HospitalInspections.org

Based on interview, record review and policy review, the hospital failed to:
- Prevent physical abuse to one discharged patient (#15) of one discharged patient reviewed when Staff MMM, Security Officer (SO), inappropriately used Crisis Prevention Institute (CPI, a type of training where staff learn safe physical holds to restrict a person's movement) techniques when a verbal exchange escalated to a physical altercation and Staff MMM hit the patient and pushed the patient's face into the wall. (A-0145)
- Report an incident of abuse to the state agency (SA) in a timely manner. (A-0145)
- Follow the hospital policy time frames for the provision of a response for patient grievances for two discharged patients (#12 and #79) of six discharged patient grievances reviewed. (A-0122)

These deficient practices resulted in the hospital's noncompliance with specific requirements found under the Condition of Participation: Patient's Rights. The hospital census was 261.

Based on interview, record review and policy review, the hospital failed to follow the hospital policy time frames for the provision of a response for patient grievances for two discharged patients (#12 and #79) of six discharged patient grievances reviewed. This practice had the potential to affect all patients that filed a grievance causing the complainant to be unaware of the status, or resolution, to their grievance. The hospital census was 261.

Findings included:

1. Review of the hospital's policy titled, "Opportunity for Improvement (OFI)/Complaint/Grievance," revised 07/09/20, showed that:
- A grievance would include any written communication expressing dissatisfaction with hospital services, personnel, or medical staff.
- Grievances should be resolved within seven business days.
- If the resolution has been completed within the seven business days, a letter regarding the investigation findings would be sent to the customer/patient within seven business days.
- If the resolution of the grievance would take longer than seven business days, a letter of acknowledgement would be sent to the customer/patient to inform them of continued investigation and expected resolution within 30 business days.
- A grievance would be considered resolved and closed when the customer/patient has expressed satisfaction with the actions taken by the hospital.

Review of Patient #12's grievance form titled, "SSM Opportunity for Improvement," showed that the grievance was received by the hospital on 09/03/21 and assigned to administration. There was no documentation of a letter having been sent or a phone call of any type, as of 09/28/21.

Review of the hospital's document titled, "Complaint/Grievance Log," on 09/28/21, showed that the hospital had not received complaints from Patient #12 and Patient #79, as they were not listed.

Review of the hospital's untitled document/list of electronically mailed (e-mail) complaints, requested by survey team on 09/28/21, showed that:
- For the month of September 2021, there had been a total of 15 complaints submitted by e-mail.
- Patient #12's complaint had been submitted on 09/01/21 at 11:33 AM.
- Patient #79's complaint had been submitted on 09/09/21 at 9:29 AM.

Review of Patient #79's grievance form titled, "SSM Opportunity for Improvement," showed that the grievance was received by the hospital on 09/28/21 and assigned to Regulatory Compliance/Risk Management.

Review of an email received from Patient #12's Power of Attorney (POA, someone legally designated to make decisions about a patient's healthcare options, who is not able to make decisions on their own) dated 09/28/21 at 5:50 PM, showed that:
- The POA received an initial phone call on 09/28/21 at 11:40 AM, from hospital administration, there had been no previous contact with the hospital.
- They were told that the administrative person whom would investigate Patient #12's wounds had been on vacation.
- The hospital admitted that the nursing staff did not document Patient #12's wound on his discharge documents, nor did they communicate to the family the extent of his wounds.
- Nursing had documented a blister on Patient #12's buttocks on 08/13/21.
- On 08/15/21, the first and only photo of Patient #12's right buttocks wound was taken.
- On 08/16/21, the wound care team evaluated and staged Patient #12's wound as a Stage Two pressure injury (a shallow opening in the skin with red or pink tissue, or may present as a fluid filled blister).

Review of a letter that Patient #12's POA received, dated 09/28/21, showed that they would contact her within 30 business days, from receipt of the complaint, with a response to her concerns regarding the care received during Patient #12's admission during August 2021. This had been the first communication with the hospital since the complaint had been filed on 09/01/21 at 11:33 AM.

During an interview on 09/28/21 at 2:15 PM, Staff III, Administrative Assistant, stated that she would receive complaints from the email listed on the hospital's website, contact.smhc@ssmhealth.com, by either logging into the system to retrieve them or directly from her email. Once obtained, she would send them out to the appropriate area, such as administration, risk management, or the direct clinical area impacted by the complaint.

