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Based on the nature of standard level deficiencies referenced to the Condition, it was determined the Condition of Participation §482.23 NURSING SERVICES, was out of compliance.

A-0395 - Standard: The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. The facility failed to provide for patients' basic needs and care. The facility failed to ensure nursing care was provided in accordance with acceptable standards of practice during medication administration and with providing hygiene care in 10 of 11 medical records reviewed (Patients' #1, 2, 3, 4, 5, 7, 8, 9, 10, 11). This failure created delays or omissions in assessing the effectiveness of medications administered for pain relief. Further, this failure resulted in delayed or missed patient care and created the potential for the transmission of healthcare acquired infections (HAIs) to patients receiving care in the facility.

Based on interviews and document review, the facility failed to ensure nursing staff documented and monitored restrained patients for safety and comfort in 3 of 11 medical records reviewed (Patients #1, #2, #4).

This failure created the potential for an unsafe patient care environment which created the risk for negative patient outcomes.

FINDINGS

POLICY

According to Restraints, patients will be monitored during the use of restraints to determine their wellbeing and assessed for the continuing need for restraints. Monitoring documentation includes, but is not limited to, the assessment of peripheral circulation, sensation, movement, and skin integrity at least every two hours. Patients will be offered food/fluid, toileting, pain and hygiene at least every two hours.

According to Nursing Assessment, Daily, staff should initial each timed box reflecting monitoring of the patient on the restraint documentation.

According to Use of an Enclosure Bed the restraint policy will be followed for monitoring and documentation purposes.

1. The facility failed to document the wellbeing and needs of physically restrained patients were addressed every two hours.

a) Review of the History and Physical (H&P) for Patient #2 revealed the patient was admitted to the facility's medical surgical unit on 06/10/16 with multiple traumatic injuries. Patient #2 remained in the facility until 06/23/16. Review of Patient #2's Nursing Notes and Physician Orders, dated 06/10/16 through 06/23/16 revealed the following lack of documentation of monitoring restraints to evaluate the patient's wellbeing and ensure personal safety needs were being met:

On 06/11/16 at 7:00 a.m. Nursing Daily Care Notes documented Patient #2 had pulled out his/her nasogastric tube and wrist restraints were ordered and placed. Patient #2's Nursing Daily Care Notes lacked a Restraint Observation Sheet indicating patient monitoring had been completed and documented on that date.

b) Review of the H&P for Patient # 4 revealed the patient was admitted on 05/26/16 with a history of a recent traumatic brain injury secondary from a bicycle accident. Patient #4 remained in the facility through 06/07/16.

Review of Patient #4's Nursing Notes and Physician Orders, dated 05/26/16 through 06/07/16, revealed physician's orders for mitten restraints for Patient #4 each day of his/her hospitalization to prevent traumatic removal of medical devices and unintentional harm to him/herself. Review of Nursing Daily Care notes showed no documentation on the Restraint Observation Sheets on 05/29/16, 06/03/16 and 06/06/16 to show the restraints had been monitored.

c) Review of the H&P for Patient #1 revealed the patient was admitted on 05/07/16 with a history of multiple medical problems including scoliosis, status post lumbar and cervical surgery with rod placement, chronic back pain, muscle weakness, depression/anxiety, neuropathy and dementia.

Review of Patient #1's Nursing Daily Care Notes and Physician Orders, showed an enclosure bed was ordered for Patient #1 from 05/07/16 to 05/13/16. However, there were no Nursing Daily Care Note observational sheets completed for restraint monitoring during this time.

d) An interview was conducted on 09/13/16 at 2:00 p.m., with Chief Nursing Officer (CNO) #2 who stated restraints should be documented on the restraint flow sheet every 2 hours.

On 09/15/16 at 1:24 p.m., an interview was conducted with Registered Nurse #13 (RN), who stated enclosure beds were considered a restraint and patients in enclosure beds should have been assessed every two hours for range of motion, pain and patient needs.

On 09/15/16 at 1:41 p.m., an interview was conducted with RN #9 who stated charting on restrained patients should be done every 2 hours on the restraint form.

