The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

GRACE COTTAGE HOSPITAL PO BOX 216 TOWNSHEND, VT 05353 Feb. 27, 2014
VIOLATION: PROVISION OF SERVICES Tag No: C1004
Based on interview and record review the CAH failed to ensure the Condition of Participation: Provision of Services requirement was met as evidenced by:

The CAH failed to assure that care and services were provided in accordance with currently established written policies and procedures.

The CAH failed to establish polices and procedures to reflect how the provision of services would be provided to include: the assessment and needs of patients who require transport to other facilities; staff use of pictures/images of patients; and how and when the Sheriffs Department and Rescue, Inc staff are to be utilized.

The CAH Nursing Services failed to follow physician orders; failed to meet the needs of patients identified as at risk for falls and skin breakdown; failed to initiate care to patients with demonstrated needs requiring ongoing monitoring and interventions for fall prevention and at risk for impaired skin integrity and breakdown; failed to follow physician orders; and failed to develop and revise the Nursing Care Plan.

The Electronic Medical Record (EMR) was not readily accessible and systematically organized to provide evidence to reflect provision of specific care and services and a failure within the EMR to accurately provide information for the ongoing monitoring for wounds.

Refer to Tags : C-271, C-273, C-278, C-294, C-295, C- 298, C-302, C-306
VIOLATION: PATIENT CARE POLICIES Tag No: C1006
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and confirmed through staff interview the CAH failed to assure that care and services were provided in accordance with currently established written policies and procedures, for 3 patients identified as at risk for falls and or skin breakdown. (Patients #1, #2 and #5) and for 1 patient who was restrained and was administered involuntary emergency medication (Patient #1). Findings include:

1. Per record review nursing staff failed to provide care in accordance with the facility's Skin Breakdown Prevention policy for Patient #2, admitted on [DATE] for rehabilitation following an accident in which s/he sustained multiple traumatic injuries which left him/her immobile in bed. The policy, dated 12/4/09, and last reviewed 8/28/13, stated, as it's purpose: "To effectively screen all inpatients for skin breakdown potential and implement appropriate precautions based on individual risk." Per the facility policy a Braden Scale Score of 15 - 18 indicates a mild risk for skin breakdown, for which the following interventions should be implemented: Frequent turning, Maximal remobilization, Protect heels, Manage moisture, nutrition, friction and shear, and Pressure reducing support surface if bed or chair bound. Although Patient #2 had a Braden Risk Assessment Scale completed on 12/20/13 which identified a score of 15, there was no indication that any of the identified interventions had been implemented. The patient, who was admitted with no evidence of any existing pressure ulcers, had a nursing progress note, dated 12/30/13 at 4:08 PM which indicated the patient's right heel was slightly boggy with some discoloration. A subsequent Interdisciplinary Team Meeting nursing note, dated 12/31/13 at 1:14 PM, identified ".....right heel pressure sore with dime size ulcer stage 2 , foot has been elevated with pillow and no pressure to heel site to promote healing.." Despite the identification of the pressure ulcer on Patient #2's right heel on 12/30/13 the care plan for Impaired Skin Integrity which included goals and interventions to facilitate wound healing, was not initiated until 1/10/14.

During interview, on the afternoon of 2/27/14, the Nurse Manager and the CNO (Chief Nursing Officer), both confirmed that the Skin Breakdown Prevention Policy had not been followed, and interventions to prevent skin breakdown should have been implemented on admission when the patient had been identified as at risk for breakdown.

2. Per record review, CAH nursing staff failed to provide care in accordance with the facility policy Fall Prevention and the use of the Morse Fall Scale last reviewed 11/3/13 for Patient #1, admitted on [DATE] for rehabilitation after experiencing a stroke resulting in physical, neurological and behavioral deficits. At the time of admission and utilizing the Morse Fall Scale (MFS), nursing staff screened Patient # 1 at a score of 90 (45 or higher ranked a patient to be at High Risk risk for falls). The policy further directs staff to initiate "High Fall Risk Precautions" to include bed/charm alarm, rounding hourly, placing "Falling Star" placard on door jamb of patient's room along with placing bed in low position. Nursing progress note for 1/21/14 at 23:37 states "s/he is a fall risk; has made no attempts to get out of bed so as of now s/he is not on alarms". However, within hours of admission, at 7:00 AM on 1/22/14 Patient #1 was found on the floor in his/her room, face down naked sustaining a bruise to his/her left temple, shoulder and hand. Patient #1 also complained of pain across shoulders, neck and head. After the fall, Patient #1 was placed in a high low bed, mats were positioned beside the bed and alarms were put in place.

Despite Patient #1's fall history and ongoing need to be maintained on "High Fall Risk Precautions", again a staff nurse failed to comply with CAH policy when on 2/15/14 at 19:30 the patient was left unattended on the toilet when a staff nurse left the bathroom to obtain clean linen and pajamas. Upon return, Patient #1 was found laying on the floor on his/her right side resulting in rib and elbow pain.

Per interview on 2/27/14 at 8:45 AM, the Nurse Manager confirmed the staff nurse on 1/21/14 failed to follow CAH policy and procedures related to fall prevention protocols. In addition, the Nurse Manager acknowledged Patient #1 should not have been left alone on the toilet on 2/15/14, noting the staff nurse used poor judgement by not identifying the potential fall risk when leaving Patient #1 unattended.

3. On 2/14/14 Patient #5, [AGE], was admitted to the CAH for treatment of a non-healing leg ulcer/cellulitis of the left ankle. Per nursing progress note for 2/14/14 at 1740 describes Patient #5 as "...slow unsteady gate, malnutrition at 78 lbs, thin and frail...". A nursing progress note for 2/15/14 states " Approx. 1600 Pt was heard crying out from the Hospice family room. Nursing found pt on the floor, shaken up. S/he had reached for a wooden chair and missed, landing on the floor stating pain under R arm/rib area. VS were elevated and s/he was shaky and not making much sense......chair and bed alarms have been put into place". Per interview on the afternoon of 2/27/14, the Nurse Manager stated s/he was involved with Patient #5's admission and had directed other nursing staff to initiate fall risk interventions. However s/he acknowledged despite Patient #5's obvious physical compromise and risk for falls, staff failed to assure that care and services were provided in accordance with CAH Fall Prevention and use of the Morse Fall Scale policy. It was not until after Patient #5 sustained a fall, nursing staff implemented appropriate precautions.

