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.

TRUMAN MEDICAL CENTER HOSPITAL HILL 2301 HOLMES STREET KANSAS CITY, MO 64108 Dec. 15, 2011
VIOLATION: FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE Tag No: A0724
Based on observation, interview and record review facility staff failed to ensure supplies used in patient care were current and stored to maintain safety and quality including:
-Foods used in patient food service were stored separately from cleaning supplies.
-Supplies beyond manufacturers expiration date were not removed from patient care area in the Emergency Department (ED).

The facility census was 212.

Findings included:

1. Record review of the facility's policy titled, "Food and Supply Storage Procedures" #B006 dated 03/11 showed direction for facility staff to store cleaning supplies separately from food and paper.

2. Observation on 12/12/11 at 4:10 PM in a facility kitchen dry food store room showed staff stored a case of liquid dish washing machine soap on the top shelf over canned sodas and canned liquid dietary supplement products.

During an interview on 12/12/11 at 4:10 PM Staff O, Director of Food and Nutrition confirmed the case of dish washing soap should not be stored in this dry food store room.

3. Record review of facility policy titled, "Outdated Supplies" dated May 11, 2011 showed direction for staff to only use supplies that are within the stated manufacturers shelf life and properly dispose of any item that exceeds the beyond use date. All items found to be beyond its use date are to be removed from the patient care area.

Observation in the ED Medication Room on 12/14/11 at 9:40 AM showed eight "green top" (used to analyze blood chemistry, tube has gel like medium in the bottom to keep blood stable) specimen tubes with an expiration date of 09/11.

During an interview on 12/14/11 at 9:40 Staff RRR, Emergency Department Director, stated that the department is checked once a month for expired supplies and these must have been missed.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on observation, interview, and policy review the facility failed:
-To perform hand hygiene (to cleanse hands with soap and water or with alcohol based hand sanitizer) per the facility policy for three patients (#4, #47 and #44) of four patient's observed for nursing procedures and for one (#12) of two patients observed with central line dressing changes;
-The Food and Nutrition (F&N) department management and the Infection Control (IC) Nurse failed to ensure dietary staff consistently used effective hand hygiene.
-To ensure a sanitary environment was preserved by not repairing wall and door damage, and removing or repairing operating room (OR) mattresses with open areas and tape residue with functional, easily cleanable surfaces that will not harbor and transmit infections.
-To ensure a sanitary environment is preserved by providing clean and easily cleanable floor surfaces that will not harbor and transmit infections in the dialysis unit
-The F&N department management and the IC Nurse failed to:
-Ensure the facility dish washing machine was operated and maintained so the sanitizing final rinse water temperature consistently reached the required 180 degree Fahrenheit
-Ensure equipment used for patient meal preparation such as a canned food storage rack and table mounted can openers were cleaned
-Ensure stored frozen foods were covered
-Ensure foods used in patient food service that were labeled "refrigerate after opening" were stored in refrigerators.
-Ensure dry foods were stored to protect against cross contamination and failed to
-Ensure dietary staff with facial hair wore effective hair restraints.

The facility census was 212.

Findings included:

1. Record review of the facility policy titled, "Hand Hygiene," dated 06/28/11 showed the following direction for facility staff for using hospital-approved alcohol based hand rub (gel or foam):
-All hospital and healthcare personnel including, but not limited to, employees, medical staff, contract workers, students and volunteers working on behalf of the organization are responsible for strict adherence to hand hygiene as a primary strategy to prevent the spread of infection;
-After contact with inanimate objects where there is known or suspected contamination;
-After gloves are removed when there is no visible soiling;
-Between patient contact and procedures on the same patient.
-Whenever contamination is suspected.
-Before having direct contact with patient;
-After contact with inanimate objects, medical equipment, instruments or supplies and/or surfaces where there is known or suspected contamination;

Record review of the facility policy titled, "Standard Precautions & Transmission-Based Precautions" dated August 13, 2008 showed the following direction:
-Gloves provide a protective barrier to prevent contamination when exposed to blood, all body fluids, non-intact skin, mucous membranes, and contaminated equipment/surfaces; and
-Gloves will be removed between patients, between tasks on different body sites of the same patient and whenever contamination is likely.

2. Observation on 12/12/11 at 3:10 PM showed Staff I, removed gloves and picked up trash off the intravenous (IV) pump (A pump the IV solution tubing is hooked into to pump the IV fluid into the patient) and then began using the computer mouse. Staff I failed to perform hand hygiene after she removed gloves.

During an interview on 12/12/11 at 3:15 PM showed Staff I stated that the policy was to use the hand sanitizer before and after gloving. She failed to use the hand sanitizer after removing gloves because she was nervous.

