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Based on observation, interview and record review, it was determined that the facility failed to protect and promote each patients' rights.

Findings include:

1. The facility failed to provide services in a safe setting for 3 out 12 sampled patients. (Refer to tag A-144)

2. The facility failed to provide services in a safe enviorment for 2 out 2 sampled restrained patients. (Refer to tag A-159)

3. The facility failed to try less restrictive interventions, initally, to protect 2 out of 2 restrained patients from possible harm. (Refer to tag A-164)


4. The facility failed use the least restrictive type of restraint to protect 2 out of 2 restrained patients from possible harm. (Refer to tag A-165)

5. The facility failed to make modification to the care plans for restraints for 2 out of 2 restrained patients. (Refer to tag A-166)

6. The facility failed to implement safe and appropriate restraints as determined by hospital policy to protect 2 out of 2 restrained sampled patients from possible harm. (Refer to tag A-167)

7. The facility failed to obtain physicians' orders for 2 restrained patients out of 12 sampled patients. (Refer to tag A-168)

8. The facility failed to have 2 out of 2 restrained patients properly monitored by a physician. (Refer to tag A-175)

9. The facility failed to have 2 out of 2 restrained patients seen within 1 hour after restraints were initiated. (Refer to tag A-178)

10. The facility failed to have 2 out of 2 restrained patients seen within 1 hour after restraints were initiated to evaluate the patient's immediate situation; their reaction to the intervention; their medical and behavioral condition; and the need to continue or terminate the restraints.
(Refer to tag A-179)

11. The facility failed to provide services with the use of restraints in a safe environment for 2 out of 2 restrained sampled patients.
(Refer to tag A-194)

12. The facility failed to adequately train and educate staff about the use of physical restraints which put 2 out of 2 restrained patients at risk for physical harm. (Refer to tag A-199)

17494

Based on observation, record review and interview, it was determined that the facility failed to provide services in a safe setting for 3 out of 12 sampled patients. (Patient identifiers: 2, 7 and 8)

Findings include:

Patient 2

Patient 2 was a 75 year of female patient who was admitted to the hospital on 7/4/14, with the diagnoses of "Probable Major Neurocognitive Disorder due to Alzheimer's, with behavioral", Psychotic Disorder, Diabetes, and High Blood Pressure.

Review of the nurse's progress notes revealed that patient 2 developed a pressure sore on her coccyx. The nurse documented that on 7/19/14, a reddened area was found on patient 2's buttocks. On 7/24/14, the nurse documented that patient 2 had a pressure ulcer on her buttocks. There was no evidence that skin checks were done routinely to monitor patient 2's skin. Patient 2's aide flow sheets from her medical record were reviewed. The aides document on the flow sheet that the patients are checked every fifteen minutes to ensure safety. The flow sheet documents where the patient is and what the patient is doing. The flow sheets revealed that patient 2 spent long periods of the day in the dayroom. The dayroom has a row of recliners in it. There was no other furniture such as a couch where patients could sleep. There was no evidence that pressure relieving devices were used. The documentation revealed that patient 2 slept in the dayroom almost every night. Patient 2 was incontinent of bowel and bladder. There was no documentation of routine toileting or incontinence care.

A registered nurse (RN) was interviewed on 9/28/14 at 4:25 pm. The nurse stated that patients should be offered a shower daily. The nurse stated that the aides do skin checks when the patients are showered. The nurse stated that nurses do not do skin checks daily. The nurse stated that she checks the patients bottom when she helps change patients who are incontinent.

On 9/25/2014 at 7:45, a certified nursing assistant (CNA) 2, was interviewed. She stated that she does skin checks on patients when she showers them. She stated the nurses do not tell her to do skin checks. She stated that,"I just do it because I am old school." When asked what she remembered about patient 2, she stated that patient 2 came in walking, then went into a wheelchair. CNA 2 stated that Physical Therapy (PT) would have us stand her up every two hours and she would scream. There was no evidence in the medical record that patient 2 had orders for physical therapy or that an assessment or treatment was done. CNA 2 remembers that a sore was found on patient 2's buttocks, just above the crack. She stated that she put some pink barrier cream on her buttock and it was getting better. Then she stated that she was off work for 4 days. CNA 2 stated that when she came back patient 2 had a 1 centimeter (CM) sore right at the top of the crack of her buttock. She stated that patient 2 would be sitting in the recliner and would get very anxious and move around a lot. She stated that staff put a chair alarm on the recliner she was sitting in it. She stated that patient 2 would "flip forward" (lean all the way forward) and staff were afraid that she would fall out of the recliner chair. To prevent that they put an "orange cone" (that is used to warn that the floor is wet) under the corner of the foot rest. She stated that when patient 2 would lean forward the cone would make a noise, so we could hear her. She stated that when the cone was under the foot rest, patient 2 could not get the foot rest down. Patient 2 would throw her legs over the arm rests of the recliner. Patient 2 could not get out of the chair with the orange cone in place. CNA 2 remembered patient 2 being diapered but if staff toileted her every 2 hours she was mostly continent. CNA 2 stated that patient 2 was bathed every other day. Patient 2 would often refuse baths but staff would talk her into one. She stated that when patient 2 was discharged she went on hospice. She stated that she was used to patients coming in in bad shape and leaving in better shape. CNA 2 remembered that patient 2 was using a walker upon arrival but was using a wheelchair and unable to walk when she left. She stated that either patient 2 didn't want to walk or was unable to walk. CNA stated that when they stood her up patient 2 wouldn't move her legs. CNA 2 stated that patient 2 "was totally declining."
A telephone interview was conducted with patient 2's daughter on 9/25/14, at 3:30 PM. The daughter stated that her mother had been living in an assisted living prior to her admission to the hospital.
The daughter stated that she came in every couple of days and her mother was always sitting in a recliner in the dayroom. Her mother was only on her bed the last couple of days because the staff found the beginning of a pressure sore on her bottom. The staff informed the daughter that she needed to be in bed so she could be turned and positioned. The daughter stated there was no padding, cushion or pressure relieving device between the patient's clothed body and the leather or vinyl surface of the recliner. She stated that on several occasions she found her mother in wet briefs and had to ask staff to change her. She noticed that her mother had a bad smell about her. On one occasion she found her mother squirming and trying to get her pajama bottoms down. The daughter stated that when the staff would stand her mother she would cry out in pain.
The daughter stated that after the patient had been in the hospital for about three weeks, around 7/23/14, a nurse called and said her mother had the beginnings of a pressure sore on her bottom. The daughter stated that when she came to visit she asked the nurse if they had been checking her mother's skin. The daughter found out that there had been no skin checks done for 21 days. The daughter stated that the log book indicated that her mother was being showered but that the aides probably did not notice the pressure sore until the skin around it became red.
The daughter stated that when she came to visit she found her mother sitting in a recliner with the feet elevated. There was an orange cone (often used to indicate a wet floor) positioned under the foot rest. The cone positioned under the foot rest would prevent the patient from lowering the footrest and getting out of the chair. The daughter stated that at first she thought the cone was there because the recliner was broken. When she asked a staff person about it she was informed that it was to prevent her mother from getting out of the chair.
The daughter stated that her mother was walking with a walker when she entered the hospital but gradually became chair bound. Her mother was talking when she entered the hospital but gradually spoke less and less.
The daughter stated that on 7/25/14, a staff person from the hospital called and informed her that her mother was dying and was being discharged on hospice and she needed to come get her. The daughter stated that she made arrangements for her mother to return to the assisted living center with hospice to provide care. The daughter stated that the hospice nurse came to the assisted living to see her mother. Patient 2's daughter was present when the nurse removed the dressing to the pressure ulcer. The dressing was in place when the patient was transferred to the assisted living center. The daughter described the pressure sore. The daughter stated there was a bad odor and that she had noticed the same odor when she visited her mother at the hospital. The daughter stated the wound was large and was covered with a black leathery layer. The daughter stated that the skin around the wound was red. The daughter stated that her mother cried out in pain when the dressing to the wound was changed.
Patient 2 was not protected from developing a pressure ulcer. Patient 2 was placed in a recliner in the dayroom. The chair was rigged so that she could not get out of it on her own. This was an atypical restraint for which there was no physician's order, no assessment was done, and no monitoring of the restraint as required. This was a safety issue because patient 2 squirmed around and fought to get out of the chair over the arm rest.
Patient 8

Patient 8 was a 65 year old male that was admitted to the facility for the third time on 9/3/2014 with diagnoses that included coronary artery disease, chronic renal failure/end stage on dialysis, chronic back pain, right sided global weakness-history of cerebral vascular accident, Major Depressive Disorder and Probable Major Neurocognitive Disorder Due to Alzheimer's Disease, with behavioral disturbances and psychotic features. The patient's first language was Spanish but also spoke English occasionally.

On 9/23/14 at 8:43 AM, patient 8 was observed in his room sitting in his wheelchair facing his outside window. At approximately 9:45 AM, certified nursing assistant (CNA) 1 and the Social Worker (SW) hurried into the room followed by the surveyor. Patient 8 was found on the floor lying on his left side between his wheelchair and his bed. Patient 8 was observed to be helped back into his wheelchair and then brought into the day/activity room.

