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.
| MERCY HOSPITAL JEFFERSON | 1400 US HIGHWAY 61 FESTUS, MO 63028 | Jan. 15, 2016 |
| VIOLATION: PATIENT RIGHTS | Tag No: A0115 | |
| Based on interview, record review and policy review, the facility failed to: - Protect two of two discharged patients (#1 and #2) from physical, verbal and emotional abuse by staff . (Refer to A-0144) - Protect and prevent two of two patients (#1 and #2) abused by staff, from continued abuse by the abuser. (Refer to A-0145) - Ensure staff did not confine and/or seclude one of one patient (#1) with no clinical justification. (Refer to A-0145). - Ensure staff was competent and trained to prevent, recognize, respond and investigate all forms of abuse and neglect (A/N) by co-workers. (Refer to A-0145) - Follow their internal policies and procedures (P/P) on A/N. (Refer to A-0145) These deficient practices resulted in the facility's non-compliance with specific requirements found under the Condition of Participation: Patient rights. The cumulative effect of these systemic practices had the potential to place all patients at risk for their health and safety, also known as Immediate Jeopardy (IJ). On 01/14/16, after the survey team informed the facility of the IJ, the staff created educational tools and began educating all staff and put into place interventions to protect patients. As of 01/15/16, at the time of survey exit, the facility had provided an immediate action plan sufficient to remove the IJ by implementing the following: - Alleged Perpetrator (AP) of patient A/N, was suspended. - Meetings were held with all facility leadership staff to discuss the IJ and guidance was provided for immediate action in response to actual or suspected abuse and/or neglect by staff. - Facility policies and procedures were written, revised, approved and presented to Leadership staff related to Abuse and Neglect Response/Reporting. - Revisions included; clarification of all forms of A/N emphasized the immediacy of recognition, patient care activity expectations, protection of patients, staff and leadership accountability and authority. All leadership staff not on duty were contacted and contracted for education prior to the next scheduled shift. - Educational tools were developed along with relevant interactive activities staff were required to demonstrate in mandatory meetings. Leadership staff was required to attest to staff competency through signatures. Monitoring for compliance included identification of all staff with measures in place to ensure all staff were educated and assessed competent before the next shift worked. - A multidisciplinary task force was established to identify mechanisms to immediately address events and complaints. - Department huddles were attended by Senior Leadership staff immediately to review all patient events and answer questions regarding patient rights. - Measures were put in place to ensure all non-employed staff reported to the facility staffing office prior to patient care assignment to ensure and/or confirm orientation to the assigned unit prior to working. |
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| VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING | Tag No: A0144 | |
| **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and policy review the facility failed to ensure patient care was provided in a safe environment that was free from physical, verbal and emotional abuse for two of two discharged patients. The facility failed to: - Remove one of one staff (A) from patient care immediately after she allegedly physically harmed and verbally and emotionally abused one patient (#1), which resulted in verbal and emotional abuse of a second patient (#2) on the same date by the same staff. - Protect two of two patients (#1 and #2) from staff who physically, verbally and emotionally abused them. - Ensure staff followed facility policy and procedure (P/P) in response to allegations of patient abuse and neglect by staff. The failure to remove the alleged perpetrator from patient care resulted in continued patient abuse, which resulted in an unsafe environment for all patients. The facility census was 150. Findings included: 1. Record review of the facility's policy and procedure titled "Abuse and Neglect (A/N)", dated 08/2015, showed Abuse and Neglect for all persons was the infliction of physical or emotional harm and the failure to provide or adequately perform services, which were necessary to meet a person's essential human needs. The policy further defined the application to persons who were sixty years of age or older, who were unable to protect their own interests or obtain services which were necessary to meet their essential needs and persons who had a mental or physical impairment that limited their activity. During an interview on 01/13/16 at approximately 1:30 PM, Staff P, Director of Compliance and Regulation, stated at the time of an alleged abuse incident on 12/01/15, the facility did not have a policy which specifically addressed staff to patient abuse. 2. Record review of the facility's self-report of A/N investigation showed a written statement dated 12/02/15 and signed by Staff C, Charge Nurse; Staff D, Patient Care Technician (PCT) and Staff E, PCT, all who had witnessed the A/N of Patients #1 and #2 that included the following: - On the night-shift of 12/01/15, Patient #1, who was confused and agitated stated that she did not want to stay in her room alone, wanted to be with people and at times wandered outside of her room and sat at the nurses station. - Staff A, Registered Nurse (RN), demanded that the patient return to her room and told the patient she could not eat until she went back to her room. Staff A made the statements, "You are acting like a three year-old" and "knock it off" which made the patient visibly more agitated. - Upon repeated demands, Staff A returned the patient to her room and closed the door to keep the patient from exiting the room. Staff A remained in the room with the patient. - When Patient #1 tried to open the door to leave, staff observed the patient's hand "smashed" in the door frame by Staff A's body weight. - Staff B, House Supervisor (nurse in charge of facility at the time) observed the incident and told Staff A to open the door and let the patient out of the room. - Patient #1 had a bruise on the left hand at the time the report was written and signed on 12/02/15. - On the same date and shift, in response to complaints of pain and request for pain medication, Staff A yelled at Patient #2 and told him he, "had a drug problem." - Patient #2 told staff he had never been talked to or treated so badly in a hospital and that he wanted to leave the facility. On 01/14/16, Staff C, D, and E, read, reviewed, verified the accuracy of the signed written statement made on 12/02/15. 