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Based on document review and interview, the facility failed to ensure care in a safe setting for 1 of 1 patients (see tag A144)

The cumulative effect of this systemic problem resulted in the facility's inability to ensure that Patient Rights were promoted.

Based on document review and interview, the facility failed to ensure protection of patient rights related to care in a safe setting as documented in 2 (patient 1 and 3) of 10 medical records (MR) reviewed:

Findings include:

1. Policy/procedure, No. II-C.107, Staffing Plan, revised/reviewed, 10/16 indicated: "In addition to acuity, including patient diagnosis, age, functioning of the patients, co-occurring conditions, physical care, equipment, technology, emotional support, education for self care, social needs, discharge planning and patient safety are considered".

2. Policy/procedure, No. I-A.9, Patient Rights and Responsibilities, revised/reviewed 10/18 indicated on page 3: "Receive care in a safe setting...".

3. Policy/procedure, No. II-C.113, Patient Observation, revised/reviewed 11/18 indicated:
A. page 1: "Providers will order specific observations for any patients who requires level of monitoring other than routine, including but not limited to: self harm; suicide".
B. page 2: "1:1 Observation: this level is for patients who are high risk for self-harm and/or suicide risk. At least one health care provider will be present with the patient at all times and observe and maintain uninterrupted close visual contact and monitoring of the patient. Documentation: Documentation of all observations will be completed in the patient's record at least once per 15 minute increment. Mental status, behavior, and response to being on this observation level should be documented in the nursing progress note each shift. Staff will complete the patient observation record using a coding system described on the Patient Observation Monitoring Form. Staff will initial, sign, date and/or time appropriate documentation in the designated area each 15 minute observation of a patient".

4. Review of patient 1's MR indicated the Every 15-Minute Patient Observation Monitoring and Nursing Reassessment Notes dated 12/3/18, 12/4/18 and 12/5/18 lacked documentation of initiation and discontinuation time of the 1:1 Increased Observation Level as requested per physician order dated 12/3/18 at 1105 hours.

5. Review of patient 3's MR indicated the Physician Order dated 12/4/18 at 1905 hours indicated: "Patient to be 1:1 due to suicidal statements to medical staff". Review of Nursing Reassessment Note dated 12/5/18 at 1845 hours indicated: "Patient found in room unattended with pillowcase around neck attempting to strangle self. Night time aide found patient. Removed pillowcase. Immediately notified staff. Medical staff for medical and psychiatry in facility, assessed patient. Patient had redness to chest and breast area. Patient visibly upset. As needed (PRN) Klonopin 1 mg ordered and given. Patient 1:1 for next shift with patient. Patient to have bedding removed...". Review of Physician Orders dated 12/5/18 at 1855 hours indicated: "Remove patient sheets, bedding due to risk for self harm and strangulation. Continue 1:1 with strict observation". Review of Physician Order dated 12/7/18 at 1115 hours indicated: "Continue 1:1 suicide precautions". Review of Physician Order dated 12/10/18 at 1125 hours indicated: "Continue 1:1 observation at this time for patient safety due to self harm". Review of Physician Order dated 12/11/18 at 1115 hours indicated: "Continue 1:1 observation at this time as patient is a safety risk to himself/herself". Review of Physician Order dated 12/12/18 at 1135 hours indicated: "Continue 1:1 supervision for patient safety and risk of harm to self". Review of Physician Order dated 12/14/18 at 1200 hours indicated: "Continue 1:1 observation and suicide precautions at this time". Review of Nursing Reassessment Note dated 12/14/18 at 1345 hours indicated: "Patient in his/her room with caregiver. Caregiver reported that when he/she was assisting patient roommate in the shower and when he/she came out to check patient, he/she noted patient's sweatshirt missing on the wheelchair. Caregiver walked to patient's bed and noted patient attempting to strangle himself/herself with sweatshirt. Caregiver removed sweatshirt around the neck...". Review of Physician Order dated 12/19/18 at 1045 hours indicated: "Continue 1:1 observation at this time for patient safety". Review of Physician Order dated 12/21/18 at 1145 hours indicated: "Continue 1:1 observation for patient safety". Review of Every 15-Minute Patient Observation dated 12/25/18 and 12/26/18 both lacked documentation of increased observation level of 1:1. Review of Physician Order dated 1/3/19 at 1415 hours indicated: "Patient can be Line-of-Sight during the day but must remain 1:1 when in his/her room and bathroom". Review of Every 15 Minute Patient Observation Monitoring dated 1/3/19, 1/4/19, 1/5/19, 1/6/19, 1/7/19, 1/8/19, 1/9/19 and 1/10/19 lacked documentation of increased observation level of line-of-sight during the day and 1:1 while patient is in his/her room and bathroom.

