HospitalInspections.org

Based on medical record review and facility document review, it was determined the facility staff failed to ensure the patient received the patient's rights and responsibilities notice for three (3) of the seven (7) records reviewed for the documentation.

The finding included:

On 6/13/23, the surveyor reviewed three (3) of the seven(7) records in the sample. SMs #7 and #13 assisted with the medical record reviews. The surveyor requested to review patient #1, patient #5 and patient #7's signed document for patient rights and responsibilities titled "Conditions of Admission and Consent for Inpatient and/or Surgical Care". SM #13 was unable to locate the documents in any of the medical records. SM #13 contacted SM #15 (patient access director) to research the medical records; SM #15 was unable to locate the documents in the three (3) records.

The surveyor discussed the findings with SM #1. SM #1 researched the medical records and could not locate the documents. SM #1 contacted SM #15 to confirm that the documents were not there.

The facility's policy titled, Patient Rights and Responsibilities 7/1/2020, was reviewed and reads, in part: "...PURPOSE:... Ensure that all patients receiving care and/or patient representatives are informed of their rights... POLICY:... All Company-affiliated facilities must provide each patient with a written statement of patient rights at the time of registration...".

On 6/13/23 during the exit conference, the surveyor reviewed the findings with SMs #1, 2, 3 (via telephone), 5, 11 and 21.

Based on interviews and document review, it was determined the facility staff failed to update the plan of care for one (1) of three (3) patients sampled.

Findings:

On 6/13/2023, the surveyor reviewed the medical records for restraint documentation for Patients #9, 10 , and 11 with Staff Member (SM)11. A review of the medical record for Patient #10 contained documentation that the patient's restraints were started on 6/13/2023 at 9:44 a.m. and the patient's plan of care was updated on 6/13/2023 at 1:25 p.m. There was no documentation that "restraints" were added to the patients plan of care that was updated on 6/13/2023 at 1:15 p.m., after the restraints had been ordered and applied. SM11 confirmed that the plan of care from 6/13/2023 at 1:15 p.m. that was updated after the restraints were applied to Patient #10, had not been updated to include "restraints" as an area of focus, and should be updated to reflect the use of restraints.

A review of the facility's policy titled "Patient Restraint/Seclusion" states in part:
... 10. Care of the Patient/Plan of Care. a. The plan of care will clearly reflect a loop of assessment, intervention, and evaluation for restraint, seclusion and medications. b. Patients and/or families should be involved in care planning to the extent possible and made aware of changes to the plan of care.... 12. Documentation Requirements ... n. Modifications of the plan of care.

The above concerns were discussed with SM1, SM2, SM3 (via telephone), SM5, SM11, and SM21 at the exit conference on 6/13/2023 at 5:45 p.m.

Based on interviews and document review, it was determined the facility staff failed to follow their policies and procedures related to completing the safety risk assessment every shift as per policy for two (2) of three (3) patients sampled.

Findings:

On 6/13/2023, the surveyor reviewed the medical records for Patients #2, 3, and 4, all patients who had a fall during their admission at the facility, for the Fall/Safety risk assessments. A review of the medical record for Patient #3 contained documentation that there was no "Morse Fall Scale score and risk level" documented for the night shift on 4/3/2023. A review of the medical record for Patient #4 contained documentation that there was no "Morse Fall Scale score and risk level" documented for the night shift on 2/4/2023.

During an interview on 6/13/2023 at 1:44 p.m., Staff Member (SM)19 stated that that the falls safety risk screening is completed for each patient every shift. SM19 stated that the fall risk section has a space to document fall interventions. SM19 stated that based on the answers submitted in the fall risk assessment, the electronic medical record (EMR) calculates the fall risk level. SM19 stated that SM19 documents fall interventions one (1) time per shift and more frequently if SM19 adds any interventions or the fall risk level changes.

A review of the facility's policy titled "Assessment/Reassessment Policy" states in part:
... An RN [registered nurse] must complete an assessment on an inpatient at least once EACH DAY.... Procedure ... 4. Each patient is to be reassessed at least q [every] shift until discharged. 5. Documentation of assessments/reassessments is to be completed on the appropriate unit form/screen.... Critical Care Unit [CCU]: ... Reassessment is to be completed every [four] 4 hours with focus on cardiac, respiratory, and pain. CCU patients are continually monitored.