During an interview on 09/28/21 at 3:00 PM, Staff JJJ, Risk Manager (RM), stated that when she received the e-mail complaint, an OFI would be created. She would then forward the complaint to the department involved, the director of that department would be responsible for the following up and resolving the complaint. Once the complaint had been completed, a letter would be sent to the customer/patient.

During an interview on 09/29/21 at 9:42 AM, Staff NNN, Regulatory Specialist, stated that when the state agency (SA) would request a list of complaints/grievances the hospital would provide a list of completed incidents, the list would not include any pending issues.

During a group phone interview on 09/29/21 at 10:10 AM, Staff GGGG, OFI Manager, and Staff FFFF, OFI Coordinator, stated that:
- Their team would be responsible for dealing with the complaints submitted to the OFI system.
- They had been struggling with completing the documentation within the defined time frame of their policy due to staffing issues.
- On average most letters are sent out to the customer/patient within the seven day time frame.
- With regards to patient #79 there had been a delay, the OFI had not been entered until 09/28/21, but a letter had been sent out today, 09/29/21.
- With regards to patient #12, an acknowledgement letter had been sent out on 09/28/21 via email; the delay was dependent on verification of Power of Attorney (POA, someone legally designated to make decisions about a patient's healthcare options, who is not able to make decisions on their own).

During an interview on 09/30/21 at 11:00 AM, Staff A, Chief Nursing Officer (CNO), stated that:
- She would expect all complaints and grievances to be addressed within the time frame allotted per hospital policy.
- She was not aware that the OFI department had an increased work load related to staffing issues.
- She would expect the emailed complaints to feed into the active list of complaints.
- The administrative team meets weekly to discuss outstanding complaints and where the hospital stands in regard to resolution.

Based on interview, record review and policy review, the hospital failed to prevent physical abuse to one discharged patient (#15) of one discharged patient reviewed when Staff MMM, Security Officer (SO), inappropriately used Crisis Prevention Institute (CPI, a type of training where staff learn safe physical holds to restrict a person's movement) techniques when a verbal exchange escalated to a physical altercation and Staff MMM hit the patient and pushed the patient's face into the wall. The hospital also failed to report the abuse event to the state agency (SA) in a timely manner. These failures had the potential to place all patients at risk for their health and safety. The facility census was 261.

Findings included:

1. Review of the hospital's policy titled, "Abuse, Neglect and Harassment in the Health Care Setting: Assessment, Investigation and Reporting," revised 02/24/21, showed the following:
- Patients have the right and expectation to receive health care services, care and treatment in a safe setting and remain free at all times from abuse, neglect and harassment.
- The hospital prohibits all forms of abuse, neglect and harassment whether from staff, other patients or visitors.
- The hospital will take all reasonable steps to ensure that patients are free from all forms of abuse, neglect or harassment and furthermore, follow prescribed processes that safeguard patients when abuse, neglect or harassment is suspected, reported or witnessed.
- Abuse is the willful or reckless infliction of injury, unreasonable confinement, intimidation, coercion, financial exploitation or punishment with resulting physical harm, pain, fear or mental anguish.
- An eligible adult is any person 60 years or older, or, a person 18-59 years of age with a disability. In this context, a 'disability" is a mental or physical impairment that substantially limits one or more major life activities, whether the impairment is congenital (born with) or acquired by accident, injury or disease, where such impairment is verified by medical findings.
- If an investigation substantiates abuse, neglect or harassment of a patient, subsequent actions taken by the hospital shall first ensure the safety and well-being of hospital patients.
- Investigations into suspected abuse, neglect or harassment of patients should be given high-priority by those individuals needed to participate in the investigation.
- In the event of a substantiated instance of abuse, neglect or harassment of a patient, senior hospital leadership will ensure appropriate reports occur with respect to outside regulatory and administrative bodies.

Review of the hospital's staff training booklet titled, "CPI Nonviolent Crisis Intervention," dated 2020, showed the following directives for staff:
- Monitor your verbal and nonverbal communication.
- Work as a team if the individual's behavior begins to escalate.
- Keep a respectful tone, slow down your speech and modify your voice volume.
- Prepare to set limits that are simple, clear, reasonable and enforceable.
- Avoid engaging in power struggles.
- Remember that behavior influences behavior.
- Stay calm and do not take the behaviors of others personally.
- Treat others in your care respectfully.
- Examples of responding inappropriately during a crisis are saying things that are not pertinent to the situation, using offensive or inappropriate language and physically striking out at someone, not being able to control your actions.
- Physical intervention is only used as a last resort when an individual engages in behavior that is a danger to self or others.
- Control your own emotions and behaviors when intervening at all times.