4. Per review, Physician #1 states in a progress note for 2/21/14 at 1945 "I was summoned by nurses saying that s/he (Patient #1) was wildly agitated, violent and had struck a nurse. They wanted police intervention to help restrain him/her so that s/he could receive Haldol. Sheriff has dispatched deputies" . Shortly after arrival of the Deputy from Windham County Sheriff's Department, decision is made by Physician #1 to administer an injection of Haldol to Patient #1. While the patient sat in his/her wheelchair in Room #2, the Sheriff assisted CAH staff with hands on restraint of Patient #1 while Physician #1 administered the injection into Patient #1's left arm. The first attempt to inject resulted in a bent needle, a second attempt to administer the Haldol proved successful.

Per policy Involuntary Procedures and Use of Restraints last reviewed on 8/28/13 states "Restraint is the direct application of physical force to a patient, with or without the patient's permission, to restrict his/her freedom of movement....Holding a patient and restricting movement constitutes restraining him/her". Per interview on 2/26/14 at 8:35 AM, the Charge Nurse on the evening of 2/21/14 confirmed Patient #1 was physically restrained with "hands on" to the patient's extremities by the Deputy, the Charge Nurse and other nursing staff during the administration of an involuntary emergency medication. Although the policy further states "9. A Certificate of Need (CON) for emergency restraint shall be entered in the patient's record that documents emergency circumstances requiring the use of restraints...." and ".....when involuntary medications are administered (the CON) will be completed by the provider". There was no evidence in the medical record a CON was completed by Physician #1. Per interview on 2/27/14 at 9:45 AM, the Nurse Manager confirmed ".....the policy was not followed...." further acknowledging the Involuntary Procedures and Use of Restraints policy has not been utilized prior to 2/21/14 noting "...we have not had to use restraints...". Furthermore there was no debriefing with either the patient or staff involved with the restraint procedure including the physician, which is also required by CAH policy.
VIOLATION: PATIENT CARE POLICIES Tag No: C1010
Based on interview and record review, the CAH failed to establish polices and procedures to reflect how the provision of services would be provided by Rescue, Inc. (Emergency Medical Services) and the Windham County Sheriffs Department; failed to establish a policy and procedure for the assessment and needs of patients who require transport to other facilities; and failed to establish a policy and procedure to reflect use of pictures/images of patients to be considered in the health information and medical treatment of patients and Findings include:

1. Per record review, during the hospitalization of Patient #1 at the CAH nurses notes reflect and staff confirmed the use of members from Rescue, Inc., to augment staff during circumstances when additional staff support was deemed essential to meet the needs of patients. Although not employed by the CAH, staff from Rescue Inc, to include EMTs and/or Paramedics, have been requested to provide assistance with patient care. Per "Statement of Understanding" last renewed by CAH and Rescue, Inc. administrative staff on 10/18/13 states services provided would include: "Initiating care on a hospital patient who was never an EMS prehospital patient or transfer patient". The agreement specifies: "Often Rescue providers are asked to assist during an emergency for non-EMS patients in emergency room s, radiology departments and occasionally on the patient floors......The care provided is done in the usual domain/locale where EMS provider activities are performed......The care provided is within approved, normal scope of care of that EMS provider."

Provision of care by EMS was noted to have occurred when nursing staff summoned Rescue, Inc to assist with the management of Patient #1 at 04:20 on 2/21/14. The patient got out of bed without assistance, fell and proceeded to crawl into the bathroom. At the time of the incident, staffing at the CAH included 2 RNs and 1 LPN, 2 out of the 3 staff members were male whom Patient #1 expressed dislike and demanded they not provide care. Without any other CAH staff available to provide assistance, the decision was made to call Rescue, Inc. Upon arrival staff from Rescue, Inc. entered Patient #1's room, conversed with Patient #1 while s/he laid on the bathroom floor. Eventually, Patient #1 accepted assistance from Rescue, Inc staff who guided Patient #1 back to bed and conducted an assessment to rule out potential injury.

Per interview on the afternoon of 2/27/14 the CNO confirmed the CAH had not developed a patient care policy and procedure to describe the services furnished through agreement with Rescue, Inc. The CNO further acknowledged, the CAH historically had a long standing arrangement with Rescue, Inc, however s/he had expressed concerns regarding the concept of utilizing Rescue, Inc staff to assist with in-patient care.

2. Per record review, Patient #1 received the administration of a involuntary emergency medication during the evening of 2/21/14. Prior to the administration of the medication, the CNO gave approval to the RN charge nurse to contact the Windham County Sheriff's office requesting a sheriff be provided to assist staff as needed during a behavioral emergency involving Patient #1. Shortly after arrival of the Sheriff from Windham County, decision is made by Physician #1 to administer an injection of Haldol to Patient #1. While the patient sat in his/her wheelchair in Room #2, the Sheriff assisted CAH staff with hands on restraint of Patient #1 while Physician #1 administered the injection into Patient #1's left arm.

A contract exists between the Windham County Sheriff's Department and the CAH dated 2/1/15 - 1/31/15 for the use of law enforcement services. The CNO confirmed on the afternoon of 2/27/14 no written patient care policy existed defining for staff the circumstances during which the use of sheriff department personnel would be requested.