A review of the facility's policy titled "EBCD Clinical Documentation" states in part:
... Purpose: To outline clinical documentation requirements that [the facility] has established to support coordinated, patient centric care processes including the assessment, plan of care and interventions within an electronic documentation system environment.... Key elements of the patient-centered electronic health record are: ... B. Screening and risk assessment ... Patient screening and risk assessment addresses each domain of the CCC [Clinical Care Classification] framework: health behavior (safety), functional, physiological, and psychological components.... 5. Risk of injury from falls is assessed for inpatients. Inpatients with positive screens are provided with appropriate supervision and injury reduction interventions.... Positive screenings identify potential problems for the plan of care and/or identify the need for additional assessment by specialists to determine if a problem exists. Notification of positive screens is automated by the electronic documentation system (i.e. order for specialists) ... D. Assessment and Reassessment: ... E. Routine care components, including environmental safety interventions that are defined in policies and procedures will be documented as a "bundle" using the WDP/WNL [sic] [within defined parameters/limits] approach.

A review of the facility's "Guidelines for Patient Care Documentation: ICU Specific Patients" states in part:
... Routine Daily Care ... Safety Measures: QShift ...

A review of the "Orientation Handbook: Critical Car RN Consolidated Stages" states in part:
... EBCD Support Tool: Critical Care Inpatient Admission and Daily Routines: ... 'Every Shift' routines and 'As-Needed' ... Safety / Risk / Regulatory ... Fall Risk.

The above concerns were discussed with SM1, SM2, SM3 (via telephone), SM5, SM11, and SM21 at the exit conference on 6/13/2023 at 5:45 p.m.

Based on interviews and document review, it was determined the facility staff failed to ensure a blood transfusion was administered according to policy and procedure for one (1) of two (2) patients sampled.

Findings:

On 6/13/2023, the surveyor reviewed blood transfusions in the medical records of Patient #9 and Patient #12 with Staff Member (SM) 11. A review of the blood transfusion for Patient #9 on 6/4/2023 contained documentation that the first unit of packed red blood cells (PRBC) type A was started at 8:07 a.m. and ended at 9:56 a.m. The second unit of PRBCs was started at 10:00 a.m. and ended at 12:02 p.m. There was no documentation of the patient's temperature when the first unit of PRBCs ended, or at the start of the the second unit of PRBCs, or at fifteen (minutes) after the start of the second unit. The only temperatures were documented at 8:15 a.m., 8:22 a.m.,, and 12:00 p.m. There was no fifteen (15) minute set of vital signs obtained after the second unit of PRBCs started at 10:00 a.m. The next set of vital signs was documented was at 10:30 a.m. and did not include a temperature.

During the medical record review on 6/13/2023, SM11 confirmed that for Patient #9, the blood transfusion documentation was missing temperatures after the first unit of PRBCs, and at the start and fifteen (15) minutes after the start for the second unit of PRBCs. SM11 also confirmed that vitals signs were not documented at fifteen (15) minutes after the start for the second unit of PRBCs. SM11 stated that vital signs should be obtained and documented at the start of the transfusion, fifteen (15) minutes after the start of the transfusion, and hourly.

A review of the facility's policy titled "Adult Blood/Blood Component Administration - Protocol" states in part:
... Policy Statements: ... N. Rate/Length of Transfusion: 1. No greater than 2ml/minute for the first [fifteen] 15 minutes of the transfusion and obtain a second set of vital signs ... O. RN remains with the patient for the first fifteen (15) minutes of the transfusion ... Procedure: ... J. Click "Document" and enter beginning set of vital signs. K. Respond "N" to the query of signs/symptoms of transfusion reaction. L. Start transfusion, then click "Begin" ... N. Patient Monitoring. 1. RN remains with the patient for the first fifteen (15) minutes of the transfusion. 2. Vital signs: Blood Pressure, Temperature, Pulse, Respirations, Pulse Oximetry. a. At the initiation of transfusion. b. [fifteen] 15 minutes after the start of the transfusion. c. Completion of the transfusion...

The above concerns were discussed with SM1, SM2, SM3 (via telephone), SM5, SM11, and SM21 at the exit conference on 6/13/2023 at 5:45 p.m.