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.


Based on medical record review, staff interview, and policy review, the facility failed to provide care in a safe sitting for Patient #1, one (1) of one (1) patients reviewed.

Findings include:

The State Office received a complaint from the Office of Attorney General which was from a former patient of this hospital. The patient stated: (1) a nurse gave him pain medication without his request (2) jerked and grabbed him in an uncaring manner (3) refused to check his blood sugar when he requested it because he was feeling funny (4) his penis was tied up with tape by a nurse in order to collect a urine specimen, despite him telling her that he could void, and (5) his bed was left unchanged after he had wet it.

On 03/07/17 at 8:30 a.m. an unannounced visit was made to the facility to investigate this complaint. The Chief Quality Officer was told the reason for the visit and was asked for the required paper work to perform the investigation. At 8:40 a.m. the Chief Nursing Officer was interviewed. He stated, "I am aware of the self-reported complaint."

Record review for Patient #1 revealed he was a [AGE] year old male admitted to the hospital's telemetry unit on 02/09/17 with diagnoses which included Acute Diastolic Congestive Heart Failure, Diabetes Type 2 and Shortness of Breath (SOB). The initial Admission Assessment documented that Patient #1 was legally blind, has [DIAGNOSES REDACTED], has limited mobility, intermittent confusion, generalized weakness, is incontinent of bladder, and denied the need for pain control.

Review of the patient's Physician's Orders revealed:
02/09/17 1705 (5:05 p.m.) Admitting Physician's Orders included orders for an accucheck AC & HS (before every meal and at hour of sleep) and Oxygen (O2) at 2 liters per minute per NC (nasal cannula).
02/09/17 2220 (10:22 p.m.) the physician gave a telephone order for Norco 10 mg (milligram) every six (6) hours PRN (as needed) for pain.
02/10/17 10:55 a.m. "Not Processed Orders: Culture Urine today, Urinalysis today.
02/11/17 2250 (10:50 p.m.) orders included urine for C&S (Culture and Sensitivity).

Review of Nurse's Notes revealed Patient #1 was anxious and was able to express his needs, but was very confused at times.
On 02/09/17 at 2220 (10:20 p.m.) "...c/o (complains of) pain to neck... new orders given." At 2245 (10:45 p.m.) "Pt felt BG (blood glucose) was low, was checked. BG was 106. Snack and juice was given. Pt report pain rating to neck 4/10. Given Norco 10/325 mg po (by mouth) i tab (tablet."
On 02/11/17 at 1921 (7:21 p.m.) Patient #1 was found sitting up in bed with his O2 off. His O2 saturation (sat) level was 85 % (percent. After O2 was put back on his O2 sat came back up to 93%. "Pt states he forgets he takes it off." At 2223 (10:23 p.m.) "Pt c/o pain to chest area...has a temp (temperature) of 100.1. Gave Lortab 10mg... At 2252 (10:52 p.m.) pt now has temp of 103.0. An order was received for a now order of Tylenol, a chest xray, Zithromicin, a U/A (urinalysis) and C&S. At 0127 (1:27 a.m.) his temp was documented as 99.8. At 0533 (5:33 a.m.) "pt c/o pain. Gave Lortab 10mg..."
On 02/12/17 at 1700 (5:00 p.m.) "Patient began complaining of chest discomforts about 1600 hours (4:00 p.m.)." NitroStat sublingual was given without any success stopping his pain" The patient had his own spray for chest pain at the bedside and had taken it several times. Lortab was given and the doctor was notified. There was no telemetry activity. His blood sugar was 71.
On 02/12/17 at 0830 (8:30 a.m.) "... Ask me about the "sock" on his penis. Small plastic bag taped to penile area to capture urine from previous shift. Informed pt I would find out reason for it..."

Review of the MAR (Medication Administration Record) for Patient #1 revealed that he received Norco 10mg on 02/09/17 at 10:45 p.m. for a pain score of 4 on a scale of 10, on 02/11/17 at 4:13 p.m. for a pain score of 7/10, on 02/11/17 at 10:23 p.m. for a pain score of 8/10 and on 02/12/17 at 5:33 a.m. for a pain score of 7/10.

Review of laboratory results revealed that on 02/10/17 at 7:00 p.m. a clean catch urine was received. Final culture on 02/13/17 was Negative. There was no documented evidence that the C&S was performed.

During an interview on 03/07/17 at 9:00 a.m. the Chief Nursing Officer stated, "A small red biohazard bag was used to attain a urine sample from the patient. However, this was not the hospital policy on collecting urine samples. The nurse taking care of this patient was a 'Travel Nurse'."

During an interview on 03/07/17 at 10:15 a.m. the Chief Quality Officer confirmed that the night of the alleged compliant there were condom catheters and clean catch specimen kits located on the nursing unit.

Review of the job description for a Travel Nurse revealed, "... nurse traveler provides total patient care in accordance of the physician's orders and individual patient needs in conformance with recognized standards of nursing practice. Observes and documents pertinent information that reflects the patient clinical condition, with respect to the entire human being. Reports the same to oncoming nurses, charge nurses and physicians. Performs or supervises treatment and administers mediation as required."

Review of the facility's "Clean Catch Urine Collection" policy (revised 10/12/15) revealed: "Policy: clean catch urines are collected upon physician's orders for diagnostic purpose ...Procedure ...on male adults, infants/children retract foreskin, if uncircumsized and foreskin is easily retractable, and cleanse around meatus and tip of penis, using cotton ball per wipe. Allow area to dry prior to applying u-bag. Apply u-bag according to manufacturer's instruction, covering urethral area, maintaining aseptic technique ...Check patient frequently for urine collection."

Review of the facility's "Urinary Catheter: Condom" revealed: "... Assessment... 6) Assess the condition of the penis. Use the manufacturer's measuring guide to measure the diameter of the penis in a flaccid state ...Procedure... 9) Apply the sheath a) Ensure that the sheath is the appropriate size for the patient's penis... 11) Apply an appropriate securing device for the sheath according to manufacturer's directions... Monitoring and Care... 2) inspect the penis with the condom catheter in place. Assess the penis for swelling and discoloration and ask the patient is he feels any discomfort."

1. The complaint regarding a nurse gave him pain medication without his request was unsubstantiated.
2. The complaint regarding the nurse jerked and grabbed him in an uncaring manner was unsubstantiated.
3. The complaint regarding the nurse refused to check his blood sugar when he requested it because he was feeling funny was unsubstantiated.
4. The complaint that his penis was tied up with tape by a nurse in order to collect a urine specimen, despite him telling her that he could void, and it was against the hospital's policy,was substantiated.
5. The complaint that his bed was left unchanged after he had wet it was unsubstantiated.
Based on medical record review, Job Description review, and staff interview, the facility failed to ensure non-employee licensed nurses who are working in the hospital adhere to the policies and procedures of the hospital.

Findings include:

Cross Refer to A144 for the facility's failure to ensure non-employee Registered Nurse #1 followed Hospital Policy and Procedure regarding obtaining a urine Culture & Sensitivity for Patient #1.