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Based on document review and interview it was determined the facility staff failed to obtain consents for treatment and patient rights acknowledgements for five (5) of thirty (30) patients in the survey sample. (Patients #8, #9, #18, #21, and #27)

The findings included:

1. Patient #18's electronic medical record (EMR) was reviewed with Staff #33 on 04/29/2015. Patient #18's EMR contained a consent for treatment and acknowledgement of receipt of patient rights information witnessed by two staff. Patient #18's EMR did not contain an explanation for why the patient did not sign the form. Patient #18's EMR did contained a signed consent for a procedure dated for the date of admission.

2. Patient #21's electronic medical record (EMR) was reviewed with Staff #33 on 04/29/2015. Patient #21's EMR contained a consent for treatment and acknowledgement of receipt of patient rights information witnessed by two staff. Patient #21's consent for treatment and rights acknowledgement form did not specify why the patient had not signed the form. Staff #33 verified the check boxes on the form related to the patient being unable to sign or no responsible party available to sign had been left unchecked.

An interview was conducted on April 29, 2015 at 8:59 a.m., with Staff #24. Staff #24 reported the facility's policy for patients that were initially unable to sign initial consents for treatment and acknowledgement of rights involved the facility staff making at least two attempts. Staff #24 stated, "I reviewed the charts in question. They don't contain evidence our staff made a second attempt." Staff #24 reported the staff was responsible for documenting in the patient's records related to attempts to obtain signatures. Staff #24 stated, "There is not a system in place that flags charts, which need to be followed up." Staff #24 reported the staff on their second pass on everyone were supposed to pull the chart and check for anything that needed to be done. Staff #24 stated, "The consent forms have not been a part of the chart audit in the past, but will be."


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3. Patient #8's electronic medical record (EMR) was reviewed on 04/28/2015. No patient rights or the initial consent for treatment was located in the EMR. Staff #1, Staff #6 and Staff #19 were given the opportunity to find missing or incomplete registration forms.

Staff #6 was interviewed on 04/30/2015 at approximately 8:30 a.m. Staff #6 stated he/she failed to locate the form acknowledging Patient #8 had consented for the initial treatment or received his/her rights. Staff #33 stated documentation indicates Patient #8 was unable to sign the registration form. No documentation of why the patient was unable to sign the form except it was documented Patient #8 was unresponsive upon arrival to the emergency room. Staff #33 further stated if the patient is unable to sign the form, the registration staff are taught to document the reason the patient is unable to sign ( e.g. no family available), however documentation showed evidence staff attempted to contact family, but attempts were unsuccessful.

4. Patient #9's EMR was reviewed on 04/28/2015. No patient rights or the initial consent for treatment was located in the EMR. Staff #1, Staff #6 and Staff #19 were given the opportunity to find missing or incomplete registration forms.

Staff #6 and Staff #33 were interviewed on 04/30/2015 at approximately 9:00 a.m. Staff #33 stated he/she failed to locate the form acknowledging Patient #9 had consented for the initial treatment or received his/her rights. Staff #6 stated a consent form could not be located.

5. Patient #27's EMR was reviewed on 04/29/2015. No patient rights or the initial consent for treatment was located in the EMR. Staff #33 was given the opportunity to find missing or incomplete registration forms.

Staff #6 and Staff #33 were interviewed on 04/30/2015 at approximately 9:15 a.m. Staff #33 stated he/she failed to locate the form acknowledging Patient #27 had consented for the initial treatment or received his/her rights. Staff #6 stated a consent form could not be located and no documentation of why the patient was unable to sign the form.

Staff #6 was interviewed on 04/28/2015 at approximately 2:00 p.m. Staff #6 went over the admission process for new patients and stated that regardless of how a patient was admitted (through the Emergency Department, a direct admission to a floor, or through inpatient admissions) all patients were given the same information by the registrar, to include Patient Rights and Responsibilities.