Review of the hospital's policy titled, "Escalation of Force," revised 03/29/21, showed the following:
- Clearly define the appropriate level of force to be utilized by Security officers in order to ensure a safe and secure environment for patients, visitors and staff.
- When faced with an incident that may require an escalation of force, a SO will be responsible for assessing the situation, collaborating with clinical staff when appropriate and utilizing the proper use of force.
- SO's are expected to use the lowest level of force necessary to de-escalate a potentially violent or unsafe situation and ensure a safe and successful outcome.
- The levels of force include:
1. Officer Presence, establish force with the officer's presence and symbol of authority; examples are the officer's uniform, physical positioning, attitude and stance.
2. Verbal, establish force with spoken direction and control; examples are CPI techniques using verbal direction and control and are the most desirable force options for SO's; SO's will complete the CPI eight hour course with annual recertification.
3. Physical Control, establish control with physical contact as taught in CPI. SO's will be properly trained to use non-violent crisis intervention techniques and defensive physical contact methods in accordance with CPI training.

Review of Patient #15's medical record showed the following:
- He was a 35-year-old male with a past medical history of generalized anxiety disorder (chronic condition where fear and worry impairs a person's ability to function and interferes with their well-being), drug abuse, schizophrenia (serious mental disorder that affects a person's ability to think, feel and behave clearly) and psychosis (a serious mental illness characterized by defective or lost contact with reality).
- He arrived to the Emergency Department (ED) on 09/04/21 at 11:25 PM by ambulance after an altercation and aggressive behavior with his parents and police.
- The patient was placed in the ED Behavioral Health Annex (BHA, a locked area of the ED where behavioral health patients are cared for). A psychiatric consult on 09/05/21 at 2:07 AM, recommended inpatient treatment for bipolar schizoaffective disorder (mental illness that is characterized by symptoms of mania, depression and mood disturbances) and Phencyclidine (PCP, a mind-altering illegal street drug that may cause hallucinations) abuse, awaiting bed placement.
- On 09/05/21 at 9:55 PM, (after the altercation with Staff MMM, SO) Staff CCC, Registered Nurse (RN), documented that the patient reported left sided facial tenderness. There was no evidence of swelling or injury/redness/discoloration to the face, eyes, lips or mouth.
- On 09/05/21 at 10:35 PM, ED physician documented that the patient reportably was struck by a security guard to the face, no loss of consciousness. The patient's facial exam was with in normal limits; there was no obvious swelling or laceration.

Review of the hospital's self-report documents titled, "SBAR for Patient #15, abuse allegation," dated 09/05/21, showed the following:
- A medical record review, video recording review and timeline for Patient #15 from 09/04/21 at 11:31 PM through his transfer on 09/07/21 at 8:15 PM.
- Caregiver interviews that included Staff MMM, SO, AP; Staff AAA, RN; Staff BBB, RN; Staff CCC, RN and Staff FFFFF, RN.
- An email correspondence, dated 09/06/21 at 6:43 AM, from Staff DDD, RN House Supervisor regarding the 09/05/21 incident.
- On 09/05/21, immediately following notification of the alleged abuse, Staff MMM, SO, was placed on administrative leave per hospital policy.
- Hospital assessment and investigative findings of the 09/05/21 incident.
- Hospital recommendation and indications for the substantiated allegation of abuse.
- An opportunity was noted that Staff MMM, SO, started the CPI module on line, but never completed the training. The hospital did not identify that six other SO's presently working had incomplete or expired CPI training.
- An action plan was reviewed and approved on 09/14/21, nine days after a staff to patient abuse event occurred, that included termination of employment for Staff MMM, SO; beginning 09/13/21, 100% of new SO's will complete online CPI modules within one week of hire and complete in-person CPI skills validation within 90 days of hire; beginning 09/14/21 through 09/24/21, 100% of SO's will review and verbalize understanding of the Abuse/neglect policy and Escalation of force policy.

2. Review of the hospital's document titled, "SSM Health Life Safety Certification Guidelines," dated 01/21/20 showed that CPI certification must be obtained within 90 days from start date for new hires and there was no renewal grace period.