During an interview on 12/12/11 at 3:20 PM Staff H, stated that after staff removed gloves hand sanitizer should be used.

Observation on 12/13/11 at 8:45 AM showed Staff S, RN, holding a urine specimen in her hand. Staff S sat the specimen on the counter and then proceeded to type on a computer key board. Staff S failed to perform hand hygiene after touching the urine specimen.

During an interview on 12/13/11 at 9:10 AM Staff S, RN, stated that staff should wash their hands after holding a specimen, but she forgot to do it.

Observation on 12/14/11 at 8:25 AM showed Staff EEE, RN, donned gloves (put on gloves) without performing hand hygiene. With the gloves on Staff EEE wiped off a cord that was hooked to an automatic blood pressure machine with a sani-wipe (a sanitizer cloth). Staff EEE removed the gloves after cleaning the cord but failed to perform hand hygiene before she removed the blood pressure cuff from Patient #47.

During an interview on 12/14/11 at 8:55 AM Staff EEE, stated that the policy is for staff to perform hand hygiene after gloves are removed.

Observation on 12/14/11 at 8:57 AM showed Staff GGG, RN, had gloves on to prepare an IV site on Patient #47. Staff GGG removed the gloves and failed to perform hand hygiene.

Observation on 12/12/11 at 2:53 PM showed Staff Y, Medical Student, touching the urinary dependent drainage bag of Patient #44 without wearing gloves. Staff Y without performing hand hygiene then examined the patients' feet, listened for heart and lung sounds and felt the patients abdomen. Staff Y again touched the urinary dependent drainage bag without wearing gloves which could have exposed her to body fluids if the bag had leaked.

During an interview on 12/14/11 at 2:58 PM Staff Y stated that she wasn't going to examine the patient's wound and therefore she did not need to wear gloves. Staff Y stated that she would not wear gloves to listen to lung sounds or heart sounds. Staff Y stated that the urinary dependent drainage is a mostly closed system and didn't require gloving.

During an interview on 12/14/11 at 2:40 PM Staff TTTT, Infection Control Practitioner, stated that hand hygiene should always be done and gloves should always be worn between tasks and touching the environment. Staff TTTT stated that anytime staff touched a urinary dependent drainage bag gloves should be worn and hand hygiene performed before patient contact.

3. Record review of the facility policy titled, "Care and Maintenance of Centrally Inserted Intravascular Catheters-Adult," (an intravenous-IV line placed to allow longer access) dated 02/04/11 showed direction for staff to wash hands, DON non-sterile gloves and remove old dressing, wash hands again, aseptically (keeping contents sterile) open the central line dressing kit, DON sterile gloves, using sterile technique cleanse the insertion site, apply anti-microbial sponge under and around tubing, apply occlusive transparent dressing, remove gloves and wash hands.

Record review of Patient #12's History and Physical showed the patient was admitted on 12/08/11 for respiratory failure and brain injury. The patient had a central line.

An observation on 12/13/11 at 10:25 AM, showed Staff Z, RN failed to wash or sanitize his hands prior to putting on non-sterile gloves. RN Z took a central line dressing partially off of Patient #12, but left the transparent dressing loose around the IV site. RN Z put a mask on, opened the central line kit, and put sterile gloves on all without washing/sanitizing his hands first. RN Z handled the dirty dressing with the sterile gloves, touched an old IV tubing and bag (contaminating the sterile gloves), and continued with the dressing change. RN Z left the room, and returned, without washing/sanitizing his hands. RN Z failed to put the anti-microbial sponge under and around the IV tubing prior to placing the transparent dressing. RN Z again failed to wash/sanitize his hands before and between glove changes.

4. Record review of the facility policy titled, "Hand Hygiene" #F007 dated 11/09 showed the following direction for Food and Nutrition department staff:
-All employees associated with the handling of food shall wash hands.
-Hands should be washed with soap and water before handling food, clean utensils/dishes or equipment, before putting on gloves and after removing gloves.
-The procedure for hand washing included direction to work up soap lather on hands for twenty seconds, include areas under fingernails, between fingers, on the inside and outside of hands.
-While on the nursing units, Food and Nutrition department staff were directed to use alcohol based hand sanitizer to decontaminate hands.

Record review of the facility policy titled, "Disposable Glove Use" #F021, dated 03/11 showed direction for facility Food and Nutrition department staff to change disposable gloves (and wash hands) when the gloves become dirty, ripped or when moving from one task to another.