Staff #6 and Staff #33 were interviewed on 04/30/2015 at approximately 10:00 a.m. Staff #33 stated he/she failed to locate the initial consent to treat or that the patient rights had been received or declined by Patient #8, # 9 and #27. Staff #6 further stated the registration staff is trained to obtain all signatures and initials on the form. Staff #6 stated if the patient is unable to sign the form, the registration staff are taught to document the reason the patient is unable to sign ( e.g. no family available) and the registered nurses will validate.

Based on document review and interview it was determined the facility failed to implement their process for the prompt resolution of a filed grievance for one of three patient complaints reviewed (Patient #16).

The findings included:

An interview and review of the facility's policies related to patient rights, complaints and grievance was conducted on April 29, 2015 at 8:58 a.m., with Staff #24. The facility's policy titled "Complaints and Grievances" read in part: "Most grievances should be responded to in writing within seven (7) calendar days of receipt with inclusion of the four (4) required elements according to CMS CoP (Centers of Medicare and Medicaid Conditions of Participation) 482.13 (a) (2) (ii) ... If the grievance will not be resolved, or if the investigation is not or will not be completed within 7 days, the patient or the patient's representative shall be informed that the Division is still working to resolve the grievance and that the Division will follow-up with a written response within 30 calendar days. An attempt shall be made to resolve all grievances and complaints as soon as possible ..." Staff #24 reported the facility followed a "Staff Present" approach, which requires the staff/unit involved to have "ownership of the grievance and be responsible for the investigation of the grievance or complaint."

An interview and review of complaint/grievance documentation was conducted on April 29, 2015 at 11:40 a.m., with Staff #40. Staff #40 and the surveyor reviewed the facility's complaint/grievance log. The surveyor identified a complaint/grievance filed by Patient #16's family member. Staff #40 reported the complaint/grievance was still open without resolution.

An interview was conducted on April 30, 2015 at 9:42 a.m., with Staff #1, Staff #2, Staff #6, Staff #11, Staff 13, Staff #24, Staff #33 and Staff #40. Staff #40 provided the background on the complaint/grievance related to the receipt of the information and handing the investigation over to the unit. Staff #40 reported a 7-day letter was sent with a proposed 30-day date for the resolution (February 27, 2015). Staff #40 reported the complaint remained open and had not been resolved. Staff #40 stated on March 2nd (2015) I received a call from [Name of Patient #16's family member]. [He/she] stated the 27th has come and gone and I didn't hear from you (referring to Staff #40)." Staff #40 reported Patient #16's family member questioned what was being done regarding the investigation. Staff #40 state, "I apologized I have not gotten back to [him/her]. After the conversation I emailed the unit to determine the status." Staff #40 acknowledged the facility had not sent a follow-up letter to inform the complainant that their complaint remained unresolved.

Based on document review and interview it was determined the facility staff failed to ensure a complainant received a response within the time frame of 30 days or send a follow-up letter related to the status of an unresolved complaint for one (1) of three (3) complaints reviewed. (Patient #16)

The findings included:

An interview and review of the facility's policies related to patient rights, complaints and grievance was conducted on April 29, 2015 at 8:58 a.m., with Staff #24. The facility's policy titled "Complaints and Grievances" read in part: "Most grievances should be responded to in writing within seven (7) calendar days of receipt with inclusion of the four (4) required elements according to CMS CoP (Centers of Medicare and Medicaid Conditions of Participation) 482.13 (a) (2) (ii) ... If the grievance will not be resolved, or if the investigation is not or will not be completed within 7 days, the patient or the patient's representative shall be informed that the Division is still working to resolve the grievance and that the Division will follow-up with a written response within 30 calendar days. An attempt shall be made to resolve all grievances and complaints as soon as possible ..." Staff #24 reported the facility followed a "Staff Present" approach, which requires the staff/unit involved to have "ownership of the grievance and be responsible for the investigation of the grievance or complaint."

An interview and review of complaint/grievance documentation was conducted on April 29, 2015 at 11:40 a.m., with Staff #40. Staff #40 and the surveyor reviewed the facility's complaint/grievance log. The surveyor identified a complaint/grievance filed by Patient #16's family member. Staff #40 reported the complaint/grievance was still open without resolution.

