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Based on observation, interview and record review, the facility failed to protect the rights of patients and failed to provide care in a safe setting resulting in the potential for injury and/or death as well as loss of rights for all patients. Findings include:

See specific tag:

1. The facility failed to provide the "Important Message from Medicare" for 3 of 5 patients with Medicare coverage with length of stays greater than 96 hours (#17,#20, and #21) resulting in the denying the rights of Medicare patients to appeal their discharge from the facility. See tag A-0117.

2. The facility failed to ensure the general consent for treatment was obtained for 4 of 8 patients (#11,#12,#17, and #21) resulting in the potential of providing medical care against the patient or guardian's approval. See tag A-0131.

3. The facility failed to provide care in a safe setting by not implementing fall precautions for 4 of 5 patients (#1,#5,#6, and #7) resulting in a fall and/or the potential of falls with injury and failed to ensure a ligature-free environment for 3 of 3 patients (#2,#3, and #4) with self-harm and/or suicidal ideation diagnosis receiving psychiatric care in the behavioral unit resulting in the potential of self-harm or death. See tag A-0144.

4. The facility failed to ensure a physician's order was obtained for 1 of 3 patients (#1) reviewed for restraints resulting in the potential for inappropriate use of restraint. See tag A-0154

Based on document review, interview, and policy review the facility failed to provide the "Important Message from Medicare" for 3 of 5 patients (#17,#20, and #21) with Medicare coverage with length of stays greater than 96 hours resulting in the denying the rights of Medicare patients to appeal their discharge from the facility. Findings include:

On 9/13/2021 at 1400 during the document review of patient #17 medical record it was revealed there was no Important Message from Medicare (IMM). Staff H, the Director of Medical Records was interviewed on 9/13/2021 at 1405. Staff H was queried if the IMM was part of the patient's medical record. Staff H stated she could not find the scanned copy in the electronic medical record.

On 9/13/2021 at 1407 during the document review of patient #20 medical record it was revealed there was no Important Message from Medicare (IMM). Staff H, the Director of Medical Records was interviewed on 9/13/2021 at 1410. Staff H was queried if the IMM was part of the patient's medical record. Staff H stated she could not find the scanned copy in the electronic medical record.

On 9/13/2021 at 1415 during the document review of patient #21 medical record it was revealed there was no Important Message from Medicare (IMM). Staff H, Director of Medical Records was interviewed on 9/13/2021 at 1420. Staff H was queried if the IMM was part of the patient's medical record. Staff H stated she could not find the scanned copy in the electronic medical record.

On 9/13/2021 at 1550, document review occurred of the policy titled, "Important Message from Medicare," dated 11/6/2017. According to the policy on page one, subtitle, "Procedure #2. Important Message from Medicare will be delivered within two (2) calendar days of admission or at preadmission, but no more than seven (7) calendar days before admission by registration." The policy further states, "#5. Medical records shall retain a copy, #6. Important Message from Medicare must be delivered as far in advance as possible before discharge, but no more than two (2) calendar days before the day of discharge. A new Important Message from Medicare may be given, and a new signature will be obtained, #7. Important Message from Medicare may be delivered on the day of discharge though that is not the preferred practice. The staff shall make every effort to provide the IM(M) to the patient at least 4 hours but no more than 48 hours prior to discharge to allow the patient's consideration of his/her rights as outlined in this document, #8. The hospital staff must document the delivery of IM(M), #10. If the patient/beneficiary is unable to sign due to mental status, the patient representative may be notified by phone (not by voicemail) with a notice mailed or faxed the same day, #11. If unable to reach the patient/beneficiary's representative by phone, the notice may be sent by certified mail."

Based on document review and interview the facility failed to ensure the general consent for treatment was obtained for 4 of 8 patients (#11,#12,#17,and #21) resulting in the potential of providing medical care against the patient or guardian's approval. Findings include:

On 9/13/2021 at 1400 during the document review of patient #17 medical record it was revealed the consent for treatment was missing. The consent for treatment was unable to be located.

