HospitalInspections.org

Based on document review and interview, the facility failed to ensure the patient and or representative was involved in care planning and treatment (see tag 130), failed to ensure patient privacy (see tag 143), failed to provide care in a safe setting (see tag 144), and failed to ensure patients were free from abuse (see tag 145).

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure that Patients Rights were promoted.

Based on document review, the facility failed to follow their policy to ensure patient and/or patient representative participation in the development, implementation and update reviews of the patient treatment/care plans for 6 of 10 patients. (Patients #3, 4, 5, 7, 9 and 10).

Findings include:

1. Facility policy titled "PLAN OF CARE-PROTOCOL FOR THE USE OF THE MULTIDISCIPLINARY FORMAT" last reviewed/revised 4/2018 indicated the following: "...PURPOSE: To provide a structure that assists the treatment team in care planning, coordination of interventions, and evaluation of patient progress toward goals for discharge...FORMAT: * Signature Sheet, which includes: * Degree of patient and/or significant other's participation in plan...Phase II - Plan of Care Development: Formulating the Multidisciplinary Individual Treatment Plan (Initial Session)...Social Services will record...the patient's participation in the planning process in the appropriate form section. ...These recordings will reflect the input of the psychiatrist, the team and the patient. When possible, the Social Worker will request patient and/or guardian signatures. ...Phase III. Individual Treatment Plan Development: Ongoing Treatment Review...The Social Worker and/or responsible staff will revise the Individual Treatment Plan, review with the patient/POA/ [Power of Attorney] Guardian and have signed when possible...."

2. Review of patient #3's medical record indicated the following:
(A) The patient was admitted on 4/2/19.
(B) The patient's "MASTER TREATMENT PLAN & NURSING CARE PLAN SIGNATURE PAGE" indicated the following: "...Participant Participation in Treatment Planning (check as appropriate): Contributed to goals and plan [box blank] Aware of plan content [box left blank] Present at team meeting [box blank] Refused to participate [box blank] Unable to sign plan [box blank] Patient or Guardians Signature and Date [box blank]...Patient's Comments (optional): [box blank] Staff Member's Comments (optional): [box blank]...Note: The above signatures document that the participants have reviewed the Master Treatment Plan on the date signed and that the agree with the plan, unless indicated otherwise under "staff member comments...." The treatment/care plan indicated the staff reviewed it on 4/5/19 at 1100 hours and it lacked a patient or patient representative's signature or any indication that the patient or patient representatives participated in the treatment plan, therefore it could not be determined that the patient or patient's representative participated in the development and implementation of the master treatment plan.
(C) The patient's "Treatment Plan Review Including Review of MASTER TREATMENT PLAN & NURSING CARE PLAN" dated 4/4/19 at 1100 hours and 4/11/19 at 1100 hours lacked a patient or patient representative's signature or any indication that the patient or patient representatives participated in the treatment plan, therefore it could not be determined that the patient or patient's representative participated in the treatment plan reviews/updates.

3. Review of patient #4's medical record indicated the following:
(A) The patient was admitted on 4/14/19.
(B) The patient's "MASTER TREATMENT PLAN & NURSING CARE PLAN SIGNATURE PAGE" indicated the following: "...Participant Participation in Treatment Planning (check as appropriate): Contributed to goals and plan [box blank] Aware of plan content [box left blank] Present at team meeting [box blank] Refused to participate [box blank] Unable to sign plan [box blank] Patient or Guardians Signature and Date [box blank]...Patient's Comments (optional): [box blank] Staff Member's Comments (optional): [box blank]...Note: The above signatures document that the participants have reviewed the Master Treatment Plan on the date signed and that the agree with the plan, unless indicated otherwise under "staff member comments...." The treatment/care plan indicated the staff reviewed it on 4/17/19 at 1100 hours and it lacked a patient or patient representative's signature or any indication that the patient or patient representatives participated in the treatment plan, therefore it could not be determined that the patient or patient's representative participated in the development and implementation of the master treatment plan.
(C) The patient's "Treatment Plan Review Including Review of MASTER TREATMENT PLAN & NURSING CARE PLAN" dated 4/16/19 at 1100 hours lacked a patient or patient representative's signature or any indication that the patient or patient representatives participated in the treatment plan, therefore it could not be determined that the patient or patient's representative participated in the treatment plan reviews/updates.