3. Record review of the facility's investigation summary of allegations of A/N of Patients #1 and #2 dated 12/11/15 showed: - A summary of events that occurred as a result of co-workers reports of witnessed A/N of Patient's #1 and #2 on 12/01/15 during the night shift (7:00 PM through 7:00 AM.) - Staff A, RN, prevented Patient #1 from leaving her room which resulted in the patient's hand having been caught between the door and door frame of the patient's room by Staff A. - Staff A used a loud voice, demeaning language and made threatening remarks to patients. - Upon complaints of hunger and request for food, Staff A withheld food from Patient #1. - Upon complaints of severe pain, nausea and the need to vomit, Staff A withheld pain and nausea medication from Patient #2. The summary, considered by the facility as the complete investigation, did not: - Identify the risks of patient A/N; - Recognize the actual patient harm or the potential for continued A/N; - Identify that management staff did not respond immediately to the alleged A/N of patients, which resulted in continued patient abuse; - Analyze causative factors or take corrective actions to eliminate or reduce the risk of harm to patients; and - Address a patient care environment free of abuse and neglect. 4. Record review of Patient #1's medical record showed the following: - The [AGE] year-old female was brought to the facility from a nursing home with diagnoses of pneumonia (infection in the lungs) and delirium (an abrupt change in the brain that causes confusion) due to her general medical condition. - The patient was assessed by Staff A at 7:52 PM as confused but could clearly state her name and could walk without assistance. - A photograph dated 12/02/15 of the patient's left hand showed bruising that was dark blue in color and covered approximately 80% of the surface of the top of her hand. 5. Record review of Patient #2's medical record showed the [AGE] year-old male presented to the Emergency Department (ED) on 11/30/15 with diagnoses of stroke (occurs if the flow of oxygen-rich blood to a portion of the brain is blocked), angina (unstable chest pain), anxiety as well as a recurrence of symptoms of a previous stroke. His current medical problems were cancer of the stomach and colon, fractured vertebrae's of the spine, severe vascular headache and chronic pain. Record review of Patient #2's medication administration record (MAR) showed the physician ordered Dilaudid for pain and Zofran as needed for nausea and vomiting. The MAR showed the patient was assessed and medicated for pain at about four hour intervals and periodically for nausea until the night shift of 12/01/15. The patient was not assessed for pain and nausea and not provided medication at regular intervals by Staff A on 12/01/15. The patient received only two of six available doses of pain medication and no medication for nausea during the night shift on 12/01/15. 6. During a telephone interview on 01/13/16 at 7:09 AM, Staff C, RN Charge Nurse on the 4th floor Med/Surg Unit on duty the night of 12/01/15, verified she was aware of the injury to Patient #1 and also that Staff A yelled at Patient #2. She was aware that Staff A refused to administer medication to treat Patient #2's pain and nausea. Patient #2 reported that he had never been talked to so badly. Staff C stated that she witnessed a commotion, loud voices and noises coming from Patient #1's door at about 10:00 PM. She stated that Staff A was aggravated at the patient and Staff B, House Supervisor, responded to the commotion of what she thought was the patient's hand being trapped in the door. Staff B told Staff A at least two to three times to let her in the room. She stated that the patient was prevented from leaving the room. She stated she didn't think withholding food was wrong if a patient wasn't doing what was expected and that she didn't know what she should have done differently as the Charge Nurse on duty. Staff C took no action to remove Staff A, RN, from patient care after she was aware of physical and verbal abuse incidents with Patient #1 and aware of neglect and verbal abuse of Patient #2. 7. During a telephone interview on 01/11/16 at 9:08 PM, Staff D, PCT, stated that the written statement provided on 12/02/15 about Staff A's actions was true and accurate. She stated that Staff A "yelled and talked badly to patients" and she kept Patient #1 from leaving her room "for no good reason". She stated that Staff B, House Supervisor and Staff C, Charge Nurse, knew what was going on but didn't do anything about it. They told her to write it up and give it to Staff F, Manager of Med/Surg. 8. During an interview on 01/12/16 at 3:08 PM, Staff F, Manager of the Med/Surg Unit stated that: - The PCTs were anxious about the way Staff A provided care and reported their concerns on 12/02/15 at the end of their shift. - She received a report on 12/02/15 that Patient #1 got her hand injured and bruised when Staff A kept the patient from leaving the room. - Staff A yelled at patients, withheld food from patients, used language that was demeaning and threatening, and Patient #2 was not provided medication for pain and nausea when he requested it on the night shift of 12/01/15. - She had some written statements from staff and a "few emails." She did not record much about the incidents because she couldn't "prove anyone saw anything, no one can see into a room when the door is closed". Staff F, did not recognize the continued unsafe patient treatment by Staff A and did not follow the facility's P/P and immediately take action. 9. During an interview on 01/11/16 at 3:10 PM, Staff B, House Supervisor, stated that Staff A was a float nurse. She confirmed that she was the House Supervisor and responsible for patient care on 12/01/15 night shift. She stated that she knew Patient #1 was confused. At about 10:00 PM, while at the nurses station, she saw Patient #1 standing in her room with the door opened approximately 24 inches. While at the door the patient "messed with the door latch". She approached the patient and led her out of the room through the open door without any physical harm, injury or any concerns. She stated that she was not aware of any problems with patient care on the shift. She stated she "personally didn't see anything wrong" with the patient care provided by Staff A and that after the recent review of A/N policy, she "wouldn't do anything different". During an interview on 01/14/16 at 12:25 PM, Staff B stated that looking back on the incident that she was told about regarding Patient #1 and #2, the only thing she would do different would be to "check on float nurses more often". Staff B failed to recognize that Staff A should have been removed from patient care after she was aware of physical and verbal abuse incidents with Patient #1 and aware of neglect and verbal abuse of Patient #2. 10. During a telephone interview on 01/21/16 at 11:42 AM, Staff A, RN, Float Nurse, who was assigned to provide care to Patients #1 and #2 stated that she was on duty 12/01/15 on the night shift on the Med/Surg floor. She stated that prior to the beginning of her shift, Staff B and Staff C knew Patient #1 needed a sitter but a sitter was refused. She stated that she typically worked in nursing units where she was assigned three or four patients and her assignment of six patients the night shift of 12/01/15 was too many and Staff C and Staff B, who were responsible for staffing, knew she needed help. Patient #1 was "oppositional (not cooperative) and capable of violent behavior" and answered "no" to all requests. While in the room with the patient she placed a chair against the closed door and sat in a chair with a bedside table in front of her. While she sat in the room against the door, without warning, the patient jumped on top of her and she (Staff A) struggled to get out of danger and pushed the tray table and chair out of the way. During the struggle, the patient tried to leave the room and put her hand in between the door and door frame. Staff A covered the patient's hand with her own to prevent an injury to the patient. Staff A stated that she provided safe patient care. She further stated that if facility nursing supervisors believed she had abused Patient #1 or provided substandard care, they should have sent her home early when they had the opportunity. 