6. Staff P1 was interviewed on 2/19/19 at approximately 1500 hours and confirmed patient 1's Nursing Reassessments and Every 15 Minute Observation Monitoring dated 12/3/18, 12/4/18 and 12/5/18 lacked documentation of initiation and discontinuation of 1:1 observation level. Staff P1 confirmed patient 3 was on an increased observation level of 1:1 on 12/5/18 and 12/14/18 when the patient was found both days self harming. Staff P1 confirmed staff should have followed policy/procedure for increased level of observation. Staff P1 confirmed patient 3's Every 15 Minute Observation Monitoring dated 12/25/18 and 12/26/18 lacked documentation of 1:1 increased level of observation. Staff P1 confirmed patient 3's Every 15 Minute Observation Monitoring dated 1/3/19, 1/4/19, 1/5/19, 1/6/19, 1/7/19, 1/8/19, 1/9/19 and 1/10/19 lacked documentation of line-of-sight during the day and 1:1 in the patient's room and bathroom.

Based on document review and interview the facility failed to ensure complete and accurate documentation by nursing staff in 1 (patient 1) of 10 MR's reviewed; failed to ensure a patient's dignity in 1 (patient 1) of 10 closed medical records (MR) reviewed and failed to ensure that nursing staff assess patients and implement treatments in 1 (patient 7) of 10 MR's reviewed.

Findings include:

1. Policy/procedure, No. III-A., Timeliness of Nursing Medical Record Completion, revised/reviewed: no date documented, indicated: "All medical record entries must be legible, complete, dated, timed and signed promptly, in written or electronic form, by the person (identified by name and discipline) who is responsible for the documentation".

2. Policy/procedure, No. I-A.9, Patient Rights and Responsibilities, revised/reviewed 10/18, indicated: "You have the right to be made comfortable and be treated with dignity".

3. Policy/procedure, I-C.40, Personal Hygiene, reviewed/revised 11/17 indicated: "All patients shall be encouraged or assisted in grooming daily or more often if needed".

4. Review of patient 1's MR lacked documentation of a complete genitourinary assessment including whether or not patient was continent or incontinent of bladder.

5. Review of patient 1's Nursing Admission Assessment dated 11/26/18 (day of admission) indicated: "Mobility Status: Transfer with Assist. Assistive Devices: wheelchair. Limitations: Weakness. Needs Assist with: Toileting, Grooming, Dressing". Review of patient 1's MR indicated the facility failed to ensure evidence of patient toileting assistance. Review of indicated by the Every 15-Minute Patient Observation Monitoring forms dated 11/26/18, 11/27/18, 11/29/18, 11/30/18, 12/2/18, 12/3/18, 12/4/18, 12/5/18, 12/6/18 and 12/7/18 lacked documentation the patient was taken to the bathroom.

6. Review of patient 1's MR indicated the facility failed to ensure the patient's dignity by failing to offer assistance with Activities of Daily Living (ADLS) daily. Review of patient 1's MR indicated the Every 15-Minute Patient Observation Monitoring dated 11/26/18 lacked documentation the patient received and/or refused ADLS including a shower, bed bath, peri-care, shave, and oral care. Review of Every 15-Minute Patient Observation Monitoring dated 11/27/18 lacked documentation the patient received and/or refused ADLS including a shower, bed bath, shave and oral care. Review of Every 15-Minute Patient Observation Monitoring dated 11/28/18 lacked documentation the patient received and/or refused ADLS including a shower, bed bath, shave and oral care. Review of Every 15-Minute Patient Observation Monitoring dated 11/29/18 lacked documentation the patient received and/or refused all ADLS including a shower, bed bath, peri-care, shave and oral care. Review of Every 15-Minute Patient Observation Monitoring dated 11/30/18 lacked documentation the patient received and/or refused a bed bath, a shave and oral care. Review of Every 15-Minute Patient Observation Monitoring dated 12/1/18 lacked documentation the patient received and/or refused ADLS including shower, bed bath, shave and oral care. Review of Every 15-Minute Patient Observation Monitoring dated 12/2/18 lacked documentation the patient received and/or refused ADLS including shower, bed bath, peri care, shave and oral care. Review of Every 15-Minute Patient Observation Monitoring dated 12/3/18 lacked documentation the patient received and/or refused ADLS including shower, bed bath, shave and oral care. Review of Every 15-Minute Patient Observation Monitoring dated 12/4/18 lacked documentation the patient received and/or refused ADLS including shower, bed bath, and oral care. Review of Every 15-Minute Patient Observation Monitoring dated 12/5/18 lacked documentation the patient received and/or refused ADLS including a shower, peri care, shave and oral care. Review of Every 15-Minute Patient Observation Monitoring dated 12/6/18 lacked documentation the patient received and/or refused ADLS including a shower, bed bath, shave and oral care. Review of Every 15-Minute Patient Observation Monitoring dated 12/7/18 lacked documentation the patient received and/or refused ADLS including a shower, bed bath, peri-care, shave and oral care.