An interview was conducted on April 30, 2015 at 9:42 a.m., with Staff #1, Staff #2, Staff #6, Staff #11, Staff 13, Staff #24, Staff #33 and Staff #40. Staff #40 provided the background on the complaint/grievance related to the receipt of the information and handing the investigation over to the unit. Staff #40 reported a 7-day letter was sent with a proposed 30-day date for the resolution (February 27, 2015). Staff #40 stated on March 2nd (2015) I received a call from [Name of Patient #16's family member]. [He/she] stated the 27th has come and gone and I didn't hear from you (referring to Staff #40)." Staff #40 reported Patient #16' family member questioned what was being done regarding the investigation. Staff #40 state, "I apologized I have not gotten back to [him/her]. After the conversation I emailed the unit to determine the status." Staff #40 reported he/she had requested a physician not involved in the case to review the chart. Staff #40 stated, "We did not have a physician on the grievance committee at that time." Staff #40 reported the physician "was off for a week." Staff #40 acknowledged as of April 29, 2015 the physician had not offered his/her review of Patient #16's medical record. Staff #40 reported "around March 16 (2015)" he/she had sent an email to Staff #2 and Staff #33 for their involvement related to additional information brought up by Patient #16's family member. Staff #40 reported he/she offered a meeting with the medical team to Patient #16's family member. Staff #40 reported Patient #16's family member "hung up" and the grievance has remained open without resolution. Staff #40 acknowledged that a 30-day letter or follow-up letter after the March 2, 2015 conversation had not been sent to Patient #16's family member.

Staff #24 reported the initial 7-day letter was sent to Patient #16's family member. Staff #24 stated, "We do not perform the investigation." Staff #24 reported the facility failed to meet the 30-day response time frame.

Based on interviews, chart reviews and document review the facility's staff failed to complete documentation of monitoring every two (2) hours for three (3) of four (4) patients while in restraints (Patients #8, #27 and #28).

The findings included:

1. Patient #8's electronic medical record (EMR) was reviewed on 04/28/2015. Patient #8 was ordered by a physician to be placed in non-violent bilateral soft wrist restraints on 12/15/2014 at 9:25 p.m. and discontinued on 12/19/2014 at 4:00 p.m. due to pulling at tubes. No documentation of restraint monitoring was found in Patient #8's medical record from 12/18/2014 at 5:00 p.m. until 12/19/2014 at 8:00 a.m. A registered nurse documented on the "Restraint Flowsheet" on 12/18/2014 at 8:00 p.m."Alarm active" and on a "Nurse's note" at 8:40 p.m. "Restraints on." Staff failed to document every two (2) hour assessments from 5:00 p.m. through 8:00 a.m. in Patient #8's EMR.

Staff #1, Staff #19 and Staff #21 were present during the findings in Patient #8's EMR and were given the opportunity to find missing or incomplete restraint documentation.

Staff #6 was interviewed on 04/30/2015 at approximately 8:30 a.m. Staff #6 stated he/she failed to locate any further documentation on Patient #8's restraint monitoring. Staff #6 stated, "The registered nurse just didn't document and this is against what is expected or taught to monitor and document every two hours."

2. Patient #27's EMR was reviewed on 04/30/2015. Patient #27 was placed in non-violent soft bilateral wrist restraints on 01/07/2015 at 4:00 a.m. due to pulling at tubes. A physician order for the soft wrist restraints was located. No restraint monitoring dated 01/18/2015 was found in Patient #27's medical record for 8:00 a.m., 10:00 a.m., 12:00 p.m., 2:00 p.m., 4:00 p.m., or 6:00 p.m. Staff failed to document every two (2) hour assessments from 8:00 a.m. through 6:00 p.m. in Patient #27's EMR.

Staff #21 and Staff #33 were present during the review of Patient #27's EMR.

Staff #6 and Staff #33 were interviewed on 04/30/2015 at approximately 9:15 a.m. Staff #6 stated he/she failed to locate any further documentation on Patient #27's restraint monitoring. Staff #6 stated, "The registered nurse just didn't document."