5. Observation on 12/13/11 at 9:50 AM in the cook's area showed Staff CC, Cook with gloved hands handled multiple pages of recipes then without removing soiled gloves or hand washing continued to chop peppers.

Observation on 12/13/11 at 10:13 AM showed Staff EE, Cook removed gloves then washed hands by rinsing hands under a stream of water for less than twenty seconds (failed to work up a lather and rinse) then returned to food handling.

Observation on 12/13/11 at 10:14 AM showed Staff DD, Cook washed hands at a sink for less than twenty seconds (failed to work up a lather and rinse, include areas under fingernails, between fingers, on the inside and outside of hands) then returned to food handling for noon meal.

Observation on 12/12/11 at 10:15 AM showed Staff BB, Cook washed hands at a sink for less than twenty seconds (failed to work up a lather and rinse, include areas under fingernails, between fingers, on the inside and outside of hands) then returned to food handling.

Observation on 12/13/11 at 12:06 PM at the patient tray assembly area showed Staff HH, Diet Aide dropped, then picked up a thermometer from the floor. Further observation showed Staff HH removed gloves then washed hands for less than twenty seconds (failed to work up a lather and rinse, include areas under fingernails, between fingers, on the inside and outside of hands) then returned to food handling.

Observation on 12/13/11 at 12:31 PM at the patient tray assembly area showed Staff HH removed gloves, re-gloved without hand washing then, handled foods for patient noon meal.

Observation on 12/13/11 at 12:34 PM at the patient tray assembly area showed Staff GG, Supervisor removed gloves; hand washed for less than twenty seconds (failed to work up a lather and rinse, include areas under fingernails, between fingers, on the inside and outside of hands) re-gloved then handled foods for patient meal service.

6. Record review of the facility policy titled, "Environmental Cleaning and Environmental Services Infection Prevention and Control Practices," dated 09/29/11 showed direction for facility staff to report any patient bed mattresses that are torn, split, or otherwise not intact immediately to Environmental Services and the mattresses will be replaced, removed from service, and discarded. The facility did not provide any other policies in regard to tape residue which is not an easily cleanable surface and may harbor and transmit infection.

7. Observation on 12/14/11 at 9:25 AM in operating room (OR) #3 showed the OR table pad with tape residue approximately a half inch in diameter on the left side surface. This does not allow for a functional, easily cleanable surface that will not harbor and transmit infection.

Observation on 12/14/11 at 9:35 AM in OR #6 showed the OR table pad for the arm with tape residue on the side surface that was one inch long and an one eighth inch wide.

Observation on 12/14/11 at 11:25 AM in the Caesarian Section (C-Section) OR #2 showed the OR table pad with the following issues:
-The OR table pad for a patient's head had two, approximately four inch long, marks consisting of several pin point openings in the pad that made a straight line. The lines intersected so it looked like an X.
-The middle pad of the OR table had a line of pin point openings that was approximately six inches long.
-The back of the middle pad had adhesive residue that was approximately one and one half inches long and one inch wide.

Observation on 12/14/11 at 11:55 AM in OR # 1 showed the OR table pad for an arm that had tape residue on both sides and top. The number of tape residue marks were too numerous to count. The largest area of tape residue was approximately three inches long and two inches wide.

During an interview on 12/14/11 2:45 PM Staff E, Director of Nursing Practice, verified all OR observations.




8. Observation on 12/12/11 at 3:45 PM through 12/13/11 at 3:00 PM showed several large spills behind equipment in the Dialysis unit, where pooled liquid had dried and exposed a white crystalline like residue that covered approximately four square feet. The vinyl bathroom floor of the Dialysis unit was dull, blackened with stains and scuffs, darkest around the perimeter, under the toe kick of the sink cabinet, storage closet, and across the threshold of the doorway.

During an interview on 12/15/11 at 8:50 AM, Staff AAAA, Director of Environmental Support Services (EVS) stated that the circular deposits on the floor of white crystalline residue were probably from dried salts in the solutions used during the dialysis process and had accumulated over a period of more than one day. He stated that orders for deep cleaning of a room are submitted through the facility's work order system by the housekeeping supervisors based on recommendations from the housekeeper. He stated that it is up to the individual housekeeper to take the initiative and make that determination on a room to room basis. He admitted he had more coaching to do on his staff and identifying floors that needed to be cleaned more frequently than others due to high acuity patient load, chemical spills and special circumstances.




9. Record review of the facility policy titled, "Dish machine Temperatures" dated 03/11 showed the following direction:
-Maintain a final rinse water temperature at one hundred eighty (180) degrees Fahrenheit (F)
-Immediately bring any substandard temperatures to the attention of management.

