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ST JOHN MACOMB-OAKLAND HOSPITAL-MACOMB CENTER 11800 EAST TWELVE MILE ROAD WARREN, MI 48093 April 16, 2015
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
Based on document review and interview, one of one patient complaints about care (for patient #9) from a total sample of 15 patients in the entire survey (14 without care complaints) was not classified as a grievance and processed according to the facility grievance process, resulting in increased risk of all patients being deprived of their grievance rights. Findings include:

Record Review:
On 4/16/2015 at 0920 patient #9's abuse and neglect allegations were reviewed with staff A and staff E. A 12/2/2015 note by Nurse Manager I stated, "I visited with patient (#9) and wife to explore complaints with nursing care...Attempted to provide resolutions regarding patient's activity, meals, and hygiene." Investigation revealed that the complaints regarding patient #9's care concerned alleged events that occurred from 11/28/2014-12/1/2014.

Staff E stated that she first became aware that patient #9's spouse had complaints about the patient's care on 12/1/2014. A 12/2/2014 note at 1054 by staff E discusses a phone conversation with patient 9's spouse on 12/2/2014. The note contains an allegation by patient #9's spouse stating that on 11/28/2014, "a nurse (staff H) and two security guards wrestled with (patient #9) and restrained him." The note accuses an unnamed female nurse of lying about these events." The note continues: "Also, they only changed (patient #9's) bed sheets on Sunday (11/30/2014) because I insisted. They were dirty and stained with blood from inserting the catheter."

Interview:
On 4/16/2015 staff E was asked whether the above complaints about patient care were processed as complaints or grievances. Staff E stated that she considered all of patient #9's allegations to be resolved on 12/2/2014 during a meeting with the patient and the patient's spouse, so she classified the allegations as complaints and did not follow the facility's grievance process. Staff E's documentation of the 12/2/2014 meeting indicates that the allegations occurred over multiple days and that patient #9's spouse stated that she was "unhappy that this happened at all" at the 12/2/2014 meeting. Staff E stated that patient #9 complaints were not investigated as grievances and no follow-up letter was sent to the patient or the patient's spouse.

Policy Review:
On 4/16/2015 at 1505 facility policy titled, "Patient-Family Complaint and Grievance Process," # 49, dated 03/2015 was reviewed. The policy stated, "Patient complaints that are considered grievances also include situations where a patient or a patient's representative telephone the hospital with a complaint regarding the patient's care or with an allegation of abuse or neglect, or failure of the hospital to comply with one or more CoPs (Conditions of Participation)...All verbal or written complaints regarding abuse, neglect, patient harm, or hospital compliance with CMS (Centers for Medicare & Medicaid) requirements are considered grievances...Most patient grievances must be responded to in writing within seven (7) working days."
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on record review and interview, one of two complaints alleging possible abuse or neglect (patient #9's complaint) from a total survey sample of 15 patients (13 without abuse/neglect allegations) did not receive a timely, through investigation, resulting in increased risk of abuse and neglect for all patients. Findings include:

Record Review and Interview:
On 4/16/2015 at 0920 documentation of patient #9's allegations of possible abuse or neglect were reviewed with staff E. A 12/2/2015 note by Nurse Manager I states: "I visited with patient (#9) and wife to explore complaints with nursing care...Attempted to provide resolutions regarding patient's activity, meals, and hygiene." Investigation revealed that the complaints concerned alleged events that occurred from 11/28/2014-12/1/2014.

Staff E stated that she first became aware that patient #9's spouse had complaints about the patient's care on 12/1/2014. A 12/2/2014 note at 1054 by staff E discusses a phone conversation with patient 9's spouse on 12/2/2014. The note contains an allegation by patient #9's spouse stating that on 11/28/2014, "a nurse (staff H) and two security guards wrestled with (patient #9) and restrained him." The note accuses an unnamed female nurse of lying about the reason for restraining the patient. The note stated, "Also, they only changed (patient #9's) bed sheets on Sunday (11/30/2014) because I insisted. They were dirty and stained with blood from inserting the catheter."