4. Review of patient #5's medical record indicated the following:
(A) The patient was admitted on 4/6/19.
(B) The patient's "Treatment Plan Review Including Review of MASTER TREATMENT PLAN & NURSING CARE PLAN" dated 4/9/19 at 1100 hours, 4/16/19 at 1100 hours and 4/23/19 at 1100 hours lacked a patient or patient representative's signature or any indication that the patient or patient representatives participated in the treatment plan, therefore it could not be determined that the patient or patient's representative participated in the treatment plan reviews/updates.

5. Review of patient #7's medical record indicated the following:
(A) The patient was admitted on 3/15/19 and discharged on 4/3/19.
(B) The patient's "MASTER TREATMENT PLAN & NURSING CARE PLAN SIGNATURE PAGE" indicated the following: "...Participant Participation in Treatment Planning (check as appropriate): Contributed to goals and plan [box blank] Aware of plan content [box blank] Present at team meeting [box blank] Refused to participate [box blank] Unable to sign plan [box blank] Patient or Guardians Signature and Date [above signature line was the following:] Not obtained prior to discharge...Patient's Comments (optional): [box blank] Staff Member's Comments (optional): [box blank]...Note: The above signatures document that the participants have reviewed the Master Treatment Plan on the date signed and that the agree with the plan, unless indicated otherwise under "staff member comments...." The master treatment/care plan indicated the staff reviewed it on 3/20/19 at 1100 hours and it lacked a patient or patient representative's signature or any indication that the patient or patient representatives participated in the treatment plan, therefore it could not be determined that the patient or patient's representative participated in the development and implementation of the master treatment plan.
(C) The patient's "Treatment Plan Review Including Review of MASTER TREATMENT PLAN & NURSING CARE PLAN" dated 3/19/19 at 1100 hours and 3/26/19 at 1100 hours lacked a patient or patient representative's signature or any indication that the patient or patient representatives participated in the treatment plan, therefore it could not be determined that the patient or patient's representative participated in the treatment plan reviews/updates.

6. Review of patient #9's medical record indicated the following:
(A) The patient was admitted on 4/22/19 and a current patient.
(B) The patient's "MASTER TREATMENT PLAN & NURSING CARE PLAN SIGNATURE PAGE" indicated the following: "...Participant Participation in Treatment Planning (check as appropriate): Contributed to goals and plan [box blank] Aware of plan content [box blank] Present at team meeting [box blank] Refused to participate [box blank] Unable to sign plan [box blank] Patient or Guardians Signature and Date [box blank] Patient's Comments (optional): [box blank] Staff Member's Comments (optional): [box blank]...Note: The above signatures document that the participants have reviewed the Master Treatment Plan on the date signed and that the agree with the plan, unless indicated otherwise under "staff member comments...." The treatment/care plan indicated the staff reviewed it on 4/25/219 at 1100 hours and it lacked a patient or patient representative's signature or any indication that the patient or patient representatives participated in the treatment plan, therefore it could not be determined that the patient or patient's representative participated in the development and implementation of the master treatment plan..

7. Review of patient #10's medical record indicated the following:
(A) The patient was admitted on 3/28/19 and discharged on 4/19/19.
(B) The patient's "MASTER TREATMENT PLAN & NURSING CARE PLAN SIGNATURE PAGE" indicated the following: "...Participant Participation in Treatment Planning (check as appropriate): Contributed to goals and plan [box blank] Aware of plan content [box left blank] Present at team meeting [box blank] Refused to participate [box blank] Unable to sign plan [box blank] Patient or Guardians Signature and Date [above signature line was the following:] Not obtained prior to discharge...Patient's Comments (optional): [box blank] Staff Member's Comments (optional): [box blank]...Note: The above signatures document that the participants have reviewed the Master Treatment Plan on the date signed and that the agree with the plan, unless indicated otherwise under "staff member comments...." The treatment/care plan indicated the staff reviewed it on 4/2/219 at 1100 hours and it lacked a patient or patient representative's signature or any indication that the patient or patient representatives participated in the treatment plan, therefore it could not be determined that the patient or patient's representative participated in the development and implementation of the master treatment plan.
(C) The patient's "Treatment Plan Review Including Review of MASTER TREATMENT PLAN & NURSING CARE PLAN" dated 4/9/19 at 1100 hours, 4/16/19 at 1100 hours and 4/2/19 lacked a patient or patient representative's signature or any indication that the patient or patient representatives participated in the treatment plan, therefore it could not be determined that the patient or patient's representative participated in the treatment plan reviews/updates.