On 9/13/2021 at 1415 during the document review of patient #21 medical record it was revealed the general consent for treatment was signed as "unable to sign." On 9/13/2021 at 1420 staff H was queried if the patient's next of kin or guardian should have signed in lieu of the patient. Staff H stated, "yes."

On 9/13/2021 at 1545, document review occurred of the medical record for patient #11. The general consent for patient #11 was missing from the medical record. On 9/13/2021 at 1548 an interview was conducted with staff H. Staff H was queried if general consents were obtained from patients for care. Staff H responded, "yes...general consents always obtained."

On 9/13/2021 at 1548, document review occurred of the medical record for patient #12. The general consent for patient #12 had "unable" on the patient/guardian signature line. On 9/13/2021 at 1549 a review of patient #12 face sheet had an emergency contact listed as "significant other" with contact information. Staff H was queried on 9/13/2021 at 1549 if contacts for the patient could provide consent for treatment. Staff H stated, "yes." No further documentation supported the patient's significant other was contacted to obtain general consent for treatment.

On 9/13/2021 at 1628 a review occurred of the policy titled, "Decision-Making: Consent Requirements for Medical Treatment/Informed Consent," dated 11/27/2018. According to the policy, subtitle "Policy," page 1, #1, it states, "1. Patients have the right to be informed about the benefits and risks of any Treatment/Procedure offered to them and to make a voluntary decision (except those under court ordered conservatorship/guardianship, that specifically give the authority to a guardian) about whether to undergo the treatment/procedure(s)." The policy further stated, "2. where patients cannot make their own decisions, respect for persons is upheld by recognizing the decision-making role of an appropriate alternate decision-maker."

According to policy #304 titled "Informed Consent," dated 11/2018, "a general consent for treatment is signed for routine care or non-invasive treatments that involve an insubstantial risk of harm to the patient."

Based on observation, interview, and document review the facility failed to provide care in a safe setting by not implementing fall precautions for 4 of 5 patients (#1,#5,#6, and #7) resulting in a fall and/or the potential of falls with injury and failed to ensure a ligature-free environment for 3 of 3 patients (#2,#3, and #4) with self-harm and/or suicidal ideation diagnosis receiving psychiatric care in the behavioral unit resulting in the potential of self-harm or death. Findings include:

During the tour of the PCU (Progressive Care Unit), patient #5 was interviewed on 9/8/2021 at 1100. On 9/8/2021 at 1108, Staff E, a registered nurse caring for patient #5 was queried if the patient was a fall risk. Staff E responded, "yes ...she is a fall risk." Patient #5 failed to have on a yellow fall-risk arm band, failed to have on yellow socks, and the room lacked any signage outside of the door indicating the patient was a fall risk. Staff E was asked how another employee would be aware that a patient was a fall risk. Staff E stated that the nursing staff would tell other staff members if a patient was a fall risk.

Further tour of the facility included the medical/surgical unit. On 9/8/2021 at 1120 patient #6 was observed to be in restraints. Patient #6 had a sitter present in the room. On 9/8/2021 at 1121 staff F, the sitter for patient #6 was asked if the patient was a fall risk. Staff F responded, "yes." Patient #6 did not have a yellow fall-risk band nor yellow fall-risk socks. When looking outside of patient #6 room there was no signage outside of the room that the patient was a fall risk. Patient #6 was unable to participate in being interviewed.

On 9/8/2021 at 1130 an interview was conducted with patient #7 and the patient's son. Patient #7 was in a confused state. Patient #7's son was queried about the care his mother was receiving at the facility. Patient #7's son stated that overall, the care was adequate, but his mother was going to require rehab to be able to walk independently. Patient #7 did not have a fall-risk band or yellow fall-risk socks on. On 9/8/2021 at 1145 an interview occurred with staff G, a registered nurse and the nurse assigned to patient #7. Staff G was queried what was required to identify a patient as a fall risk patient. Staff G responded that patient's that are a fall risk that a yellow arm band would be placed on the patient and yellow socks were in used.

On 9/8/2021 at 1150 Staff B, the Chief Nursing Officer was asked where the arm bands and socks could be located. Staff B stated that the armbands were located at the nurse's station. Staff B then stated that yellow socks could be located in the clean supply area. On 9/8/2021 at 1152 review of the clean storage area revealed the only size of yellow socks available were size XXL (extra extra large).