On 10/1/2014, the following "Case Management Note" dated 9/23/2014 at 9:25 AM, authored by the facility SW was reviewed. The following was documented; "I went on to the unit and noticed" patient 8 "on the floor of his room. I stopped what I was doing and went over to help him. He reported he had fallen but was not in pain. I told him I would get another aide and we would help him. He reported he did not fall from standing up but was leaning over his chair and fell out of the chair. He reports he was not injured but did need help getting back into his char (sic)."...CNA 1 "was able to assist me in helping" patient 8 "into a wheel chair....I notified the floor nurse about the incident and asked her to follow up with the CNA 1 and" patient 8.

On 9/23/14 at 3:15 PM, registered nurse (RN) 1, who was patient 8's nurse that shift, was interviewed. When asked if she had any knowledge of patient 8 falling from his wheelchair that morning, she stated, "No". RN 1 then asked the surveyor what had occurred and started to fill out an incident report. The nurse then stated that patient 8 had slid out of his "chair 4 times last night."

The following was documented on a "Nursing Note" dated 9/23/2014 at 5:48 AM, that patient 8 "has slid out of the chairs 4 times tonight. requiring assist to get up...." There was no further documentation about these incidents found. There was no documentation found of a full body assessment being done to visualize bruises or other potential signs of injury. There was no documentation found describing alternative management to prevent the patient from coming out of the chair.

On 10/1/2014, the following "Nursing Note" dated 9/23/2014 at 4:51 AM, authored by RN 1 was reviewed. The following was documented; "It was brought to this staff member's attention that" patient 8 "was found on the floor in his room this morning at approximately 9:40 a.m. This staff member was notified of the event at 1518" (3:18 PM). A review of patient 8's medical/psychiatric chart revealed that there was no documentation found of a full body assessment to visualize for bruises or other signs of injury. There was no documentation found describing alternative management to prevent the patient from coming out of the chair.


On 9/25/14 at 11:15 AM, patient 8 was observed in the shower. The following bruises were observed:
a. His right top of shoulder had a 2 1/2 inch in diameter bruise
b. His left top of shoulder had a 1 inch in diameter bruise,
c. His left side of the stomach had a 2 inch in diameter bruise.
d. His right hip and outer thigh had an approximately 8" by 6" bruise.
e. His left hip and outer thigh had an approximately 10" by 6" bruise.

A review of patient 8's clinical chart revealed that there was no documentation pertaining to patient 8's stomach, bilateral hip and biltateral outer thigh bruises.

On 9/25/14 at approximately 1:30 PM, the DON and the Administrator were informed of patient 8's bruises.

On 10/1/2014, a "Progress Note" dated 9/25/2014 at 2:45 PM, for patient 8 was reviewed. It was authored by the facility's medical physician. It was documented that the patient had a bruise on the top of his right shoulder and on the patient's right outer hip "3-4 inches by 12-15 inches". There was no documentation of the bruise on patient 8's left hip. The physician then documented that he had a "concern for more extensive trauma to account for significant drop in hct" (hemtocrit - the amount of red blood cells found in a 100 milliliters of blood. Patient 8's hct was 22%. Normal for a male patient is 40% - 54%).

On 10/1/2014, the following "Nursing Note" dated 9/27/2014 at 6:43 PM, authored by RN 2 was reviewed. The following was charted; "Writer attempted to assess" patient 8's bilateral "hip bruises this morning and" patient 8 "allowed writer to visualize them for only a moment. They are purple (slightly less so than when writer visualized them on 9/25/2014), and are warm to the touch. When questioned as to the source of his pain he indicates his hips."

Patient 7

Patient 7 was a 79 year old female that was involuntarily admitted on 9/13/2014, with diagnoses that included dementia, anxiety, verbally and physically aggressive, with increased agitation.

On 9/25/2014 at 10:35 AM, patient 7 was observed in the shower to assess her skin. The following bruises were observed;

a. an approximately 2" circular bruise to left lower abdomen
b. an approximately 5" X 2" bruise to left stomach apron
c. an approximately 1" circular bruise times 2, upper right inside of arm
d. an approximately 1/2" circular bruise times 3, upper right outside of arm
e. an approximately 2" circular bruise times 2 on right lower stomach apron

There was no documentation found in patient 7's chart pertaining to the bruises.

17494

Based on observation, record review and interview, it was determined that the facility failed to provide services in a safe enviorment pertaining to the use of restraints for 2 out 2 sampled restrained patients. (Patient identifiers: 2 and 8)

Findings include:

Patient 2

Patient 2 was a 75 year of female patient who was admitted to the hospital on 7/4/14, with the diagnoses of "Probable Major Neurocognitive Disorder due to Alzheimer's, with behavioral", Psychotic Disorder, Diabetes, and High Blood Pressure.

Review of the flow sheets where the aides document the every fifteen minute checks. The flow sheet documents where the patient is and what the patient is doing. The flow sheets revealed that patient 2 spent long periods of time in the dayroom. The surveyors observed the dayroom which had a row of recliners where patients were observed sitting and watching TV.

Interviews

On 9/25/2014, at 7:45, a certified nursing assistant (CNA) 2, was interviewed. When asked what she remembered about patient 2, she stated that patient 2 came in walking and left using a wheelchair. CNA 2 stated that Physical Therapy (PT) would have them stand her up every two hours. There was no evidence in the medical record that patient 2 had orders for physical therapy or that an assessment or treatment had been done. CNA 2 remembers that a sore was found on patient 2's buttocks, just above the crack. She stated that patient 2 would be sitting in the recliner and would get very anxious and move around a lot. She stated that staff put a chair alarm on the recliner she was sitting in it. She stated that patient 2 would "flip forward" (lean all the way forward) and staff were afraid that she would fall out of the recliner. To prevent that they put an "orange cone" (that is usually used to warn that the floor is wet) under the corner of the foot rest. She stated that when patient 2 would lean forward the cone would make a noise, so we could hear her. She stated that when the cone was under the foot rest, patient 2 could not get the foot rest down. Patient 2 would throw her legs over the arm rests of the recliner. Patient 2 could not get out of the chair with the orange cone in place. She stated that when patient 2 was discharged she went on hospice. She stated that she was used to patients coming in in bad shape and leaving in better shape. CNA 2 remembered that patient 2 was using a walker upon arrival but was using a wheelchair when she left. CNA 2 stated that when they stood her up patient 2 wouldn't move her legs. CNA 2 stated that patient 2 "was totally declining."

A telephone interview was conducted with patient 2's daughter on 9/25/14, at 3:30 PM. The daughter stated that her mother had been living in an assisted living prior to her admission to the hospital. The daughter stated that her mother had become aggressive and was hitting and kicking other residents and staff. Patient 2 had been wandering into other resident's rooms.
The daughter stated that she came in every couple of days and her mother was always sitting in a recliner in the dayroom. Her mother was only on her bed the last couple of days after staff found the beginning of a pressure sore on her bottom. The staff informed the daughter that she needed to be in bed so she could be turned and positioned. On one occasion she found her mother squirming and trying to get her pajama bottoms down.
On 9/30/2014 at 11:45 AM, Registered Nurse (RN) 1 was interviewed. She was asked if she remembered being inserviced sometime in July or August about not using orange cones under the foot rests of the recliners to prevent patients from getting up from the recliner. She stated that she remembered the orange cones being used under the foot rest of the recliner. RN 1 stated that the situation was discussed with her but there was no formal inservice.

Patient 8

Patient 8 was a 65 year old male that was admitted to the facility for the third time on 9/3/2014 with diagnoses that included coronary artery disease, chronic renal failure/end stage on dialysis, chronic back pain, right sided global weakness-history of cerebral vascular accident, Major Depressive Disorder and Probable Major Neurocognitive Disorder Due to Alzheimer's Disease, with behavioral disturbances and psychotic features. The patient's first language was Spanish but also spoke English occasionally.

On 9/25/2014 at 10:10 AM, patient 8 was observed in his room asleep. There was a vinyl triangular covered positioning wedge about 3 feet long by about 6 inches by 6 inches by 6 inches placed between the mattress and the metal spring foundation of the bed. It caused a large hump in the mattress that prevented patient 8 from turning over. Patient 8 was observed to be up against the wall asleep. CNA 3 was in the room sitting. CNA 3 was asked why the position block was placed between the mattress and the foundation. She stated that the night shift placed it there.

On 9/25/2014 at 10:25 AM, RN 2 was interviewed. RN 2 was patient 8's nurse for that shift. He stated that on a previous admission patient 8 had fallen out of bed and hit his eye on the bedside table. He stated that the wedge was placed there to prevent patient 8 from falling out of bed and injuring himself.

A review of patient 8's chart that was completed on 10/1/2014, revealed that there was no documentation in patient 8's chart that the facility tried to use less restrictive interventions to keep the patient safe.

The bed was rigged so that patient 8 could not get out of it on his own. This was an atypical restraint for which there was no physician's order, no assessment was done, and no monitoring of the restraint as required. This was a safety issue because patient 8 was entrapped by the wedge.