3. On 2/27/14 Patient #1 required transportation to another hospital for diagnostic testing. The decision by CAH staff on 2/26/14 was to send Patient #1, who has both physical and mental deficits with behavioral issues and poor safety awareness, without CAH personnel and only accompanied by Patient #1's significant other. Upon discussion with surveyors on 2/26/14, CAH administrative staff recognized sending Patient #1 without a CAH staff escort was a safety risk. Staff was subsequently assigned to accompany Patient #1 during transport and testing. Upon further discussion on 2/27/14 at 3:50 PM, the CNO confirmed the CAH has not developed a patient care policy regarding transport of patients to another facility for testing, to include the level of supervision required, the degree of assistance needed and evaluation of safety precautions if necessary.

4. Per record review, on 2/26/14, Patient #2 had a physician progress note, dated 12/31/13 that indicated the patient had developed a pressure ulcer on his/her right heel. Despite the documentation, by Physician #1, that stated; ".......on [his/her] right heel [s/he] has a 1 cm(2) area that is tender to palpation with a Q-tip and is non-blanchable and necrotic. Photograph taken....", there was no photograph of the wound included as part of the patient's health information and medical treatment in his/her medical record.

During interview, at 3:28 PM on the afternoon of 2/27/14, Physician #1 confirmed that s/he had taken a photograph of Patient #2's pressure ulcer, had used his/her personal cell phone to capture the image and that the image was still stored on the phone. The CNO (Chief Nursing Officer), confirmed, during interview at 3:33 PM, that staff should not use personal cell phones to take pictures of patients. S/he further stated that although pictures used as part of a patient's health information and medical treatment should be obtained using the facility's camera, there was currently no established policy and procedure to reflect the use of pictures/images for that purpose.
VIOLATION: POLICIES - INFECTION CONTROL Tag No: C0278
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, CAH staff failed to follow a physician's order to obtain a wound culture for 1 applicable patient. (Patient # 5) Findings include:

Per record review, Patient #5 was admitted on [DATE] for the management and treatment of a non-healing cellulitis and abscess of wound of the left ankle. Admission orders included obtaining a wound culture. There was no evidence in the record a wound culture was obtained nor did the laboratory have evidence a culture was received. Per interview on the afternoon of 2/26/14, the Nurse Manager confirmed nursing staff failed to follow a physician order to obtain a wound culture.
VIOLATION: NURSING SERVICES Tag No: C1046
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, Nursing Services failed to meet the needs of patients identified as at risk for falls and skin breakdown. (Patients #1, #2 and #5). Findings include:

1. Per record review, nursing staff failed to prevent development of a pressure ulcer for Patient #2, who was admitted on [DATE] for rehabilitation following an accident in which s/he sustained multiple traumatic injuries which left him/her immobile in bed. The patient, who was admitted with no evidence of any existing pressure ulcers, was identified, through use of the Braden Scale Assessment on 12/20/13, as being at risk for skin breakdown. Despite the identified risk, there was no evidence that staff had implemented interventions to prevent skin breakdown, which were indicated in the CAH's Skin Breakdown Prevention policy and included; Frequent turning, Maximal remobilization, Protect heels, Manage moisture, nutrition, friction and shear, and Pressure reducing support surface if bed or chair bound. A nursing progress note, dated 12/30/13 at 4:08 PM, indicated the patient's right heel was slightly boggy with some discoloration. A subsequent Interdisciplinary Team Meeting nursing note, dated 12/31/13 at 1:14 PM, identified ".....right heel pressure sore with dime size ulcer stage 2 , foot has been elevated with pillow and no pressure to heel site to promote healing.." In addition, although staff identified a pressure ulcer on Patient #2's right heel on 12/30/13 the care plan for Impaired Skin Integrity, which included goals and interventions to facilitate wound healing, was not initiated until 1/10/14.

During interview, on the afternoon of 2/27/14, the Nurse Manager and the CNO (Chief Nursing Officer), both acknowledged the lack of evidence that strategies to prevent skin breakdown had been implemented prior to identification of a pressure ulcer on 12/30/13. Both also confirmed the care plan had not been revised to reflect the patient's heel pressure ulcer until 1/10/14.

2. Per record review, nursing services failed to meet the needs of a patient identified at high risk for falls. Patient #1, admitted on [DATE] for rehabilitation after experiencing a stroke resulting in physical, neurological and behavioral deficits. At the time of admission and utilizing the Morse Fall Scale (MFS), nursing staff screened Patient # 1 at a score of 90 (45 or higher ranked a patient to be at High Risk risk for falls). The policy further directs staff to initiate "High Fall Risk Precautions" to include bed/charm alarm, rounding hourly, placing "Falling Star" placard on door jamb of patient's room along with placing bed in low position. Nursing progress note for 1/21/14 at 23:37 states "...s/he is a fall risk; has made no attempts to get out of bed so as of now s/he is not on alarms". However, within hours of admission, at 7:00 AM on 1/22/14 Patient #1 was found on the floor in his/her room, face down naked sustaining a bruise to his/her left temple, shoulder and hand. Patient #1 also complained of pain across shoulders, neck and head. After the fall, Patient #1 was placed in a high low bed, mats were positioned beside the bed and alarms were put in place. Per interview on 2/27/14 at 8:45 AM, the Nurse Manager confirmed the staff nurse on 1/21/14 failed to meet the patient needs by not following CAH policy and procedures related to fall prevention protocols.