7. Review of patient 7's MR indicated nursing staff failed to document communication of the patient's medical decline to medical staff and failed to initiate timely treatment. Review of Nursing Reassessment dated 12/22/18 at 1700 hours indicated: "Noted patient to be having abnormal movements (tremors) to his/her upper extremities this evening...Patient refused to eat his/her dinner when F1 left, but drank all his/her fluids. Patient has a fever with a temp of 100.8 degrees Fahrenheit this evening. Tylenol offered to patient. No signs of pain noted at this time". Review of Nursing Reassessment Note dated 12/23/18 at 1800 hours indicated: "Patient was brought in the common area for lunch but he/she could not eat kept spitting or choking...patient was later taken back to bed...During dinner time patient was offered 120 cc of fluid and pudding while he/she only ate a couple of spoons...". Review of Nursing Reassessment Note dated 12/23/18 at 2100 hours indicated: "Patient in bed on approach...He/she is unable to communicate with writer. He/she appears very weak. Writer spoon fed patient pudding. Writer unable to perform thorough assessment. Unable to assess pain...Respirations are shallow but even at 18. Temperature at 97.3". Review of Nursing Reassessment Note dated 12/24/18 at 1600 hours indicated: "Patient is aphasic, tries to talk but hard to understand. He/she is a 1:1 observation for safety. He/she is unable to ambulate or move himself/herself in a wheelchair. He/she is incontinent of bowel and bladder. He/she needs assistance eating. He/she has a hard time sitting upright in a chair and leans to the far right even in bed. He/she is very weak and cannot make his/her needs known...He/she is in obvious pain when ADLS are performed, both of his/her arms/shoulders are painful...". Review of Nursing Reassessment Note dated 12/26/18 at 1730 hours indicated: "Patient in dayroom. Patient seems to have hard time swallowing liquids. Per nursing judgement, patient is to have thickened liquids. Will notify medical staff...". Review of Nursing Reassessment Note 12/28/18 at 1000 hours indicated: "Patient discharging today at 1100. F1 picking up patient...Review of Discharge Summary dated 12/28/18 per medical staff D1 indicated: Discharge Physical Exam: Weight: Admission weight: 149.8, discharge weight 149.8 Discharge Status: Psychiatrically, patient was oriented to person. Activity: Wheelchair with assist. Patient's appetite was reported as good. Socially, interacting with staff and others in the milieu". Review of H&P dated 12/22/18 indicated the patient's admission weight was 158. Review of Nursing Reassessment Note dated 12/22/18 lacked documentation of communication from nursing staff to medical staff reporting the patient's signs/symptoms of upper extremity tremors and increased temperature. Review of Nursing Reassessment Note dated 12/23/18 lacked documentation of communication from nursing staff to medical staff reporting the patient's difficulty swallowing, increased weakness, shallow respirations and inability to obtain a head-to-toe assessment. Review of Nursing Reassessment Note dated 12/26/18 lacked documentation of communication from nursing staff to medical staff reporting the patient's continued difficulty swallowing. Review of Physician Orders dated 12/23/18, 12/24/18, 12/25/18, and 12/26/18 lacked documentation the medical staff addressing the patient's difficulty swallowing as documented in Nursing Reassessment Notes on 12/23/18 and 12/26/18. Review of Every 15 Minute Patient Observation Monitoring dated 12/22/18, 12/23/18, 12/24/18, and 12/25/18 indicated: "Fluid Type: Thin. Diet Type: Regular". Review of Every 15 Minute Patient Observation Monitoring dated 12/26/18 and 12/27/18 indicated: "Fluid Type: Nectar Thick. Diet Type: Pureed".

8. On 2/19/19 at approximately 1500 hours, staff P1 (Chief Executive Officer [CEO]) was interviewed and confirmed patient 1's MR lacked documentation of a complete genitourinary assessment by nursing on admission date of 11/26/18. Staff P1 confirmed patient 1's MR lacked documentation of whether or not patient was continent of bladder/bowel and lacked documentation the patient was taken to the bathroom on 11/26/18, 11/27/18, 11/29/18, 12/2/18, 12/3/18 12/4/18, 12/5/18, 12/6/18 and 12/7/18. Staff P1 confirmed patient 7's MR lacked documentation of medical staff addressing the patient's difficulty swallowing until 12/26/18. Staff P1 confirmed nursing staff did not document communication to medical staff on 12/22/18, 12/23/18 and 12/26/18 reporting patient tremors, increased temperature, increased weakness, difficulty swallowing and shallow respirations. Staff P1 confirmed that patient 7's MR indicated the patient was on a regular/thin liquid diet until 12/26/18. Staff P1 confirmed that patient 7's MR lacked documentation of a physician order for change in diet beginning 12/26/18.