Based on document review, observation and interview the facility failed to follow their policy to ensure patients are treated with dignity and personal privacy is respected for 1 of 10 patients. (Patient #6).

Findings include:

1. Facility policy titled "PATIENT RIGHTS AND RESPONSIBILITIES" last reviewed/revised 6/2018 indicated the following: "...PURPOSE: Every person who enters the hospital for care has rights and responsibilities. He/she may exercise these rights while hospitalized. ...You have the right to: 1. Receive considerate ethical behavior and respectful care in treatments, services, and business practices. You have the right to be made comfortable and be treated with dignity. ..11. Receive effective communication and reasonable responses to any reasonable request made for services. ...14. Have personal privacy respected...18. Receive care in a safe setting, free from verbal or physical abuse or harassment...."

2. Review of patient #6's medical record indicated the following:
(A) The patient was admitted on 5/1/19 and a current patient.
(B) The Nursing Admission Database form dated 5/1/19 indicated the patient was alert and oriented to person, place and time.
(C) Nurse note dated 5/1/19 at 0845 hours "Tearful + [and] upset this AM [morning] - doesn't have clothes to wear or briefs that fit. Called NH [Nursing Home] + requested clothing + briefs that fit. Will send some as well as [his/her] w/c [wheelchair]. ...1300 [hours] ...no clothes being brought in @ [at] this time. Covered [with] blanket...1720 [hours] ...Facility still has not brought any clothes or w/c...."

3. During a facility tour beginning on 5/2/19 at approximately 1045 hours of the 100 unit with staff member A7 (Corporate Director of Quality and Risk), patient #6 was observed in his/her room wearing only an adult brief covered up by a sheet/blanket.

4. During an interview on 5/2/19 at approximately 1100 hours, patient #6 was interviewed and confirmed that on 5/2/19 at approximately 0300 hours staff member N12 (Certified Nurse Aide) removed his/her sheet and blanket from the bed leaving him/her exposed lying in bed wearing only an adult brief. Patient #6 confirmed he/she was not given a sheet and blanket until staff member N10 (Certified Nurse Aide) returned to the room approximately an hour later asking him/her if "his/her attitude" had changed. Patient #6 stated he/she could not call staff for assistance/help due to the call button on the bedrail did not work. Patient #6 stated he/she needed to yell to get the attention of a staff member. Patient #6 stated "staff can't hear me when I yell." Patient #6 confirmed he/she is lying in bed wearing only an adult brief because the facility has not provided him/her with clothing/gown.

5. During an interview on 5/2/19 at approximately 1115 hours, staff member N15 (Certified Nurse Aide) was interviewed and confirmed call lights located on the bedrails of patients' beds are not working. Staff member N15 confirmed patients do not have the ability to call for help from their rooms except in the bathroom.

6. During an observation of patient rooms 103, 104 and 108 with staff member N15 on 5/2/19 during tour of the 100 unit beginning at approximately 10:45 a.m., the call lights located on the bedrails were tested in all three patient rooms and found to be not working.

7. During an interview on 5/2/19 at 1616 hours, staff member A1 (Director of Nursing) was interviewed and confirmed patients have the ability to call for help via a chair alarm or "yelling-out". Staff member A1 confirmed the call lights located on the bedrails do not work.

Based on document review, the facility failed to ensure patients received care in a safe setting for 6 of 1 0 patients (patient #1, 3, 4, 5, 6 and 9).

Findings include:
1. Facility policy titled "FALL RISK IDENTIFICATION/PREVENTION AND EVALUATION" last reviewed/revised 12/2018 indicated the following: "...POLICY: " ...A Fall Prevention Program will be implemented and maintained to assure the safety of all patients admitted to the facility. The program will be inclusive of measures which determine the individual needs of each patient by assessing the risk of falls, and implementation of appropriate staff interventions to assure a safe environment is maintained, adequate supervision is provided, and assistive devices are utilized when necessary. All falls occurring during hospitalization will be evaluated to determine the potential causative factors and discern appropriate interventions. ...PROCEDURE: POST FALL EVALUATION: ...4. Risk Management/Patient Safety Committee will be responsible for reviewing patient falls, monitoring the effectiveness of fall prevention strategies, and for recommending revisions to the Fall Prevention Program as deemed necessary.