The hospital allowed staff required to have CPI training (Security, ED and Behavioral Health), to care for and interact with patients up to 90 days without the proper education.

Review of Staff MMM's personnel file showed that the hospital hired him as a SO on 05/2021. There was no evidence of any CPI training. He completed use of force training on 06/11/21 and regulatory and ethical considerations for new employees on 06/01/21.

Review of the hospital's undated document of the list of SO's and the completion date and expiration dates of the employees' CPI training showed the following:
- Staff HHHHH: CPI Renewal Certification expired on 08/04/21;
- Staff IIIII: CPI Renewal Certification expired on 08/24/21;
- Staff JJJJJ: CPI Renewal Certification expired on 09/04/21;
- Staff MMMMM: CPI Renewal Certification expired on 06/24/21;
- Staff KKKKK: CPI Part One Online Module completed 12/20/20. He had not completed CPI Part Two, Physical Validation; and
- Staff LLLLL: CPI Part One Online Module completed 12/20/20. He had not completed CPI Part Two, Physical Validation.

Review of the hospital's documents titled, "Security Printable Schedule," dated 09/05/21 through 09/29/21 showed the following SO's with expired or incomplete CPI training worked since the allegation of abuse regarding an untrained CPI SO towards a behavioral health patient:
- Staff HHHHH worked 11 days;
- Staff IIIII worked 13 days;
- Staff JJJJJ worked 16 days;
- Staff MMMMM worked 17 days;
- Staff KKKKK worked 17 days; and
- Staff LLLLL worked 15 days.

The hospital failed to identify and investigate the CPI training status of all SO's on staff which resulted in six out of 23 SO's employed at the hospital had incomplete and/or expired CPI training. These six SO's were allowed to work after 09/05/21 with incomplete and/or expired CPI training and placed all patients within the hospital at continued risk for their safety.

During a telephone interview on 09/28/21 at 9:00 AM, Staff AAA, RN, ED Charge Nurse, stated that:
- She was the ED charge nurse the evening of 09/05/21.
- Staff CCC, RN, was working in the ED BHA and asked if she would assist with giving an Intramuscular (IM) injection to Patient #15 due to escalating behavior.
- Staff CCC, Staff MMM, SO, Staff BBB, RN, Staff FFFFF, RN and she went into Patient #15's room.
- Patient #15 was sitting on the windowsill and did not move from that position.
- Staff MMM spoke to the patient first and informed the patient that he was going to receive medication to calm down.
- Staff CCC explained to the patient that he was going to get a shot to calm down because of the behaviors he had been having.
- The patient stated that if he was given a shot, he would spit on them. Staff MMM stated that he would "knock Patient #15's head off if he spit on him."
- Patient #15 spit on Staff MMM and Staff MMM drew his arm back and hit the patient, she did not know if his hand was opened or closed when he struck the patient. Staff MMM then held the patient's head to the side with his hand.
- She told Staff MMM that what he did was not ok and after exiting the patient's room she immediately called Staff DDD, RN House Supervisor and reported the incident.
- Staff CCC called her shortly after the incident and asked her to return to the ED BHA because Patient #15 and Staff MMM were talking back and forth.
- Patient #15 and Staff MMM were in the hallway outside of the nurse's station; the patient told Staff MMM, "You hit like a bitch." Staff MMM stated, "Oh yeah, I've never lost a fight."
- She told Staff MMM he was not helping the situation and he needed to remove himself. Staff MMM took a couple steps back and stopped talking to the patient.
- Another SO came and relieved Staff MMM.
- She was CPI certified. CPI does not teach to hit patients or push their face against a wall.
- Intimidation was considered abuse.
- She felt that the actions of Staff MMM towards Patient #15 was abuse.

