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||April 27, 2016|
|VIOLATION: CONSULTATION WITH MEDICAL STAFF||Tag No: A0053|
|Based on interview and record review the facility failed to ensure that the governing body had direct consultation with the leader of the Medical Staff or the designee to discuss matters related to the quality of medical care provided to patients. The Governing body also failed to adopt policies and procedures to address how it would implement and evidence that the required consultations took place. This failure had the potential to affect the quality of care and safety of all patients. The facility census was 153.
1. Record review of the Medical Staff Bylaws and the Governing Body Board Meeting Minutes did not contain any evidence that there were scheduled direct consultations between the Governing Body and the leader of the Medical Staff.
2. During a telephone interview on 04/27/16 at 11:10 AM, Staff X, Chief Executive Officer (CEO), stated that there were no direct consultation meetings between the Governing Body and the leader of the Medical Staff. He stated that he was a member of the Governing Board but that he did not schedule one to one meetings with the head of the Medical Staff to discuss the quality of care to patients.
During an interview on 04/27/16 at 11:25 AM, Staff A, Chief Nursing Officer (CNO), stated, "We don't have a policy or procedure and it's not in the Bylaws, we are just straight up deficient". She stated that she contacted Staff B, Director of Accreditation and Licensing and Director of Quality Management, and he stated that he had read the regulation requirements and that there had been no provisions for periodic consultations throughout the year.
|VIOLATION: PATIENT RIGHTS: GRIEVANCES||Tag No: A0118|
|Based on interview, record review, and policy review the facility failed to notify four current Behavioral Health Units (BHU) patients (#5, #9, #11, and #14) of four current BHU patients and one discharged BHU patient (#10) of one discharged BHU patient of the grievance process. This failed practice affected all patients on the BHU and had the potential to deny patients their right to a formal process to communicate and resolve complaints/grievances. The BHU census was 25. The facility census was 153.
1. Record review of the facility's policy titled, "Patient Rights and Responsibilities," dated 07/2013, showed that the policy provided mechanisms to resolve potential or actual issues related to Patients' Rights.
Record review of the facility's policy titled, "Grievance Process for Patients," dated 10/2014, showed that:
- A grievance was a formal or informal, written or verbal complaint made regarding patient care, abuse/neglect, and issues related to compliance with regulatory requirements.
- The grievance process provided a mechanism for patients to communicate complaints and grievances.
- The facility's patient handbook included Patients' Rights and Responsibilities and was given to all patients upon admission.
- The facility was committed to timely and effective resolution of concerns expressed by patients/representatives and family members.
2. An undated patient handbook pamphlet titled, "Patient Rights and Responsibilities," showed mechanisms for patients to express concerns or grievances to managers, directors and patient relations staff. It also provided the names and contact information of a regulatory agency and an accrediting organization that patients could contact to lodge a grievance whether or not they used the facility's process.
3. Record review of current patients' (#5, #9, #11, and #14) and discharged patient's (#10) medical records showed a facility two-sided form titled, "Behavioral Health Services: Rights and Responsibilities of Patients," dated 01/2009, that had a process to report complaints/concerns within the facility, but had no process on how to report complaints/grievances to external sources. The records failed to show that patients were given a Patients' Rights and Responsibilities pamphlet that included the names and contact information of the regulatory agency and accrediting organization, per policy.
During an interview on 04/26/16 at 10:50 AM, Patient #11 stated that he was not informed of the grievance process either verbally or in written form, and he saw no posting on the unit.
During an interview on 04/26/16 at 2:30 PM, Patient #9, stated that she was not informed of the grievance process either verbally or in written form, and she saw no posting on the unit.
During an interview on 04/26/16 at 3:35 PM, Patient #14, stated that she was not informed of the grievance process either verbally or in written form, and she saw no posting on the unit.
During an interview on 04/26/16 at 4:00 PM and on 04/27/16 at 9:30 AM, Staff H, Director of Nursing for BHU, stated that:
- BHU staff reviewed admission documents and all patients signed BHU's Patients' Rights form upon admission.