2. Review of patient #1's medical record indicated the following:
(A) The patient was admitted on 3/28/19 and discharged AMA (against medical advice) by family on 4/13/19 at 1645 hours.
(B) The nurse's note dated 4/6/19 at 0947 hours for patient #1 indicated the following: "...At 0927 [hours], patient heard calling out for help as [he/she] was walking and then was observed falling backwards. Patient hit head - small laceration noted to...the top of head, tongue, and [left] side of lower lip..."
(C) A review of the POST-FALL EVALUATION dated 4/6/19 at 0947 hours indicated "...Ambulatory status of patient ...[box checked] Ambulatory with assistive device...Functional status of patient: Needs assistance in most ADLs...Immediate post-fall interventions: Alarm device placed in...chair [chair was underlined] ...Other pt [patient] given wheelchair...."
(D) The medical lacked follow-up documentation of injuries and the treatment plan/care plan was not updated post fall on 4/6/19.
(E) A review of the "EVERY 15 MINUTE PATIENT OBSERVATION MONITORING" form dated 4/7/19, 4/8/19 and 4/9/19 indicated fall interventions of non-slip socks and fall band. The box for the intervention of chair alarm was not checked or filled in.
(F) A review of a late entry nurse note dated 4/13/19 at 1500 [hours] for 1445 [hours]. POA [Power of Attorney] of pt here et [and] insisting [he/she] is taking pt [with] [him/her]...
(G) A review of a late entry nurse note dated 4/13/19 for 1645 hours indicated the following: "...[Patient #1] left...[with] family...POA stated "We are going to the ER [Emergency Room]..."
(H) A review of Facility #2's Emergency Department [ED] medical record for patient #1 indicated the patient was admitted to the Emergency Department on 4/13/19 at 17:12 hours and indicated the following: "...presents to the ED c/o [complaints of] CP [chest pain] and back pain. Pt was brought by [family members] from [Facility #1]...[family member] concern about patient being mistreated at that facility. Pt began c/o SOB [shortness of breath], CP, headaches. ...family discharged [him/her] from that facility AGAINST MEDICAL ADVICE and brought here to the ED for further evaluation. ...Review of Systems: Cardiovascular: CP Respiratory: SOB Neurological: Headaches Musculoskeletal: Large bruise on chest/sternum and lumbar spine pain. ...Physical Exam: ...Skin: ...Bruise on lateral aspect of proximal left forearm, contusion on mid sternal area which seems relatively new with no green or yellow discoloration. Mostly black and blue and maroon in color...Respiratory: ...SOB at rest nonetheless...Musculoskeletal: Peristernal tenderness in the area of the sternal ecchymosis. Also diffusely tender throughout [his/her] back..."
(I) A review of computed tomography (CT) report dated 4/13/19 at 7:33 p.m. of patient #1's chest, abdomen and pelvic indicated the following: "Impression: CTA (computed tomography angiography) chest: ...2. Lucency through the sternum with horizontal orientation suggesting fracture. There is some periosteal bone reaction around an soft tissue swelling or hematoma noted anterior and posterior to the fracture...CT abdomen and pelvis: 1. Superior endplate L1 vertebral body fracture which may be recent or acute...3. Body wall edema/anasarca. Small amount of pelvic ascites is seen...."
(J) A review of an ED physician note from signed on 4/13/19 at 2028 hours, indicated the following: "...Assessment/Plan: 1. Sternal fracture/non-disclosed 2. Compression fracture of L1 lumbar vertebra...4. Severe Dementia...."

3. Review of patient #3's medical record indicated the following:
(A) The patient was admitted on 4/2/19.
(B) A review of an incident reports indicated the patient had a fall on 4/3/19 and 4/6/19.
(C) A review of physician orders dated 4/8/19 at 1110 hours indicated make patient 1:1 for safety due to fall risk.
(D) A review of a nurse's note dated 4/19/19 at 1810 hours indicated the following: "...Called to Pt room by staff. Staff stated Pt alarm was sounding. Pt observed sitting on side of bed facing window. Side rail up. Bruising noted under [left] eye..." The medical record lacked documentation of how the patient received the bruising under the eye.