During a telephone interview on 10/04/21 at 8:17 AM, Staff MMM, SO, stated that:
- He had worked at the hospital as a SO approximately four months before he was "fired."
- He had not had any CPI training.
- He had been a police officer for 28 years.
- He worked on 09/05/21, the 2:00 PM to 10:00 PM shift in the ED triage area and ED BHA.
- Around 9:15 PM, he received a call from the nurse in the ED BHA to assist with giving a patient an injection.
- He entered Patient #15's room with other nursing staff and told the patient the doctor ordered a shot to relax him and make his evening better. The patient said if you come near me, he would spit in my face. He told Patient #15 if he did that, he would knock his head off and there would be consequences for spitting.
- He went to hold Patient #15 in order for the nurse to give the injection and the patient spit on him. He then pushed the patient's face with force against the wall and held the patient's arm.
- He did not harm the patient, there was no blood. He didn't take him to the ground. If he were on the streets, he would have gotten him into a better hold. Patients in the hospital have to be handled with "kit gloves."
- After the patient was given the injection, staff left the patient's room. He was in the hallway and Patient #15 comes out of his room and started telling him he couldn't fight, he was his "bitch." If he didn't respond it would be a sign of weakness, so he repeated everything the patient said to him. After about five minutes, another SO relieved me.
- He did not get training after he was hired on what to do in these situations and he felt the hospital should have been more specific on what training was expected to be completed by the security staff.

During a telephone interview on 09/28/21 at 10:30 AM, Staff DDD, RN House Supervisor, stated that:
- She worked 7:30 PM on 09/05/21 to 7:30 AM on 09/06/21.
- She received a call on 09/05/21 from Staff AAA, RN, ED Charge Nurse, that a SO punched a patient in the face and there were four witnesses.
- She immediately called Staff EEE, Security Supervisor, to remove Staff MMM, SO, from the area and send him home.
- The actions of Staff MMM absolutely was abuse. Striking a patient, pushing a patient's face against a wall, intimidation, harassment and having an attitude with a patient were all forms of abuse. Staff should not act that way with any patient.
- Staff pulled to the ED BHA were used as sitters and were not expected to be hands on and don't have to be CPI trained.
- She was CPI certified. Anyone that worked with behavioral health patients, all ED, Behavioral Health Unit and Security staff had to be CPI certified.

During a telephone interview on 09/28/21 at 11:00 AM, Staff EEE, Security Supervisor, stated that:
- She was the supervisor on duty the evening of 09/05/21. She worked 2:30 PM to 10:30 PM.
- She received a call from Staff DDD, House Supervisor, regarding an incident in the ED BHA in which a SO had struck a patient and she needed to remove the SO from his duties and off the property.
- She interviewed Staff MMM, SO, after the incident and he said the patient spit on him and he demonstrated how he pushed the patient's face against the wall.
- SO's are not to place hands on patients unless someone was at risk. Spitting would not be considered an at risk behavior.
- She was CPI certified. CPI did not teach to push a patient's face against a wall. CPI taught to put hands up and shield ourselves.
- Abuse was threatening language, strikes and kicks. She felt the actions of Staff MMM was abuse.
- All SO's were supposed to be CPI trained.

During an interview on 09/27/21 at 3:00 PM, 09/28/21 at 4:00 PM and 09/29/21 at 9:00 AM, Staff W, Security Manager, stated that:
- He worked on 09/05/21 and had left about an hour before the abuse allegation incident occurred.
- Staff EEE, Security Supervisor, notified him of the abuse allegation incident and he returned to the hospital.
- The event could not be seen from video recording, but through staff interviews the allegation of staff to patient abuse from Staff MMM, SO, to Patient #15 was substantiated.
- He agreed the allegation of abuse was substantiated due to the physical harm, unnecessary threats and intimidation of the patient.
- Education was given to all the SO's regarding the Abuse and Neglect policy, Escalation of Force policy, how to respond to an escalating patient and reviewed patient rights.
- As of today, all SO staff have received education.
- SO's at this hospital do not carry guns. They do carry tasers, batons and handcuffs and were only allowed to use them on a patient if the patient was displaying a weapon and as a last resort to protect other patients and staff.
- SO's were not allowed to hit patients. SO's should use CPI techniques to properly hold patients.
- His expectation of staff was to wear proper PPE before going in a patient's room. If a staff member was spit on, they were to exit the room and don proper PPE in order to care for the patient.
- His expectation of security staff was to complete CPI before the certification expired.
- The job description for a SO was to have current CPI within 90 days of hire.
- He was not aware that six current SO's had incomplete or expired CPI training.
- He agreed that an incident of abuse could happen again with security staff since there were security staff working that had incomplete or expired CPI training.

During an interview on 09/28/21 at 4:30 PM, Staff NNNNN, RN, Clinical Educator Emergency Services, stated that he was a CPI instructor for the hospital. CPI does not teach staff to hit patients or push a patient's face against a wall. He was not asked by administration to review current SO's CPI verification after the abuse incident on 09/05/21.