Document review of patient #1's medical record occurred on 9/9/2021 at 0930. According to the patient's medical record the patient arrived at the facility on 4/8/2020 at 0212. Patient #1 was described as a 92-year-old male patient that arrived via ambulance to the Emergency Department (ED) with hypoxia and confusion.

The patient's past medical history was acute and chronic encephalopathy, chronic hypernatremia, PNA (pulmonary nodular amuloidosis - pneumonia infection involving the air sacs of the lung causing difficulty in breathing), Covid 19 and lactic acidosis. The patient was described as having waxing and waning mentation throughout the hospital stay. The patient's initial orientation upon admission on 4/8/2020 was "A & O X 0 (alert and oriented times zero) and has no verbal response at this time".

Further review of patient #1 medical chart revealed on 4/8/2020 at 0232 a computed tomography (CT) brain scan-stroke protocol was performed due to the patient presenting with confusion. The CT results were charted as, "Impression: CT Brain: Grossly negative for hemorrhage. Atrophy noted. No gross territorial infarct." According to the nurse's documentation 4/8/20 at 0400 it states, "behavior necessitating use of restraints continues, alternatives not successful." Supporting documentation noted the patient was "agitated, restless and pulling at lines, writer attempted to reorient with no positive outcome." No documentation could be found in the chart what alternative methods were used to prevent the use of restraints with the patient. Further documentation showed the use of soft bilateral wrist restraints were used from 4/8/2020 to 4/9/2020 with no physician orders for the use of medically indicated restraints.

On 4/8/2020 at 0323 it is documented the patient's Morse Fall Risk Scale Total was documented as "45". On 4/9/20 at 1154 the patient's Morse Fall Risk total was documented as "60". No documentation could be located that the patient had a fall risk band, yellow socks or fall risk signage on the door.

On 4/9/2020 at 1313 Staff Q, the attending physician taking care of the patient at the time documented the following, "the patient fell while trying to get out of bed". On 4/9/2020 at 1313 a Rapid Response was documented in the medical record. According to the documented physician's note by Staff #Q, "Rapid response was called on patient after he sustained a mechanical fall, trying to get out of bed, and hit his head on the ground and suffered a laceration on the right temporal scalp. Immediate pressure was held on the wound to control bleeding. Patient periodically was asked mental status and pupils were continually checked. Wound was stapled closed and pressure dressing was applied. Cervical collar was applied, and patient was placed in bed and taken down for head and neck CT. CBC (complete blood count) was ordered due to amount of blood loss. Patient pupils were equal round and reactive and mental status was unchanged throughout rapid." The patient had a CT scan on 4/9/2020 at 1424.

According to the initial impression of the CT Brain scan w/o contrast impression on 4/9/2020 at 1424, it stated, "Extensive soft tissue laceration overlying the right frontal scalp superiorly with surgical staples in place, however without a discrete soft tissue hematoma or underlying calvarial (topmost part of the neural cranium) fracture. There is a small hyperdense extra-axial fluid collection overlying the right temporal lobe which may relate to a small acute subdural or epidural hematoma. There is minimal underlying mass effect with no intracranial hemorrhage elsewhere".

A neurosurgery consult note on 4/9/20 at 1424 by Staff AA, neurologist, stated, "Discussed CT findings with daughter". Staff #AA's note stated "Initial head CT on admission was grossly negative for hemorrhage. Patient fell while trying to get out of bed today and hit his head. CT brain revealed a right temporal subdural hemorrhage".

Patient #1 was transferred to the intensive care unit (ICU) on 4/9/2020 at 1424. There was no further documentation of the patient having any additional falls while at the facility. The patient was pronounced dead at the facility on 4/17/2020 at 1117.

On 9/9/2021 at 0930 an interview was conducted with staff Q the physician who responded to the rapid response code for patient #1 on 4/9/2021. Staff Q was queried about the rapid response. Staff Q stated that he first came to the patient's room to find the patient with a laceration on his head from a fall. Staff Q was asked if the patient was awake at the time he first saw the patient during the rapid response. Staff Q replied, "yes but he was confused."