3. Nursing services failed to meet the needs of a patient with identified fragility and at risk for falls. On 2/14/14 Patient #5, [AGE], was admitted to the CAH for treatment of a non-healing ulcer/cellulitis of the left ankle. Per nursing progress note for 2/14/14 at 1740 describes Patient #5 as "...slow unsteady gate, malnutrition at 78 lbs, thin and frail...". A nursing progress note for 2/15/14 states " Approx. 1600 Pt was heard crying out from the Hospice family room. Nursing found pt on the floor, shaken up. S/he had reached for a wooden chair and missed, landing on the floor stating pain under R arm/rib area. VS were elevated and s/he was shaky and not making much sense......chair and bed alarms have been put into place". Per interview on the afternoon of 2/27/14, the Nurse Manager stated s/he was involved with Patient #5's admission and had directed other nursing staff to imitate fall risk interventions. However s/he acknowledged despite Patient #5's obvious physical compromise and risk for falls, staff failed to assure that care and services were provided in accordance with CAH Fall Prevention and use of the Morse Fall Scale policy.
VIOLATION: PERIODIC EVALUATION & QA REVIEW Tag No: C0330
Based on staff interviews and record review the Condition of Participation: Periodic Evaluation and Quality Assurance Review was not met as evidenced by the failure of the CAH to ensure all patient care services and other services affecting patient health and safety had an effective and responsive Quality Assurance Program.

There was a failure to identify opportunities for improvement to include: Administration of emergency medication without following policy and procedure; failure to effectively evaluate patient falls and implement further interventions to prevent falls; failure to evaluate the necessity to utilize non-hospital employees with the provision of patient care; failure to identify the development and prevention of pressure ulcers; and failure of consistent auditing and monitoring of the provision of services.

Refer to C-337
VIOLATION: QUALITY ASSURANCE Tag No: C0337
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the CAH failed to monitor and evaluate patient care services for quality purposes, and failed to identify opportunities for improvement of those services including: the failure to identify that patient care services were not provided in accordance with established policies and procedures regarding Involuntary Procedures and Use of Restraints, Skin Breakdown Prevention and Fall Prevention; failure to recognize the lack of policies and procedures to direct and guide staff regarding the roles and expectations of law enforcement and Rescue organization personnel to assist in the provision of care and treatment of patients; the use of pictures/images of patients to be considered in the health information and medical treatment of patients; and assessment and needs of patients who require transport to other facilities. Findings include:

1. Per record review nursing staff failed to provide care in accordance with the facility's Skin Breakdown Prevention policy for Patient #2, admitted on [DATE] for rehabilitation following an accident in which s/he sustained multiple traumatic injuries which left him/her immobile in bed. Per the policy, dated 12/4/09, and last reviewed 8/28/13, a Braden Scale Score of 15 - 18 indicates a mild risk for skin breakdown, for which the following interventions should be implemented: Frequent turning, Maximal remobilization, Protect heels, Manage moisture, nutrition, friction and shear, and Pressure reducing support surface if bed or chair bound. Although Patient #2 had a Braden Risk Assessment Scale completed on 12/20/13 which identified a score of 15, there was no indication that any of the identified interventions had been implemented. The patient, who was admitted with no evidence of any existing pressure ulcers, developed a ".....right heel pressure sore with dime size ulcer stage 2 ...", and, despite the identification of the pressure ulcer on 12/30/13, the care plan for Impaired Skin Integrity which included goals and interventions to facilitate wound healing, was not initiated until 1/10/14.

During interview, on the afternoon of 2/27/14, the Nurse Manager and the CNO (Chief Nursing Officer), both confirmed that the Skin Breakdown Prevention Policy had not been followed, and interventions to prevent skin breakdown should have been implemented on admission when the patient had been identified as at risk for breakdown. The CNO further confirmed that although the patient had developed the pressure wound after admission to the CAH there had been no quality review of the medical record to determine whether or not the wound had been avoidable and therefore, no opportunity for improvement in skin breakdown prevention had been identified.

2. Per record review, CAH nursing staff failed to provide care in accordance with the facility policy Fall Prevention and the use of the Morse Fall Scale last reviewed 11/3/13 for Patients #1 & #5. The policy directs staff to initiate "High Fall Risk Precautions" to include bed/charm alarm, rounding hourly, placing "Falling Star" placard on door jamb of patient's room along with placing bed in low position. Patient #1 was admitted on [DATE] for rehabilitation after experiencing a stroke resulting in physical, neurological and behavioral deficits. At the time of admission and utilizing the Morse Fall Scale (MFS), nursing staff screened Patient #1 at a score of 90 (45 or higher ranked a patient to be at High Risk risk for falls). Despite the identification of high fall risk staff failed to follow the policy and did not implement use of bed/chair alarms and the patient sustained a fall within hours of admission resulting in injuries. In addition, staff again failed to follow the facility policy when, on 2/15/14, Patient #1 was left unattended in the bathroom and sustained another fall.

Patient #5, admitted on [DATE] for treatment of a non-healing ulcer/cellulitis of the left ankle, was described in a nursing note as "...slow unsteady gate, malnutrition at 78 lbs, thin and frail..." Per interview, on the afternoon of 2/27/14, the Nurse Manager stated s/he was involved with Patient #5's admission and had directed other nursing staff to initiate fall risk interventions. Despite the nursing assessment, bed/chair alarms had not been initiated in accordance with the policy and Patient #5 sustained a fall on 2/15/14.

Per interview on 2/27/14 at 8:45 AM, the Nurse Manager confirmed that nursing staff failed to follow CAH policy and procedures related to fall prevention protocols for Patients #1 and #5. In addition, the CNO and the Director of Quality both confirmed during interview, on

3. Per record review, a CON (Certificate of Need) was not completed in accordance with the CAH's policy for Involuntary Procedures and Use of Restraints, regarding the physical restraint and administration of an involuntary medication to Patient #1. Per review the policy states: "9. A Certificate of Need (CON) for emergency restraint shall be entered in the patient's record that documents emergency circumstances requiring the use of restraints...." and ".....when involuntary medications are administered will be completed by the provider." Although the patient was restrained, on 2/21/14, for the purpose of administration of an involuntary medication by Physician #1, there was no evidence in the medical record a CON was completed by the physician.

Per interview on 2/27/14 at 9:45 AM, the Nurse Manager confirmed ".....the policy was not followed...." further acknowledging the Involuntary Procedures and Use of Restraints policy has not been utilized prior to 2/21/14 noting "...we have not had to use restraints...". Furthermore there was no debriefing with either the patient or staff involved including the physician after the procedures took place, which is also required by CAH policy. The CNO confirmed, during interview on the afternoon of 2/27/14, that there had been no quality review of Patient #1's medical record related to the use of restraints and involuntary medication administration and the failure to identify opportunity for improvement in the use of restraints and emergency involuntary procedures.