During an interview on 09/30/21 at 11:00 AM, Staff A, Chief Nursing Officer (CNO), stated that:
- She was aware of the incident that had occurred over the Labor Day weekend.
- The administrator on call had been notified, along with Risk Management (RM).
- The investigation was started immediately and the SO had been placed on administrative leave pending the completion of the investigation.
- RM interviewed all employees involved and reviewed the video with security leadership.
- The information had been thoroughly reviewed for any regulatory reporting requirements.
- The SO involved had been former law enforcement, he was terminated for putting hands on a patient.
- De-escalation had not been successful.
- The SO had not been removed immediately from the ED, they had to wait for a back-up security officer to respond to the ED.
- All security staff were re-educated with de-escalation techniques and were to have CPI training.
- Nursing staff were not re-educated, but have abuse and neglect annual review in the computer training modules.
- The hospital developed a training program for all charge nurses in the ED to include de-escalation and CPI training, which would begin in October 2021.

During an interview on 09/29/21 at 3:30 PM, Staff JJJ, RM Manager, stated that:
- She was in charge of investigating the allegation of abuse that occurred on 09/05/21 between Staff MMM, SO, and Patient #15.
- An event report was submitted online on 09/05/21, she reviewed it on 09/06/21.
- She tried to complete the investigation as quickly as possible, she had been stretched due to staffing and was covering more than one facility.
- After she completed the investigation, she had regulatory review it and submit the self-report to the state agency on 09/14/21, nine days after the abuse incident occurred.
- She was not aware that the SA recommended that they be informed of an abuse allegation prior to completion of the hospital investigation.

During an interview on 09/29/21 at 2:30 PM, Staff B, Regulatory Specialist, stated that:
- She assisted with the action planning and self-report submission to the SA after the investigation of abuse was completed by Staff JJJ, Risk Management Manager.
- She learned of the 09/05/21 staff to patient abuse allegation on 09/06/21.
- After Staff JJJ completed the investigation, it had to go through regional review and campus review before accepted to ensure the plan was approved.
- SO Education was not started until 09/14/21 (nine days after a patient was abused by a SO) due to waiting for the investigation to be completed.
- She does not recall if she asked Staff W, Security Manager, to review all SO CPI training transcripts for verification of current and up to date certification and training. That should have been done.

An allegation of staff to patient abuse occurred at this hospital on 09/05/21 between a SO and a behavioral health eligible adult patient. The incident of staff to patient abuse was not reported to the SA until 09/14/21 and SO education was not started until 09/14/21, nine days after the incident occurred. The hospital failed to identify and investigate the CPI training status of all SO's on staff which resulted in six out of 23 SO's employed at the hospital had incomplete and/or expired CPI training. These six SO's were allowed to work after 09/05/21 with incomplete and/or expired CPI training and placed all patients within the hospital at continued risk for their safety.

Based on observation, interview, record review, and policy review the hospital failed to ensure that:
- Nursing staff appropriately assessed, recognized, and treated a pressure injury (injury to the skin and/or underlying tissue, usually over a bony area) wound for one discharged patient (#12) of one discharged patient reviewed with pressure injury wounds.
- Nursing staff followed wound care orders for daily dressing changes for two current patients (#34 and #35) of nine current patients observed.
These failures placed all patients within the hospital at risk for their health and safety and had the potential to lead to poor outcomes. The hospital census was 261.

Findings included:

1. Review of the hospital's policy titled, "Required Elements of Daily Assessment/Reassessment (REDA)," dated 11/29/2019, showed that an initial physical assessment would include a head to toe assessment (complete assessment of all patient body systems, including heart, lung, skin, vital signs, etc.), any reassessment would be based on the patient's diagnosis, change in condition, any previous abnormal findings, and response to interventions provided. A complete head to toe assessment must be completed once per shift in the Intensive Care Unit (ICU, a unit where critically ill patients are cared for).

Review of the hospital's policy titled, "Skin Care for Adults," revised 08/05/19, showed that:
- A head to toe assessment should be conducted upon admission and at least once per shift for any patient at risk for skin breakdown (destruction of skin tissue) or with any alteration in skin integrity (refers to skin health, to be free of wounds or irritation).
- An appropriate assessment of the wound should be completed every shift and include the status/integrity of the dressing in present, observation for changes in drainage, foul odor, and tissue necrosis.
- Dressing changes should be documented, along with observations of changes of surrounding skin, such as inflammation, edema and tenderness.
- Wound care should be consulted for complex wounds or deterioration of skin integrity.

