Health Care Facility by written correspondence or by utilizing the bureau's incident report form. The incident report form and instructions for the completion and filing are available at the division's website, at https://dhi.health.state.nm.us/elibrary/ironline/hflc_instructions.php or may be obtained from the department by calling the toll-free number at 1-800-752-8649."

C. During an interview on 3/1/2023 at approximately 3:00 pm with S(staff)1, Chief Executive Officer, confirmed the Patient Rights and Responsibilities was the form given to patients to inform them of how to file a complaint.

Identify Grievance:

D. Record review of policy titled Patient Complaints and Grievances effective date December 7, 2020 states: "Definitions 2. b. A written complaint is always considered a grievance. 2.d. Complaints or grievances received by email or fax from a complainant is considered a grievance. 2. G. All verbal or written complaints regarding abuse, neglect, patient harm, or hospital compliance with CMS requirements are considered grievances for the purpose of this policy."

E. Record review of email communication from P1 sister to facility [via facility website] states " I was calling to 1) clarify some details around an unplanned transfer of care and 2) acquire a name and email address. Please contact me to discuss the items listed above. Thank you, [Name]" Response to the email from the facility dated Thu, Nov 10, 2022 10:32 am states " Thank you for contacting us here at [Facility Name]. We will get back to you soon."

F. Record review of email communication from P1 sister to facility [via facility website] states " Hello, I have had an unpromising communication experience with [facility]. Two voice mails were left for [S2], I never heard back. The first voice mail was regarding an incident report pertaining to my mother [P1] trauma and aide participation. The second voice mail was in reference to the unplanned transfer of care of my mother and Nurse [S16] lack of assistance. Further, a voice mail was left at [unknown staff] number with no return call to myself. Finally, I sent a previous email, but have received no communication from [facility]. This lack of communication is unfortunate. Sincerely, [name] 11-20-2022"

G. During an interview on 3/3/2023 at 1:42 pm with P1 sister confirmed that facility did not contact her regarding the 2 above complaints nor the 2 phone calls to S2.

H. During an interview on 3/1/2023 at approximately 1 pm with S8, Health Information Management, confirmed that she was in fact the person who handled grievances for the facility. When asked about where grievances come from? S8 confirmed: being told by the CEO and DON, being told by floor staff, and patient satisfaction survey, the facility website was not mentioned.

Based on record review and interview the facility failed to ensure that the RN (Registered Nurse) was evaluating nursing care by failing to conduct an initial assessment and ongoing assessment of a wound and failed to utilize a facility approved treatment of a wound for 1 (P1) of 10 (P1 - P10) patients reviewed. This failed practice lead to neglect of the patient's injury.

The findings are:

A. Record review of P1 facesheet shows an admission date of 11/6/2022 at 1724 (5:24 pm) and a discharge date of 11/8/2022 at 1940 (7:40 pm).

B. Record review of P1 incident report with an incident date of 11/7/2022 and incident time of 10:35pm states that P1 "bumped her right arm" [Aide was transporting patient in a wheelchair from bathroom to bed] and obtained a "skin tear".

C. Record review of P1 incident report with an incident date of 11/7/2022 and incident time of 10:35pm states under "Follow up Action/Recommendations: Unable to follow up due to fact patient left AMA (Against Medical Advice)."

D. During an interview on 3/3/2023 at 1:42 pm with P1 sister confirmed that she took P1 out of Facility 1 AMA to obtain emergency treatment at Facility 2 for the skin tear and a possible urinary tract infection. P1 was admitted to Facility 2 inpatient after that emergency treatment and stayed there for 7 days.


Lack of Initial Assessment and Ongoing Assessment of wound:
E. Record review of policy # NS(Nursing Service)-15 titled Wound Prevention, Assessment, and Treatment approved by Governing Body on 9/8/2022 states "II. Policy: Patients' skin integrity will be assessed on admission using Braden Skin Risk Assessment Tool [an assessment tool to identify a patient's risk for developing pressure injuries]...every patient's skin integrity will be reassessed every 12 hours and/or as needed..." III. Procedure: Assessment: Admission: A. A registered Nurse utilizing the Braden Skin Risk Assessment Tool, will assess patient's skin integrity... Documentation: D. Initial assessment findings will be documented in the medical record." There is no mention in the policy of the time frame that the Initial Assessment needs to be completed. "III. H. Other wounds/breakdown will be classified using the following scale: Superficial: skin loss involving only the epidermis and presents as a mild abrasion. Partial Thickness: skin loss involving epidermis, dermis, or both. Full thickness: skin loss involving subcutaneous tissue. ... skin tears ... will be noted and described."