4. Per record review the CAH failed to establish a policy and procedure to direct and guide staff in the utilization of non hospital personnel, including Rescue, Inc. and the Windham County Sheriff's Department to assist in providing direct care and/or medical treatment for Patient #1. Per record review nurses notes reflect, and staff confirmed, the use of members from Rescue, Inc., non hospital employees, to augment staff during circumstances when additional staff support was deemed essential to meet the needs of patients. Provision of care by EMS was noted to have occurred when nursing staff summoned Rescue, Inc to assist with the management of Patient #1 at 04:20 on 2/21/14. The patient got out of bed without assistance, fell and proceeded to crawl into the bathroom. At the time of the incident, staffing at the CAH included 2 RNs and 1 LPN, 2 out of the 3 staff members were male whom Patient #1 expressed dislike and demanded they not provide care. Without any other CAH staff available to provide assistance, the decision was made to call Rescue, Inc. Upon arrival staff from Rescue, Inc. entered Patient #1's room, conversed with Patient #1 while s/he laid on the bathroom floor. Eventually, Patient #1 accepted assistance from Rescue, Inc staff who guided Patient #1 back to bed and conducted an assessment to rule out any potential injury.

Per record the CNO gave approval to the RN charge nurse, on the evening of 2/21/14, to contact the Windham County Sheriff's office requesting a sheriff be provided to assist staff as needed during the behavioral emergency involving Patient #1. The record indicated that the Sheriff assisted staff in physically restraining Patient #1 while an involuntary medication was administered by Physician #1.

Although a contract exists between the Windham County Sheriff's Department and the CAH for the use of law enforcement services, the CNO confirmed on the afternoon of 2/27/14, that no written patient care policy existed defining for staff the circumstances during which the use of sheriff department personnel would be requested. The CNO further confirmed the CAH had not developed a patient care policy and procedure to describe the services furnished through agreement with Rescue, Inc. S/he acknowledged, the CAH historically had a long standing arrangement with Rescue, Inc, however s/he had expressed concerns regarding the concept of utilizing Rescue, Inc staff to assist with in-patient care.

5. On 2/27/14 Patient #1 required transportation to another hospital for diagnostic testing. The decision by CAH staff on 2/26/14 was to send Patient #1, who has both physical and mental deficits with behavioral issues and poor safety awareness, without CAH personnel and only accompanied by Patient #1's significant other. Upon discussion with surveyors on 2/26/14, CAH administrative staff recognized sending Patient #1 without a CAH staff escort was a safety risk. Staff was subsequently assigned to accompany Patient #1 during transport and testing. Upon further discussion on 2/27/14 at 3:50 PM, the CNO confirmed the CAH has not developed a patient care policy regarding transport of patients to another facility for testing, to include the level of supervision required, the degree of assistance needed and evaluation of safety precautions if necessary.

6. Per record review Physician #2's personal cell phone was used to obtain an image of Patient #2's pressure wound. The physician confirmed, during interview on the afternoon of 2/27/14, that the image was still stored on his/her phone and had not been included in the patient's medical record. During interview on the afternoon of 2/27/14 the CNO confirmed that although the CAH did possess a camera for the use of obtaining patient pictures/images for consideration in the patient's health history or medical treatment, there is no policy and procedure to direct and guide staff in the use of patient pictures/images.

Per interview on 2/26/14 at 2:03 PM the Director of Quality/Compliance confirmed although there have been significant events involving the care and services provided to Patient #1 to include instances of at least 6 falls since admission on 1/24/14, s/he had not reviewed each individual event, stating it was the responsibility of the CNO and Nurse Manager. The Director also confirmed his/her awareness of nursing staff utilizing Rescue, Inc during an incident with Patient #1 on 2/21/14, but failed to evaluate circumstances for the need to augment staff with EMS personnel. In addition, the Director failed to identify the opportunity for improvement after Patient #1 was physically restrained and administered emergency involuntary medication. As per Involuntary Procedures and Use of Restraints policy states "All instances of involuntary administration of medication, chemical and mechanical restraints, should be automatically, independently and regularly reviewed." At the time of interview, the Director confirmed an evaluation of the involuntary procedures, experienced by Patient #1 on the evening of 2/21/14, had not been conducted to include the appropriateness of the medication and its dosage, whether alternatives were available and offered or whether the required documentation was complete. The Director stated a Root Cause Analysis was pending in the near future.
VIOLATION: COMPLIANCE FED, ST, AND LOCAL LAWS AND REGS Tag No: C0812
Based on record review and staff interview, the Critical Access Hospital (CAH) failed to be in compliance with State of Vermont Statute Title 18, Chapter 42: Bill of Rights for Hospital Patients for 2 applicable patients. (Patients # 1, # 2). Findings include:

Per State Statute 1852. Patients' Bill of Rights for Hospital Patients: "(6) The patient has the right to every consideration of privacy concerning the patient's own medical program. Case Discussion, consultation, examination, and treatment are confidential and shall be conducted discreetly".

1. Per record review, on 2/26/14, a photograph of Patient #2's pressure wound was taken and stored on Physician #2's personal cell phone, on 12/31/13, potentially exposing the patient's private and confidential medical information to those who have no need of the information. A physician progress note, dated 12/31/13 that indicated the patient had developed a pressure ulcer on his/her right heel. Despite the documentation, by Physician #2, that stated; ".......on [his/her] right heel [s/he] has a 1 cm (2) area that is tender to palpation with a Q-tip and is non-blanchable and necrotic. Photograph taken....", there was no photograph of the wound included as part of the patient's health information in the patient's medical record.