Review of Patient #12's History and Physical (H&P) dated 08/08/21, showed that he had a complex medical history which included chronic (long term, ongoing) kidney disease, end stage renal disease (ESRD, the final stage of kidney disease, where the kidneys can no longer function on their own), chronic obstructive pulmonary disease (COPD, a lung disease that prevents normal airflow and breathing), diabetes (a disease that affects how the body produces or uses blood sugar, and can cause poor healing), and hypertension (high blood pressure). He was on hemodialysis (process that removes excess water and toxins from the blood when the kidneys can no longer perform these functions), had bilateral (pertaining to both right and left sides) legs amputated (removal of an injured or diseased body part), and had suffered a stroke (occurs if the flow of oxygen-rich blood cannot reach a portion of the brain).

Review of Patient #12's Nursing flowsheet documentation dated 08/08/21 through 08/20/21, showed that:
- On 08/11/21 at 8:00 AM, Staff WWW, RN, Unit Three ICU, documented that a protective dressing was applied to Patient #12's buttocks.
- His skin was documented as within defined limits appropriate for race until 08/13/21.
- On 08/13/21 at 6:00 AM, Staff HHHH, RN, Unit Three ICU, described the wound as an open blister to the right buttock, no measurements noted.
- On 08/15/21, the first order for wound care was entered.

Review of Patient #12's wound documentation on 08/15/21 at 6:01 PM, showed one photo of the right buttock stage two (a shallow opening in the skin with red or pink tissue, or may present as a fluid filled blister) pressure ulcer injury with no measurements documented. There were no other photos of the wound within the medical record.

Review of Patient #12's Wound/Skin documentation on 08/16/21 at 4:57 PM, showed that:
- The wound care nurse completed the wound care consult.
- She recommended wound care orders for bilateral buttocks, to include cleansing the wound with saline (a solution of salt in water) and gauze, to pat dry, to apply skin care ointment to open areas twice a day, with a foam dressing to cover.
- He should be placed on a low air loss mattress.
- The right buttock wound was beefy red with serosanguinous (blood and the liquid part of blood) drainage and measured 10 centimeter (cm, unit of measure) by eight and a half cm, stage two.
- The left buttock wound was beefy red with serosanguinous drainage and measured two and a half cm by one and a half cm, stage two; this was the first documentation of a wound on the left buttock.

Patient #12 was admitted on 08/08/21 with no wounds present. On 08/13/21, a wound described as an open blister, without any measurements or photo documentation. There was no further documentation regarding the wound until the photo is taken on 08/15/21, which shows the wound to measure 10cm by eight and a half cm. The wound was not assessed or described for more than 48 hours.

Review of Patient #12's Discharge Summary, dated 08/20/21, showed that he was being discharged to a rehabilitation unit (an inpatient area devoted to the rehabilitation of patients with various muscular-skeletal conditions), there were no notations regarding wounds or wound care orders.

During an interview on 09/29/21 at 3:15 PM, Staff WWW, RN, Three ICU, stated that she vaguely remembered Patient #12 but not his wound. Patients with skin breakdown would be placed on a low air loss mattress. Any wound would be treated according to the wound algorithm until seen by the wound care team. Any nurse can consult the wound care team.

During an interview on 09/29/21 at 4:00 PM, Staff EEEE, RN, Three ICU, stated that she did not remember Patient #12 or his wound. When staff identify a wound they would follow the standing wound care order set and consult the wound care team.

During an interview on 09/29/21 at 1:30 PM, Staff XXX, Charge Nurse Three ICU, stated that:
- Staff have access to the skin care protocol orders and were able to initiate treatment based on description of the patient's wound.
- In the ICU setting the nurses had direct access to a physician, and it was very easy for them to obtain a wound care consult.
- Most patients in the ICU had a preventative protective dressing applied to the coccyx/buttocks upon admission.
- There would not be an order required for a barrier cream.
- Once wound care has been consulted, they respond very quickly, staff were expected to follow the protocol till the patient was evaluated.
- There were no wound care nurses on during the weekend.