11. During an interview on 01/11/16 at 1:45 PM, Staff N, Chief Nursing Officer (CNO), stated that: - She was made aware of an incident that occurred on 12/01/15 during the night shift that involved Staff A, which had caused a hand injury to Patient #1. - She had no knowledge of staffs reports of Staff A's inappropriate behavior while she provided care to Patient #2. She stated, "If anyone told me about Staff A yelling at Patient #2, I can't remember it". - On 12/02/15, at approximately 8:30 AM, Staff F, Nurse Manager of the Med/Surg Units, notified her that staff did not want Staff A assigned to the Med/Surg unit again. - Staff F reported that the PCT's didn't like the way Staff A "was" with patients and that Staff A yelled at a patient and that the same patient got her hand smashed in the door while trying to get out of her room. - The incident on the night shift of 12/01/15 was "just another he said, she said" and that the incident was investigated, opportunities for improvement were identified, a policy was revised to include how to report suspected A/N by co-workers and staff received training related to the policy and reporting requirements. - Other than the request for Staff A not to be assigned to the Med/Surg Unit again, she stated that there were no concerns identified related to the staff's failure to recognize all forms of A/N. She stated the nursing supervisors failed to remove the potential threat of harm from recurring, and failed to notify all responsible persons in a timely fashion. She stated that the facility failed to conduct a thorough investigation per facility policy. During an interview on 01/14/16 at 11:30 AM, Staff N, CNO, stated that: - She did not recognize the incidents with Patients #1 and #2 as A/N. - Staff didn't remove the threat of harm when it first occurred (to Patient #1 early in the shift) and if they would have, Patient #2 wouldn't have been neglected and yelled at. - She "thought they did enough to keep patients safe". - She didn't recognize or identify all the forms of abuse witnessed or take the appropriate action to maintain a safe patient care environment. During an interview on 01/15/16 at 9:20 AM, Staff N, CNO, stated that all nursing supervisors failed to protect the patients from forms of abuse that included verbal intimidation, the withholding of food for purposes of coercion and seclusion without clinical justification. These failures resulted in an actual injury. The nurses failed to assess and meet the needs of Patient's #1 and #2 "on many levels". 12. During an interview on 01/14/16 at 3:20 PM, Staff O, Chief Executive Officer, stated that he was not notified of the nature or degree of allegations of A/N by staff. His expectation was that all staff, especially staff with the responsibility of patient safety and oversight, follow facility policy and procedures and notify him immediately upon any allegation of actual or potential A/N reports. He stated that the facility failed to provide a safe patient care setting for Patients #1 and #2. |
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| VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT | Tag No: A0145 | |
| Based on interview, record review, and policy review, the facility failed to ensure two of two discharged patients (#1 and #2) were not physically, verbally and emotionally abused/neglected by staff. - Staff did not identify patient abuse and neglect and took no measures to prevent further abuse for two of two patients (#1 and #2). - One patient (#1) was physically abused and injured by staff who secluded her with no clinical justification. - Two of two patients (#1 and #2) were verbally and emotionally abused by staff who yelled and spoke to them in a manner that was belittling, demeaning and threatening. - One patient's (#2) complaints of pain and nausea were neglected and he was refused ordered medication. - Two of two patients (#1 and #2) abused by staff did not receive timely and adequate abuse/ neglect (A/N) investigations. - Nursing supervisors failed to follow the facility policy's and procedures (P/P) related to A/N response and reporting. These failures to identify and respond to A/N by staff resulted in continued harm and had the potential to place all patients at risk for harm. The facility census was 150. Findings included: 1. Record review of the facility's policy and procedure titled "Abuse and Neglect (A/N)", dated 08/2015, showed A/N for all persons was the infliction of physical or emotional harm and the failure to provide or adequately perform services, which were necessary to meet a person's essential human needs. The policy further defined that this applied to persons who were sixty years of age or older, who were unable to protect their own interests or obtain services which were necessary to meet their essential needs and persons who had a mental or physical impairment that limited their activity. Record review of the facility policy titled, "Just Culture Response to Individuals Involved in Patient Safety Events", dated 08/01/15 showed the following guidance: - The organization was responsible for safe processes, recognition of risk and conducted a system approach to reduce patient harm. - All leaders proactively responded immediately to patient safety events which ensured a safe patient care environment. - All safety events were consistently reported, investigated appropriately, was accurate and included all the facts of the events. - The Performance Management Decision Guide was a multidisciplinary tool used in response to a patient safety event that assessed and analyzed the event information to identify causative factors and needed corrective activity. During an interview on 01/13/16 at approximately 1:30 PM, Staff P, Director of Compliance and Regulation, stated at the time of an alleged abuse incident on 12/01/15, the facility did not have a policy which specifically addressed staff to patient abuse. 