4. Review of patient #4's medical record indicated the following:
(A) The patient was admitted on 4/14/19 on fall precautions.
(B) A review of an incident report indicated the patient had a fall on 4/24/19 at 11:00 a.m.
(C) The patient's "...Nursing Care Plan - Increased Risk for Falls" dated 4/13/19 indicated the patient has fall interventions which included wearing non-skid socks.

5. Review of patient #5's medical record indicated the following:
(A) The patient was admitted on 4/6/19 and on fall precautions.
(B) The patient's "...Nursing Care Plan - Increased Risk for Falls" initiated on 4/6/19 indicated the patient has fall interventions which included wearing non-skid socks.

6. Review of patient #6's medical record indicated the following:
(A) The patient was admitted on 5/1/19.
(B) The patient's "...Nursing Care Plan - Increased Risk for Falls" initiated on 5/1/19 indicated the following: "...Impaired mobility or gait (e.g. wheelchair...) [wheelchair was partially circled]...Educate patient regarding use of call light...Refer to physical therapy...and/or for assessment for assistive device..."
(C) Nurse note dated 5/1/19 at 0845 hours "...Called NH [Nursing Home]...Will send...[his/her] w/c [wheelchair]. ...1720 [hours] ...Facility still has not brought...w/c...."

7. Review of patient #9's medical record indicated the following:
(A) The patient was admitted on 4/22/19 and on fall precautions.
(B) A review of the incident reports for the patient indicated the patient had a fall on 4/28/19 at 1:50 p.m. with injury and on 4/29/19 at 8:30 p.m. with injury.
(C) The patient's "Treatment Plan Review Including Review of MASTER TREATMENT PLAN & NURSING CARE PLAN" dated 4/25/19 lacked documentation of falls and implementation of fall interventions post falls.

8. During an interview on 5/1/19 at 1523 hours, staff member A1 (Director of Nursing) and A5 (Vice President of Clinical And Regulatory) was interviewed and verified the fall on 4/6/19 for patient #1, the nursing documentation of injury/wounds post fall next shift and days later lacked follow-up documentation of injury. A1 and A5 verified patient #1 was signed out AMA by a family member on 4/13/19. A1 and A5 verified the treatment plan/care plan was not updated post fall on 4/6/19.

9. During an interview on 5/2/19 at approximately 1100 hours, patient #6 was interviewed and stated he/she could not call staff for assistance/help due to the call button on the bedrail did not work. Patient #6 stated he/she needed to yell to get the attention of a staff member. Patient #6 stated "staff can't hear me when I yell. Patient #6 reported the facility has not provided a walker that he/she felt was safe. Patient #6 reported staff gave him/her a walker that was too tall for his/her height and the tennis balls attached to the feet of the walker were worn through. Patient #6 reported he/she has not been up from bed since his/her admission."

10. During a facility tour beginning on 5/2/19 at approximately 1045 hours of the 100 unit with staff member A7 (Corporate Director of Quality and Risk), patient #6 was observed in his/her room and no wheelchair or walker was observed in the patient's room.

11. During an interview on 5/2/19 at approximately 1115 hours, staff member N15 (Certified Nurse Aide) was interviewed and confirmed call lights located on the bedrails of patients' beds are not working. Staff member N15 confirmed patients do not have the ability to call for help from their rooms except in the bathroom.

12. During an observation of patient rooms 103, 104 and 108 with staff member N15 on 5/2/19 during tour of the 100 unit beginning at approximately 10:45 a.m., the call lights located on the bedrails were tested in all three patient rooms and found to be not working. It was also observed that patient #4 and patient #5 were observed ambulating on the 100 Unit without non-slip Fall-Risk identification socks on.

13. During an interview on 5/2/19 at 1616 hours, staff member A1 was interviewed and confirmed patients have the ability to call for help via a chair alarm or "yelling-out". Staff member A1 confirmed the call lights located on the bedrails do not work.