- She acknowledged that the form did not include information for external reporting of complaints/grievances.
- She stated that BHU had the grievance process posted on each unit (2nd and 3rd floors), that included external contact information.
- A patient on the 3rd floor tore off the unit's sign over the weekend, it had not been replaced, and she had no interim process in place to notify patients of the grievance process to an external agency/organization.
- She had no knowledge that the facility had patient handbooks or pamphlets that included contacts for external reporting.
- She had no knowledge that patients were unaware of the grievance process.
|VIOLATION: NURSING CARE PLAN||Tag No: A0396|
|**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, record review, and policy review, the facility failed to individualize interventions and/or goals for four current patients (#7, #1, #2 and #14) of nine current patients and one discharged patient (#8) of one discharged patient care plans reviewed. These failures had the potential to affect all patients when their needs were not identified and interventions were not implemented which could lead to poor patient outcomes. The facility census was 153.
1. Record review of the facility policy titled, "Interdisciplinary Care Planning," showed that the Care Plan (section of medical record that contained goals and interventions entered by nurses and other staff that directed the care of the patient) should include:
- The patient's individual care needs;
- The patient's treatment goals and objectives;
- The patient's patient specific interventions;
- A review with patient/and or family every 24 hours.
2. Observation on 04/25/16 at 3:45 PM, showed Patient #7 awake, arms and legs contracted (muscle stiffness), with spontaneous movement but was not able to communicate.
3. Record review of Patient #7's History and Physical (H&P) showed he was a [AGE] year old male with a history of [DIAGNOSES REDACTED] (a disease that affected body movement and muscle coordination), awake but not able to follow commands.
Record review of Patient #7's care plan showed no problems, individualized goals and objectives, or interventions related to his communication needs.
During an interview on 04/25/16 at 3:50 PM Staff FF, Registered Nurse (RN), stated that Patient #7 could not push the nurse call button if he needed help, did not speak, and care providers had to use facial expressions to determine the patient's needs.
During an interview on 04/25/16 at 4:00 PM, Staff U, RN Educator, stated that Patient #7's communication needs should be included in the care plan but it had not been addressed. Staff U further stated that there was no documentation that a nurse had discussed how the patient's mother (his care provider at home) identified his needs, the best way to communicate with the patient, or the patient's care plan.
4. Record review of Patient #1's H&P showed that she was admitted on [DATE] with the following diagnoses[DIAGNOSES REDACTED]
- Acute congestive heart failure (a rapid onset condition in which the heart is unable to maintain adequate circulation of blood);
- Acute cardiogenic pulmonary edema (increased pressure in the heart); and
- Acute hypoxic respiratory failure (a condition where there is not enough oxygen reaching the tissues of the body caused by a failure of the respiratory system).
Record review of Patient #1's medication orders showed a preventive treatment of a blood thinner (Heparin, a high risk medication that can cause unwanted bleeding) and a medication used to prevent blood clots (Lovenox, another medication considered high risk for unwanted bleeding) by injection every 24 hours.
Record review of Patient #1's treatment orders showed:
- Change wound dressing every 72 hours and as needed for the patient's skin breakdown on her buttocks.
- Wound should be visualized and inspected every shift by gently peeling back dressing and reapply.
- Change dressing every three days until no longer at risk.
- Two times daily cleanse, irrigate and soak with soap and water the patient's abdomen.
- Apply medication powder to the abdomen daily.
Record review of Patient #1's care plan showed no individualized care plan problem that addressed a bleeding risk associated with use of his medications or interventions for specific areas of skin break down.
5. Record review of Patient #2's H&P showed he was admitted on [DATE] for:
- Congestive Heart Failure (CHF) exacerbation (worsening of condition in which the heart is unable to maintain adequate circulation of blood in the tissues of the body).
- [DIAGNOSES REDACTED](an abnormal heart rhythm characterized by rapid and irregular beating).
- Chronic Obstructive Pulmonary Disease (COPD, a lung disorder that persistently obstructs airflow).