A review of the policy and procedure titled, "Restraint and Seclusion Management: NON-Violent or Self Destructive Behavior in Non Behavioral Health Areas" read in part: "Purpose: To provide direction to care providers about management of non-violent high risk behaviors using non-restraint and restraint interventions that support medical healing. Procedure: 6. "RN (Registered Nurse) or LPN (Licensed Practical Nurse) Document behaviors, causes of behaviors, non-restraint interventions and results of interventions at least every 1.5-2.5 hours."


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3. A review was conducted of Patient #30 electronic medical record on April 29, 2015 at 4:50 p.m., with Staff #20. The EMR documented Patient #30 was admitted to the facility on January 6, 2015 for complaints of chronic obstructive pulmonary disease (COPD). The EMR documented Patient #28 did not speak English and would become agitated and confused when family members were not available. Documentation on January 14, 2015 indicated Patient #28 had been placed on a one to one with staff related to pulling out intravenous lines. Patient #28's EMR documented the patient continued to pull on lines and had pulled out his/her urinary catheter. An order was obtained for bilateral mitten restraints. Review of the restraint documentation for January 15 through 16, 2015 failed to document every two hour restraint assessments. The documentation for January 15, 2015 read in part "No mitts- pulled out Foley (urinary catheter) and IV (intravenous)." The next entry at 9:00 p.m. on January 15, 2015 read in part "took mittens off ..." Review of the documentation revealed staff had not taken off Patient #28's bilateral mittens. The documentation revealed the patient had removed his/her own mittens and had been able to dislodge IV lines and urinary catheter. Patient #28's EMR did not provide evidence staff had monitored and assessed the patient regarding his/her restraints, which allowed the patient to dislodge IV lines and catheters.

Staff #20 verified Patient #28's EMR did not have evidence after January 14, 2015 of monitoring and assessing the patient every two hours while in restraints.

Based on interviews and document review the facility failed to ensure the registered nurse evaluate the nursing care plan for one (1) of thirty (30) patients included in the survey sample (Patient #1).

The findings included:

Review of Patient #1's electronic medical record (EMR) was reviewed on 04/28/2015. Patient #1's EMR revealed he/she arrived at the facility's Emergency Department on 12/30/2014 at 2:55 p.m. with a chief complaint of "shortness of breath and cough." Patient #1 was admitted to the facility on 12/30/2014 as an inpatient being observed in the "Emergency Room Observation Area" and discharged home on 12/31/2014. The surveyor, along with assistance from facility staff (Staff #19 and #21) who were navigating the electronic medical record, were unable to locate any specific nursing care plan; however the "Nurse's Flowsheet and notes" on 12/30/2014 and 12/31/2014 documented a "focused" nursing assessment on Patient #1. The nursing assessment did not show evidence Patient #1's assessment was a complete head to toe assessment, the assessment only focused on shortness of breath, cough and care of same. The documentation of patient/family teaching did not contain measurable objectives and timetables and the identification of steps taken to assist the resident to meet his/her objectives. There was no documentation found that the patient participated in the care plan, or the reason the patient was unable to participate.

On 04/28/2015 at approximately 4:00 p.m., the survey team reviewed the concerns with the administrative Staff #1, #2, #6, #19, #21 and #33.

An interview was conducted on 04/29/2015 at 10:10 a.m., with Staff #13, Staff #20 and Staff #33. Staff #13 verified Patient #1's EMR failed to have documentation related to an inpatient initial nursing assessment or documentation of inpatient teaching. Staff #13 acknowledged when a patient is seen in the Emergency Department (ED) a "focused assessment" is completed for the patient's presenting symptoms. Staff #13 verified the ED staff do not have access to the inpatient computer database; the ED staff only have access to the computer database "ASAP" which does not go into an inpatient initial nursing assessment.

An interview was conducted on 04/30/2015 at approximately 8:20 a.m., with Staff #6. Staff #6 validated Patient #1's care plan could not be located. Staff #6 acknowledged the facility does need to work on giving the ED staff access to the inpatient computer database "EPIC" because a new "Emergency Department Observation Area" was upcoming and the facility needed to have this fixed as he/she was not aware of this problem until it was brought to his/her attention by the surveyor.

