HospitalInspections.org

Based on record review, policy review, observation and interview, it was determined that the facility failed to protect and promote the rights of patients as evidenced by:

--failure to inform each patient, or when appropriate, the patient's representative (as allowed
under State law) of the patient's treatment rights (A-0117)
--failure to offer Guardians the opportunity to be involved in developing patient's Master Treatment Plans
--failure to provide a safe setting for patient care (A-0144)
--failure to obtain a physician's order for use of restraints (A-0168).

Based on interview and record review, the facility failed to inform the patient's legal representative of patient rights for 3 of 5 current patients (#3, #4 and #6). Findings include

Facility policy 7.00 #7.36, titled "Informed Consent" does not specify procedures to be followed if a patient has a legal representative and is not available to sign consents on behalf of the patient at admission and during the course of treatment. Specific staff follow-up responsibilities for attempting to obtain consent from legal representatives are not stated.

? Patient #4 was admitted on 1/7/12, discharged 1/16/12 and readmitted on 1/18/12. Guardianship papers were noted in notes in the medical record. The following forms were unsigned in the chart with no indication of attempts to provide these forms to the patient's guardian: "An Important Message from Medicare," "Acknowledgement of Receipt of Notice of Privacy Practices and Medicare Information Sheet," "Adult Inpatient Program Inpatient Program Regulations and Procedures," and "Consent for the Use of Psychotropic Mediation."
? Patient #6 was admitted on 1/25/12 and had a copy of full Guardianship papers in the medical record. Intake documentation indicates that the patient was speaking irrationally and behaving erratically at admission. The following forms were noted unsigned in patient #6's record: "Acknowledgement of Receipt of Notice of Privacy Practices and Medicare Information Sheet,"Patient Recipient Rights Information Verification," and "Consent for the Use of Psychotropic Medication."
? Patient #3 was admitted 1/6/12. A note by the Social Worker states "please have (patient's) guardian sign both forms." No further notes regarding efforts to obtain signatures were noted. The following consents were unsigned in the record: "Patient Recipient Rights Information Verification," "Consent for the Use of Psychotropic Medication," "Patient Recipient Rights Information Verification," and "An Important Message from Medicare."
? These findings were verified by the Director of Patient Programs on 1/31/12 at approximately 1130 hours and 2/1/12 from 0900-0945 hours.

Based on interview and record review, the facility failed to ensure that 2 of 2 current patients (#3 and #6) with legal representatives had the opportunity to participate in the development of patient treatment plans. Findings include

? Patient #6 was admitted on 1/25/12 and had a copy of full Guardianship papers in the medical record. Patient #6's Master Treatment Plan" was signed by the treatment team on 1/25/12-1/27/12. The line for Guardian's signature was left blank. No documentation of the Guardian's involvement in the treatment plan was noted. These findings were verified by Social Worker #1 on 2/1/12 at approximately 0930 hours.
? Patient #3 was admitted 1/6/12. A note by Social Worker #1 states "please have (patient's) guardian sign both (consent) forms." On 2/1/12 at 0920 hours Social Worker #1 stated that she was aware that the patient had a Guardian. Patient #3's Master Treatment Plan, signed by the treatment team on 1/7/12 and 1/8/12 was left blank on the line for Guardian's signature. There was no documentation of the Guardian being involved in the treatment plan. These findings were verified by Social Worker #1on 2/1/12 at 0920 hours.

Based on interview and record review, the facility failed to complete Incident Reports and communicate Incidents of patient abuse (per policies) and initiate interventions to address the behavior for 1 of 1 current patients ( #4) with abusive behavior and to monitor 1 of 1 transferred patients (#1) for oxygen status, pain and blood pressure resulting in increased risk of patient injury and negative health outcomes. Findings include:

Patient #4:

Facility policy 1.00, #42A defines an Occurrence requiring completion of an Incident Report as:
"An event, which may result in injury to or may have an adverse effect on an employee, patient or visitor..." The policy states that: "All Incident Reports must be completed at the time of discovery of the occurrence."

Facility policy 0.02 #9.02.12 states: "All Incidents of patient abuse...which are apparent to, or suspected by, staff...shall be immediately reported orally and in writing to the office of Recipient Rights."