2. Record review of the facility's investigation summary of allegations of A/N of Patients #1 and #2 dated 12/11/15 showed: - A summary of events that occurred as a result of co-workers reports of witnessed A/N of Patient's #1 and #2 on 12/01/15 during the night shift (7:00 PM through 7:00 AM); the results of the A/N investigation and opportunities for improvement that were implemented by the facility. - Staff A, Registered Nurse (RN), prevented Patient #1 from leaving her room which resulted in the patient's hand having been caught between the door and door frame of the patient's room by Staff A. - Staff A used a loud voice, demeaning language and made threatening remarks to patients. - Upon complaints of hunger and request for food, Staff A withheld food from Patient #1. - Upon complaints of severe pain, nausea and the need to vomit, Staff A withheld pain and nausea medication from Patient #2. The summary, considered by the facility as the complete investigation showed a lack of a thorough investigation as the facility failed to: - Address any disciplinary actions taken with Staff A; - Identify that management staff did not respond immediately to the alleged A/N of patients, which resulted in continued patient abuse; - Address the lack of a policy regarding staff to patient abuse; and - Analyze causative factors of the A/N. 3. Record review of the facility's self-report of A/N investigation showed a written statement dated 12/02/15 and signed by Staff C, Registered Nurse (RN) Charge Nurse, Staff D, Patient Care Technician (PCT) Medical/Surgical (Med/Surg) Unit and Staff E, PCT Med/Surg Unit. The written statement included the following: - On the night-shift of 12/01/15, Patient #1, who was confused and agitated stated that she did not want to stay in her room alone, wanted to be with people and at times wandered outside of her room and sat at the nurses station. - Staff A demanded that the patient return to her room and told the patient she could not eat until she went back to her room. Staff A made the statements, "You are acting like a three year-old" and "knock it off" which made the patient visibly more agitated. - Upon repeated demands, Staff A returned the patient to her room and closed the door to keep the patient from exiting the room. Staff A remained in the room with the patient. - While Patient #1 tried to open the door to leave, the patient's hand was observed "smashed" in the door frame by Staff A's body weight. - Staff B, House Supervisor (Nurse in charge of facility at the time) observed the incident and told Staff A to open the door and let the patient out of the room. - Patient #1 had a bruise on the left hand at the time the report was written and signed on 12/02/15. - On the same date and shift, in response to complaints of pain and requests for pain medication, Staff A yelled at Patient #2 and told him he, "had a drug problem." - Patient #2 stated that he "had never been talked to that way" and that he wanted to leave the hospital. On 01/14/16, Staff C, D, and E, read, reviewed and verified the accuracy of the signed written statement made on 12/02/15. 4. Record review of the facility documents related to the reported allegation of abuse, neglect and harassment of Patients #1 and #2 included the following: - Email message on 12/03/15 at 1:01 PM, written and sent by Staff B to Staff F, Nurse Manager of the Med/Surg Unit, of her direct involvement and observation of Patient #1's hand injury while the patient was prevented from leaving her patient room by Staff A. Staff B described the events of the night. She reported that Staff A was assigned to one confused patient who was not combative but easily disoriented and wandered the halls. While at the nurses station across from the patient's room 450 B, Staff B heard a loud noise and saw Patient #1's arm sticking out of the door at the door jam. The patient was trying to get out of the room, while Staff A was on the other side of the door. Staff B helped the patient and told Staff A to open the door. Staff B phoned the physician and received orders for Haldol and Ativan. - Email message on 12/03/15 at 3:26 PM from Staff F, that documented her knowledge of suspected A/N of Patient #1. The email message was sent to Staff K, Manager of the Nurse Float Pool, Staff M, Director of Nurse Staffing and Staff U, Manager of Human Resources. Staff F forwarded an email with Staff B's message of the events of the night. Staff F stated that she had received the statement from Staff B, who was a credible House Manager and witness to the event. Staff F stated that the patient incurred an injury to her left hand from the event and a picture of the injury had been obtained and placed in the medical record. - Email message on 12/03/15 at 4:59 PM from Staff U, sent to Staff F which documented knowledge of the reported A/N with actual injury and asked for someone else to "follow up". 5. During a telephone interview on 01/13/16 at 7:09 AM, Staff C, RN Charge Nurse on the 4th floor Med/Surg Unit, stated that: - She was in charge of patient care and on duty on 12/01/15 during the night shift. - She had submitted a written statement dated 12/02/15 about concerns she had with Staff A's attitude and patient care because she didn't want her sent back to work the Unit. - Patient #1 was hungry and Staff A withheld food from her for no clinical reason. - At about 10:00 PM, while at the nurses station within a direct line of sight of Patient#1's room and "about five feet away", she heard a "commotion, loud noises and loud voices" that came from the patient's room while Staff A was alone with the patient in the patient's room with the door closed. - She saw the patient's hand sticking outside of the room entrapped in the door (between the door and door frame) while the patient tried to get the door open and and get out. - She witnessed a nurse respond to the "commotion" and try to open the door (from the hall/outside of the room) to help the patient and get her smashed hand out from between the door and door frame. - The nurse on the outside of the room was heard repeatedly saying to Staff A, "let us in" and "open the door". - Her impression was that Staff A forcibly held the door closed, had prevented the patient from leaving the room and attempted to keep staff out of the room. - At one point in the interview Staff C stated that other than Staff A, she could not recall the names of staff involved with the incident; however Staff C also stated in the interview that Staff B, House Manager responded to the commotion of what she thought was the patient's hand being trapped in the door. - She did not assess Patient #1 for injury and didn't know if the patient's hand was assessed by anyone. - Patient #2 was in pain and nauseated and Staff A used inappropriate language, yelled, argued, and refused to give him pain medication when he needed it and it was available. - She didn't remove Staff A after she knew about her behavior with Patient #1. She stated about seven hours later, Staff A argued with Patient #2, refused to give him available medication he needed and upset him so badly that he left the hospital before he should have. - She stated she wouldn't do anything differently. Staff C did not recognize that Staff A's actions toward Patient #1 caused an unsafe environment for all patients. She did not recognize that physical harm, unsafe patient seclusion, withholding food and medication, and belittling and threatening language were forms of abuse and neglect. She failed to recognize the potential for continued abuse and neglect to patients. 