The facility policy and procedure "Delivery and Documentation of Nursing Care" was reviewed and read in part: "1. Nursing Assessment: The RN performs the initial nursing assessment within 24 hours of the patient's arrival to an inpatient area. The RN may use data collected by others in order to perform the assessment. The RN collects/reviews and documents ongoing assessment data (reassessment) daily for inpatients. 3. Care Planning: The RN develops a Plan of Care within 24 hours of admission (if not initiated) based on patient problem. The RN involves the patient and/or significant others in the delivery and planning of care and keeps them informed of progress towards goals and outcomes. The RN reviews/evaluates and updates the Inter-disciplinary Care Plan at least daily."

Based on staff interviews and document review the facility failed to develop an individualized interdisciplinary plan of care and failed to update the plan of care to reflect current needs for four (4) of thirty (30) medical records included in the survey sample (Patients #1, 16, 27, and 28).

The findings included:

Thirty (30) electronic medical records (#1-30) were reviewed 04/28/2015 through 04/30/2015.

An interview was conducted on 04/28/2015 at approximately 11:00 a.m. with Staff #1, Staff #2 and Staff #6. A request was made for the facility's policy and procedure for plan of care. Review of the facility's policy titled "Delivery and Documentation of Nursing Care" read in part: "1. Nursing Assessment: The RN performs the initial nursing assessment within 24 hours of the patient's arrival to an inpatient area. The RN may use data collected by others in order to perform the assessment. The RN collects/reviews and documents ongoing assessment data (reassessment) daily for inpatients. 3. Care Planning: The RN develops a Plan of Care within 24 hours of admission (if not initiated) based on patient problem. The RN involves the patient and/or significant others in the delivery and planning of care and keeps them informed of progress towards goals and outcomes. The RN reviews/evaluates and updates the Inter-disciplinary Care Plan at least daily."

1. Patient #1 was admitted to the facility on 12/30/2014 and discharged home on 12/31/2014.

Review of Patient #1's electronic medical record (EMR) on 04/28/2015 did not include a plan of care on admission by the Registered Nurse (RN). A request was made to review Patient #1's plan of care. Staff #19 stated, "I can't find [Patient #1's name]'s plan of care."

An interview was conducted on 04/29/2015 at 10:10 a.m., with Staff #13, Staff #20 and Staff #33. Staff #13 verified Patient #1's EMR failed to have documentation related to a plan of care, or an inpatient initial nursing assessment. Staff #13 acknowledged when a patient is seen in the Emergency Department (ED) a "focused assessment" is completed for the patient's presenting symptoms. Staff #13 verified the ED staff do not have access to the inpatient computer database; the ED staff only have access to the computer database "ASAP" which does not go into an inpatient initial nursing assessment and did not reflect an ongoing assessment of the patient's needs or response to interventions as per the facilities policy and procedure requirements.

2. Patient #27 was admitted to the facility on 01/04/2015 and expired on 01/19/2015.

Review of Patient #27's EMR on 04/29/2015 did not include an updated plan of care by the RN on 01/16/2015 and 01/17/2015. A request was made to review Patient #27's plan of care. Staff #33 stated, "[Patient #27's name]'s plan of care was not done by the RN on 01/16/2015 and 01/17/2015."

An interview was conducted on 04/30/2015 at approximately 9:15 a.m. with Staff #6 and Staff #33. Staff #6 reported the documentation on the "Interdisciplinary Plan of Care" and "Treatment Interventions" had not been updated and did not provide an accurate picture of what Patient #27 needed. Staff #6 acknowledged Patient #27's "Interdisciplinary Plan of Care" and "Treatment Interventions" did not reflect an ongoing assessment of the patient's needs or response to interventions.


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3. Patient #16 was admitted to the facility through the emergency department (ED) on January 18, 2015 and was discharged home from the inpatient unit on January 21, 2015. A review of Patient #16's electronic medical record (EMR) was conducted on April 28, 2015. The review revealed the ED staff documented Patient #16 had a skin rash and a skin opening on admission to the facility. Patient #16's EMR documented the patient was boarded in the ED until an inpatient bed was available on January 19, 2015.