During interview, at 3:28 PM on the afternoon of 2/27/14, Physician #2 confirmed that s/he had taken a photograph of Patient #2's pressure ulcer, had used his/her personal cell phone to capture the image and that the image was still stored on the phone. The CNO (Chief Nursing Officer), confirmed, during interview at 3:33 PM, that staff should not use personal cell phones to take pictures of patients. S/he further confirmed that the image of Patient #2's wound, taken on 12/31/13, had still not been included as part of the patient's health information or medical treatment in the patient's medical record, as of the date of survey.

2. Per record review, Patient #1 experienced on 12/24/13 a nontraumatic cerebral hemorrhage (stroke) requiring neurosurgery. Post operative complications included seizures, impaired cognition, swallowing and mobility defects. On 1/21/14 Patient #1 was transferred to the CAH for rehabilitation. Shortly after admission to the CAH Patient #1 demonstrated erratic behaviors including paranoia, impulsivity, anger, belligerence toward staff and was assessed to be at high fall risk, subsequently experiencing multiple falls at the CAH.

During the evening and into the early morning of 2/21/14 Patient #1's behaviors began to escalate. A Physician Progress note for 2/21/14 states " Around midnight however s/he became flamboyant paranoid and agitated, throwing furniture, breaking equipment, crawling into the bathroom and locking himself/herself repeatedly" (in the bathroom). At 04:20 on 2/21/14 Patient #1 got out of bed without assistance, fell and proceeded to crawl into the bathroom. At the time of the incident, staffing at the CAH included 2 RNs and 1 LPN, 2 out of the 3 staff members were male whom Patient #1 expressed dislike and demanded they not provide care. Without any other CAH staff available to provide assistance, the decision was made to call Rescue, Inc. ( Emergency Medical Systems provider) based adjacent to the CAH. Although only authorized staff should be directly involved in treatment and care and services for Patient #1, Rescue, Inc. staff became involved with patient care in the patient's room while s/he laid on the bathroom floor. Patient #1 accepted assistance from Rescue, Inc staff who guided Patient #1 back to bed. Despite privacy concerns for Patient #1, Rescue, Inc staff, who are not employed by the CAH, proceeded to conduct a physical assessment of the patient to rule out any potential injury.
VIOLATION: STAFFING AND STAFF RESPONSIBILITIES Tag No: C0970
Based on staff interview and record review, the Condition of Participation: Staffing and Staff Responsibilities was not met as evidenced by the failure of the CAH to ensure sufficient staff coverage was available at all times to provide essential services and able to respond to emergent events or procedures and to be sufficient to meet the needs of all patients.

Refer to Tag: C-253
VIOLATION: SUFFICIENT STAFF Tag No: C0974
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff interview and record review, the CAH failed to ensure sufficient staff coverage was available at all times to respond to emergent events or procedures and to provide essential services to include Nursing and all therapy services. (Patients #1, #2, #3 ) Findings include:

1. Per record review, Patient #1 experienced on 12/24/13 a nontraumatic cerebral hemorrhage (stroke) requiring neurosurgery. Post operative complications included seizures, impaired cognition, swallowing and mobility deficits. On 1/21/14 Patient #1 was transferred to the CAH for rehabilitation. Shortly after admission to the CAH Patient #1 demonstrated erratic behaviors including paranoia, impulsivity, anger, belligerence toward staff and was assessed to be at high fall risk, subsequently experiencing multiple falls at the CAH. During Patient #1's course of rehabilitation, s/he remained more cooperative with rehabilitation staff and nursing staff on days and evening shift, but during late evening and night Patient #1's behaviors became more challenging. The census fluctuates between 11-17 CAH patients. During the 11 PM to 7:00 AM nursing staff also is required to provide nursing coverage for the 4 beds in the Emergency Department, this assignment is generally the responsibility of the assigned Charge Nurse. As a result, when only 3 nursing staff were regularly scheduled during the night shift, only 2 would be available to provide floor care duties at the CAH, limiting the ability of staff to consistently deliver patient care services and assure the safety for all patients was being met.

During the evening and into the early morning of 2/21/14 Patient #1's behaviors began to escalate. A Physician Progress note for 2/21/14 states " Around midnight however s/he became flamboyant paranoid and agitated, throwing furniture, breaking equipment, crawling into the bathroom and locking himself/herself repeatedly" (in the bathroom). At 04:20 on 2/21/14 Patient #1 got out of bed without assistance, fell and proceeded to crawl into the bathroom. At the time of the incident, staffing at the CAH included 2 RNs and 1 LPN, 2 out of the 3 staff members were male whom Patient #1 expressed dislike and demanded they not provide care. Without any other CAH staff available to provide assistance, the decision was made to call Rescue, Inc. ( Emergency Medical Systems provider) based adjacent to the CAH. Although not hospital employees, staff from Rescue, Inc. entered Patient #1's room, conversed with Patient #1 while s/he laid on the bathroom floor. Eventually, Patient #1 accepted assistance from Rescue, Inc staff who guided Patient #1 back to bed and conducted an assessment to rule out any potential injury.