Record review of the Dish machine Temperature Log dated 12/05/11 through 12/11/11 showed the following temperatures on specific dates and times:
-Thursday 12/08/11 at 10:00 AM documented as 171 degrees F.
-Friday 12/09/11 at 9:30 AM documented as 175 degrees F.
-Saturday 12/10/11 at 7:00 AM documented as 178 degrees F.
-Sunday 12/11/11 at 8:30 AM documented as 177 degrees F.

10. During an interview on 12/12/11 at 4:35 PM Staff O, Director of Food and Nutrition reviewed the dish washing machine temperature log and stated that the machine relied on hot water to sanitize dishes and equipment and the temperatures recorded from 12/08/11 through 12/11/11 would not be sufficient to sanitize.

During an interview on 12/12/11 at 4:40 PM Staff R, Diet Aide stated the following:
-She had been employed as a dish washer for approximately one year.
-She did not know what temperature the final rinse water should be.
-She had not had in-service training on temperatures the dish washing machine should be.

During an interview on 12/12/11 at 4:40 PM Staff P, Dietitian reviewed the Dish machine Temperature Log dated 12/05/11 through 12/11/11 and confirmed the following about the form:
-The form did not have any direction for dietary staff to call or inform management about substandard temperatures.
-The form did not have a minimum acceptable final rinse water temperature.
-"It's just not there." (The minimum temperature).
-"It's just confusing."

11. Record review of the facility's policy titled, Food Services and Infection Prevention and Control" dated 08/05/11 showed the following direction:
-Procedure: paragraph VI.A. Equipment and Supplies directed equipment would be maintained in a clean condition and in good repair.
-Procedure: paragraph VI.B. Equipment directed food contact surfaces and utensils would be cleaned throughout the day every day.

12. Observation on 12/12/11 at 4:10 PM showed staff failed to clean a nine rack canned foods rack with visible accumulated dust and debris along each of the rails in direct contact with the rims of the cans.

During an interview on 12/12/11 at 4:10 PM Staff O looked at the dusty rails of the canned food rack and confirmed the rack needed to be cleaned.

Observation on 12/12/11 at 4:19 PM showed staff failed to clean a table mounted can opener sticky with black food debris and slivers of metal can shavings imbedded into the black debris.

Observation on 12/12/11 at 4:23 PM showed staff failed to clean a second table mounted can opener sticky and covered with food debris.

During an interview on 12/12/11 at 4:23 PM Staff O stated staff should be cleaning the table mounted can openers at least once a day.

13. Record review of the facility policy titled, "Food and Supply Storage Procedures" #B006 dated 03/11 showed direction for staff to:
-Wrap foods in frozen storage tightly to prevent cross contamination.
-Store opened packages of foods in NSF (National Sanitation Foundation, a public health organization that provides standards development, product certification and education used in food services) approved containers.

14. Observation on 12/12/11 at 4:10 PM in the facility walk-in freezer showed staff stored a case of chicken on a shelf with the plastic liner of the case opened to air.

During an interview on 12/12/11 at 4:10 PM Staff O confirmed the case of chicken was opened to air in the freezer.

Observation on 12/12/11 at 4:19 PM showed staff stored a torn partial twenty-five pound paper bag of rice in a bulk bin with the bottom of the paper bag on the surface of rice stored in the bottom of the bin.

During an interview on 12/12/11 at 4:19 PM Staff O confirmed the partial bag of rice should not be stored on top of the rice in the bottom of the bin.

15. Observation on 12/12/11 at 4:20 PM in the cook's area of the facility kitchen showed staff stored an opened partial gallon container of soy sauce with a manufacturer's label to "refrigerate after opening" out on a shelf near the stove.

During an interview on 12/12/11 at 4:20 PM Staff Q, Cook confirmed the opened containers of soy sauce were always stored on the shelf near the stove.

Observation on 12/12/11 at 4:23 PM showed staff stored an opened partial quart container of lemon juice with a manufacturer's label to "refrigerate after opening" out on a shelf near the stove.

During an interview on 12/12/11 at 4:23 PM Staff O, Director of Food and Nutrition confirmed the staff routinely stored opened containers of lemon juice on the shelving near the stove.

16. Record review of the facility's policy titled, "Food Services and Infection Prevention and Control" dated 06/10/09 showed direction for food service personnel to wear proper hair covering, including a beard restraint/cover with trimmed moustaches, sideburns and beards.

Observation on 12/12/11 at 4:19 PM in the Cook's area of the facility kitchen showed Staff Q, Cook failed to wear a hair restraint over a moustache (sections greater than one quarter inch in length) while preparing foods.