On 9/9/2021 at 1400 an interview occurred with staff C, the Risk and Quality Director of the facility. Staff C was queried if an investigation occurred as a result of the patient (pt.#1) fall with injury. Staff C stated that a post fall occurrence was completed but not a Root Cause Analysis (RCA). Staff C stated that the post fall occurrence sheet was completed, and it stated that the patient's bed alarm was not engaged. Staff C was then asked if the patient had a sitter at the time of the fall. Staff C stated, "no."

On 9/9/2021 at 1400 a review of the most recent reporting of patient falls in the facility indicated falls for the month of July 2021 were reported as 29 total (10.6 / 1000 patient days). On 9/13/2021 at 0930, a document review of the 2021 Performance Improvement Dashboard listed fall rate/1000 patient days as 3.5 in Quarter 1 (2021) and 1.6 in Quarter 2 (2021). On 9/13/2021 at 0930 an interview with Staff B, the Chief Nursing Officer occurred. Staff B presented a document titled, "Fall Guidelines," (no date provided) as part of the action plan for decreasing falls. Staff B stated the "Fall Guidelines" had been presented at the House Supervisor/Nursing Leadership Meeting on 8/11/2021. Staff B was queried if any improvements had occurred since the implementation of the "Fall Guidelines." Staff B responded improvements had been difficult to achieve with the struggle of trying to obtain and keep nursing staff.

On 9/13/2021 at 1400 a review occurred of the policy titled, "Falls Reduction/Injury Prevention Policy," dated 11/27/2018. According to the policy under subtitle, "Fall Prevention Interventions are defined by the fall risk assessment," #3.3, it states the following, "Patients identified as high risk for falls, C. High risk for falls interventions which may include but are not limited to: place a fall risk armband (i.e. yellow colored armband or armband labeled "Fall Risk"), Place fall prevention instructions across from patient in patient room, Use bed alarm, a chair alarm or similar device - Fall prevention devices available for use may include bout are not limited to a gait belt, chair sear alarm, non-skid seat, pummel cushion, and bed alarm, hip protectors, floor pad, etc.), Identify the patient as a high fall risk applying yellow band and yellow socks, patients." Further review of the policy states, " #5, 5.10, Hourly rounding, 5.13, Consider a sitter, 5.14, Consider Fall Monitoring."

Additionally, the "Morse Fall Scale Screening Tool Shift Assessment" sheet was attached as an addendum to the policy, "Falls Reduction/Injury Prevention Policy." According to the "Morse Fall Scale Screening Tool" the following is the criteria for calculating fall risk scores: "1. History of falling within 3 months: NO = 0, YES = 25, 2. Secondary Diagnosis: NO = 0, YES = 15, 3. Ambulatory Aid: None/Bedrest/nurse assist = 0, Crutches/cane/walker = 15, Furniture = 30, 4. IV/IV access: NO = 0, YES = 20, 5. Gait: Normal/bed rest/wheelchair = 0, Weak = 10, Impaired = 20, 6. Mental Status Oriented to own ability = 0, Overestimates/forgets limitations = 15."

On 9/13/2021 at 1005 a tour of the Behavioral unit was conducted. The unit had a census of five patients. The unit was observed to be clean. The milieu was calm. An empty room was observed for ligature risks. Upon observation of room #213 on 9/13/2021 at 1010 it was revealed one of the two beds in the room had the potential of ligature risk. Staff Z, the Director of the Behavioral unit was queried if the bed posed a ligature risk. Staff Z stated that per the consultant that was hired for the construction and design of the unit that the beds were not a ligature risk. Staff Z and Staff B, the Chief Nursing Officer were shown where a ripped sheet could be used in the opening between the bed and the bed rails. Further tour of the unit revealed that 20 of 28 beds (rooms #302 - 1 bed, #302 - 1 bed, #305 - 1 bed, #307 - 2 beds, #308 - 2 beds, #309 - 2 beds, #310 - 2 beds, #311 - 2 beds, #312 - 2 beds, #313 - 2 beds, #314 - 1 bed, #315 - 1 bed, #316 - 1 bed) located in the Behavioral unit posed ligature risks.