A subsequent interview with was conducted on 09/15/16 at 2:25 p.m., with CNO #2 who stated patients with restraints were to be assessed every 2 hours. CNO #2 stated Posey (enclosure) beds were considered restraints and had to be documented on the same restraint documentation form. CNO #2 stated s/he knew staff had done their jobs; however, at times when staff were busy they chose priorities and some things like documentation would fall through the cracks.

Based on interviews and document review, the facility failed to provide for patients' needs and care. The facility failed to ensure nursing care was provided in accordance with acceptable standards of practice during medication administration and with providing hygiene care in 10 of 11 medical records reviewed (Patients #1, 2, 3, 4, 5, 7, 8, 9, 10, 11).

This failure created delays or omissions in assessing the effectiveness of medications administered for pain relief. Further, this failure resulted in delayed or missed patient care and created the potential for the transmission of healthcare acquired infections (HAIs) to patients receiving care in the facility.

FINDINGS:

POLICY

According to Pain Management-Education, the assessment of pain and adequacy of treatment are reassessed at regular intervals, appropriate to the patient's condition but not less than once every shift. The effectiveness of pain relief measures will be evaluated and documented.

According to Administration of Drugs, the nurse administering the medication should record the effect of the medication in the patient's record.

REFERENCE

According to Indwelling Urinary Catheter Protocol, management of indwelling urinary catheters included routine hygiene with meatal cleansing during daily bathing.

According to Protocol for Reducing the Burden of Multi-Drug Resistant Organisms (MDROs) and Hospital Acquired Infection (HAI), Patient is bathed on regular bathing schedule (daily in Intensive Care Unit (ICU), every other day on medical/surgical floors) by nursing using 2 ounces of Chlorhexadine Gluconate (CHG) 2% diluted in 1.5 liters of water from the neck down. This is documented in the Activities of Daily Living (ADLs) section of nursing notes.

According to Lippincott Manual of Nursing Practice, 10th Edition, 2014:
Monitor for possible adverse effects of analgesic therapy. Although the health care provider is responsible for prescribing the appropriate medication, it is the nurse's responsibility to make sure the drug is given safely and assessed for efficacy (page 117).

Routinely assess pain in cancer patients using the following parameters: Response to pain relief and adverse effects (page 156).

1. The facility failed to determine the effectiveness of medications administered to patients for pain management.

a) Medical record reviews revealed the following lack or delay in reassessments conducted on patients who received pain medications to determine if they were effective in managing the patient's pain:

Review of the History and Physical (H&P) and Discharge Summary for Patient #3 revealed the patient was admitted from 04/23/16 to 04/28/16 after sustaining a traumatic brain injury which required 2 brain surgeries at a separate facility. The patient was admitted with a tracheostomy, a central intravenous line, a feeding tube, and a urinary catheter in place. Review of Patient #3's MAR (Medication Administration Record) and Nursing Daily Care Notes revealed the patient received Oxycodone 10 mg at 2:14 p.m. for a pain score of 7 out of 10. The next assessment for pain occurred at 8:00 p.m., which was 5 hours and 46 minutes after the patient had received the Oxycodone.

Review of the History and Physical (H&P) for Patient #8 revealed the patient was admitted from 04/01/16 to 05/06/16 with a history of paraplegia, seizure disorder and for treatment of a chronic stage IV ulcer of the ischium (part of the hip bone). Review of Patient #8's MAR and Nursing Notes revealed the following examples of documentation of medications administered for pain management and reassessments to evaluate their effectiveness:

On 04/06/16 at 9:45 p.m., Patient #8 received 2 Codeine with Tylenol (Tylenol #3) tablets; however, there was no further pain assessment documented until the following shift, 9 hours later.

On 04/10/16 and 04/11/16, there was no pain assessment documented until the p.m. shift (beginning at 7:00 p.m.); however, Patient #8 received 2 Tylenol #3 tablets at 10:30 a.m. on both days.

On 04/18/16 at 9:38 p.m., Patient #8 received 2 Tylenol #3 tablets; however, there was no pain assessment documented before or after the medication had been administered to assess if the medication had been effective.