Based on document review and interview, the facility failed to ensure patients were free from abuse and that the facility abuse and neglect policy was followed for 1 of 10 patients. (Patient #10)

Findings include:

1. Facility policy titled "PATIENT ABUSE AND NEGLECT" last reviewed/approved 11/2017 indicated the following: "...PURPOSE: To provide procedures for reporting, investigating, and following up when an allegation of patient abuse or neglect is made, or when other information is received indicating that patient abuse or neglect may have occurred. ...POLICY: All patients have the right to be free from abuse or neglect as well as the fear of being abused or neglected. Allegations or information indicating that abuse or neglect may have occurred will be thoroughly and promptly investigated with appropriate action taken. All hospital employees have an obligation to protect patients, prevent abuse or neglect from occurring...Responsibilities: Employee Responsibilities and Initial Notification Procedures: Employees who witness or have knowledge of patient abuse shall immediately report the incident to the Director of Nursing during normal business hours or the Charge Nurse assigned to the unit where the patient is located after normal business hours. The Charge Nurse then will report the incident to the Director of Nursing. If for any reason an employee believes they cannot or should not inform the Charge Nurse or Director of Nursing of the alleged abuse, the employee may contact the Hospital Administrator, Administrator on Call or Compliance Officer. ...V. PROCEDURE: If the alleged assailant is an employee or a member of the Hospital staff, the following procedures must take place. * After the incident occurs, the staff member involved will be suspended...until the internal investigation has been completed. Ensure the immediate care and protection of the victim...."

2. A review of a Patient Grievance Form dated 4/14/19 at 10:17 a.m. for Patient #10 indicated staff member A1 (Director of Nursing) and MD#1 (Psychiatrist) were the staff whom received a complaint from patient #10. The following was indicated in the grievance by Patient#10: "... [Staff member N14; Nurse Supervisor] ...got in my face and told me to "bring it" and I was provoked already so I went after [him/her]. Staff held me back as I got my hair pulled by [staff member N14]. Staff tried to get [him/her] off of me and I grabbed [him/her] hair back. I was restrained and on the ground, when another staff held my neck and I could barely talk. My voice sounded raspy in the hold like I was being chocked. After the whole thing I didn't get a head check and I only got a towel for my bleeding face." The following was indicated in the grievance investigation from staff member N16 (Registered Nurse) on 4/15/19 at 1357 hours: "[staff member N14] the supervisor on night shift on Saturday April 13th [2019] between 1830 -1915 hours was physically aggressive [with] a patient [patient #10] in the dayroom after the patient [patient #10] was physically aggressive with another patient...Patient #10 had sat down at the table by the nurse's station. [Staff member N14] was in the dayroom [with] staff and was talking to [Patient #10]. [Patient #10] started yelling at [staff member N14] this writer [staff member N16] came out to the dayroom to help calm the [patient #10]. [Patient #10] told [staff member N14], "I will beat your ass." [Staff member N14] stated, "Come at me." [Patient #10] started charging after [staff member N14], this writer [staff member N16] tried to stop [patient #10] but [patient #10] swang at [staff member N14] and got ahold of [staff member N14's] hair pulling out some of [staff member N14's] hair before staff could break [patient #10] away from [staff member N14]. Staff had [patient #10] held back away from [staff member N14]. [Staff member N14] then got red in the face and came aggressively at [patient #10]. [Staff member N14] grabbed [patient #10's] hair [with] both hand[s] pulling [patient #10's] head down to [his/her] chest and started punching [him/her] in the head [with] [his/her] right fist repeatedly. This writer [staff member N16] told [staff member N14] repeatedly to stop, step away. go calm down, etc. [Staff member N14] hit [him/her] (punched) multiple times until [staff member N14] finally listened, let go, backed away. Staff eased [patient #10] to the floor to stabilize hold on [the patient]. [Staff member N14] then went back to [patient] and started pushing [him/her] hands into [him/her] body. [Patient #10] tried biting [staff member N14] on the leg and got ahold of [his/her] pant leg. This writer [staff member N16] helped get pants out of [patient #10's] hands and yelled at [staff member N14] to "get back and go calm down." [Staff member N14] left to get orders...came back [with] 2 injections and gave them. This writer [staff member N16] was able to calm [patient #10] and get [patient #10] to agree to talk [with] staff...[Staff member N14] was bragging in the nurse's station about how [patient #10] "Got the wrong one. I'll beat [his/her] ass" "[He/she] don't know me." "If [he/she] come at me, I'll beat [his/her] ass. [He/she] don't know." [Patient #10] was upset when [he/she] talked to this writer [staff member N16] and this writer [staff member N16] assured [patient #10] that [patient #10] and [staff member N14] would be kept away from contact [with] each other...."

3. A review of staff member N14's payroll for April 2019, indicated staff member N14 worked on Saturday 4/13/19 from 6:32 p.m. to 7:14 a.m. and on Sunday 4/14/19 from 6:27 p.m. to 7:41 a.m.