On 9/13/2021 at 1015 a document review of the medical chart of patient #2 was conducted. According to the petition and certification documentation the patient was noted to have suicidal ideation. Patient #2 was located in room 313.

On 9/13/2021 at 1022 a document review of the medical chart of patient #3 was conducted. According to the petition and certification documentation the patient was noted to be suicidal. Patient #3 was located in room 316.

On 9/13/2021 at 1028 a document review of the medical chart of patient #4 was conducted. According to the petition and certification documentation the patient was noted as potential for self-harm. Patient #4 was located in room 312.

Based on document review, interview, and policy review the facility failed to ensure a physician's order was obtained for 1 of 3 patients (#1) reviewed for restraints resulting in the potential for inappropriate use of restraint. Findings include:

Document review of patient #1's medical record occurred on 9/9/2021 at 0930. According to the nurse's documentation 4/8/2020 at 0400 it states, "behavior necessitating use of restraints continues, alternatives not successful." Supporting documentation noted the patient was "agitated, restless and pulling at lines, writer attempted to reorient with no positive outcome." No documentation could be found in the chart what alternative methods were used to prevent the use of restraints with the patient. Further documentation showed the use of soft bilateral wrist restraints were used from 4/8/2020 to 4/9/2020 with no physician orders for the use of medically indicated restraints.

On 9/9/2021 at 1545, Staff H, the Director of Medical Records confirmed that no orders for the restraints on 4/8/2020 could be found for patient #1.

On 9/13/2021 at 1545 document review of the policy titled, "Restraints: Non-Violent Behavior," dated 12/17/2018. According to the policy on page 5, under the subtitle, "Time limits for orders - Non-violent restraints or non-self-destructive," it states, "#1. If restraints are applied by an RN, the attending physician is consulted as soon as possible and no longer than 1 hour of initiation and an order is obtained at that time." The policy further stated, "#2. A written order based on an examination of the patient by the physician is entered into the patient's medical record within 24 hours of initiation of restraint."

Based upon observation, interview, and policy review the facility failed to ensure the Infection Control Preventionist maintained ongoing education for infection control resulting in the potential of not following current Centers for Disease Control (CDC) recommendations, failed to screen all visitors and patients entering the facility for Covid-19 resulting in the potential for the spread of Covid-19 to patients receiving care at the facility, and failed to ensure adherence of all staff utilized personal protection equipment (PPE) resulting in the potential for the spread of infectious disease amongst all 110 patients receiving care in the facility. See tags A-0748 and A-0749.

Based on interview, and document review the facility failed to ensure the Infection Control Preventionist maintained ongoing education for infection control resulting in the potential of not following current Centers for Disease Control (CDC) recommendations and the potential for the spread of Covid-19 to patients receiving care at the facility. Findings include:

On 9/9/2021 at 1530 an interview occurred with Staff Y, the facility Infection Control Preventionist. Staff Y was queried about the lack of screening for COVID-19 at the entrances of the hospital. On 9/9/2021 at 1532, staff Y responded, "We were screening visitors coming into the facility until we were not allowing any visitors ...visitors have just been allowed back into the facility starting in July. There is a device that screens for temperatures like those at the airports. If a visitor enters the facility and has a temperature an alarm goes off." Staff Y was then queried if she was aware that temperature was not the only sign or symptom of COVID-19 and that some infected individuals were afebrile (without an elevated temperature). Staff Y responded, "yes." Staff Y was then queried if she conducted surveillance of staff for the use of proper PPE (personal protection equipment) specifically the use of face masks. Staff Y stated she did conduct weekly rounds in the hospital. Staff Y was then queried if she ever saw staff not wearing PPE. Staff Y stated that staff were adherent to policy. Staff F was queried if she had training in infection control. Staff Y stated she had participated in extensive training in infection control. Staff Y was queried about the lack of masks being available for all individuals walking into the facility through the ED. Staff Y stated, "We do not have masks available at the ED entrance because people are stealing them (masks)." Staff Y was then asked if the masks were not readily available could a potentially infected person infect others waiting in the ED waiting room." Staff Y stated she understood the concern.