On 05/02/16 at 10:20 a.m., Patient #8 received 50 mg of Tramadol; however, there was no pre or post pain assessment documented and the last pain assessment for the day was documented at 6:45 a.m.

Review of the H&P for Patient #9 revealed the patient was admitted to the facility's Intensive Care Unit (ICU) on 06/09/16 with a history of a recent Myocardial Infarction (MI). Patient #9 was admitted to the facility for care and treatment including physician rounding as well as 24-hour Registered Nurse (RN) assessment and interventions. Patient #9 remained at the facility until his/her death on 09/15/16. Review of Patient #9's MAR and Nursing Notes during the time frame of 08/01/16 to 09/05 16 revealed the following examples of documentation of medications administered for pain management and reassessments to evaluate their effectiveness:

On 08/03/16 at 5:40 a.m., Patient #9 received 2 tablets of Hydrocone 5 milligrams (mg)/325 mg acetaminophen (Norco-5); however, there was no pain assessment documented before or after the medication had been administered to assess if the medication had been effective.

On 08/03/16 at 8:30 p.m., Patient #9's pain level was documented at a level of 7/10. At 8:30 p.m. Patient #9 received 2 Norco-5 tablets; however, no post pain reassessment was documented. On 08/04/2016 at 3:30 a.m., Patient #9's pain level was documented at a level of 8/10. At 3:30 a.m., Patient #9 received 2 Norco-5 tablets; however, no post pain reassessment was documented.

On 08/06/16, Patient #9 received 50 mg of Tramadol at 9:07 a.m. and 7:00 p.m. for a pain level of 7/10 and 2 Norco-5 tablets at 1:20 p.m. for a pain level of 8/10; however, no post pain medication reassessment was documented.

On 08/10/16, Nursing Daily Care Notes documented Patient #9's pain level at a 7/10 at 3:00 a.m. and that Norco had been administered; however, there was no record on the MAR documenting the administration of Norco at that time, nor was there a post pain reassessment documented.

On 08/12/16, Nursing Daily Care Notes revealed no pain assessments documented after 4:00 p.m.; however, the patient received 2 Norco-5 tablets at 8:40 p.m.

On 08/27/16, Nursing Daily Care Notes revealed the last documented pain assessment for the day was at 4:30 p.m.; however, Patient #9 received 50 mg of Tramadol at 11:52 p.m.

On 08/28/16, Nursing Daily Care Notes revealed the last documented pain assessment for the day was at 12:20 p.m.

On 08/29/16 at 5:30 p.m., Patient #9 received 25 micrograms (mcg) of intravenous (IV) Fentanyl; however, no post pain medication reassessment was documented.

Similar findings were found for Patients' #1, 2, 4, 5, 7, 10, and 11 in which the patients were not assessed for pain levels and reassessed after pain medications were administered to assess the effectiveness of the medication.

b) On 09/15/16 at 1:30 p.m., an interview was conducted with a Registered Nurse (RN #9). RN #9 stated nurses were expected to assess patient's pain levels upon admission, when administering pain medications, and within 1 hour after administering pain medications to assess the effectiveness of the intervention.

c) On 09/15/16 at 2:24 p.m., an interview was conducted with the Education Coordinator (Coordinator #6). Coordinator #6 stated staff were trained and expected to assess the effectiveness of pain medication between 30 to 60 minutes after the medication was administered and document the results in the medical record. Coordinator #6 stated the importance of conducting a pain reassessment was to evaluate the effectiveness of the pain management intervention. Coordinator #6 then stated the policy pertaining to pain management did not include outlining the time frame expected for staff to follow when managing patients' pain.

d) On 09/15/16 at 11:46 a.m., an interview was conducted with the Chief Nursing Officer (CNO #2), who stated staff were expected to assess patients' pain levels at least once per shift and to assess the effectiveness of pain medication administration within an hour of administration. CNO #2 then stated although the policy regarding pain management instructed staff to assess and document pain relief measures, there was no guidance available on specific time frames of when pain was to be reassessed after pain medication administration.