4. A review of daily assignment sheets for 4/13/19 and 4/14/19 indicated staff member N14 worked on the 100 unit.

5. A review of the "PRELIMINARY CENSUS REPORT" dated 4/13/19 and 4/14/19 indicated patient #10 was inpatient on the 100 unit.

6. During an interview with A2 (Chief Executive Officer/Vice President) and A5 (Vice President of Clinical and Regulatory) on 5/2/19 at 3:52 p.m., A2 verified the assault on patient #10 by staff member N14 occurred on 4/13/19 at shift change at approximately 6:30 p.m. A2 verified that staff member N14 worked on 4/13/19 from 6:32 p.m. to 7:14 a.m. and again on 4/14/19 at 6:27 p.m. to 7:41 p.m. after he/she had assaulted patient #10 on 4/13/19 at approximately 6:30 p.m. A2 verified that staff should immediately contact their supervisor to report staff to patient abuse/assault or him/her. A2 verified he/she would expect the staff member accused of patient abuse/assault to be immediately suspended until an investigation was completed.

Based on document review and interview, the Registered Nurse failed to reassess patient post fall injuries for 3 of 10 medical records (MR) reviewed (patient #1, 3 and 9).

Findings include:

1. Facility policy titled "ASSESSMENT OF PATIENTS" last reviewed/revised 3/2019 indicated the following:
"...POLICY: ...7. Nursing will re-assess each patient every shift and as warranted by the patient's medical condition and documented in the patient record.

2. Facility policy titled "CHANGE OF CONDITION" last reviewed/revised 1/2019 indicated the following: "...PROCEDURE: ...3. The assessments...will be documented in the nursing notes of the patient's medical record along with the patient's response. The change of condition will continue to be monitored and documented until resolved...Documentation should reflect when the change has been resolved. 4. ...possible changes in condition would include but not limited to: ...b. Falls...j. Change in skin condition, color, and/or integrity...8. The nurse will continue to document on the change of condition until the time of resolution, or until the patient is discharged."

3. Review of patient #1's medical record indicated the following:
(A) The patient was admitted on 3/28/19.
(B) The nurse's note dated 4/6/19 at 0947 hours for patient #1 indicated the following: "...At 0927 [hours], patient heard calling out for help as [he/she] was walking and then was observed falling backwards. Patient hit head - small laceration noted to...the top of head, tongue, and [left] side of lower lip..."
(C) A review of nurse notes from 4/6/19 at 1845 hours though 4/13/19 at 1654 hours lacked documentation of any post fall re-assessment of wounds from patient #1's fall on 4/6/19. The nurse's notes indicated patient #1's skin was intact and that no lacerations, bruises or skin tears were noted or even resolved.
(D) A review of a late entry nurse note dated 4/13/19 for 1645 hours indicated the following: "...[Patient #1] left...[with] family...POA stated "We are going to the ER [Emergency Room]..."
(E) A review of Facility #2's Emergency Department [ED] medical record for patient #1 indicated the patient was admitted to the Emergency Department on 4/13/19 at 17:12 hours and indicated the following: "...presents to the ED c/o [complaints of] CP [chest pain] and back pain. Pt was brought by [family members] from [Facility #1]... [family member] concern about patient being mistreated at that facility. Pt began c/o SOB [shortness of breath], CP, headaches. ...family discharged [him/her] from that facility AGAINST MEDICAL ADVICE and brought here to the ED for further evaluation. ...Review of Systems: Cardiovascular: CP Respiratory: SOB Neurological: Headaches Musculoskeletal: Large bruise on chest/sternum and lumbar spine pain. ...Physical Exam: ...Skin: ...Bruise on lateral aspect of proximal left forearm, contusion on mid sternal area which seems relatively new with no green or yellow discoloration. Mostly black and blue and maroon in color...Respiratory: ...SOB at rest nonetheless...Musculoskeletal: Peristernal tenderness in the area of the sternal ecchymosis. Also diffusely tender throughout [his/her] back..."
(F) A review of computed tomography (CT) report dated 4/13/19 at 7:33 p.m. of patient #1's chest, abdomen and pelvic indicated the following: "Impression: CTA (computed tomography angiography) chest: ...2. Lucency through the sternum with horizontal orientation suggesting fracture. There is some periosteal bone reaction around an soft tissue swelling or hematoma noted anterior and posterior to the fracture...CT abdomen and pelvis: 1. Superior endplate L1 vertebral body fracture which may be recent or acute...3. Body wall edema/anasarca. Small amount of pelvic ascites is seen...."
(G) A review of an ED physician note from signed on 4/13/19 at 2028 hours, indicated the following: "...Assessment/Plan: 1. Sternal fracture/non-disclosed 2. Compression fracture of L1 lumbar vertebra...4. Severe Dementia...."