A note by staff E, dated 12/2/2014 at 1400 stated, "met with pt (patient #9), wife, Manager, RN and myself...Wife upset with incident with RN H, that he wouldn't help (patient #9) and threatened to tie the patient down...Then (patient's spouse) said other people are lying and not doing job." The note concludes that (patient's spouse) was "satisfied we are doing what we are supposed to do now but unhappy that this happened at all with RN H." Staff E was asked for all investigative notes into these allegations of possible patient abuse and neglect. Staff E stated that she was was told that nurse H had been counseled by his manager and that she was not aware of any other investigative actions or documentation. Staff E stated that she was unaware of any effort to interview staff or patients to determine the validity of these allegations. The 12/1/2014 note by staff E states that the patient's spouse heard "hearsay from husband's roommate." Staff E stated that she was not aware of any attempts to interview the patient's roommate as a possible witness. Staff E stated that two security guards assisted patient #9 to get out of bed on 11/28/ . Staff E was unable to explain why security guards were needed to assist with patient #9's care on 11/28/2014. Staff E stated that the security guards who were called to assist with patient #9's care on 11/28/ did not write a report and no attempt was made to interview them. Staff E stated that these allegations were treated as complaints that were resolved at the time they occurred and did not require investigation as grievance allegations of possible abuse or neglect. The above findings were confirmed by staff E during record review.

On 4/16/2014 at approximately 1330 nursing administrator C stated that the only documentation of any action taken by the Nursing Department to investigate patient #9's spouse's allegations of possible abuse and neglect of the patient was a note by staff I, placed in staff H's personnel file, stating that nurse H was counseled to speak to patients respectfully. The note stated that nurse H denied all allegation that he acted inappropriately in caring for patient #9.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on observation, interview and record review the facility failed to provide appropriate nursing services that followed the nursing process of monitoring, identifying and responding to patient needs through assessment, care planning, interventions and documentation resulting in a delay in meeting the needs of patients which caused altered skin integrity. Findings include:

The facility failed to provide adequate monitoring, care planning, and follow the recommended orders for pressure ulcer treatment for one current patient (#11) and one discharged patient (#9) who both developed facility acquired pressure wounds. (A-0396)
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interviews and record review, the facility failed to assess, develop and implement nursing care plans and interventions and follow the recommended orders for treatment for two (#9, and #11) of three patients reviewed for altered skin integrity from a total sample of 15 residents, resulting in the development of multiple facility acquired pressure sores including an unstageable pressure sore with necrotic tissue for #9, and the development of two new pressure sores for #11. Findings include:

On 04/15/2015 at 1345 during a wound observation, the Wound Care Nurse (D) was queried about the skin integrity of Patient #11, and the nurse reported that the patient developed a fissure on his coccyx as a result of excess moisture because the patient was incontinent of bowel and bladder. The nurse explained that she first assessed the wound on 04/06/15, but the present condition of the wound was worse than it was when she first observed it. Wound Care Nurse (D) stated, "it is not healing." The wound appeared to be approximately one inch long by one-half inch wide and was on the coccyx. There also was another area observed on the patient's right buttock that appeared to be a resolving wound about the size of a nickel. The wound care nurse stated that she would change the treatment order for Patient #11 since the wound was not healing adequately.

Review of the medical record on 04/ 5 at 0930 revealed that Patient #11 was a [AGE] year old male admitted into the facility on [DATE] with diagnoses that included end stage renal disease, hematemesis (vomiting blood) and diabetic gastroparesis (delayed gastric emptying), among other diagnoses. The initial nursing assessment dated [DATE] indicated no open areas on the patients skin. The patient had impaired cognition and was immobile and required assistance with repositioning.

The integumentary document dated 04/03/15 revealed that a pressure ulcer was present and the description noted indicated, "Allevyn dry and intact to buttocks area." The was no documentation that described the size, shape, color or location of the wound.

The Braden Scale for predicting pressure ulcer risk dated 04/06/15 and 04/15/15 revealed a score of 14 and 12, respectively. A score of less than 18 indicated a risk for the development of pressure ulcers.

A Wound Care Consultation was conducted on 04/06/15 at 1255 and interventions that Nurse (D) planned for the patient were "Medihoney HCS Hydrocolloid dressing, Barrier paste TID (three times daily) and as needed, low air loss overlay, offload heels and wound and skin care."

The medical record did not indicate that the order for the Medihoney was ever placed and there were not any treatment records in the clinical record that revealed when and by whom wound treatment was performed. Wound Care Nurse (F) was queried on 04/16/15 at approximately 1045 and he confirmed that there was no documentation that indicated if wound treatment was performed for the patient.

Further review of the clinical record revealed Assessment Skin Care Forms dated 04/03/15 that indicated that Patient #11 had two wounds. One wound was on the coccyx and the second wound was on the right buttock. However, no detailed description including the size, character of drainage or condition of the wound was provided.