6. During an interview on 01/11/16 at 3:10 PM, Staff B, House Supervisor, stated that: - She was on duty as the House Manager and in charge of patient care and nurse staffing at the facility on 12/01/15 night shift. - She stated that it was a busy night and Staff A had a "full assignment like any RN would" and float nurses were expected to carry full assignments. - She knew Staff A had needed help at times during her shift and that she had helped her. - She was not informed of any incident regarding an injury to Patient #1 during the shift. - She had received training that prepared her to identify all forms of abuse, neglect and harassment and verbalized a thorough understanding of all forms of A/N as well as the staffs expectation in reporting actual or suspected A/N. - She stated that she had no knowledge of any A/N to patients by staff. - Facility staff had reviewed the A/N policy and procedure as a refresher. - She understood that the A/N policy review was in response to an incident reported by "techs" about how Staff A treated patients. She stated she "personally didn't see anything wrong" with the patient care provided by Staff A and that after the recent review of A/N policy, she "wouldn't do anything different". During an interview on 01/14/16 at 12:25 PM, Staff B stated that looking back on the incident that she was told about regarding Patient #1 and #2, the only thing she would do different would be to "check on float nurses more often". 7. During a telephone interview on 01/11/16 at 9:46 PM, Staff E, PCT, stated that the written statement she provided on 12/02/15 about Staff A's actions was true and accurate. She stated that Patients #1 and #2 didn't receive good care. She stated that: - Patient #1 got her hand "smashed" in the door when Staff A wouldn't let her out of her room. - Staff A didn't have a reason to keep Patient #1 in her room or not give her food when she was hungry. - Staff A yelled at patients. - Patient #2 wasn't given pain medications when he needed them. 8. During a telephone interview on 01/13/16 at 7:09 AM, Staff I, PCT assigned to Patients #1 and #2 on 12/01/15 night shift, stated that Staff A yelled at the patients all night long. 9. During an interview on 01/15/16 at 9:20 AM, Staff N, CNO, stated that all nursing supervisors failed to protect the patients from forms of abuse that included verbal intimidation, the withholding of food for purposes of coercion and seclusion without clinical justification. These failures resulted in an actual injury. The nurses failed to assess and meet the needs of Patient's #1 and #2 "on many levels". |
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| VIOLATION: NURSING SERVICES | Tag No: A0385 | |
| Based on interview, record review and policy review, the facility failed to: - Ensure the Chief Nursing Officer supervised patient care services. (Refer to A-0386) - Ensure nursing staff adequately supervised, evaluated and provided nursing care that met the needs of two patients (#1 and #2). (Refer to A-0395) - Ensure non-employee nursing staff were oriented, supervised, trained and competent to provide nursing care as assigned for two patients (#1 and #2) who received inadequate care that resulted in physical and emotional abuse. (Refer to A-0398) These failures caused actual harm and the potential for harm to all patients in the facility who received unsupervised substandard nursing care. The facility census was 150. The cumulative effect of these systemic practices had the potential to place all patients at risk for their health and safety, also known as Immediate Jeopardy (IJ). On 01/14/16, after the survey team informed the facility of the IJ, the staff created educational tools and began educating all staff and put into place interventions to protect patients. As of 01/15/16, at the time of survey exit, the facility had provided an immediate action plan sufficient to remove the IJ by implementing the following: - Alleged Perpetrator (AP) of patient A/N, was suspended. - Meetings were held with all facility leadership staff to discuss the IJ and guidance was provided for immediate action in response to actual or suspected abuse and/or neglect by staff. - Facility policies and procedures were written, revised, approved and presented to Leadership staff related to Abuse and Neglect Response/Reporting. - Revisions included; clarification of all forms of A/N emphasized the immediacy of recognition, patient care activity expectations, protection of patients, staff and leadership accountability and authority. All leadership staff not on duty were contacted and contracted for education prior to the next scheduled shift. - Educational tools were developed along with relevant interactive activities staff were required to demonstrate in mandatory meetings. Leadership staff was required to attest to staff competency through signatures. Monitoring for compliance included identification of all staff with measures in place to ensure all staff were educated and assessed competent before the next shift worked. - A multidisciplinary task force was established to identify mechanisms to immediately address events and complaints. - Department huddles were attended by Senior Leadership staff immediately to review all patient events and answer questions regarding patient rights. - Measures were put in place to ensure all non-employed staff reported to the facility staffing office prior to patient care assignment to ensure and/or confirm orientation to the assigned unit prior to working. |
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| VIOLATION: ORGANIZATION OF NURSING SERVICES | Tag No: A0386 | |
| Based on interview, record review, and policy review, the facility failed to ensure nursing services demonstrated appropriate and timely authority, accountability and responsibility for safe and effective nursing services to meet the needs of two of two discharged patients (#1 and #2). - The Chief Nursing Officer failed to ensure the quality of patient care provided by staff. - Two of two discharged patients (#1 and #2) were harmed and received substandard nursing care by unsupervised nursing staff. - All lines of nursing authority failed to recognize and respond to reported actual patient harm for two of two patient's (#1 and #2). - The Chief Nursing Officer (CNO) and all nursing supervisors failed to follow the facility's policy related to "Just Culture Response to Individuals Involved in Patient Safety Events". These failures by all lines of nursing authority contributed to poor quality of care for patients and inadequate, unsupervised nursing care which had the potential to cause harm to all patients admitted to the facility. The facility census was 150. Findings included: 1. Record review of facility policy titled, "Just Culture Response to Individuals Involved in Patient Safety Events", dated 08/01/15 showed the following guidance: - The organization was responsible for safe processes, recognition of risk and conducted a system approach to reduce patient harm. - All leaders proactively responded immediately to patient safety events which ensured a safe patient care environment. - All safety events were consistently reported, investigated appropriately, was accurate and included all the facts of the events. - The facility Performance Management Decision Guide was a multidisciplinary tool used in response to a patient safety event that assessed and analyzed the event information to identify causative factors and needed corrective activity. 