An ED note by Staff #34 dated January 18, 2015 and timed at 12:52 p.m. read in part: "High temp (temperature) ... Patient is here because [he/she] had an allergic reaction of some kind and has rash to [his/her] buttocks and has a fever of 103.1 upon arrival. (Sic)"
An ED note by Staff #31 dated January 18, 2015 and timed at 3:00 p.m. read in part: "Pt (Patient) skin is hot and dry noted that pt has some redness throughout [his/her] body that appears to be some skin rash. Family member stated that pt started having the rash yesterday ... Noted pat (patient) has a skin opening Underneath [his/her] left buttock ... (Sic)"
Review of Patient #16's "Admission History and Physical" performed by Staff #23 and cosigned by Staff #35 was timed at 4:41 p.m. and dated January 18, 2015. Patient #16's "Admission History and Physical" indicated the patient's chief complaint was "Left leg redness since yesterday. Today, redness is worsening and extending into left back." The "Admission History and Physical" in the section titled "Review of Systems" read: "Skin: Not assessed." The same "Admission History and Physical" under the section "Physical Assessment" in part read "Skin: dry, intact and warm."
An ED note by Staff #36 for January 19, 2015 at 7:17 p.m. read in part: "1 inch in diameter bed sore is noted on right butt cheek ... (Sic)."
Review of Patient #16's nursing flowsheet for January 19, 2015 read in part: "pressure ulcer Right buttock ... open to air moisture barrier [name of product applied] Site assessment: Dry; Clean; Intact; Pink ... Size (length x [times] width x depth) cm [centimeter]: 4cmx3cmx0cm Treatment: Reposition; site care ... " The nursing flowsheet for January 21, 2015 documented "Pressure Ulcer Properties - Ulcer Location and Orientation: Right buttock (lower, healing, dry) Pre-existing: Yes Identified date 01/19/15 Identified time: 2245 (10:45 p.m.) Healed date 01/21/15 Healed time: 1705 (5:05 p.m.)" The flow sheet documented that Patient #16 had a "Mobility Score of 1." According to the key on the flowsheet the interventions required of staff would include: "Turn/Reposition; Range of Motion; Bed in chair position/mode;Transfer to chair with mechanical lift; and Sit on edge of bed/dangle legs.
An entry by Staff #38 titled "Nutrition Assessment" dated January 20, 2015 at 2:39 p.m. under "Skin Report" documented Patient #16 had "redness on left lower ext (extremity)." Staff #38 documented in the section related to "Skin Integrity" that Patient #16 had "pressure ulcer RIGHT BUTTOCKS (Sic)."
Review of Patient #16's EMR for both the ED and inpatient unit did not provide documentation the patient was turned and re-positioned at least every two (2) hours per the facility's policy
Review of the facility's policy titled "Pressure Ulcer Risk/ Skin Integrity Impairment, Risk/Actual" read in part: "1. Inspect skin thoroughly and all bony prominence(s) daily for skin rashes, blisters, redden areas, bruised or discolored areas and/or impaired skin. All direct caregivers shall inspect skin during all activities of daily living ... 4. Minimize pressure on bony prominences for immobile, bed bound, and/or confused patients. Turn/position every 2 hours while in bed ..."
