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Based on surveyor observations, staff interviews and review of hospital documents and medical records, the hospital failed to ensure the patient's rights were protected.

Findings:

1. The hospital failed to provide the patients/complainants with a written notice of the complainant's grievance resolution containing all the required information. Refer to Tag A-0123.

2. The hospital failed to inform the patient's representative of changes in the patient's condition/health status. Refer to Tag A-0131.

3. The hospital failed to ensure patient were protected from neglect. Refer to Tag A-0145

Based on review of hospital documents and interviews with hospital staff, the hospital did not provide the patients/complainants with a written notice of the complainant's grievance resolution containing all the required information in four of six (#5, 12, 13, 15) grievances reviewed for the past year at the hospital. All six grievances had documentation that the grievances were resolved.

Findings:

Review of a hospital policy titled, "Grievance-Adult/Geri Patient", approved on 02/22/2013, documented, "...Give written report to patient for review, comments and signature. Mail a written report (by certified mail) if the complainant is not the patient or the patient has been discharged..."

~ On 05/04/2015, Patient #5's representative stated she filed a grievance concerning patient care, but had not received notification of the hospital's investigation and conclusion with action taken.

~ On 05/05/2015 at 4:50 p.m. Staff S told the surveyors that staff went over the grievances with patients and families, but did not always provide written resolutions.

~ On 05/05/2015 Staff L stated she could only find documentation that the grievance had been received for Patient #5 ,but did not have documentation of resolution.

Based on review of hospital documents and interviews with hospital staff, the hospital failed to inform the patient's representative of changes in the patient's condition/health status in four of seven (#7, 8, 14 and 17) medical records reviewed.

Findings:

1. Record #8 - The patient's representative was not informed about the patient's skin condition upon arrival at the hospital. The hospital did not inform the patient's representative about changes in the patient's skin conditions that were present on admission and that occurred during the hospitalization..

2. On 05/04/2015 at 1:20 p.m., Staff S told the surveyors that patient family members/patient representatives were notified whenever a patient on the geriatric unit fell. Two (Records #14 and 17) of four patient records reviewed for falls did not contain evidence the patient's representative was notified of the falls.

3. Record #7 - The patient's representative was not notified of the patient's transfer to an emergency room for treatment.

Based on review of hospital documents and interviews with hospital staff, the hospital failed to protect the patients from neglect. This occurred in one of six (# 8) patient medical records reviewed that had wounds.

Findings:

A hospital policy titled, "Assessment and reassessment Protocol", documented the assessment included, "...Skin-evaluation of color,turgor, temperature as well as any bruising, lacerations, skin tears, swelling, tenderness, bleeding..."

A hospital policy titled, "Abuse", documented, "...Staff is to immediately report suspected or alleged abuse, neglect, or exploitation to the CEO/designee..."

The admission wound assessment for Patient #8 contained documentation of bruising to both arms, thigh, buttocks and hand.

On May 5, 2015 at 3:55 p.m., hospital staff interviewed stated if patient abuse was suspected upon admission, the abuse hotline would be notified. Hospital staff stated Adult Protective Services were not called regarding Patient #8.

Review of hospital documents did not contain evidence of any abuse investigation and no injury reports had been completed for Patient #8.

The hospital did not follow their abuse policy.

Based on review of hospital documents and patient records and interviews with staff, the hospital failed to ensure the quality assessment and performance improvement (QAPI) program tracked, analyzed, and developed plans to improve patient safety and quality of care.

Findings:

1. On 05/04/2015 at 1:20 p.m., Staff S told the surveyors that patient falls on the geriatric unit were to be reported to family members/patient's representative.

~The hospital's policy did not specify family/patient representative notification.

~Two (Records #14 and 17) of four patient records reviewed for falls did not contain evidence the patient's representative was notified of the falls.

~ On 05/04/2015 at 4:50 p.m., Staff S stated she reviewed falls and they were reported to the Chief Nursing Officer and to QAPI, but they were not analyzed to ensure the patient's representative was kept informed of the patient falls.

2. Facility investigation reports were not analyzed in QAPI for trending of unit, shift, etc., or to determine if changes needed to occur to improve patient safety and quality of care.

~ On 05/05/2015, Staff S stated that QAPI did not analyze facility investigation reports. Staff S stated each was reviewed on an individual basis.

Based on review of hospital documents and interviews with hospital staff, the hospital failed to ensure the registered nurse:

a. supervised care provided by licensed practical nurses; and

b. provided complete skin assessments with evalutation, interventions and reevaluations.

Refer to Tag A-0395.

Based on review of hospital documents and interviews with hospital staff, the hospital failed to ensure the registered nurse (RN) assessed, planned, supervised and reassessed/evaluated the nursing needs and care for each patient. This occurred in eight of fourteen (#3, 5, 6, 7, 8, 9, 10, 21) patient medical records reviewed.

Findings:

Review of a hospital policy titled, "Assessment and Reassessment Protocol", dated 06/2013, documented, "...All patients will be assessed every shift (during waking hours) by the RN assigned to their care. The assessment will be documented on the Nursing Reassessment form and/or progress note..."

On 05/04/2015 at 3:35 p.m., The surveyors asked Staff S if Licensed Practical Nurses (LPN) were allowed to assess the patients. Staff S stated no. Staff S went on to say the Registered Nurses (RN) were responsible for performing the patient assessments, not the LPN's.

LPN's completed and signed the nursing assessments in the following records on the following dates:

#3- 01/31/2015 and 02/01/2015;
#5- 01/04/2015, 01/30/2015 and 02/15/2015;
#6- 02/03/2015 and 03/02/2015;
#7- 03/08/2015;
#8- 04/08/2015, 04/09/2015, 04/12/2015 and 04/13/2015;
#10- 01/30/2015 and 02/15/2015;
#21- 04/12/2015, 04/13/2015 and 04/14/2015.

Record #9 did not contain a nursing assessment for the date of 04/10/2015. This was confirmed by Staff S during medical record review.

A hospital policy titled, "Skin Assessment & Wound Care", documented, "...4. Any time a patient develops a wound after being admitted, the Wound Assessment form will be initiated. Also an Incident report will be completed and forwarded to the Chief Nursing Officer the day of the incident. 5. All patients at risk for skin breakdown will receive a skin assessment daily..."

A hospital form titled, "Nursing Department: Review of Systems" for Record #8 contained the following documentation:

~03/23/2015- Bruises to front of both forearms, back of the left thigh and buttock and back of the right hand, and patches to the back of the neck.

~ 03/31/2015- Multiple bruises to the front right arm, and bruises to the right chest area, the left upper arm and the right back area.

~ On 04/07/2015 - Small wound on left foot (no exact location or measurements were recorded); redness and warmth to left lower extremity; bruises to right forearm, front chest area, back of left shoulder, back of right upper arm; skin tears to back of left and right wrist areas; and redness to right back forearm.

~ On 04/10/2015- The physician ordered "butt paste" due to "decubitus ulcer." A daily skin assessment was not initiated per policy.

~04/13/2015- Bruises to the chest area, back of left shoulder area, back of right forearm and right buttock; scab to left lower extremity; slight edema to the left lower extremity; skin tears to the back of the left and right arm; red area to the back of left and right forearms.

~04/14/2015- Bruises to the front right and left arms; fading bruises to the front chest area; and skin tears/(scrapes) to right and left palms; and a midline surgical scar.

~All skin assessments were inconsistent and did not include wounds previously identified.