Policy Review

On 9/23/2014, upon entrance to the facility, a copy of the facility's policy for restraints and seclusion was requested. A paper titled "PROCEDURE: RESTRAINT SECLUSION" was given to the surveyors. The following was documented; "It is the policy of " this facility "that we are a restraint and seclusion free facility." It was documented that the last time that this policy was reviewed was on February of 2014.

17494

Based on record review, observation and interview, it was determined that the facility failed to try less restrictive interventions, initally, to protect 2 out of 2 restrained patients from possible harm.
(Patient identifiers: 2 and 8)

Findings include:

Patient 8

Patient 8 was a 65 year old male that was admitted to the facility for the third time on 9/3/2014 with diagnoses that included coronary artery disease, chronic renal failure/end stage on dialysis, chronic back pain, right sided global weakness-history of cerebral vascular accident, Major Depressive Disorder and Probable Major Neurocognitive Disorder Due to Alzheimer's Disease, with behavioral disturbances and psychotic features. The patient's first language was Spanish but also spoke English occasionally.

Observations

On 9/25/2014 at 10:10 AM, patient 8 was observed in his room asleep. There was a vinyl triangular covered positioning wedge about 3 feet long by about 6 inches by 6 inches by 6 inches placed between the mattress and the metal spring foundation of the bed. It caused a large hump in the mattress that prevented patient 8 from turning over. Patient 8 was observed to be up against the wall asleep. Certified Nursing Assistant (CNA) 3 was in the room sitting. CNA 3 was asked why the position block was placed between the mattress and the foundation. She stated that the night shift placed it there.

Interview

On 9/25/2014 at 10:25 AM, RN 2 was interviewed. Registered Nurse (RN )2 was patient 8's nurse for that shift. He stated that on a previous admission patient 8 had fallen out of bed and hit his eye on the bedside table. He stated that the wedge was placed there to prevent patient 8 from falling out of bed and injuring himself.

Medical Record

A review of patient 8's chart that was completed on 10/1/2014, revealed that there was no documentation in patient 8's chart that the facility tried to use less restrictive interventions to keep the patient safe.

The bed was rigged so that patient 8 could not get out of it on his own. This was an atypical restraint for which there was no physician's order, no assessment was done, and no monitoring of the restraint as required. This wedge entrapped patinet 8 in the bed.

Patient 2

Patient 2 was a 75 year of female patient who was admitted to the hospital on 7/4/14, with the diagnoses of "Probable Major Neurocognitive Disorder due to Alzheimer's, with behavioral", Psychotic Disorder, Diabetes, and High Blood Pressure.

The flow sheets where the aides document the every fifteen minute checks were reviewed. The flow sheet documented where patient 2 was and what she was doing. The flow sheets revealed that patient 2 spent long periods of time in the dayroom. The surveyors observed the dayroom which had a row of recliners where patients were observed sitting and watching TV.

Interviews

An interview with CNA 2 was conducted on 9/25/14. CNA 2 stated that she had not seen patient 2 have behaviors like hitting, biting, kicking or scratching. Mostly patient 2 would yell or scream. CNA 2 stated that Physical Therapy (PT) would have them stand her up every two hours. There was no evidence in the medical record that patient 2 had orders for physical therapy or that an assessment or treatment had been done. She stated that patient 2 would be sitting in the recliner and would get very anxious and move around a lot. She stated that staff put a chair alarm on the recliner she was sitting in. She did not indicate why they quit using it. She stated that patient 2 would "flip forward" (lean all the way forward) and staff were afraid that she would fall out of the recliner. To prevent that they put an "orange cone" (that is usually used to warn that the floor is wet) under the corner of the foot rest. She stated that when patient 2 would lean forward the cone would make a noise, so that she could hear her. She stated that when the cone was under the foot rest, patient 2 could not get the foot rest down and get up.
On 9/25/14, a telephone interview was conducted with patient 2's daughter. The daughter stated that she came in every couple of days and her mother was always sitting in a recliner in the dayroom. Her mother was only on her bed the last couple of days. On occasion she would find her mother sitting in the recliner with the feet elevated and an orange cone (used to indicate a wet floor) positioned under the foot rest. The cone positioned under the foot rest would prevent the patient from lowering the footrest and getting out of the chair. The daughter stated that at first she thought the cone was there because the recliner was broken. When she asked a staff person about it she was informed that it was to prevent her mother from getting out of the chair.
There was no evidence that patient 2 was a threat to any other patient's or staff.
There was no documentation indicating that less restrictive measures were tried prior to implementing an unorthodox restraint (orange cone). During an interview CNA 2 stated that a chair alarm was tried while patient 2 sat in the recliner. There was no documentation in the medical record that a chair alarm had been used. There was no documentation that the orange cone was used.

17494

Based on observation and record review, it was determined that the facility did not use the least restrictive type of restraint to protect 2 out of 2 restrained patients from possible harm. (Patient identifiers: 2 and 8)

Findings include:

Patient 8

Patient 8 was a 65 year old male that was admitted to the facility for the third time on 9/3/2014 with diagnoses that included coronary artery disease, chronic renal failure/end stage on dialysis, chronic back pain, right sided global weakness-history of cerebral vascular accident, Major Depressive Disorder and Probable Major Neurocognitive Disorder Due to Alzheimer's Disease, with behavioral disturbances and psychotic features. The patient's first language was Spanish but he also spoke English occasionally.

Observation

On 9/25/2014 at 10:10 AM, patient 8 was observed in his room asleep. There was a vinyl triangular covered positioning wedge about 3 feet long by about 6 inches by 6 inches by 6 inches placed between the mattress and the metal spring foundation of the bed. It caused a large hump in the mattress that prevented patient 8 from turning over. Patient 8 was observed to be up against the wall asleep. Cerified Nursing Assistant (CNA) 3 was in the room sitting. CNA 3 was asked why the position block was placed between the mattress and the foundation. She stated that the night shift placed it there.

Interview

On 9/25/2014 at 10:25 AM, Registered Nurse (RN) 2 was interviewed. RN 2 was patient 8's nurse for that shift. He stated that on a previous admission patient 8 had fallen out of bed and hit his eye on the bedside table. He stated that the wedge was placed there to prevent patient 8 from falling out of bed and injuring himself.

Medical Record

A review of patient 8's chart that was completed on 10/1/2014, revealed that there was no documentation in patient 8's chart that the facility tried to use the least restrictive interventions to keep the patient safe.

The bed was rigged so that patient 8 could not get out of it on his own. This was an atypical restraint for which there was no physician's order, no assessment was done, and no monitoring of the restraint as required. This wedge entrapped patient 8 in the bed.

Patient 2

Patient 2 was a 75 year of female patient who was admitted to the hospital on 7/4/14, with the diagnoses of "Probable Major Neurocognitive Disorder due to Alzheimer's, with behavioral", Psychotic Disorder, Diabetes, and High Blood Pressure.

Medical Record

Review of patient 2's medical record revealed documentation that patient 2 spent long periods of time in the dayroom which was observed to be furnished with several recliners arranged in a row.

Interviews

An interview with CNA 2 was conducted on 9/25/14. CNA 2 stated that Physical Therapy (PT) would have them stand her up every two hours. There was no evidence in the medical record that patient 2 had orders for physical therapy or that an assessment or treatment had been done. She stated that patient 2 would be sitting in the recliner and would get very anxious and move around a lot. She stated that staff put a chair alarm on the recliner she was sitting in. She did not indicate why they quit using it. She stated that patient 2 would "flip forward" (lean all the way forward) and staff were afraid that she would fall out of the recliner. To prevent that they put an "orange cone" (that is usually used to warn that the floor is wet) under the corner of the foot rest. She stated that when patient 2 would lean forward the cone would make a noise, so they could hear her. She stated that when the cone was under the foot rest, patient 2 could not get the foot rest down and get up. CNA 2 stated that patient 2 would throw her legs over the arm rest of the recliner trying to get out of the chair.

On 9/25/14, a telephone interview was conducted with patient 2's daughter.

The daughter stated that she came in every couple of days and her mother was always sitting in a recliner in the dayroom. Her mother was only on her bed the last couple of days of her stay.
The daughter stated that when she came to visit she found her mother sitting in a recliner with the feet elevated. There was an orange cone (used to indicate a wet floor) positioned under the foot rest. The cone positioned under the foot rest would prevent the patient from lowering the footrest and getting out of the chair. The daughter stated that at first she thought the cone was there because the recliner was broken. When she asked a staff person about it she was informed that it was to prevent her mother from getting out of the chair.
The hospital staff did not try less restrictive interventions before placing patient 2 in an unorthodox restraint.

17494

Based on observation and record review, it was determined that the facility failed to make modification to the care plans for restraints for 2 out of 2 sampled restrained patients. (Patient identifiers: 2 and 8)

Findings include:

Patient 8

Patient 8 was a 65 year old male that was admitted to the facility for the third time on 9/3/2014 with diagnoses that included coronary artery disease, chronic renal failure/end stage on dialysis, chronic back pain, right sided global weakness-history of cerebral vascular accident, Major Depressive Disorder and Probable Major Neurocognitive Disorder Due to Alzheimer's Disease, with behavioral disturbances and psychotic features. The patient's first language was Spanish but also spoke English occasionally.