The universal care plan indicated, "teach pressure ulcer risk" (dated 03/26/15) and "reposition to maintain maximum comfort" (dated 04/15/15). It was unclear how a cognitively impaired patient could comprehend instruction on pressure sore risk, and why the intervention to reposition the patient was implemented on 04/15/15, at the time of the survey.

A "Wound Care" care plan was initiated on 04/15/15 (during the time of the survey) which indicated "Initiate Pressure Ulcer Protocol, Protect Peri-Wound Skin, Promote Tissue Perfusion, Maintain Vacuum Assisted Therapy, Monitor for signs and symptoms of additional breakdown, Float Heels, Turn and Reposition, and Position Off Wound/Bony Prominences."

On 04//16/15 at 1345 Wound Care Nurse (D) confirmed that the recommended order for the Medihoney had never been ordered for the patient. Nurse (D) stated "I recommended it but I didn't put in an order for the Medihoney." Thus, it was unclear if treatment had ever been provided for the patient since there was no treatment order. The Wound Care Nurse (D) also was unable to explain why the "Wound Care" care plan had just been initiated on 04/15/15 when the wound had first been identified on 04/03/15.

Review of the facility policy entitled, "PRESSURE ULCER PREVENTION, MANAGEMENT AND TREATMENT" REVISED 10/2014 revealed, "Following assessment a plan of care to prevent/treat pressure ulcers is established and initiated in a timely manner, care and treatment of ...hospital acquired pressure ulcers should be provided by the Registered Nurse in accordance with established protocols..." The policy further indicated the documentation should include "location, size, dressing changes, drainage, undermining/tunneling, character of wound and stage."




Record Review and Interview:
Documentation regarding patient #9's facility acquired pressure ulcer was reviewed with Wound Care Nurse D on 4/16/2015 from 1215-1430. Patient #9 was admitted on [DATE]. A 11/28/2014 "Flowsheet" describes skin abnormalities on patient #9's leg and abdomen. No skin abnormalities on patient #9's buttocks were noted.

The facility's policy titled, "Pressure Ulcer Prevention, Management and Treatment," # 7, dated 10/2014, was reviewed with Wound Nurse D on 4/16/2015 during record review from 1215-1430. The policy does not require that the Wound Care Nurse be notified of pressure ulcers until they reach stage III. The policy does not require detailed documentation of the appearance of pressure ulcers until they reach Stage III. The first documentation of a skin abnormality on patient #9's buttocks appeared on a "Flowsheet" dated 12/6/2014, when blisters were documented on the patient's right buttock. Daily documentation of blisters on patient #9's buttocks continued until a 12/10/2014 note stated "suspected deep tissue injury." A detailed description of the progression of the patient #9's buttocks wounds (including the number, location, color and size of the blisters) from 12/6/2014-12/10/2014 was not found in the patient's clinical record. Nurse D stated that a detailed description of patient #9's skin's deterioration was not required until the buttocks wound(s) reached Stage III, per policy.

An initial Wound Care Specialist note by nurse D, dated 12/11/2014, stated, "Pt (patient) presents with extensive DTI deep tissue injury - DTI to Bilateral buttocks." Patient #9's buttocks wounds were first measured on 12/11/2014. At that time the left buttock wound measured 12 cm x 12 cm and the right buttock wound measured 12 cm x 10 cm. On 12/22/2014 a second Wound Care Specialist note describes one buttock wound as: "13 cm x 21 cm with hard firmly attached black escharic regions to the bilateral buttocks." On 12/22/2014 nurse D requested physician orders for "consult for debridement options." The buttocks wound was debrided on 12/22/2014, the date of the second consultation by the Wound Care Nurse.

A "Facility Acquired Pressure Ulcer (FAPU) Debriefing Form" for patient #9, dated 12/11/2014, stated that there was a delay in obtaining a bariatric bed air mattress for patient #9. All interventions listed in Wound Care Consultation notes and physician orders were not included in patient #9's Plan of Care. On 12/29/2014 a third "Wound Care Consultation" note stated, "The bilateral buttock has thick moist brown eschar that encompasses the entire region of bilateral buttocks...the length is unchanged at 13 cm x 21 cm." Patient #9's "Universal Plan of Care," updated on 12/31/2014, stated that the goal that "Skin Integrity is Maintained" was evaluated, met and discontinued on 12/27/2014. Nurse D confirmed these findings during record review from 1215-1430 on 4/16/2015.