- An implantable cardioverter-defibrillator (ICD, a battery-powered device placed under the skin that keeps track of the heart rate. Thin wires connect the ICD to the heart. If an abnormal heart rhythm is detected the device will deliver an electric shock to restore a normal heartbeat) in place.
Record review of Patient #2's medication orders showed that patient takes a blood thinner (Coumadin a high risk medication for unwanted bleeding) daily. The patient also had an order for, "Nothing by mouth" (NPO) after midnight for an ICD procedure the next morning.
Record review of Patient #2's care plan showed no individualized care plan problem addressing bleeding risk associated with use of the blood thinner and to reflect the presence of Patient #2's ICD.
During an interview on 4/25/16 at 3:25 PM, Staff O, RN, stated that the only blood thinner/blood clot prevention medications that she would care plan for high risk of unwanted bleeding would be something like a Heparin drip (medication continuously injected directly into the vein over a period of time). She stated that Patient #1's care plan should have specific skin risks included. Staff O stated that the presence of the ICD is an important part of Patient #2's medical history and should have been reflected on the patient's care plan given the patient's cardiac history. Staff O stated that care plans are updated every shift (12 hours) and should be updated before this shift is over to reflect the new order received for cardioversion (a medical procedure by which an abnormally fast heart rate (tachycardia) or cardiac arrhythmia is converted to a normal rhythm using electricity or drugs) procedure.
Record review of Patient's care plan on 4/26/16 at 2:00 PM showed that Patient #2's care plan had not been updated to reflect the ICD procedure.
6. During an interview on 04/26/16 at 3:35 PM, Patient #14, stated that she had a suprapubic catheter (a tube that is surgically inserted from the belly to the bladder to allow urine to drain from the body) and that nurses were changing the dressing daily,
During an interview on 04/26/16 at 4:10 PM, Staff P, RN, stated that Patient #14 cared for herself daily, including dressing changes.
During an interview on 04/26/16 at 4:15 PM and concurrent patient record (#14) review, Staff H, Director of Nursing, Behavioral Health Unit, acknowledged that:
- The patient was admitted on [DATE] with problems including suicidal risk (acts, threats, or thoughts to self harm), Diabetes, Type-One (a disease when the body cannot rid itself of excess glucose/sugar in the blood and requires insulin/hormone to control); and a kidney infection (a bacterial infection that travels from the urinary tract up to the kidneys requiring prompt medical attention); and she had been non-compliant with taking care of herself.
- The patient had a suprapubic catheter placed about three and one-half years ago.
- The care plan had no individualized goals or interventions related to care of the patient's suprapubic catheter site, and it should have.
7. Record review of discharged Patient #8's H&P showed she was a [AGE] year old female from a nursing home with a history of [DIAGNOSES REDACTED] and dementia (loss of memory). Physician noted that patient had significant psychiatric issues and could not give any medical history. Patient #8 was admitted on [DATE] and discharged on [DATE] at 2:00 PM.
Record review of nursing notes showed that Patient #8 was combative, aggressive, agitated, pulled out intravenous (IV-small tube placed into vein to give patient medicine or fluid) tube, unable to follow commands, and spit at care providers throughout her admission. Record did not show any attempt to contact nursing home or family to determine if this was the patient's normal condition.
Record review of Patient #8's care plan showed no individualized goals or interventions related to her communication needs or agitation.
During an interview on 04/25/16 at 4:15 PM, Staff U, RN Educator, stated that Patient #8's communication needs should have been included in the care plan but was not. Staff U further stated that there was no documentation of nurse communication with the nursing home, patient family, or primary care physician to determine if this was the patient's normal condition and identify appropriate care plan interventions.
During an interview on 04/25/16 at 4:30 PM Staff B, Director of Quality Management, stated that the facility was aware of issues related to care plans and a team has been assigned to make corrections.
During an interview on 04/27/16 at 1:05 PM, Staff A, Chief Nursing Officer, stated that care planning was a weak area and a focus for improvement. At present, there were multiple places to document and it made it harder for nurses to find the right location to enter a care plan.