Observations

On 9/25/2014 at 10:10 AM, patient 8 was observed in his room asleep. There was a vinyl triangular covered positioning wedge about 3 feet long by about 6 inches by 6 inches by 6 inches placed between the mattress and the metal spring foundation of the bed. It caused a large hump in the mattress that prevented patient 8 from turning over. Patient 8 was observed to be up against the wall asleep.

On 9/25/2014 at 10:25 AM, Registered Nurse (RN) 2 was interviewed. RN 2 was patient 8's nurse for that shift. He stated that on a previous admission patient 8 had fallen out of bed and hit his eye on the bedside table. He stated that the wedge was placed there to prevent patient 8 from falling out of bed and injuring himself.

Review of patient 8's care plans revealed no evidence the patient had any less restrictive measures attempted or that he was formally placed in restraints. The patient's care plan was not modified to include the restraint.

Patient 2

Patient 2 was a 75 year old female patient who was admitted to the hospital on 7/4/14, with the diagnoses of "Probable Major Neurocognitive Disorder due to Alzheimer's, with behavioral", Psychotic Disorder, Diabetes, and High Blood Pressure.

Interviews

On 9/25/14 an interview with Certified Nursing Assistant (CNA) 2 was conducted. CNA 2 stated that when patient 2 was in the recliner the staff sometimes used an orange cone under the recliners foot rest so patient 2 could not get up.

An interview with patient 2's daughter on 9/25/14, was conducted. She stated that when she visited her mother she would find her sitting in the recliner in the dayroom. At first she thought the recliner was broken because there was an orange cone under the footrest. The daughter stated that at first she thought the chair was broken but when she asked the staff they said it was to keep her mother from getting out of the recliner.

Medical Record

Review of patient 2's medical record revealed documentation that patient 2 spent almost all of her time in the dayroom. Observation of the dayroom revealed that there was a row of recliners where patients could sit. Review of the care plans revealed no evidence that patient 2 had any less restrictive measures attempted or that she was formally placed in restraints. There was no documentation to show the patient's care plan had been modified to include this restraint.

17494

Based on observation and record review it was determined that the facility failed to implement safe and appropriate restraints as determined by hospital policy to protect 2 out of 2 restrained patients from possible harm. (Patient identifiers: 2 and 8)

Findings include:

Policy

On 9/23/2014, upon entrance to the facility, a copy of the facility's policy for restraints and seclusion was requested. A paper titled "PROCEDURE: RESTRAINT SECLUSION" was given to the surveyors. The following was documented; "It is the policy of " this facility "that we are a restraint and seclusion free facility." It was documented that the last time that this policy was reviewed was on February of 2014.

Patient 8

Patient 8 was a 65 year old male that was admitted to the facility for the third time on 9/3/2014 with diagnoses that included coronary artery disease, chronic renal failure/end stage on dialysis, chronic back pain, right sided global weakness-history of cerebral vascular accident, Major Depressive Disorder and Probable Major Neurocognitive Disorder Due to Alzheimer's Disease, with behavioral disturbances and psychotic features. The patient's first language was Spanish but also spoke English occasionally.

Observation

On 9/25/2014 at 10:10 AM, patient 8 was observed in his room asleep. There was a vinyl triangular covered positioning wedge about 3 feet long by about 6 inches by 6 inches by 6 inches placed between the mattress and the metal spring foundation of the bed. It caused a large hump in the mattress that prevented patient 8 from turning over. Patient 8 was observed to be up against the wall asleep. Certified Nursing Assistant (CNA) 3 was in the room sitting. CNA 3 was asked why the position block was placed between the mattress and the foundation. She stated that the night shift placed it there.

Interview

On 9/25/2014 at 10:25 AM, Registered Nurse (RN) 2 was interviewed. RN 2 was patient 8's nurse for that shift. He stated that on a previous admission patient 8 had fallen out of bed and hit his eye on the bedside table. He stated that the wedge was placed there to prevent patient 8 from falling out of bed and injuring himself.

Patient 2

Patient 2 was a 75 year of female patient who was admitted to the hospital on 7/4/14, with the diagnoses of "Probable Major Neurocognitive Disorder due to Alzheimer's, with behavioral", Psychotic Disorder, Diabetes, and High Blood Pressure.

Interviews

On 9/25/14 an interview with CNA 2 was conducted. CNA 2 stated that when patient 2 was in the recliner the staff sometimes used an orange cone under the recliners foot rest so patient 2 could not get up.

An interview with CNA 2 was conducted on 9/25/14. CNA 2 stated that Physical Therapy (PT) would have them stand her up every two hours. There was no evidence in the medical record that patient 2 had orders for physical therapy or that an assessment or treatment had been done. She stated that patient 2 would be sitting in the recliner and would get very anxious and move around a lot. She stated that staff put a chair alarm on the recliner she was sitting in. She did not indicate why they quit using it. She stated that patient 2 would "flip forward" (lean all the way forward) and staff were afraid that she would fall out of the recliner. To prevent that they put an "orange cone" (that is usually used to warn that the floor is wet) under the corner of the foot rest. She stated that when patient 2 would lean forward the cone would make a noise, so they could hear her. She stated that when the cone was under the foot rest, patient 2 could not get the foot rest down and get up. CNA 2 stated that patient 2 would throw her legs over the arm rest of the recliner trying to get out of the chair.

An interview was conducted with patient 2's daughter on 9/29/14. The daughter stated that when she came to see her mother she was almost always sitting in the recliner. On occasion she would see an orange cone under the footrest. When she asked the staff about it she was told it was to keep her mother from getting out of the chair.

The restraints applied to patients 2 and 8 were unorthodox restraints, implemented without safe and appropriate restraint techniques and against hospital policy.

17494

Based on observation, interview and policy review, it was determined that the facility failed to obtain physicians' orders for 2 out of 2 restrained patients. (Patient identifiers: 2 and 8)

Findings include:

Policy

On 9/23/2014, upon entrance to the facility, a copy of the facility's policy for restraints and seclusion was requested. A paper titled "PROCEDURE: RESTRAINT SECLUSION" was given to the surveyors. The following was documented; "It is the policy of " this facility "that we are a restraint and seclusion free facility." It was documented that the last time that this policy was reviewed was on February of 2014.

Patient 8

Patient 8 was a 65 year old male that was admitted to the facility for the third time on 9/3/2014 with diagnoses that included coronary artery disease, chronic renal failure/end stage on dialysis, chronic back pain, right sided global weakness-history of cerebral vascular accident, Major Depressive Disorder and Probable Major Neurocognitive Disorder Due to Alzheimer's Disease, with behavioral disturbances and psychotic features. The patient's first language was Spanish but also spoke English occasionally.

On 9/25/2014 at 10:10 AM, patient 8 was observed in his room asleep. There was a vinyl triangular covered positioning wedge about 3 feet long by about 6 inches by 6 inches by 6 inches placed between the mattress and the metal spring foundation of the bed. It caused a large hump in the mattress that prevented patient 8 from turning over. Patient 8 was observed to be up against the wall asleep. Certified Nursing Assisitant (CNA) 3 was in the room sitting. CNA 3 was asked why the position wedge was placed between the mattress and the foundation. She stated that the night shift placed it there.

On 9/25/2014 at 10:25 AM, Registered Nurse (RN) 2 was interviewed. RN 2 was patient 8's nurse for that shift. He stated that on a previous admission patient 8 had fallen out of bed and hit his eye on the bedside table. He stated that the wedge was placed there to prevent patient 8 from falling out of bed and injuring himself.

A review of patient 8's chart that was completed on 10/1/2014, revealed that there was no documentation in patient 8's chart that the facility had a physician's order for the use of the vinyl triangular covered positioning wedge.

Patient 2

Patient 2 was a 75 year of female patient who was admitted to the hospital on 7/4/14, with the diagnoses of "Probable Major Neurocognitive Disorder due to Alzheimer's, with behavioral", Psychotic Disorder, Diabetes, and High Blood Pressure.

Interviews

CNA 2 stated that when patient 2 was sitting in the recliner she (lean all the way forward) and staff were afraid that she would fall out of the recliner. To prevent that they put an "orange cone" (that is usually used to warn that the floor is wet) under the corner of the foot rest. She stated that when patient 2 would lean forward the cone would make a noise, so they could hear her. She stated that when the cone was under the foot rest, patient 2 could not get the foot rest down and get up. CNA 2 stated that patient 2 would throw her legs over the arm rest of the recliner trying to get out of the chair.

An interview was conducted with patient 2's daughter on 5/29/14. The daughter stated that when she came to see her mother she was almost always sitting in the recliner. On occasion she would see an orange cone under the footrest. When she asked the staff about it she was told it was to keep her mother from getting out of the chair.

Medical Record Review

Patient 2's medical record was reviewed. There was no physician's orders for the orange cone or any other restraint device.