F. Record review of P1 Electronic Medical Record shows the following documentation
1. "Rehab Adult System Assessment" Subsection "Braden Assessment" shows an incomplete assessment completed on 11/7/2022 between the time of 18:00 (6 pm) to 21:59 (9:59 pm). The assessment is missing the "Braden Score". This is the first skin assessment for P1 since admission on 11/6/2022 at 5:24 pm.
2. Internal Medicine Progress Note dated 11/8/2022 at 11:42 am completed by Staff S12, Nurse Practitioner, notes that the 'Nursing reports a skin tear... dressing to the right wrist CDI (clean dry and intact)." There is no description of the wound.
3. "Rehab Adult System Assessment" Subsection "Incision/Wound" shows the first time the skin tear was described was by S17, Licensed Practical Nurse, on 11/8/2022 between the time of 10:00 am and 13:59 (1:59 pm). The description does not clarify if the skin tear is superficial, partial thickness, or full thickness.
4. Rehab Medicine Progress Note dated 11/8/2022 at 15:32 (3:32 pm) completed by S13, Medical Doctor, notes "She unfortunately had a skin tear in her right forearm ...as per the Registered Nurse this morning. She had some bleed that is dissipated. I will discontinue aspirin since patient has no real indication for this." There is no description of the wound.
5. Wound Note dated 11/8/2022 at 18:31 (6:30 pm) by S17, Licensed Practical Nurse, states: Pt (patient) sustained skin tear during toileting at night. Wound cleaned and steri-strips applied, calcium alginate applied to absorb drainage. No S/S (signs and symptoms) of infection during shift. Providers made aware, no new orders followed." There is no description of the wound.

G. Record review of entire medical chart for P1 revels that there are no other notes about the wound.

H. During an interview on 02/28/2023 at 4:30pm with S6, Wound Care RN, when asked if she was aware of P1 skin tear, she stated "I knew about it but then the patient was discharged." S6 then stated: "I'm the only wound care nurse and I'm not here 24/7"


Unapproved treatment:
I. Record review of policy # NS (Nursing Services)-15 titled Wound Prevention, Assessment, and Treatment approved by Governing Body on 9/8/2022 under Treatment Guidelines states:
"Superficial/Partial thickness: Hydrocolloid [type of wound dressing] 2-7 day dressing changes, Transparent film [type of wound dressing] up to 7 day dressing.
Superficial/Partial of Full thickness minimal drainage: Hydrogel [type of wound dressing] 2 to 5 day dressing, Contact layer [type of wound dressing] 1 to 3 day dressing, Calcium Alginate [type of wound dressing] up to 5 days dressings.
Full thickness Moderate/heavy drainage: Calcium alginate up to 5 days dressing, Foam pad up to 7 day dressing, Hydrocolloid 2-7 day dressing.
Full Thickness Wound Moderate/Heavy drainage: Calcium Alginate Pad up to 5 day dressing, Wound Vac.
Venous Ulcer Treatment: Compression up to 7 days.
Antimocrobial: Antimicrobial [type of topical treatment] up to 7 day dressing.
Antifungal: [type of topical treatment] Fungal sites and folds.
Debridement: Enzymatic agents [type of topical treatment] up to twice daily. Physician surgical debridement.
Wound Cleanser: with dressing change.
Incontinence Skin Care: After incontinence episode."

J. Record review of P1 Wound Note dated 11/8/2022 at 18:31 (6:30 pm) by S17, Licensed Practical Nurse, states: Pt (patient) sustained skin tear during toileting at night. Wound cleaned and steri-strips applied ..." There is no description of the wound to use as a guide, referring to the policy mentioned above as to what approved treatment should be utilized.

K. Record review of Facility 2 Wound Care Consult Note dated 11/14/2022 at 12:05pm for P1 describes the wound as "Acute Skin Tear horizontal Right forearm... Wound Length: 1.5cm. Wound width: 9cm. Wound depth: 0.1cm. Nonviable tissue: 95%. Viable tissue: 5%. Wound Management Plan of Care: Healing/Aggressive plan. Wound Debridement: Chemical/Enzyme."

L. During an interview on 3/3/2023 at 1:42 pm with P1 sister stated "The Head Nurse and Night Nurse were uncomfortable doing anything with it (wound), so they wrapped it in gauze, then the Nurse the next day put on these 3 wide steri-strips." P1 sister was present during the time of this conversation and witnessed the application of gauze and then steri-strips.

Based on record review and interview the facility failed to ensure that Nursing Staff develop and keep Nursing Care Plans for 1 (P(patient)1) of 10 (P1 - P10) patients reviewed. This failed practice could lead to failure to meet patient's goals and needs.