4. Review of patient #3's medical record indicated the following:
(A) The patient was admitted on 4/2/19.
(B) A review of nurse's note dated 4/3/19 at 2130 hours indicated the following: "...Patient had [a]...fall...noted to have a bump on the [left] side of the head and skin tear on [left] side of the face...order given to monitor the area...."
(C) A review of the nurse's notes on 4/5/19 from 2005 hours to 0615 hours on 4/6/19 and 4/6/19 from 1845 hours to 0510 hours on 4/7/19 indicated patient #3's skin integrity was intact and that no lacerations, bruises or skin tears were noted or resolved. A review of nurse's notes also indicated a lack of documentation of re-assessment every shift of the patient's post fall injuries from the patient's fall on 4/3/19.

5. Review of patient #9's medical record indicated the following:
(A) The patient was admitted on 4/22/19.
(B) A review of the nurse's notes for the patient indicated the patient had a fall on 4/28/19 at 1350 hours that resulted in a skin tear to the right elbow and a fall on 4/29/19 at approximately 2030 hours that resulted in a bump on the left side of the patient's head.
(C) A review of physician orders for patient #9 indicated the following: "...4/28/19 [at] 1350 [hours]...Nursing to monitor [right] elbow wound every shift for signs and symptoms of infection and healing...."
(D) A review of nurse's notes beginning on 5/1/19 at 0750 hours to 1800 hours indicated patient #9's skin integrity was intact and that no lacerations, bruises or skin tears were noted or resolved. A review of nurse's notes also indicated a lack of documentation related to the right elbow skin tear re-assessment beginning on 5/1/19 at 1942 hours to 5/2/19 at 0523 hours from the patient's fall on 4/28/19.

6. During an interview on 5/1/19 at 1523 hours, staff member A1 (Director of Nursing) and A5 (Vice President of Clinical And Regulatory) was interviewed and verified the fall on 4/6/19 for patient #1, the nursing documentation of injuries/wounds post fall on the next shift and days later lacked follow-up documentation of the injuries/wounds.

Based on document review and interview, the facility failed to follow their policy to ensure patient treatment/care plans were updated post patient falls for 2 of 10 patients. (Patients #1 and 9).

Findings include:

1. Facility policy titled "PLAN OF CARE-PROTOCOL FOR THE USE OF THE MULTIDISCIPLINARY FORMAT" last reviewed/revised 4/2018 indicated the following: "...POLICY: ...The Multidisciplinary Team will review the patient progress and revise the plan on a weekly basis as is necessary...."

2. Review of patient #1's medical record indicated the following:
(A) The patient was admitted on 3/28/19.
(B) The nurse's note dated 4/6/19 at 0947 hours for patient #1 indicated the following: "...At 0927 [hours], patient heard calling out for help as [he/she] was walking and then was observed falling backwards. Patient hit head - small laceration noted to...the top of head, tongue, and [left] side of lower lip..."
(C) The medical lacked documentation of an update to the treatment plan/care plan post patient fall on 4/6/19.

3. Review of patient #9's medical record indicated the following:
(A) The patient was admitted on 4/22/19 and on fall precautions.
(B) A review of the incident reports for the patient indicated the patient had a fall on 4/28/19 at 1:50 p.m. with injury and on 4/29/19 at 8:30 p.m. with injury.
(C) The patient's "Treatment Plan Review Including Review of MASTER TREATMENT PLAN & NURSING CARE PLAN" dated 4/25/19 lacked documentation of falls and implementation of fall interventions post falls.

4. During an interview on 5/1/19 at 1523 hours, staff member A1 (Director of Nursing) and A5 (Vice President of Clinical and Regulatory) was interviewed and verified the fall on 4/6/19 for patient #1. A1 and A5 verified the treatment plan/care plan was not updated post fall on 4/6/19 for patient #1.