17494

Based on observation, interview and policy review, it was determined that the facility failed to ensure that 2 out of 2 restrained patients were monitored by a physician. (Patient identifiers: 2 and 8)

Findings include:

Policy

On 9/23/2014, upon entrance to the facility, a copy of the facility's policy for restraints and seclusion was requested. A paper titled "PROCEDURE: RESTRAINT SECLUSION" was given to the surveyors. The following was documented; "It is the policy of " this facility "that we are a restraint and seclusion free facility." It was documented that the last time that this policy was reviewed was on February of 2014.

Patient 8

Patient 8 was a 65 year old male that was admitted to the facility for the third time on 9/3/2014 with diagnoses that included coronary artery disease, chronic renal failure/end stage on dialysis, chronic back pain, right sided global weakness-history of cerebral vascular accident, Major Depressive Disorder and Probable Major Neurocognitive Disorder Due to Alzheimer's Disease, with behavioral disturbances and psychotic features. The patient's first language was Spanish but also spoke English occasionally.

On 9/25/2014 at 10:10 AM, patient 8 was observed in his room asleep. There was a vinyl triangular covered positioning wedge about 3 feet long by about 6 inches by 6 inches by 6 inches placed between the mattress and the metal spring foundation of the bed. It caused a large hump in the mattress that prevented patient 8 from turning over. Patient 8 was observed to be up against the wall asleep. Certified Nursing Assistant (CNA) 3 was in the room sitting. CNA 3 was asked why the position block was placed between the mattress and the foundation. She stated that the night shift placed it there.

On 9/25/2014 at 10:25 AM, RN 2 was interviewed. RN 2 was patient 8's nurse for that shift. He stated that on a previous admission patient 8 had fallen out of bed and hit his eye on the bedside table. He stated that the wedge was placed there to prevent patient 8 from falling out of bed and injuring himself.

There was no evidence in the medical record indicating that the physicians were aware that patient 8 was restrained and no monitoring by a physician occurred.

Patient 2

Patient 2 was a 75 year of female patient who was admitted to the hospital on 7/4/14, with the diagnoses of "Probable Major Neurocognitive Disorder due to Alzheimer's, with behavioral", Psychotic Disorder, Diabetes, and High Blood Pressure.

Interviews

An interview was conducted with CNA 2 on 9/25/14. CNA 2 stated that when patient 2 was in the recliner staff would put an "orange cone" (that is usually used to warn that the floor is wet) under the corner of the foot rest. She stated that when patient 2 would lean forward the cone would make a noise, so they could hear her. She stated that when the cone was under the foot rest, patient 2 could not get the foot rest down and get up.

An interview was conducted with patient 2's daughter on 5/29/14. The daughter stated that when she came to see her mother she was almost always sitting in the recliner. On occasion she would see an orange cone under the footrest. When she asked the staff about it she was told it was to keep her mother from getting out of the chair.

Medical Record

There was no evidence in the medical record that the physicians were aware that patient 2 was restrained and no monitoring by a physician ocurred.

Based on observation, record review and interview, it was determined that the facility failed to adequately train and educate staff about restraints which put 2 out of 2 restrained patients at risk for physical harm. (Patient identifiers: 2 and 8)

Findings include:

On 9/23/2014, upon entrance to the facility, a copy of the facility's policy for restraints and seclusion was requested. A paper titled "PROCEDURE: RESTRAINT SECLUSION" was given to the surveyors. The following was documented; "It is the policy of " this facility "that we are a restraint and seclusion free facility." It was documented that the last time that this policy was reviewed by the facility was on February of 2014.

Patient 8

Patient 8 was a 65 year old male that was admitted to the facility for the third time on 9/3/2014 with diagnoses that included coronary artery disease, chronic renal failure/end stage on dialysis, chronic back pain, right sided global weakness-history of cerebral vascular accident, Major Depressive Disorder and Probable Major Neurocognitive Disorder Due to Alzheimer's Disease, with behavioral disturbances and psychotic features. The patient's first language was Spanish but also spoke English occasionally.

On 9/25/2014 at 10:10 AM, patient 8 was observed with a vinyl covered triangular positioning wedge about 3 feet long by about 6 inches by 6 inches by 6 inches placed between the mattress and the metal spring foundation of the bed to keep patient 8 from falling out of the bed and /or to keep patient 8 safe. Registered Nurse (RN) 2, who was caring for patient 8, stated that the positioning device kept patient 8 from falling out of bed and hurting himself. RN 2 did not recognize the intervention used as a "restraint".

Patient 2

Interviews conducted on 9/25/14, with Certified Nursing Assistant (CNA) 2 and Patient 2's daughter revealed that staff members were keeping an orange cone (used to warn that floor is wet) under the foot rest of the recliner patient 2 was sitting in. This restrained patient 2 so she would not fall forward out of the recliner or get out of it. When interviewed CNA 2 did not view the cone as a restraint. She stated that the noise the cone made when patient 2 was wiggling around cued her to check on her.

Staff Training

On 9/30/14, the Administrator informed the survey team that after he found out that staff using "orange cones" as a restraint, staff were inserviced not to do so. He stated that the inservice took place sometime in August of 2014. He stated that there had been no formal inservice meeting but staff had been individually inserviced by the director of nurses. He stated that the inservice documentation could not be found.

On 9/30/2014 at 11:45 AM, RN 1 was interviewed. She was asked if she remembered being inserviced sometime in August about not using orange cones under the foot rests of the recliners to prevent patients from getting up from the recliner. She stated that she remembered the orange cones being used under the foot rest of the recliner and that being discussed with her but nothing formal occurred.

On 9/23/2014, in the afternoon 4 registered nurses personnel records were reviewed and 3 certified nursing assistants personnel records were reviewed. It was documented that all the above staff had training in the Nonviolent Crisis Intervention Training Program. However, there was no documentation found that staff was trained about what constitutes a physical restraint or the use of physical restraints.

Without adequate staff training and competency, the direct care staff, patients, and others are placed at risk. Patients have a right to the safe application of restraint or seclusion by trained and competent staff.

Based on observation, interview and chart review, it was determined that the facility failed to ensure that patients' needs were being met, to adequately supervise and evaluate nursing care for patients and failed to ensure that nursing staff developed and kept a current nursing plan for 3 out of 12 patients.

Findings include:

1. The facilty failed to adequately supervise and evaluate the nursing cares for 3 out of 12 sampled patients. Two patients were found to have injuries that nursing staff were unaware of and 1 patient developed a pressure sore. (Refer to tag A-395)

2. The facility failed to ensure that the nursing staff developed and kept a current nursing plan for 3 out of 12 sampled patients. (Refer to tag A-396)

Based on observation, record review and interview, it was determined that the facility failed to adequately supervise and evaluate the nursing care for 3 out of 12 sampled patients. Two patients were found to have injuries that nursing staff were unaware of and 1 patient developed a pressure sore. (Patient identifiers: 2, 7 and 8)

Findings include:

Patient 8

Patient 8 was a 65 year old male that was admitted to the facility for the third time on 9/3/2014 with diagnoses that included coronary artery disease, chronic renal failure/end stage on dialysis, chronic back pain, right sided global weakness-history of cerebral vascular accident, Major Depressive Disorder and Probable Major Neurocognitive Disorder Due to Alzheimer's Disease, with behavioral disturbances and psychotic features. The patient's first language was Spanish but also spoke English occasionally.

On 9/23/14 at 8:43 AM, patient 8 was observed in his room sitting in his wheelchair facing his outside window. At approximately 9:45 AM, certified nursing assistant (CNA) 1 and the Social Worker (SW) hurried into the room followed by the surveyor. Patient 8 was found on the floor lying on his left side between his wheelchair and his bed. Patient 8 was observed to be helped back into his wheelchair and then brought into the day/activity room.

On 10/1/2014, the following "Case Management Note" dated 9/23/2014 at 9:25 AM, authored by the facility SW was reviewed. The following was documented; "I went on to the unit and noticed (patient 8) on the floor of his room. I stopped what I was doing and went over to help him. He reported he had fallen but was not in pain. I told him I would get another aide and we would help him. He reported he did not fall from standing up but was leaning over his chair and fell out of the chair. He reports he was not injured but did need help getting back into his char (sic)."...CNA 1 "was able to assist me in helping (patient 8) into a wheel chair....I notified the floor nurse about the incident and asked her to follow up with the CNA 1 and (patient 8)."

On 9/23/14 at 3:15 PM, registered nurse (RN) 1, who was patient 8's nurse that shift was interviewed. When asked if she had any knowledge of patient 8 falling from his wheelchair that morning, she stated, "No". RN 1 then asked the surveyor what had occurred and started to fill out an incident report. The nurse then stated that patient 8 had slid out of his "chair 4 times last night."

The following was documented on a "Nursing Note" dated 9/23/2014 at 5:48 AM, that patient 8 "has slid out of the chairs 4 times tonight. requiring assist to get up...." There was no further documentation about these incidents found. There was no documentation found of a full body assessment to visualize for bruises or other signs of injury.

On 10/1/2014, the following "Nursing Note" dated 9/23/2014 at 4:51 AM, authored by RN 1 was reviewed. The following was documented; "It was brought to this staff member's attention that" patient 8 "was found on the floor in his room this morning at approximately 9:40 a.m. This staff member was notified of the event at 1518" (3:18 PM). A review of patient 8's medical/psychiatric chart revealed that there was no documentation found of a full body assessment to visualize for bruises or other signs of injury.