The findings are:

A. Record review of policy # NS-15 titled Wound Prevention, Assessment, and Treatment approved by Governing Body on 9/8/2022 states "III. Procedure: Plan of Care: A. Based on the identification of skin integrity issues during assessment and reassessment, a Plan of Care will be initiated." "Documentation: F. The plan of care will be initiated on first identification of the wound ..."

B. Record review of P1 incident report dated 11/7/2022 at 10:35 pm states that P1 "bumped her right arm" and obtained a "skin tear".

C. Record review of P1 Electronic Medical Record shows no care plans were written during P1 entire length of stay.

D. In an interview on 02/28/2023 at 4:30pm with S(Staff) 6, Wound Care Nurse, S6 confirmed that there are no care plans for P1. When asked why there was no care plans for P1 stated: "I don't know, they got missed."

Based on record review and interview the facility failed to ensure that Nurses were following facility policy regarding a patient leaving the facility Against Medical Advice (AMA) for 1 (P1) of 10 (P1 - P10) patients reviewed. This failed practice could leave to a lack of continuity of care and a violation of patient rights.

The findings are:

A. Record review of policy titled Discharge Against Medical Advice effective date: 12/7/2022 states "Procedure 1 ...a staff member will attempt to explore with the patient his/her concerns prompting the decision. All conversations between staff members and the patient must be documented in the patient's medical record, to include date, time, and where conversation took place, and patient's mood, affect, etc. 2. The Nurse in charge and/or Case Manager will contact the Medical Director and the patient's attending Physician of the AMA discharge request. 3. The patient will be encouraged to discuss the request with their Physician prior to making a final decision. a. If the patient refuses, an AMA form will be completed by the patient and witnessed by a rehabilitation staff member. b. The patient will be fully informed that the AMA form releases the Physician, hospital staff, and rehabilitation program from responsibility and that the discharge is against medical advice ... 5. Should the attending Physician approve the AMA discharge, an order will be written in the AMA form filed in the patient's medical record. 6. All interventions with rationale will be documented in the patient's medical record "

B. Record review of P1 incident report with an incident date of 11/7/2022 and incident time of 10:35pm states under "Follow up Action/Recommendations: Unable to follow up due to fact patient left AMA. CEO [name] notified by Nursing [illegible name] RN that patient's daughter took patient out of facility AMA."

C. Record review of P1 Electronic Medical Record shows no documentation from Nurses, Case Manager, Physicians or Medical Director about the patient leaving the facility AMA.

D. During an interview with on 3/3/2023 at 3:47 pm with S(staff)16 Registered Nurse, the Nurse that was responsible for P1's care the evening she left AMA, when asked: Are you familiar with the AMA policy? stated "I think I would call the doctor and inform the Lead Nurse". Who is the Lead Nurse at nights? "At one point, we used to have a Lead Nurse assigned but lately they don't assign a lead anymore. Its just the 4 of us [Nurses]." Have you read the AMA policy at (facility)? "To be honest, No, I have not."

E. During an interview on 3/3/2023 at 1:42 pm with P1 sister when asked: Did any of the staff discuss AMA with you? stated "No I asked [S16] to please look at my mother, she refused and said later, then I asked if I could speak to the Head Nurse, she wouldn't allow me or tell me where the Head Nurse was located. So, I transferred my mom into a wheelchair and left." Did anyone go after you? "No, no one, I asked an unrelated staff that was outside to take the wheelchair back inside, and they did."

F. During an interview on 2/28/2023 at 4:55 pm S1, Chief Executive Officer, confirmed that the AMA policy for P1 was not followed correctly.

Based on record review and interview the facility failed to maintain practitioners' orders for wound care of a skin tear obtained on site for 1 (P1) of 10 (P1-P10) patients reviewed. This failed practice could lead to poor patient outcomes as the physician is not aware of the problem or how the nurses are handing the problem.

The findings are:

A. Record review of P1 incident report with an incident date of 11/7/2022 and incident time of 10:35pm states that P1 "bumped her right arm" and obtained a "skin tear".

B. Record review of P1 electronic medical record under section titled "orders" shows the following: "Consult to Wound Care" 11/6/2023 at 15:37 (3:37 pm) routine, Examine for Pressure Ulcers." No other wound care orders noted that address the skin tear obtained on 11/7/2022.

C. During an interview on 2/28/2023 at approximately 3 pm with Staff (S)6, Registered Nurse, during electronic medical record review confirmed that this is the only place that wound care orders would be located.

D. In an interview on 3/1/2023 at 12:30pm with S2, Director of Nursing Operations, when asked about the expectation of contacting the doctor when the skin tear happened stated "[P15] should have notified the physician."