2. Record review of Staff N, Chief Nursing Officer (CNO), Job Description dated 04/17/14 showed the CNO was responsible for the overall administration, direction and coordination of Nursing in all areas where nursing is practiced. The CNO was accountable for professional nursing practice and nursing care provided to patients through delineation of responsibility and authority at all levels. 3. Record review of the facility's investigation summary of allegations of A/N of Patients #1 and #2 dated 12/11/15 showed: - A summary of events that occurred as a result of co-workers reports of witnessed A/N of Patient's #1 and #2 on 12/01/15 during the night shift (7:00 PM through 7:00 AM.) - Staff A, RN (float nurse, designated nurse available to work on various units in times of heavy workloads or for absent personnel), prevented Patient #1 from leaving her room which resulted in the patient's hand having been caught between the door and door frame of the patient's room by Staff A. - Staff A used a loud voice, demeaning language and made threatening remarks to patients. - Upon complaints of hunger and request for food, Staff A withheld food from Patient #1. - Upon complaints of severe pain, nausea and the need to vomit, Staff A withheld pain and nausea medication from Patient #2. - Staff C, Charge Nurse and Staff B, House Supervisor, were aware of Staff A's behavior. - Nurse Supervisors failed to demonstrate accountability and authority for a safe patient care environment and remove Staff A from direct patient care and immediately report the allegation of A/N. 4. During a telephone interview on 01/13/16 at 7:09 AM, Staff C, RN Charge Nurse on the 4th floor Med/Surg Unit on duty the night of 12/01/15, verified she was aware of the injury to Patient #1 and also that Staff A yelled at Patient #2. She was aware that Staff A refused to administer medication to treat Patient #2's pain and nausea. Patient #2 reported that he had never been talked to so badly. Staff C stated that she witnessed a commotion, loud voices and noises coming from Patient #1's door at about 10:00 PM. She stated that Staff A was aggravated at the patient and Staff B, House Supervisor, responded to the commotion of what she thought was the patient's hand being trapped in the door. Staff B told Staff A at least two to three times to let her in the room. She stated that the patient was prevented from leaving the room. She stated she didn't think withholding food was wrong if a patient wasn't doing what was expected and that she didn't know what she should have done differently as the Charge Nurse on duty. Staff C was the Charge Nurse at the time of the incident and failed to supervise the quality of care given by Staff A and did not address inadequate patient care given by Staff A. 5. During an interview on 01/11/16 at 9:08 PM, Staff D, Patient Care Technician (PCT), stated that she reported to Staff C, Charge Nurse, Staff B, House Supervisor, Staff H, Clinical Supervisor and Staff F, Manager of the Medical/Surgical (Med/Surg) Unit that she witnessed abusive patient care by Staff A. She stated that Staff B, House Supervisor and Staff C, knew what was going on but didn't do anything about it; they told her to write it up and give it to Staff F, Manager of Med/Surg. She stated that Patients #1 and #2 remained in the care of Staff A after she had reported her concerns of abusive patient care. 6. During an interview on 01/11/16 at 9:46 PM, Staff E, PCT, stated that she reported to Staff C, Charge Nurse, Staff B, House Supervisor, Staff H, Clinical Supervisor and Staff F, Manager of the Med/Surg Unit that she witnessed abusive patient care by Staff A. She stated that Patients #1 and #2 remained in the care of Staff A after she had reported her concerns. All nursing lines of delineated authority failed to recognize the poor quality of patient care, an unsafe patient care environment, take immediate corrective action or report as required by policy. 7. During an interview on 01/11/16 at 3:10 PM, Staff B, House Supervisor, stated that: - She was on duty as the House Manager and in charge of patient care and nurse staffing at the facility on 12/01/15 night shift. - She stated that it was a busy night and Staff A had a "full assignment like any RN would" and float nurses were expected to carry full assignments. - She knew Staff A had needed help at times during her shift and that she had helped her. - She was not informed of any incident regarding an injury to Patient #1 during the shift. - She had received training that prepared her to identify all forms of abuse, neglect and harassment and verbalized a thorough understanding of all forms of A/N as well as the staffs expectation in reporting actual or suspected A/N. - She stated that she had no knowledge of any A/N to patients by staff. - She stated she "personally didn't see anything wrong" with the patient care provided by Staff A and that after the recent review of A/N policy, she "wouldn't do anything different". During an interview on 01/14/16 at 12:25 PM, Staff B stated that looking back on the incident that she was told about regarding Patient #1 and #2, the only thing she would do different would be to "check on float nurses more often". Staff B did not recognize the delegated authority, responsibility and accountability to patient care as the Nurse in Charge of patient care services at the time Patients #1 and #2 experienced patient safety events. 8. During an interview on 01/11/16 at 1:45 PM, Staff N, DON, stated that: - On 12/02/15, at approximately 8:30 AM, Staff F, notified her that the staff did not want Staff A assigned to the Med/Surg unit again. Staff F had reported that the PCT's didn't like the way Staff A was with the patients. - Staff A had yelled at a patient and that the same patient got her hand smashed in the door while trying to get out of her room. - She had no knowledge of staffs reports of Staff A's inappropriate behavior while she provided care to Patient #2. She stated, "If anyone told me about Staff A yelling at Patient #2, I can't remember it". - Nursing managers or supervisors did not tell her about everything that happened. - The incident that occurred on the night shift of 12/01/15 was "just another he said she said" and that the incident was investigated, opportunities for improvement were identified, a policy was revised to include how to report suspected A/N of co-workers and staff received training related to the policy and reporting requirements. - No written documentation of the investigation was available other than the summary. - Staff A, was a float nurse, and was not supervised or evaluated by her or anyone at the facility. Staff A's supervisor was not a facility employee. - She thought that the float nurses were oriented to the facility; however, she couldn't be sure. During an interview on 01/15/16 at 9:20 AM, Staff N, CNO, stated that: - All nursing supervisors failed to ensure patients needs were met and that the a high standard of patient care was given. - If staff would have provided better patient care and assessed patients appropriately, Patient #1 wouldn't have been injured and Patient #2 would have gotten medications he needed. - Nursing staff knew better than to allow staff to yell at patients, or withhold care they needed. - Nurses were educated and knew how to care for confused patients (Patient #1), patients who had pain and nausea (Patient #2)...it was basic nursing care. -Quality patient care was a priority. - Staff A should have been supervised and sent home (away from patient care) the first time she mistreated a patient on 12/01/15. - If the nursing supervisors supervised patient care and staff, Staff A would not have continued to abuse patients for the entire shift. - She did not recognize the nursing care problems as significant when she reviewed the adverse incident reports related to Patients #1 and #2. - Staff A did not provide an adequate standard of care to Patients #1 or #2. - Patients #1 and #2 did not receive appropriate nursing assessments, evaluations and the nursing care they needed. - She was ultimately responsible for nursing outcomes. |