On 9/25/14 at 11:15 AM, patient 8 was observed in the shower. The following bruises were observed:
a. His right top of shoulder had a 2 1/2 inch in diameter bruise
b. His left top of shoulder had a 1 inch in diameter bruise,
c. His left side of the stomach had a 2 inch in diameter bruise.
d. His right hip and outer thigh had an approximately 8" by 6" bruise.
e. His left hip and outer thigh had an approximately 10" by 6" bruise.

A review of patient 8's medical/psychiatric chart revealed that there was no documentation pertaining to patient 8's stomach, hip and outer thigh bruises until after a meeting was held with the Director of Nursing (DON) and the Administrator.

On 9/25/14 at approximately 1:30 PM, the DON and the Administrator were informed of patient 8's bruises.

On 10/1/2014, a "Progress Note" dated 9/25/2014 at 2:45 PM, for patient 8 was reviewed. It was authored by the facility's medical physician. It was documented that the patient had a bruise on the top of his right shoulder and on the patient's right outer hip "3-4 inches by 12-15 inches". There was no documentation of the bruise on patient 8's left hip. The physician then documented that he had a "concern for more extensive trauma to account for significant drop in hct" (hemtocrit - the amount of red blood cells found in a 100 milliliters of blood. Patient 8's hct was 22%. Normal for a male patient is 40% - 54%).

Patient 8's "Observation Check Sheet for 15 Minute Checks" (OCS) forms dated 9/03/2014 through 9/24/2014 were reviewed for frequency of bathing. The sheets have the patient's name on them and each sheet tracks the patient's activities, locations and behaviors for a 24 hour period starting at 7:00 AM through 6:45 AM the next day every 15 minutes. It was documented on the 9/03/2014 sheet that patient 8 was admitted to the facility at 4:00 PM. It was documented that patient 8 was showered on 9/6/2014, then on 9/11/2014, 5 days later. It was documented that patient 8 was showered on 9/12/2014 and then on 9/21/2014, 8 days later. Patient 8 was walker and wheelchair bound and had dementia and was unable to care for himself.

There was no consistent plan of care for showering the patients or identifying skin problems.

Patient 7

Patient 7 was a 79 year old female that was involuntarily admitted on 9/13/2014, with diagnoses that included dementia, anxiety, verbally and physically aggressive, with increased agitation.

On 9/25/2014 at 10:35 AM, patient 7 was observed in the shower to assess her skin. The following bruises were observed;

a. an approximately 2" circular bruise to left lower abdomen
b. an approximately 5" X 2" bruise to left stomach apron
c. an approximately 1" circular bruise times 2, upper right inside of arm
d. an approximately 1/2" circular bruise times 3, upper right outside of arm
e. an approximately 2" circular bruise times 2 on right lower stomach apron

There was no documentation found in patient 7's chart pertaining to the bruises.

Patient 7's "Observation Check Sheet for 15 Minute Checks" (OCS) forms dated 9/13/2014 through 9/24/2014 were reviewed for frequency of bathing. The sheets have the patient's name on them and each sheet tracks the patient's activities, locations and behaviors for a 24 hour period starting at 7:00 AM through 6:45 AM the next day every 15 minutes. It was documented on the 9/13/2014 sheet that patient 7 was admitted to the facility at 6:45 PM. It was documented that patient 7 was first showered on 9/22/2014, 8 days after admittance. Patient 7 was wheelchair bound and had dementia and was unable to care for herself.

There was no consistent plan of care for showering the patients or identifying skin problems.



04804

PATIENT 2

Patient 2 was a 75 year of female patient who was admitted to the hospital on 7/4/14, with the diagnoses of "Probable Major Neurocognitive Disorder due to Alzheimer's, with behavioral", Psychotic Disorder, Diabetes, and High Blood Pressure.

1. Review of the nurse's documentation on an admission evaluation form dated 7/4/14 revealed that patient 2 had resided in an assisted living center prior to admission to the hospital.

2. On 9/30/14, the survey team visited the assisted living where patient 2 had resided. Copies of the documentation of skin assessments completed on patient 2 were obtained. The form was titled "Shower Check List/Skin check". Review of the forms reveals no documentation of redness or skin breakdown on patient 2's coccyx. Forms were reviewed for 7/3/14 (patient 2 was admitted to the hospital in the early morning hours on 7/4/14) and 6/28/14. Interview with the director of nurses at the assisted living revealed that patient 2 was walking with a walker and she was unaware of any skin problems.

MEDICAL RECORD REVIEW

3. Review of Patient 2's medical record revealed the following information:

A. Further review of the nurse's admission evaluation revealed documentation of an initial skin assessment. The nurse documented that patient 2's skin was intact; with a small bruise in the inside of arm, a large scar over the middle of the chest, and a small bruise to the left hand. There was no documentation that redness or skin break-down was present on the lower back, buttocks or sacral area.

The nurse documented that according to patient 2's daughter, the patient had recently lost over 5 pounds and since May, had lost 12 pounds. The nurse documented that Patient 2 appeared thin. Patient 2 also had problems with incontinence of bowel and bladder and was requiring assistance with all ADL's (Activities of Daily Living). The nurse documented that patient 2's dietary status was reported to the APRN (Advanced Practice Registered Nurse).

B. Review of the nurse's documentation dated 7/5/14, at 1:18 AM, revealed that patient 2 had been calmly watching TV and fell asleep in the recliner.

C. At 7:27 AM, the nurse documented that patient 2 had been monitored every 15 minutes, and had been awake and sitting in wheelchair all shift.

Sitting for long periods of time in a chair places pressure on the skin of the coccyx and sacral area which can over time lead to a skin breakdown.

D. On 7/6/14, at 5:28 AM, the nurse documented that patient 2 slept 7 1/4 hours in the recliner.

E. On 7/9/14, at 12:07 PM, the nurse documented that patient 2 had been asleep in the day room all morning. The nurse described the patient as "drowsy, arouses easily to touch, but drifts immediately back to sleep".

F. On 7/13/14, at 9:06 AM, the nurse documented that patient 2 had been agitated and was given a Geodon injection. Patient 2 then slept at intervals in the recliner for six hours.

G. On 7/19/14, at 12:11 AM, the nurse documented that the patient had redness on the buttocks and barrier cream was applied. The nurse documented that the family visited earlier in the evening and patient 2 was agitated and did not seem to enjoy the visit. Patient 2 was talking to herself and trying to continuously undress in the dayroom.

H. On 7/24/14, at 6:53 PM, the nurse documented that patient 2 was sleepy but aroused to touch. The nurse documented that he had been informed by the aides that while providing incontinence care it was noted that patient 2 had a pressure sore on the coccyx/sacral area. The nurse documented that a dressing was applied to the ulcer. The nurse documented that patient 2 was lying in bed on her left side. This was the first nursing documentation indicating that the patient was in bed and not sleeping in the recliner. The nurse documented that the medical physician was notified of the pressure ulcer and gave a verbal order to have the patient stand every hour while out of bed.

The nurse's progress note documented that a dressing was applied to the coccyx. There was no description of the pressure sore; including measurements of the wound, color of wound, whether there was drainage present or if there was a odor from the wound.

I. On 7/25/14, at 6:20 PM, the nurse documented that patient 2 had been sleepy throughout the shift. She was described as arousable to touch, and to voice at times, but drifted immediately back to sleep. The nurse documented that patient 2 was in bed and had been turned every 2 hours.
In this progress note the nurse documented that at 1:00 PM, patient 2 was found to have an elevated temperature of 100.7. The temperature was rechecked 1:15 PM. and found to be 99.8. Patient 2's oxygen saturation was 86 to 88%. (An oxygen saturation less than 90% is abnormal). The nurse documented that patient 2 was placed on 2 liters of oxygen and the patient's oxygen saturation came up to 91-92%. The nurse described the patient as being difficult to rouse and was moaning "John, John". The nurse documented that the medical doctor and psychiatrist were both notified of patient 2's condition. The nurse documented that at 5:45 PM, patient 2 left the unit and was transported by auto with her daughter back to the assisted living facility. The nurse documented that patient 2 was discharged from the hospital to hospice care.

J. There was no evidence that patient 2's skin had been checked from the time of admission 7/4 until 7/19/14, when redness of the buttocks was noted.

There was no nursing documentation indicating that pressure relieving devices were used such as chair cushions.

K. Review of the physician's and advanced practitioner's documentation revealed the following:

On 7/4/14 at 7:06 PM, an APRN (Advanced Practice Registered Nurse) documented a "Complete Evaluation / Inpatient" on patient 2. The APRN documented that the patient had a decreased appetite and that some weight loss had occurred. Patient 2 was described as having increasing difficulty with using the toilet, and bathing and dressing appropriately. The APRN documented that patient 2 had medical risk factors including falls due to unsteady gait, and was a high nutritional risk. There was no documentation concerning the condition of patient 2's skin upon admission to the hospital.