An interview was conducted on April 29, 2015 at 9:09 a.m., with Staff #25. Staff #25 reviewed Patient #16's EMR. Staff #25 reviewed his/her "Braden Score" documentation performed to assessment Patient #16's risk for skin breakdown. Staff #25 reported he/she had documented Patient #16 was bedfast and had a wound, which lowered the patient's Braden Score sore to 11. Staff #25 reported the lower number would create a plan of care to direct treatment. Staff #25 reported part of the treatment would be to turn and reposition the patient if the person could not perform the task. The surveyor asked which staff would have the responsibility for turning and repositioning the patient. Staff #25 stated, "Anyone that was taking care of the patient. It's the responsibility of the nurse and the tech (technician or aide)." The surveyor asked Staff #25 to review his/her documentation for January 20, 2015, for evidence of turning and repositioning of Patient #16. Staff #25 stated, I don't always chart it, we do it, we have to do it, it's part of the care for our patients. If we just do it (turning patients) and then have to chart there's just not enough time. I'd spend more time charting than doing care. I know we say if it's not charted it's not done. We're required to make rounds during the day it is every hour. At night, it's every two (2) hours but if their condition requires we round every hour." When asked about performing incontinence care; Staff #25 stated, "The tech might help, but you stop and do it. It's easier and quicker to just do it, then call someone else. They might be busy too."
An interview was conducted on April 29, 2015 at 3:05 p.m., with Staff #31. Staff #31 reviewed Patient #16's EMR. Staff #31 stated, "The family thought it was an allergic reaction." I remember [he/she] couldn't move on [his/her] own. [He/she] had an AKA (above knee amputation). We turn anyone with an AKA frequently. I may not have charted. I only had [him/her] for four (4) hours; I was moved to another part of the department (ED)." The surveyor inquired if Staff #31 wanted to check for other charting within the EMR that Patient #16 had been turned. Staff #31 stated, "We don't use the flowsheets it is just easier to chart everything in the notes. The notes are our primary place to chart." Staff #31 acknowledged changing Patient #16's brief and "probably repositioned [him/her] at that time around 3 (p.m.) on the 18th (of January 2015)." Staff #31 affirmed Patient #16 should have been turned and re-positioned at least twice within four-hours according to facility policy, the patient's plan of care and mobility Score.
An interview was conducted on April 30, 2015 at 9:05 a.m., with Staff #1, Staff #2, Staff #6, Staff #13 and Staff #33. Staff #6 reported the "entire facility follows the "Pressure Ulcer Risk/ Skin Integrity Impairment, Risk/Actual" policy, which included the emergency department. Staff #6 stated, "For people that can not turn we should be turning them and documenting that the patient is turned." Staff #2 and Staff #6 acknowledged the facility staff failed to document Patient #16 had been turned at least every two (2) hours according to policy and the patient's inpatient plan of care. Staff #13 reported the ED nurses will need training related to providing and following a plan of care for patients boarded in the ED for observations or while waiting for an inpatient bed.
[According to www.nlm.nih.gov:- The average normal body temperature is generally accepted as 98.6?F (37?C). Some studies have shown that the "normal" body temperature can have a wide range, from 97?F (36.1?C) to 99?F (37.2?C). Your temperature may actually be 1?F (0.6?C) or more above or below 98.6 ?F (37 ?C). A temperature over 100.4?F (38?C) usually means you have a fever caused by an infection or illness.]
4. Patient #28 was admitted to the facility on January 14, 2015 related to bilateral decrease in breath sounds. Patient #28 was admitted to the critical care inpatient unit. The nursing assessment and Braden scale triggered a plan of care for being at risk for skin breakdown The facility's nursing staff documented Patient #28 had a "Mobility Score" of 1. Patient #28 was placed in bilateral mitten restraints on January 14, 2015 through January 16, 2015.