On 1/31/12 at approximately 1130 hours, patient #4's medical record was reviewed with the Director of Program Services (DPS). Patient # 4's medical contained documentation of the patient physically abusing other patients on the following dates:
-1/19/12 @ 2150 hours "hitting peers"
-1/22/12 @ 0740 hours "scratched peer"
-1/23/12-@ 1640 hours "kicking patients with cast and screaming at them."
-1/26/12 @ 1830 hours "combative with peer" and physical altercation with another resident.
-1/27/12 @ 0900 hours attacked roommate in her sleep
-1/29/12 @ 1125 hours "found choking peer."
-1/29/12 @1620 hours "extremely aggressive, attempting to fight other patients, kicking peers."
-1/29/12 @ 1748 hours "combative with peers"

Review of all Incident Reports for January 2012 revealed that only 2 of the above occurrences/incidents resulted in completion of Incident Reports. During an interview with the Recipient Rights Officers (RROs) on 2/2/12 at approximately 1000 hours, the RROs stated that they did not receive notification of all of the above Incidents. Review of patient #4's Individual Plan of Service (IPOS) revealed no updates related to the patient's aggressive behavior from 1/19/12-1/29/12. The facility did not initiate increase staff supervision of patient #4 until 1/29/12, even though the patient had attacked a sleeping patient on 1/27/12.

Patient #1:

On 2/1/12 at approximately 1300 hours patient #1's closed medical record was reviewed with the Chief Nursing Officer (CNO) and Director of Program Services (DPS). Patient # 1 was admitted to the facility on 11/19/11, shortly after midnight. Review of pre-admission documents received by the facility received documentation of a diagnosis as type A aortic dissection from the sending facility. On 11/18/11 at 1118 hours, the Case Manager from the sending facility documented patient #1's pulse oximetry measurements on room air as 74%-88%. This note (part of the facility's record) documented a pulse oximeter reading on 11/18/11 of 92% on 4 liters of oxygen. The facility's "Intake Form," for patient # 1, dated 11/18/11, states "he also is on 4 Liters continuous oxygen."

The facility's floor nurse (RN#1) documented the patient #1's admission to the floor in a Progress Note dated 11/19/11, timed 0110 hours. Per a 11/19/11 Progress Note timed 1415 hours, RN # stated: "Med Dr's order 02/2L/M." (Oxygen at 2 Liters per minute) "Pt on 4 L continuous Ox b/4."{sic} (Patient on 4 Liters continuous oxygen before.) This was a phone order. There was no documentation explaining why the patient's oxygen was cut from 4 Liters to 2 Liters per minute. The "Nursing Comprehensive Assessment" dated 11/19/11 at 1310 hours, documents that the patient's breathing is labored. No orders for monitoring the patient's oxygen saturation rate were noted. The floor nurse documented that the patient's oxygen was not set up until 0215 hours.

Patient #1's list of medications from the transferring facility included Ipratropium-Albuterol 0.5 mg-3 mg. Solution for nebulization, administered every 6 hours. This medication was not ordered by the facility and the record contains no documentation explaining why the medication was not continued.

On 11/19/11 from 2300-0700 a pulse oximetry rate of 81 for patient #1 was documented on the Vital Signs Flow Sheet. There was no documentation of physician notification or other response to this sub-normal rate. These findings were verified by the CNO on 2/2/12 at approximately 1430 hours.

Patient #1's medication list from the transferring hospital listed Morphine 15 mg. every 8 hours for pain. Upon admission to the facility, no orders for Morphine were obtained. Patient #1's "Nursing Comprehensive Assessment" noted severe (maximum) pain ratings on 2 pain scales. Morphine was ordered at 1500 hours on 11/19/11, and scheduled for administration at 0900 and 2100 hours. It was never administered prior to the patient's transfer at 2144 hours. Patient # 1's pain was documented as 10 out of 10 at the time of transfer. There was no documentation in the patient's record to explain why Morphine was not administered at any time despite documentation of severe pain (10/10) at 1600 hours and 1815 hours. These findings were verified by the CNO on 2/2/12 at approximately 1430 hours.

The facility's record contained an order from the transferring facility timed 2125 hours, stating: "maintain blood pressure SBP (systolic blood pressure) under 120 in view of aortic dissection and repair. Inform the nursing home about the blood pressure controls." No orders for blood pressure control monitoring were noted in patient #1's medical record. Per a Nursing Progress Note, patient # had a systolic blood pressure reading of 130 at 0110 hours on 11/19/11. Per the Vital Signs Flowsheet for 2300-0700 hours, patient #1 had a systolic blood pressure of 130. There was no documentation of physician notification of these readings. These findings were verified by the CNO on 2/2/12 at approximately 1430 hours.

Based on interview and record review, the facility failed to obtain a physician's order for 1 of 2 patients (#4) who were physically restrained. Findings include:

On 1/31/12 at approximately 1130 hours patient #4's medical record was reviewed with the Director of Program Services (DPS). Per Progress Notes, patient #4 was "placed in quiet room" due to the patient's aggressive, combative behavior toward staff and peers. An order for an injection of Haldol 10 mg. and Ativan 2 mg by injection was obtained No order for physical restraint was obtained despite the documentation of placing the patient in the quiet room. These findings were verified by the DPS.