On 7/23/14, at 3:41 PM, the psychiatrist documented that the patient stated "I want to go. I need to get out of this chair." The psychiatrist documented that patient 2 had symptoms of severe dementia including: refusal to eat, refusal to swallow, inability to speak normally and needed assistance with all activities of daily living.

On 7/24/14, at 9:37 AM, the psychiatrist documented that patient 2 was very sleepy and only aroused briefly but was unable to communicate meaningfully.

On 7/25/14 at 11:06 AM, the psychiatrist documented that patient 2 had developed a pressure sore on the sacral area. The psychiatrist documented that patient 2 had lost a small amount of weight and had diminished food and fluid intake. Documentation of the psychiatrist's examination of patient 2 revealed that her condition was deteriorating and she was becoming more somnolent. The psychiatrist documented that patient 2 probably needed to be transferred to hospice care.

On 7/25/14, at 2:07 PM, a medical physician documented in his consultant's report that patient 2 had "decreased activity, hypoxia (low oxygen level), not eating." The physician documented that patient 2 had been a patient in the hospital since 7/4/14, and that morning had taken a significant decline in condition. The physician documented that patient 2 had not eaten that morning, remained in bed, had hypoxia and limited function.

The physician documented that on the day before (7/24) patient 2 was found to have the beginnings of skin breakdown in the sacral area.

The physician documented his action plan. Significant change in mental status and unable to do ADLs (activities of daily living) including feeding. Patient 2 had no desire to eat and had abnormal vital signs. The physician documented that in the past few days patient 2's family had expressed interest in hospice due to the decline in condition. The physician documented that he had reviewed his concerns with nursing. The physician documented that there was a need to have the patient evaluated at the emergency room or consider hospice care. The physician documented that the social worker was to contact the family to see how they wanted to proceed.

L. Review of the aide's documentation revealed the following concerning patient 2's activities on the hospital unit:

There were flow sheets in patient 2's medical record documenting that visual checks were done every 15 minutes to ensure her safety. The flow sheet included documentation of where patient 2 was and what she was doing.

Observation of the patient communal area revealed that it was a large room with an area for dining. Another area had recliners arranged in a row where patient's could sit (dayroom). There were other chairs and a love seat in another area.

7/4/14: Patient 2 was in bed sleeping from the time she arrived on the unit at 12:50 AM until 5:30 AM.

7/5/14: Patient 2 was sleeping in her bed from 3:00 PM to 7:00 PM. From 10:00 PM until 6:15 AM patient 2 was sleeping.

7/6/14: Patient 2 slept through the night in the dayroom 10:15 PM until 9:15 AM.

7/7/14: Patient 2 was in the dayroom from 9:15 PM until 6:15 AM.

7/8/14: Patient 2 was in the day room all day other than eating in the dining room for a half hour. Patient 2 slept in the day room from 11:00 PM to 5:30 AM.

7/9/14: Patient 2 was in the dayroom sleeping for several hours intermittently. Patient 2 was in her bed for 2 hours total. Patient 2 slept in the dayroom from 11:45 PM until 7:15 AM.

7/10/14: Patient 2 was in the dayroom from 7:15 AM. until 1:45 PM. Patient 2 had a shower at 2:00 PM. The patient slept in the dayroom from 9:00 PM until 7:15 am.

7/11/14: Patient 2 slept in the dayroom from 12:30 AM to 10 AM. Patient 2 was in her bed for only 15 minutes.

7/12/14: Patient 2 was in the dayroom sleeping from 10:30 PM until 10:45 AM. Patient spent 1 hour and 15 minutes in her bed.

7/13/14: Patient 2 was in the dayroom sleeping from 10:30 PM until 6:45 AM. There was no documentation that patient 2 laid on her bed for 24 hours.

7/14/14: Patient 2 slept in the dayroom from 9:30 PM until 6:30 AM. There was no documentation that patient 2 spent any time in bed.

7/15/14: Patient 2 slept in the dayroom from 9:30 PM until 4:45 AM. Patient 2 spent no time in her bed.

7/16/14: Patient 2 slept in the dayroom from 10:00 PM until 5:30 AM. Patient 2 spent no time in her bed.

7/17/14: Patient 2 slept in the dayroom from 9:30 AM until 5:15 AM. Patient 2 was in her bed for 1 hour and a half during the night .

7/18/14: Patient 2 slept in the dayroom from 2:15 AM until 9:45 AM. Patient 2 spent 2 hours 15 minutes in her bed.

7/19/14: Patient 2 spent the night in the dayroom. Patient 2 spent approximately 5 hours in her bed. This was the day the nurse documented that patient 2 had redness to her buttocks.

7/20/14: Patient 2 spent the night in the dayroom. Patient 2 spent 1 half hour in bed.

7/21/14: Patient 2 spent all day in the dayroom other than taking a shower. Patient 2 slept from 10:00 PM to 6:45 AM. No time was spent in her bed.

7/22/14: Patient 2 spent all night in the dayroom sleeping intermittently. Patient 2 spent no time in her bed.

7/23/14: Patient 2 slept in the dayroom from 8:15 PM to 6:15 AM. Patient 2 spent no time in her bed.

7/24/14: Patient 2 slept in the day room from 7:00 AM until 11:45 AM and 1:00 PM until 6:00 PM. and from 12:30 AM until 10:30 AM. Patient 2 spent 6:15 PM until 9:00 PM in her bed. This was the day the staff found that patient 2 had a pressure sore on her coccyx.

7/25/14: Patient 2 spent most of the day in her bed and was discharged at 5:45 PM.

Review of the aides flow sheet of every 15 minute checks revealed that there was no documentation that patient 2 was consistently assisted with toileting, incontinence care, and showering.

Patient 2 was admitted on 7/4/14. Showers were recorded 7/10/14 at 6:30 AM (first shower in 6 days), 7/13/14 at 1:15 PM (three days), 7/14/14, (1 day), 7/16/14 at 6:00 AM (2 days), 7/18/14 at 5:45 AM (2 days), 7/19/14 (1 day), 7/21/14 at 7:45 PM (2 days), 7/24/14 at 9:00 PM (3 days).

Documentation in the flow sheets of patient 2 going to the toilet was sporadic averaging 1 to 2 times a day.

Review of the aides flow sheets revealed no documentation that patient 2's skin was inspected when she was assisted with showers.

4. The survey team went to the hospice agency which assumed care of patient 2 when she was discharged from the hospice. The hospice Administrator provided a copy of the hospice nurse's initial assessment dated 7/25/14, of patient 2. The nurse documented the following: "She is being admitted to hospice for end stage cardiac disease with significant co-morbidity of advanced Alzheimer's and Vascular Dementia and a large unstageable pressure ulcer (at least stage 3, maybe stage 4)" (Pressure ulcers are staged from 1 to 4 according to the level of tissue damage. Stage 1 redness of skin. Stage 2 is a shallow wound through the top skin layers. Stage three is through all layers of skin to the underlying tissue. Stage 4 is through all skin layers, through the underlying tissue to the bone. An unstageable sore would be covered up by scabbing or dead tissue so the depth of damage would not be known.) The hospice nurse documented that patient 2 was incontinent of both bowel and bladder and was wearing an adult incontinence brief. The hospice nurse documented that the pressure ulcer was on patient 2's coccyx and extended to her right buttock. The hospice nurse measured the wound. The wound was 6 centimeter long, 9 centimeter wide and 1 centimeter deep.

4. Interviews

a. RN 1 was interviewed on 9/28/14 at 4:25 PM. The nurse stated that patients should be offered a shower daily. The nurse stated that the aides do skin checks when the patients are showered. The nurse stated that nurses do not do skin checks daily. The nurse stated that she checks the patients bottom when she helps change patients who are incontinent.

b. On 9/25/2014 at 7:45 AM , certified nursing assistant (CNA) 2 was interviewed. She stated that she does skin checks on patients when she showers them. She stated the nurses do not tell her to do skin checks. She stated that,"I just do it because I am old school." CNA 2 was asked what she remembered about patient 2. CNA 2 remembered patient 2 was using a walker upon arrival but left in a wheelchair and was unable to walk. She stated that either patient 2 didn't want to walk when she left or was unable to walk. CNA 2 stated they would stand her up and patient 2 would not move her legs.