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| VIOLATION: RN SUPERVISION OF NURSING CARE | Tag No: A0395 | |
| **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and document review, the facility failed to ensure nursing staff adequately supervised, evaluated and provided nursing care that met the needs of two discharged patients (#1 and #2). The facility failed to ensure one patient (#1) received adequate supervision and assessment of safety needs related to known problems with mental status and hand injury and one patient (#2) received nursing care and medication for pain and nausea. The facility census was 150. Findings included: 1. Record review of the facility's "Registered Nurse Job Description - Clinical", dated 05/06/13 showed all Registered Nurses (RN's) who provided patient care were responsible and accountable for the evaluation of the overall effectiveness of patient care they provided and the care provided by other direct care givers. The RN would use the nursing process to to assess, evaluate and perform nursing care based on the ongoing needs of patients and document the findings and patient care using the nursing process. RN's were responsible for maintaining current standards of care within a safe patient care environment. 2. Record review of the facility's investigation summary of allegations of A/N of Patients #1 and #2 dated 12/11/15 showed: - A summary of events that occurred as a result of co-workers reports of witnessed A/N of Patient's #1 and #2 on 12/01/15 during the night shift (7:00 PM through 7:00 AM). - Staff A, Registered Nurse (RN), prevented Patient #1 from leaving her room which resulted in the patient's hand having been caught between the door and door frame of the patient's room by Staff A. - Staff A used a loud voice, demeaning language and made threatening remarks to patients. - Upon complaints of hunger and request for food, Staff A withheld food from Patient #1. - Upon complaints of severe pain, nausea and the need to vomit, Staff A withheld pain and nausea medication from Patient #2. 3. Record review of the facility's written summary of adverse outcomes dated 12/11/15 showed Staff A, RN : - Failed to ensure Patient #1 was adequately assessed, evaluated and provided nursing care to meet her medical conditions that included an injury to her hand, confused mental status, complaints of fear when left alone in her room and safety needs related to wandering alone in the general patient care areas. - Failed to ensure Patient #2 was adequately assessed, evaluated and provided nursing care to meet his medical conditions that included anxiety, severe pain and nausea/vomiting. - Was a float nurse who had reported to Staff C, Medical /Surgical (Med/Surg) Unit Charge Nurse, and Staff B, House Manager that she needed help taking care of her assigned patients who consisted of two patients who were confused and others who needed frequent pain medication. - Had requested a sitter (one person to provided one to one supervision for patient safety) be assigned to Patient #1 from Nursing Supervisors Staff B and Staff C. 4. Record review of Patient #1's medical record showed the following: - The [AGE] year-old female was brought to the facility from a nursing home with diagnosis of pneumonia (infection in the lungs) and delirium (an abrupt change in the brain that causes confusion) due to her general medical condition. - The patient was assessed by Staff A at 7:52 PM as confused but could clearly state her name and could walk without assistance. -Patient #1 had an injury to her hand at approximately 10:00 PM on 12/01/15 but the record contained no documentation of an assessment by nursing of the injury. - A photograph dated 12/02/15 of the patient's left hand showed bruising that was dark blue in color and covered approximately 80% of the surface of the top of her hand. - An X-ray of her left hand related to her complaints of pain as a result of injury was not ordered until the afternoon of 12/02/15. The results showed no broken bones. No documentation was found in the medical record of nursing or physician assessment of the patient's hand injury, of behaviors that had the potential for causing harm to herself or others, or an event whereby the patient was injured on 12/01/15. No documentation was found in the medical record of any clinical indications why the patient was prevented from leaving her room or why food was withheld. The patient did not receive adequate supervision of nursing care related to her confusion, wandering, safety needs, hunger or injury. 5. During a telephone interview on 01/21/16 at 11:42 AM, Staff A, RN, who was assigned to provide care to Patients #1 and #2 stated that she was on duty 12/01/15 night shift on the Med/Surg floor. She stated that prior to the beginning of her shift, Staff B and Staff C knew Patient #1 needed a sitter but a sitter was refused. 6. Record review of the facility's staffing and Med/Surg Unit shift report for 12/01/15 night shift through 12/02/15 day shift showed that Patient #1 was not assigned a sitter as requested until 12/02/15 at 10:00 AM (more than 12 hours after the request was made.) 7. Record review of Patient #2's medical record showed the [AGE] year-old male presented to the Emergency Department (ED) on 11/30/15 with diagnoses of stroke (occurs if the flow of oxygen-rich blood to a portion of the brain is blocked), angina (unstable chest pain), anxiety as well as a recurrence of symptoms of a previous stroke. His current medical problems were cancer of the stomach and colon, fractured vertebrae's of the spine, severe vascular headache and chronic pain. Record review of Patient #2's medication administration record (MAR) showed the physician ordered Dilaudid for pain and Zofran as needed for nausea and vomiting. The MAR showed the patient was assessed and medicated for pain at about four hour intervals and periodically for nausea until the night shift of 12/01/15. The patient was not assessed for pain and nausea and not provided medication at regular intervals by Staff A on 12/01/15. The patient received only two of six available doses of pain medication and no medication for nausea during the night shift on 12/01/15. 