During the evening of 2/21/14 Patient #1's behaviors again escalated. Per Nursing progress note at 1940 "Pt. has pulled bed alarm wire and bed control out of bed and wall and wrapped the wires around his hand.....". During an attempt to remove the equipment from Patient #1 a LNA (Licensed Nursing Assistant) was repeatedly hit with bed control equipment by the patient. Shortly after the patient placed himself/herself in their wheelchair, exited his/her room, wheeling up and down hallways past other patient rooms and attempted to get into the elevator. The census on the evening of 2/21/14 was 15 and scheduled nursing staff was 1 RN (who was both charge nurse and assigned to the ED) and 2 LPNs. After contacting the Administrator on call to report concerns regarding Patient #1's ongoing behavioral incidents the RN charge nurse was authorized to contact the Windham County Sheriff's Department to request assistance. Per MD Progress note for 1/21/14 at 19:45 Physician #1 states "I was summoned by nurses saying that s/he was wildly agitated, violent and had struck a nurse. They wanted police intervention to help restrain him/her so that s/he could receive his/her Haldol. Sheriff has dispatched deputies". At 2000 Patient #1 is approached in his room by Physician #1 and 3 other staff members and is offered Haldol 10 mg. orally. Patient #1 accepts the Haldol, but when given, throws the pill, refusing to take the medication. Upon arrival of the Sheriff into the patient's room, Patient #1 is informed an injection of Haldol will be administered at which time Patient #1 again refused to receive the medication. As the patient sat in a wheelchair, the Sheriff restrained Patient #1's right arm, and other staff restraining other extremities, Physician #1 attempted to inject Haldol 10 mg. into Patient #1's left deltoid muscle, however the patient flexed their arm and the needle bent. A second attempt was made with a new needle and Physician #1 was successful at administering the medication. Per interview on 2/26/14 at 3:15 PM, Physician #1 confirmed after changing the gauge size of the needle for injection, the patient did receive the full dose of medication.

A Nursing progress note reflecting Patient #1's history of falls and wandering via wheelchair for 2/20/14 at 16:44 states " Patient does not have one to one care so staff are not present in room with patient on a constant basis." Physician #1 documents on 2/21/14 at 17:16 "S/he needs huge amounts of reassurance and watching". When questioned regarding having sufficient staff the Chief Nursing Officer (CNO)/Interim Chief Operating Officer (COO) stated during interview on 2/26/14 at 3:50 PM "Our per diem pool has been decimated, we will mandate people to stay if we have to but we don't want to because it affects moral. No we do not have enough staff".

In addition, although the CAH has a policy and procedure for calling a "Code Gray" when staff are requiring immediate assistance with a safety or behavioral situation/event, staff response would be sufficient during the day and for part of the evening, however after 9:00 PM and throughout the night ancillary services are not available and therefore only 3-4 nursing staff members are present without the assistance of other support staff and/or security.

2. Per record review Patient #2, who was admitted on [DATE], for rehabilitation following an accident in which s/he sustained multiple traumatic injuries, did not consistently receive physical therapy (PT) treatment as directed in the plan of care. Per review of a PT Daily Note, dated 1/3/14, the treatment plan included: Bed mobility training, Pain management, Patient education, Therapeutic activities, Therapeutic exercises, Transfer training, Wheelchair assessment and management and Safety education. The PT treatments were to occur daily for a period of 3 weeks. However, subsequent progress notes on two separate days, 1/4/14 at 5:27 PM and 1/5/14 at 5:31 PM, respectively, indicated "patient not seen for PT due to staffing constraints".

3. Per review Patient #3, who was admitted on [DATE] for rehabilitation following a stroke, had an initial Occupational Therapy (OT) evaluation, dated 2/6/14, that identified a plan of treatment for problems including: Balance deficits, basic ADL (Activities of Daily Living) deficits, and Strength/ROM (Range of Motion) deficits. The treatment plan indicated the patient would receive daily OT treatment for a period of 4 weeks. A progress note, dated 2/9/14 at 3:12 PM stated: "OT tx (treatment) withheld this date secondary to staffing limitations. "
During interview, at 9:30 AM on 2/27/14, the Director of Rehabilitation services confirmed PT and OT treatments did not occur for Patients #2 and #3 on each of the respective dates related to a lack of staff to offer the services.
VIOLATION: NURSING SERVICES Tag No: C1050
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review the Nursing Care Plan was not revised to address fall interventions in an effort to reduce falls and injury for 1 applicable patient. (Patient #1) and failure to develop a care plan upon admission to reflect identified potential risks for skin breakdown for 1 applicable patient. (Patient #2) Findings include:

1. Per record review nursing staff failed to develop and revise in a timely manner, the care plan for Patient #2, to reflect the patient's risk for skin breakdown and the actual development of a pressure ulcer. The patient was admitted on [DATE] for rehabilitation following an accident in which s/he sustained multiple traumatic injuries which left him/her immobile in bed. Although Patient #2, admitted with no evidence of any existing pressure ulcers, was identified as being at risk for skin breakdown, the care plan did not reflect the identified risk. A nursing progress note, dated 12/30/13 at 4:08 PM, indicated the patient's right heel was slightly boggy with some discoloration. A subsequent Interdisciplinary Team Meeting nursing note, dated 12/31/13 at 1:14 PM, identified ".....right heel pressure sore with dime size ulcer stage 2 , foot has been elevated with pillow and no pressure to heel site to promote healing.." Despite the identification of a pressure ulcer on Patient #2's right heel on 12/30/13 the care plan for Impaired Skin Integrity, which included goals and interventions to facilitate wound healing, was not initiated until 1/10/14.

During interview, on the afternoon of 2/27/14, the Nurse Manager and the CNO (Chief Nursing Officer), both confirmed the care plan had not reflected the patient's risk for skin
breakdown and had not been revised to reflect the patient's heel pressure ulcer until 1/10/14.

2. Per record review, on 12/24/13 Patient #1 experienced a nontraumatic cerebral hemorrhage (stroke) requiring neurosurgery. Post operative complications included seizures, impaired cognition, swallowing and mobility deficits. On 1/21/14 Patient #1 was transferred to the CAH for rehabilitation. Shortly after admission to the CAH Patient #1 demonstrated erratic behaviors including paranoia, impulsivity, anger, belligerence toward staff and was assessed to be at high fall risk, subsequently experiencing multiple falls at the CAH. Review of Patient #1's Interdisciplinary Team Meeting notes, where multiple CAH's disciplines discuss Patient #1's progress, therapies, discharge plans and review/revise the care plan. Although "Risk for Falls Plan of Care" was initiated on 1/21/14, there was a lack of evidence to demonstrate additional precautions or interventions to be attempted in order to prevent further falls. Despite the "High Fall Risk Precautions", no other interventions were discussed or incorporated into Patient #1's care plan in an effort to prevent further falls with injury. Patient #1 had sustained 6 falls, some with injury during CAH hospitalized from [DATE] through 2/28/14.
VIOLATION: RECORDS SYSTEM Tag No: C1104
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff interview and record review, The Electronic Medical Record (EMR) was not readily accessible and systematically organized to provide evidence to reflect provision of specific care and services. CAH staff failed to accurately document the interventions and provision of care provided for 1 applicable patient with impaired skin integrity (Patient #2). The CAH staff failed to complete required documentation after the use of restraint and administration of an involuntary emergency medication for 1 applicable patient. (Patient #1) Findings include:

Per record review nursing staff failed to consistently and accurately document the description of an identified pressure ulcer for Patient #2, admitted on [DATE] for rehabilitation following an accident in which s/he sustained multiple traumatic injuries which left him/her immobile in bed. The patient, who was admitted with no evidence of any existing pressure ulcers, had a nursing progress note, dated 12/30/13 at 4:08 PM which indicated the patient's right "heel was slightly boggy with dry skin splits that pt says [s/he] gets, with a couple of discolored areas black/blue." A note, at 7:00 PM on the same date, identified the area as "darkened, bruised area on heel, blanchable. Skin on heel dry and cracked but otherwise intact." On 12/31/13 at 6:00 AM, the note described the wound as a 2cm x 2cm Stage 3 (open ulcer -full thickness tissue loss), however, it identified the wound tissue as intact. An Interdisciplinary Team Meeting nursing note, also dated 12/31/13 at 1:14 PM, identified ".....right heal pressure sore with dime size ulcer stage 2...." (open, shallow ulcer or intact blister like area) The next note that described the right heel pressure wound was dated 1/4/14 and identified a Stage 1 wound. A subsequent right heel wound assessment, dated 1/10/14 indicated a Stage 2 wound with wound bed tissue type identified as necrotci tissue, eschar. On 1/15/14 the note stated the pressure wound was "tender to touch, spot of necrotic black tissue" and in a final note on 1/19/14 the wound is described as "dry, cracked bruising". In addition, although a physician progress note, dated 12/31/13 indicated that a photograph of the wound had been obtained on that date, there was no evidence of the photograph in the medical record.

During interview, on the afternoon of 2/27/14, the Nurse Manager and the CNO (Chief Nursing Officer), both confirmed the description of the patient's pressure ulcer was inconsistently and inaccurately documented and both stated they were unable to determine in the medical record when the wound was healed. The CNO further confirmed that there was no photograph of the wound in the patient's medical record.

2. Per policy Involuntary Procedures and Use of Restraints last reviewed on 8/28/13 states "Restraint is the direct application of physical force to a patient, with or without the patient's permission, to restrict his/her freedom of movement....Holding a patient and restricting movement constitutes restraining him/her". Per interview on 2/26/14 at 8:35 AM, the Charge Nurse on the evening of 2/21/14 confirmed Patient #1 was physically restrained with "hands on" patient limbs by the Deputy, the Charge Nurse and other nursing staff during the administration of an involuntary emergency medication. Although the policy further states "9. A Certificate of Need (CON) for emergency restraint shall be entered in the patient's record that documents emergency circumstances requiring the use of restraints...." and ".....when involuntary medication s are administered will be completed by the provider..." there was no evidence in the medical record a CON was completed by Physician #1. Per interview on 2/27/14 at 9:45 AM, the Nurse Manager confirmed ".....the policy was not followed...." and there was no evidence in the Electronic Medical Record or paper record, a CON had been completed.
VIOLATION: RECORDS SYSTEM Tag No: C1116
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review there was a failure within the EMR to accurately provide information for the ongoing monitoring of an identified wound and the inability to determine when a wound was healed for 1 applicable patient (Patient #2) and the failure to acknowledge and promptly respond to a physician order to obtain a wound culture for 1 applicable patient. (Patient #5) Findings include:

1. Per record review nursing staff failed to consistently and accurately document the description of an identified pressure ulcer for Patient #2, admitted on [DATE] for rehabilitation following an accident in which s/he sustained multiple traumatic injuries which left him/her immobile in bed. The patient, who was admitted with no evidence of any existing pressure ulcers, had a nursing progress note, dated 12/30/13 at 4:08 PM which indicated the patient's right "heel was slightly boggy with dry skin splits that pt says [s/he] gets, with a couple of discolored areas black/blue." A note, at 7:00 PM on the same date, identified the area as "darkened, bruised area on heel, blanchable. Skin on heel dry and cracked but otherwise intact." On 12/31/13 at 6:00 AM, the note described the wound as a 2cm x 2cm Stage 3, however, it identified the wound tissue as intact. An Interdisciplinary Team Meeting nursing note, also dated 12/31/13 at 1:14 PM, identified ".....right heel pressure sore with dime size ulcer stage 2...." The next note that described the right heel pressure wound was dated 1/4/14 and identified a Stage 1 wound. A subsequent right heel wound assessment, dated 1/10/14 indicated a Stage 2 wound with wound bed tissue type identified as necrotic tissue, eschar. On 1/15/14 the note stated the pressure wound was "tender to touch, spot of necrotic black tissue" and in a final note on 1/19/14 the wound is described as "dry, cracked bruising".

During interview, on the afternoon of 2/27/14, the Nurse Manager and the CNO (Chief Nursing Officer), both confirmed the description of the patient's pressure ulcer was inconsistently and inaccurately documented and both stated they were unable to determine in the medical record when the wound was healed.

2. Per record review, Patient #5 was admitted on [DATE] for the management and treatment of a non-healing cellulitis and abscess of wound of the left ankle. Admission orders included obtaining a wound culture. There was no evidence in the record a wound culture was obtained. Per interview on the afternoon of 2/26/14, the Nurse Manager confirmed the EMR lacked evidence whether staff had followed physician orders.