CNA 2 stated that Physical Therapy (PT) would have us stand her up every two hours and she would scream. (There was no evidence that physical therapy was ordered for patient 2 or that she received physical therapy.) CNA 2 remembers when they found a sore on her buttocks just above the crack. She stated that she put some pink barrier cream on her buttock and it was getting better. Then she stated that she was off work for 4 days. CNA 2 stated that when she came back patient 2 had a 1 centimeter (CM) sore right at the top of the crack of her buttock. She stated that patient 2 would be seated in the recliner and would get very anxious and move around a lot. She stated that staff put a chair alarm on the recliner she was sitting in. She stated that patient 2 would "flip forward" (lean all the way forward) and that staff was afraid that she would fall out of the recliner chair so they put an "orange cone" (used to warn that floors are wet) under the corner of the foot rest. She stated that when patient 2 would lean forward the cone made a noise, so we could hear her. She stated that when the cone was under the foot rest, patient 2 could not get the foot rest down, so patient 2 would throw her legs over the arm rests of the recliner. CNA 2 remembered patient 2 being diapered but if staff toileted her every 2 hours she would remain continent. CNA 2 stated that patient 2 was bathed every other day but patient 2 would often refuse baths. Staff would talk her into one. She stated that as soon as patient 2 was discharged she went on hospice. She stated that she was used to patients coming in in bad shape but leaving in better shape.

c. A telephone interview was conducted with patient 2's daughter on 9/25/14, at 3:30 PM. The daughter stated that her mother had been living in an assisted living prior to her admission to the hospital.
The daughter stated that she came in every couple of days and her mother was always sitting in a recliner in the dayroom. Her mother was only on her bed the last couple of days; after the staff found the beginning of a pressure sore on her bottom. The staff informed her that she needed to be in bed so she could be turned and positioned. The daughter stated there was no padding or cushion between the patient's body and the leather or vinyl surface of the recliner. She stated that on several occasions she found her mother in wet briefs and had to ask staff to change her. She noticed that her mother had a bad smell about her. On one occasion her mother would be squirming and trying to get her pajama bottoms down. The daughter stated that when the staff would stand her mother she would cry out in pain.
The daughter stated that after the patient had been in the hospital for about three weeks on around 7/23/14, a nurse called and said her mother had the beginnings of a pressure sore on her bottom. The daughter stated that when she came to visit she asked the nurse if they had been checking her mother's skin. The daughter found out that there had been no skin check done for 21 days. The daughter stated that the log book indicated that her mother was being showered but that the aides probably did not notice the pressure sore until the skin around it became red.
The daughter stated that when she came to visit she found her mother sitting in a recliner with the feet elevated. There was an orange cone (often used to indicate a wet floor) positioned under the foot rest. The cone positioned under the foot rest would prevent the patient from lowering the footrest and getting out of the chair. The daughter stated that at first she thought the cone was there because the recliner was broken. When she asked a staff person about it she was informed that it was to prevent her mother from getting out of the chair.
The daughter stated that her mother was walking with a walker when she entered the hospital but gradually became chair bound. Her mother was talking when she entered the hospital but gradually spoke less and less.
The daughter stated that on 7/25/14, a staff person from the hospital called and informed her that her mother was dying and was being discharged on hospice and she needed to come get her. The daughter stated that she made arrangements for her mother to return to the assisted living center with hospice to provide care. The daughter stated that the hospice nurse came to the assisted living to see her mother. When the nurse removed the dressing which was applied in the hospital the daughter was present. The daughter described the pressure sore. The daughter stated there was a bad odor and that she had noticed the same odor when she visited her mother at the hospital. The daughter stated the wound was large and was covered with a black leathery layer. The daughter stated that the skin around the wound was red. The daughter stated that her mother cried out in pain when the dressing to the wound was changed.

Based on observation, interview and record review, it was determined that the facility failed to ensure that the nursing staff developed and kept a current nursing plan for 3 out of 12 sampled patients.
(Patient identifiers: 2, 7 and 8. )

Findings include:

Patient 8

Patient 8 was a 65 year old male that was admitted to the facility for the third time on 9/3/2014 with diagnoses that included coronary artery disease, chronic renal failure/end stage on dialysis, chronic back pain, right sided global weakness-history of cerebral vascular accident, Major Depressive Disorder and Probable Major Neurocognitive Disorder Due to Alzheimer's Disease, with behavioral disturbances and psychotic features. The patient's first language was Spanish but also spoke English occasionally.

On 9/23/14 at 9:43 AM, patient 8 was observed in his room sitting in his wheelchair facing his outside window. At approximately 9:45 AM, certified nursing assistant (CNA) 1 and the Social Worker (SW) hurried into the room followed by the surveyor. Patient 8 was found on the floor lying on his left side between his wheelchair and his bed. Patient 8 was observed to be helped back into his wheelchair and then brought into the day/activity room.

On 9/25/2014 at 10:10 AM, patient 8 was observed in his room asleep. There was a vinyl triangular covered positioning wedge about 3 feet long by about 6 inches by 6 inches by 6 inches placed between the mattress and the metal spring foundation of the bed. It caused a large hump in the mattress that prevented patient 8 from turning over. Patient 8 was observed to be up against the wall asleep.

On 9/25/2014 at 10:25 AM, Registered Nurse (RN) 2 was interviewed. RN 2 was patient 8's nurse for that shift. He stated that on a previous admission patient 8 had fallen out of bed and hit his eye on the bedside table. He stated that the wedge was placed there to prevent patient 8 from falling out of bed and injuring himself.

The following was documented on a "Nursing Note" dated 9/23/2014 at 5:48 AM, that patient 8 "has slid out of the chairs 4 times tonight. requiring assist to get up...." There was no further documentation about these incidents found.

Patient 8's "Nursing Notes" dated 9/22/2014 was reviewed. The following was documented in the "Fall Assessment" section; "Fall Prevention Recommendations: Night stand within reach. Bed height to lowest position Treaded slipper socks or shoesLock (sic) moveable equipment".

A "Treatment Plan" dated 9/25/2014 for patient 8 was reviewed. It was documented that patient 8 was a "fall risk". This was manifested by "History of recent fall" and "identified as at risk by fall-risk assessment - with impaired balance - with impaired strength". The following interventions were documented;
a. "Nurse will ensure ambulation assistance as needed this will occur and will last ."
b. Nurse will have patient evaluated for assistance device This will occur daily and will last ."
No other interventions were documented for falls.

Patient 8's "Observation Check Sheet for 15 Minute Checks" (OCS) forms dated 9/03/2014 through 9/24/2014 were reviewed for frequency of bathing. The sheets have the patient's name on them and each sheet tracks the patient's activities, locations and behaviors for a 24 hour period starting at 7:00 AM through 6:45 AM the next day every 15 minutes. It was documented on the 9/03/2014 sheet that patient 8 was admitted to the facility at 4:00 PM. It was documented that patient 8 was showered on 9/6/2014, then on 9/11/2014, 5 days later. It was documented that patient 8 was showered on 9/12/2014 and then on 9/21/2014, 8 days later. Patient 8 was walker and wheelchair bound and had dementia and was unable to care for himself.

There was no consistent plan of care for showering the patients.

Patient 7

Patient 7 was a 79 year old female that was involuntarily admitted on 9/13/2014, with diagnoses that included dementia, anxiety, verbally and physically aggressive, with increased agitation.

Patient 7's "Observation Check Sheet for 15 Minute Checks" (OCS) forms dated 9/13/2014 through 9/24/2014 were reviewed for frequency of bathing. The sheets have the patient's name on them and each sheet tracks the patient's activities, locations and behaviors for a 24 hour period starting at 7:00 AM through 6:45 AM the next day every 15 minutes. It was documented on the 9/13/2014 sheet that patient 7 was admitted to the facility at 6:45 PM. It was documented that patient 7 was first showered on 9/22/2014, 8 days after admittance. Patient 7 was wheelchair bound and had dementia and was unable to care for herself.

There was no consistent plan of care for showering the patient.


04804

Patient 2

Patient 2 was a 75 year of female patient who was admitted to the hospital on 7/4/14, with the diagnoses of "Probable Major Neurocognitive Disorder due to Alzheimer's, with behavioral", Psychotic Disorder, Diabetes, and High Blood Pressure.

Review of patient 2's medical record revealed that she developed a pressure sore while in the hospital.

Review of the treatment plan for patient 2 revealed the following information:

1. Review of the initial care plan dated 7/4/14, revealed plans for fall risk, hypertension, diabetes cognitive impairment, suicidal impulses, psychotic symptoms and discharge planning. There was no plan for assessing patient 2's skin.

2. Review of the treatment plan dated 7/8/14, revealed no plan to address skin assessments for patient 2. There was no plan to address patient 2's bowel and bladder incontinence which can contribute to skin breakdown.

3. Review of the treatment plan dated 7/10/14, revealed no changes in the care plan to address skin assessments and incontinence care.

4. Review of the treatment plan dated 7/18/14, revealed no changes in the care plan to address the prevention of skin breakdown including routine skin assessments, pressure relieving measures, and incontence care. The reddened area on patient 2's buttocks was observed on 7/19/14

5. Review of the treatment plan dated 7/24/14, revealed no change in the care plan to address the skin and pressure ulcer prevention.

On 7/25/14 the nurse documented that patient 2 had a pressure ulcer to her coccyx.

6. Review of the aides flow sheet of every 15 minute checks revealed that there was no documentation that patient 2 was consistently assisted with toileting, incontinence care, and showering.

Patient 2 was admitted on 7/4/14. Showers were recorded 7/10/14 at 6:30 AM (first shower in 6 days), 7/13/14 at 1:15 PM (three days), 7/14/14, (1 day), 7/16/14 at 6:00 AM (2 days), 7/18/14 at 5:45 AM (2 days), 7/19/14 (1 day), 7/21/14 at 7:45 PM (2 days), 7/24/14 at 9:00 PM (3 days).

There was no consistent plan of care for showering the patients.