A document review of infection control surveillance from January 2021 through August 2021 was conducted on 9/9/2021. According to the surveillance documentation all units had 100% compliance for the use of masks for the eight month period.

A document review of staff Y employee file was conducted on 9/13/2021 at 1500. Staff Y most recent documented infection control training with the exception of annual competencies for all hospital staff occurred on 10/3-4/2018. Staff Y's employee file failed to support ongoing training since 10/3-4/2018 including any advanced training for COVID-19 public health emergency.

Based upon observation, interview, and policy review the facility failed to ensure visitors were screened prior to entry to the facility and failed to ensure adherence of all staff utilized personal protection equipment (PPE) resulting in the potential for the spread of infectious disease amongst all 110 patients receiving care in the facility. Findings include:

Upon entry to the facility on 9/8/2021 at 1000, it was revealed the facility was not actively screening any individuals entering the facility through the main entrance. At the time of entry there was no signage at the point of entry for individuals with any signs or symptoms of COVID-19 to notify staff. Inside of the entry of the facility there were masks and hand sanitizer available for visitors and patients to use, but no active screening.

On 9/9/2021 at 1500 a tour of the Emergency Department (ED) waiting area was conducted. At the main entry of the ED, it was revealed no screening process was in place for the screening of persons entering the ED. Staff B, the Chief Nursing Officer was queried about screening of individuals seeking care in the ED. Staff B stated that in the busier times of the ED that a staff member was placed in the ED entry. On 9/9/2021 at 1510 it was revealed that there was no hand sanitizer or facemasks available for the general public to use upon entry to the ED. Staff B was queried on 9/8/2021 at 1511 where might facemasks and hand sanitizer be located. Staff B stated that masks were located behind the glass of the registration clerk's desk. Staff B was then asked if those entering with COVID-19 symptoms would be exposing the rest of the ED if they did not have a mask upon entry. Staff B concurred that a mask should be available at entry.

A tour of the facility began on 9/8/2021 at 1035. The progressive care unit (PCU) was observed to be busy. Nurses and nurse technicians were observed providing care to patients. At 1025 on 9/8/2021, staff CC a registered nurse was observed walking into a patient's room with a mask under his chin. The nurse was observed to be less than six feet from the patient and visitor talking to the patient. At 1055, Staff CC was observed in conversation with Staff B, the Chief Nursing Officer. Staff CC was completely void of any mask protection. Staff CC was queried at 1057 if he needed to have a mask on when in the facility, and if he understood why masks were required and about the potential spread of COVID-19. Staff F responded, "yes...I had COVID a few weeks ago." Staff CC was then asked if it was the policy of the facility to have a mask on while in the facility. Staff CC responded, "yes."

On 9/13/2021 at 1515 a document review of staff CC's employee file was conducted. Staff CC was noted to have current training in infection control related to COVID-19.

On 9/13/2021 at 1545 a document review occurred of the policy titled, "Covid-19 (2019-nCOV) Visitor guidelines Interim Policy," undated addendum. Under the subtitle, "New Visitation Guidelines," it states the following, "(facility) has revised its patient visitation policy for Non-Covid-19 patients effective today (no date provided). The hospital will permit limited visitations on non Covid patients as following: #3. All visitors will be screened at the entrance for symptoms of Covid-19. Visitors with respiratory infection, including but not limited to fever, cough or shortness of breath will not be permitted to enter the facility." Further review of the policy stated under the subtitle, "PPE Guideline revision," "use of surgical mask...We have implemented a universal masking program. The mask is to be worn at all times, except to eat or drink by all healthcare workers. It must be properly positioned over the nose and mouth."

On 9/13/2021at 1550 a document review occurred of the policy titled, "Universal Masking for Covid-19," dated 5/2020. According to the policy, under the subtitle, "Clinical staff, EVS workers, and Physicians - Source Control and PPE," it states, "The mask is to be worn at all times, except to eat or drink. It must be properly positioned over the mouth and nose."