2. The facility failed to ensure patients received ongoing hygiene care in order to meet the basic care needs of patients in accordance with facility expectations and policies.

a) Medical record reviews revealed the following lapses of hygiene care offered or conducted:

Review of Patient #3's Medical Record revealed no evidence that a bath was offered or conducted during the patient's visit in the Intensive Care Unit (ICU) from 04/23/16 to 04/28/16.

Review of Patient #8's H&P and Discharge Summary revealed the patient was admitted from 04/01/16 to 05/06/16. Review of Patient #8's Bedside Clinical Care Record and Nursing Notes revealed no evidence a bath was offered or conducted on April 1, 2, 4, 7, 8, 11, 12, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 28, 29, 30, 2016 and May 1, 2, 3, 4, 2016. In addition, there was no evidence of urinary catheter care performed on April 14, 15, 16, 21, 2016 and May 2, 2016. This was in contrast to the facility's protocols stating patients on medical surgical floors were to be bathed every other day and have urinary catheter hygiene care daily.

Review of Patient #9's H&P and Discharge Summary revealed the patient was in the ICU from 06/09/16 to 09/15/16. Review of Patient #9's Bedside Clinical Care Record and Nursing Notes during the time frame of 07/30/16 to 09/05/16 revealed no evidence a bath was offered or conducted on July 30-31, 2016, August 1, 2, 5, 8, 9, 10, 14, 15, 20, 24, 26, 27, and 28, 2016. In addition, there was no evidence of urinary catheter care performed on August 5, 6, 9, 10, 12, 13, and 24, 2016. This was in contrast to the facility's protocols stating patients in the ICU were to be bathed and have urinary catheter hygiene care daily.

b) On 09/15/16 at 1:15 p.m., an interview was conducted with a Certified Nursing Assistant (CNA #7), who stated patients on the medical surgical units were expected to be bathed every other day. On non-bath days, CNA #7 stated staff were expected to change linens, gowns and provide perineal and oral care for all patients.

c) On 09/14/16 at 3:02 p.m., an interview was conducted with a Registered Nurse (RN #8), who stated s/he worked in all of the patient care units at the facility. RN #8 stated patients in the ICU were expected to be bathed daily and patients on the medical surgical units were expected to be bathed every other day. RN #8 then stated all patients were expected to receive perineal and urinary catheter care daily and that it would not be acceptable for a patient to go more than 24 hours without receiving hygiene care. RN #8 further stated any type of hygiene care conducted by staff was expected to be documented in the patients' medical record.

d) On 09/14/16 at 1:05 p.m., an interview was conducted with the Education Coordinator (Coordinator #6), who stated s/he was responsible for orienting and training nursing staff. Coordinator #6 stated staff were trained according to guidelines provided by Lippincott on providing patient care at the facility. Coordinator #6 stated the facility did not have a policy stating the expected frequency of hygiene care to be provided for patients. Coordinator #6 further stated staff were expected to follow the Indwelling Catheter Protocol when caring for any patients with urinary catheters in order to help decrease the potential for urinary tract infections.

According to the Indwelling Catheter Protocol, staff were instructed to provide routine hygiene with meatal cleansing daily.

e) On 09/14/16 at 11:30 a.m., and interview was conducted with CNO #2, who stated nursing staff were educated through orientation and through verbal instruction on the expected frequency of providing hygiene care to patients. CNO #2 stated patients in the Intensive Care Unit (ICU) were expected to be bathed daily and patients on the medical surgical units were expected to be bathed every other day. CNO #2 then stated all patients were expected to receive perineal and urinary catheter care daily. CNO #2 further stated all hygiene care or patient refusal of hygiene care was expected to be documented on the Bedside Clinical Care Record of the medical record.

On 09/14/16 at 1:05 p.m. an additional interview was conducted with CNO #2, who stated the facility did not have a policy instructing staff of the expectations of providing hygiene care.
CNO #2 then explained managerial and administrative staff would conduct a minimum of 5 medical record reviews per month. The results would be inputted into a computer program which would be sent to the corporate office; however, CNO #2 stated s/he would not receive a final report of the findings from the medical record reviews. CNO #2 stated s/he did not think the computer program allowed him/her to receive data needed to conduct quality projects geared toward improving patient care.