8. During an interview on 01/12/16 at 1:26 PM, Staff G, Lab Technician, stated that, while in Patient #2's room on 12/02/15 at about 5:15 AM, Staff A, told the patient that she wasn't going to give him medication for pain and nausea and that he could just "throw up on himself...do what you gotta do". She heard the patient state that he had been in pain most of the night, had never been treated so badly and wanted to go home. Patient #2 became anxious when he did not receive medications. 9. During an interview on 01/13/16 at 7:09 AM, Staff C, Med/Surg Unit Charge Nurse stated that Staff A did not assess Patient #2's pain and nausea and refused to give him medications to treat his pain. She reviewed the patient's physician orders for pain medications and the patient had appropriate medications available. She stated that Staff A did not provide good nursing, assess him for pain and nausea like she should have on the night shift on 12/01/15 and that she gave the patient pain medication because Staff A didn't. 10. During an interview on 01/12/16 at 11:00 AM, Staff Q, Clinical Nurse Specialist that provided nursing education and orientation stated that: - Patient safety was the priority for all care delivered and that the nursing process of initial and ongoing assessment, evaluation and treatment was essential for good patient outcomes. - All nursing policies' and procedures required nursing staff to provide ongoing assessment, evaluation and care of patients actual and/or potential problems. - All staff received training and education related to the care of patients who were confused, in pain and anxious and patients assessed with those problems required competent nurses to assess frequently and provide all necessary care to avoid harm and or increased distress. - Patients who needed a sitter for safety were provided a sitter as soon as possible. 11. During an interview on 01/15/16 at approximately 9:00 AM, Staff N, CNO, stated that; - She did not recognize the nursing care problems as significant when she reviewed the adverse incident reports related to Patients #1 and #2. - Staff A did not provide an adequate standard of care to Patients #1 or #2. - Patients #1 and #2 did not receive appropriate nursing assessments, evaluations and the nursing care they needed. - She was ultimately responsible for poor staffing and nursing outcomes. |
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| VIOLATION: SUPERVISION OF CONTRACT STAFF | Tag No: A0398 | |
| Based on interview and record review the facility failed to ensure the non-employee Registered Nurses (RN's) assigned to direct patient care were adequately oriented, supervised and evaluated by facility nursing services. Two discharged patients (#1 and #2) of two patients reviewed, received nursing care from staff who was not supervised by facility nursing services or oriented to unit specific patient care or facility policies and procedures. This failure to orient and supervise non-employee staff resulted in inadequate assessment of patients's conditions, physical abuse and neglect of patients and had the potential to cause harm to all patients. The facility census was 150. Findings included: 1. Record review of the facility's "Registered Nurse - Job Description" showed all staff who provided patient care or worked in the facility received mandatory education, training and were assessed competent to provide patient care in the facility. The RN's were required to complete unit specific and orientation to all patient care areas assigned. 2. Record review of the facility's written summary of adverse patient outcomes that included patient harm, dated 12/11/15 showed Staff A, RN float nurse (designated nurse available to work on various units in times of heavy workloads or for absent personnel) showed: - Failed to ensure Patient #1 was adequately assessed, evaluated and provided nursing care to meet her medical conditions that included; confused mental status, complaints of fear when left alone in her room and safety needs related to wandering alone in the general patient care areas. - Failed to ensure Patient #2 was adequately assessed, evaluated and provided nursing care to meet his medical conditions that included anxiety, severe pain and nausea/vomiting. - Reported to Staff C, Medical/Surgical (Med/Surg) Unit Charge Nurse, and Staff B, House Supervisor that she needed help taking care of her assigned patients who consisted of two patients who were confused and others who needed frequent pain medication. - Had requested additional assistance from Nursing Supervisors Staff B and Staff C. 3. During a telephone interview on 01/21/16 at 11:42 AM, Staff A, RN, who was assigned to provide care to Patients #1 and #2 stated that: - She was on duty during the night shift on 12/01/15 on the Med/Surg Unit. - She worked on the unit years ago and many things had changed. - She requested help from Staff B and Staff C, at the beginning of her shift but they refused to help. - She "didn't know how to go about getting what she needed". - She typically worked in nursing units where she was assigned only three or four patients and her assignment of six patients the night shift of 12/01/15 was "horrible". - She didn't know how to contact the physicians when needed, did not know where needed supplies were, and couldn't access the automated medication dispenser to administer patients' medications. 4. Record review of Staff A's personnel record showed no documentation of unit specific orientation to the Med/Surg Unit. 5. During an interview on 01/11/16 at 3:10 PM, Staff B, House Supervisor, stated that Staff A was a float nurse. She stated that float nurses aren't oriented to the areas to which they are assigned. 6. During an interview on 01/12/16 at approximately 9:00 AM, Staff L, Director of Human Resources, stated that Staff A was a float nurse and that orientation documentation could not be located. She stated that she was not familiar with nursing's orientation process. However, all staff were required to be oriented and assessed competent to provide patient care wherever they are assigned. She did not know how nursing services at the facility communicated with Staff K, Manager of the float pool staff (supervisor of Staff A and not employed at the facility) about float nurse staff qualifications, performance or competence. She stated "We should have a way to ensure everything is in place (before assigned to duty)." 7. During an interview on 01/13/16 at 11:00 AM, Staff K, Manager of Float Pool Nurses stated that: - She couldn't find documentation of orientation or confirm that Staff A had been oriented to the Med/Surg Unit's policies or procedures. - She was not able to state if Staff A had been assessed competent for patient care on the Med/Surg Unit. - She was unable to identify any process to ensure float nurses were supervised or evaluated as competent prior to patient care assignments. - Staff A was not supervised or evaluated by nursing staff at the facility. 8. During an interview on 01/15/16 at 9:00 AM, Staff N, Chief Nursing Officer (CNO), stated that the facility did not have a process in place to make certain the float nurses were oriented to the units and patients they were assigned to care for. She stated that there was no system to communicate or check that staff who weren't employed by the facility were safe or competent. |
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