A review was conducted of Patient #28's EMR with Staff #20 for documentation related to staff turning/repositioning the patient. The nursing staff documented the following: January 15, 2015 only one turn at 8:00 p. m.; January 16, 2015 at 8:00 a.m. and 8:00 p.m.; January 17, 2015 at 8:00 a.m., 11:00 a.m., 9:00 p.m., and 10:00 p.m.; January 18, 2015 8:30 a.m. and physical therapy (PT) performed a transfer at 3:28 p.m.; January 19, 2015 at 8:45 a.m., 10:45 a.m., 2:44 p.m. PT performed a transfer, and 8:00 p.m.; January 20, 2015 11:56 a.m., 12:49 p.m. PT walked the patient twice, 1:00 p.m., and 8:53 p.m.; and only once at 8:01 a.m. on January 21, 2015. Staff #20 verified the facility staff failed to follow the interventions for the mobility Score and Patient #28's plan of care.

Review of the restraint documentation for January 15 through 16, 2015 failed to document every two hour restraint assessments. The documentation for January 15, 2015 read in part "No mitts- pulled out Foley (urinary catheter) and IV (intravenous)." The next entry at 9:00 p.m. on January 15, 2015 read in part "took mittens off ..." Review of the documentation revealed staff had not taken off Patient #28's bilateral mittens. The documentation revealed the patient had removed his/her own mittens and had been able to dislodge IV lines and urinary catheter. Patient #28's EMR did not provide evidence staff had monitored and assessed the patient regarding his/her restraints, which allowed the patient to dislodge IV lines and catheters.

Staff #20 verified Patient #28's EMR did not have evidence after January 14, 2015 of monitoring and assessing the patient every two hours while in restraints or documenting to the plan of care.

[According to www.nlm.nih.gov:- The Braden Scale: "Purpose: The Braden Scale for Predicting Pressure Sore Risk is a clinically validated tool that allows nurses and other health care providers to reliably score a patient/client's level of risk for developing pressure ulcers. It measures functional capabilities of the patient that contribute to either higher intensity and duration of pressure or lower tissue tolerance for pressure. Lower levels of functioning indicate higher levels of risk for pressure ulcer development."]

Based on document review and interviews it was determined the facility staff failed to follow approved policies and procedures for one (1) of two (2) patients included in the survey sample that had blood products administered (Patient #30).

The findings included:

A review was conducted of Patient #30 electronic medical record on April 29, 2015 at 4:50 p.m., with Staff #20. The EMR documented Patient #30 was admitted to the facility on January 6, 2015 for complaints of chronic obstructive pulmonary disease (COPD) with possible gastrointestinal bleed. The physician ordered two (2) units of fresh frozen plasma (FFP) to be administered prior to the patient's EGD (esophagogastroduodenoscopy) procedure. The nursing documentation for January 9, 2015 read in part: "2 units of FFP transfused, and tolerated well ..." The nursing note did not include the patient's vital signs. Review of Patient #30's nursing flowsheet for January 9, 2015 documented the FFP was started at 3:41 a. m. and completed at 5:31 a.m. The nursing flowsheet only documented Patient #30's vital signs at the start and completion of the FFP transfusion. The surveyor questioned Staff #20 whether the protocol for monitoring a FFP transfusion had different requirements, which did not include monitoring the patient for transfusion reaction. Staff #20 reported that fresh frozen plasma required the staff to follow the same monitoring protocol as with any other blood product. Staff #20 stated, "The nurse should have recorded vital signs initially, then within fifteen minutes, at the half-hour and hourly until the transfusion was completed. Staff #20 requested to review Patient #30's EMR for other places the staff might have documented vital signs.

An interview was conducted on April 30, 2015 at 8:50 a.m., with Staff #33. Staff #33 stated, "The unit manager reviewed the medical record for [Patient #30's name]. There were no other vital signs documented.

The surveyor requested the facility's policy and procedure for the transfusion of blood products. Staff #33 reported the facility utilized nursing best practices.

According to www.health.gov three of the eleven requirements that are necessary for monitoring the patient for safe blood transfusions include:
"7. Date and start time of transfusion shall be documented.

8. Recipient vital signs shall be monitored and documented before the transfusion begins, within the first 15 minutes of starting the transfusion, every hour during the transfusion and 30 minutes after completion of the transfusion.

9. The transfusionist shall assess the patient during the transfusion for signs and symptoms of adverse transfusion reactions that include but are not limited to: fever, chills, shakes, hives or itching, difficulty breathing, backache, pain ..."

According to Americannursetoday.com "Rules of transfusion: Best Practice for blood product administration" read in part: "Detecting and managing transfusion reactions
During the transfusion, stay alert for signs and symptoms of a reaction, such as fever or chills, flank pain, vital sign changes, nausea, headache, urticaria, dyspnea, and broncho spasm. Optimal management of reactions begins with a standardized protocol for monitoring and documenting vital signs. As dictated by facility policy, obtain the patients vital signs before, during, and after the transfusion ... Monitor the patient's vital signs. "