During an interview on 09/30/21 at 11:00 AM, Staff A, CNO, stated that:
- She expected staff to document a wound any identified wounds with a photo and measurements.
- Staff should work with the physicians to determine appropriate treatment of the wounds and whether a wound care consult would be needed.
- The wound care team were available to answer any questions, review the orders, initiate any treatment changes, and implement preventative measures such as specialty mattresses.
- Staff should follow all wound care orders as written.

Review of the medical record for Patient #34 showed wound care orders, dated 09/08/21, with direction for nursing to peel back the foam dressing twice a day, cleanse the wound, apply ointment then reattach and date the dressing to the patient's right buttock wound. There was only one wound care documentation for 09/24/21, 09/26/21 and 09/27/21.

Review of staffing sheets for Four East showed Staff KKK, RN had cared for Patient #34 on 09/24/21, 09/26/21 and 09/27/21.

During an interview on 09/28/21 Staff KKK, RN stated that she didn't have to provide wound care to Patient
#34's wounds as they were only ordered to be done once a day and that they had already been completed earlier that morning on night shift around 4:00 AM. When she reviewed the wound care recommendations she realized that the orders were for twice daily and stated that she hadn't read the order all the way through and didn't realize it was supposed to be done twice a day.

Review of the medical record for Patient #35, (Four West) showed wound care orders, dated 09/18/21, with direction for nursing to clean the wound and apply new dressing twice a day and as needed to the patient's sacrum (triangular shaped bone which lies above the tailbone). There was only one wound care documentation for 09/20/21.

During an interview on 09/28/21 at 3:08 PM, Staff PP, Four East/West Director, stated that nursing was aware of what the wound care orders were from the previous nurse during shift report. He stated that nursing was responsible for reviewing the wound care orders to see what wound care was ordered so that they knew the details of the order and when the wound care was to be completed

During an interview on 09/29/21 at 10:06 AM, Staff ZZ, RN, Wound Nurse, stated that she expected nursing staff to follow her wound consult recommendations/orders. She stated that she followed up weekly to check the progression or regression of the patient's wounds but she didn't routinely check nursing documentation to ensure the wound care was being followed per her orders.




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Based on observation, interview, record review, and policy review the hospital did not maintain the environment to ensure patient safety by failing to secure sharps (a term used for devices with sharp points or edges that can puncture or cut skin), and failing to ensure cabinets containing syringes with needles, lab collection tubes, intravenous start needles, and butterfly hypodermic needles were secured on the Transitional Care Unit (TCU, a unit for complex medical patients requiring more intensive treatment than those patients on a general hospital floor) and in the Emergency Department (ED).

These failures allowed unauthorized access to safety hazards and placed all patients within the hospital at risk for injury. The hospital census was 261.

1. Review of the hospital's policy titled, "Needle and Sharps Safety," reviewed 01/27/21, directed that sharps (a term used for devices with sharp points or edges that can puncture or cut the skin) should not be left unattended in unsecured or patient care areas.

Observation on 09/27/21 at 2:45 PM, of the fourth floor TCU, showed an unsecured storage cabinet that contained bins of syringes and needles, within the medication room without a door.

During an interview on 09/27/21 at 2:45 PM, Staff K, Manager TCU, stated that the cabinet containing sharps should be locked.

Observation on 09/28/21 at 10:25 AM, in the ED, showed unlocked and unsecured cabinets in rooms 25, 34, 35, 37, 41, 42, and 44, which contained various sizes of IV start needles, lab supplies that included needles, syringes with attached needles and oxygen tubing. These unlocked and unsecured cabinets in rooms 25, 34, 35, 37, 41, 42, and 44 were accessible to patients and visitors.

Observation on 09/28/21 at 10:25 AM, in the ED hallway, showed an unlocked and unsecured Chest Tube Cart. The cart contained suture needles, needles, and chest tubes. This cart was accessible to patients and visitors.

During an interview on 09/28/2021 at 10:30 AM, Staff RRR, ED RN Charge Nurse, stated that all cabinets in the ED rooms were supposed to be locked at all times except when in use by hospital staff.

During an interview on 09/30/21 at 11:00 AM, Staff A, Chief Nursing Officer, stated that she expected staff to ensure that the hospital's policy regarding safety of any sharps be followed and that any storage areas should be locked.

The failure of nursing staff to appropriately secure sharps, within locked cabinets of the patient care areas, allowed easy access to these items for any patient or visitor wandering the unit or looking in cabinets, which could result in serious injury to patients, visitors or staff.