Observation on 12/13/11 at 9:45 AM in the cold food prep area of the facility kitchen showed Staff VV, Cook failed to wear a hair restraint over a moustache (sections greater than one quarter inch in length) while preparing sandwiches.

Observation on 12/13/11 at 9:50 AM in the Cook's area of the facility kitchen showed Staff DD, Cook failed to wear a hair restraint over a moustache (sections greater than one quarter inch in length) while cleaning the tables.

During an interview on 12/13/11 at 9:50 AM Staff DD stated no one had ever asked him to wear a hair restraint over facial hair.

Observation on 12/13/11 at 10:25 AM near the tray assembly area showed Staff FF, Diet Aide failed to wear a hair restraint over an untrimmed beard (sections greater than three inches in length) and moustache (sections greater than one quarter inch in length).
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observations, interviews, record reviews and policy reviews the facility failed to ensure the staff followed the facility policy to call the physician when a patient refused an ordered medication for one (Patient #11) of two patients observed. The facility also failed to prevent the development of a pressure sore, and failed to follow the recommendations of the wound care nurses for one of one patient reviewed with pressure sores (Patient #13). The facility census was 212.

Findings included:

1. Record review of the facility policy titled, "Administration of Medication/Self-Administration of Medication" dated 12/02/10 showed direction for the nurse to call the physician if a patient refuses a medication.

Record review of Patient #11's History and Physical (H&P) showed the patient had been admitted to the facility on [DATE] for chest pain and had a history of Deep Vein Thrombosis (a blood clot which forms in a deep vein in the body).

Observation on 12/13/11 at 8:35 AM showed Staff W, Registered Nurse (RN), offered a SQ (meaning an injection given just under the skin) Heparin (a medication, called an anticoagulant, which is used to treat and prevent blood clots) medication to Patient #11 who refused the medication saying that it made her nose bleed.

Record review of the Electronic Medication Administration Record (the electronic report that serves as a legal record of the drugs administered to a patient at a facility by a health care professional) showed the Heparin was to be started on 12/04/11 at 9:00 PM and given every 12 hours. Further review of the EMAR showed the patient had refused the medication twice a day since admission.

During an interview on 12/13/11 at 8:40 AM Staff W, RN, stated that she would call the physician if a patient refused a medication but it is nursing judgment whether to call or not. Staff W stated a lot of the patients refused Heparin because they know they don't have a bleeding problem. Staff W stated that all patients were given an anticoagulant such as Heparin as a preventative measure because studies have shown hospitalized patients are at risk for blood clots due to their increased immobility. Staff W, after reviewing the chart stated there was no documentation that the physician had been called regarding the patient's refusal of the Heparin.

During an interview on 12/13/11 at 9:05 AM, Staff ZZZZ, RN, stated that if a patient refused a medication he would first educate the patient as to why the medication needed to be taken. Staff ZZZZ stated that if the patient still refused to take the medication, he would call the charge nurse and then call the physician and document the refusal and the calls to the charge nurse and to the physician in the clinical notes.

2. Record review of a facility policy titled, "Pressure Ulcer Prevention-Inpatient," dated 07/11/11 showed the following:
-Preventative strategies will be implemented based on the patient's assessed needs;
-Patients will be classified as a skin risk if their Braden Scale (a tool used to identify risk for development of pressure sores) is less than 18;
-If Braden is less than 15, an automatic wound care consult will be triggered;
-A suspected deep tissue injury (DTI) is a purple or maroon localized area of intact skin due to damage of underlying soft tissue from pressure or shear;
-The RN will initiate pressure ulcer prevention for those with a Braden score less than 18;
-Consider pressure relief, waffle boots (an inflated soft boot) or elevate heels on pillow for areas of pressure on heels;
-The plan of care should be amended to reflect wound care as indicated.

The facility failed to provide a policy specificly regarding wound care nurse recommendations and staff responsibility to follow.

3. Record review of Patient #13's H & P showed that the patient was admitted on [DATE] with a diagnosis of respiratory failure. The H & P did not show any abnormal skin issues.

Record review of the patient's Braden score on 12/07/11 showed a score of "10." Review of further Braden scores from 12/08-12/11 showed scores ranging from 10-17, but always less than 18 (indicating the need for pressure ulcer prevention).

Review of a wound care/Ostomy note dated 12/8/11 showed the patient had a Braden score of "10" and the wound care nurse recommended waffle boots to relieve pressure on the feet/heels. The wound care nurse did not identify any current issues.

Review of nurses' wound assessment documentation dated 12/11/11, timed 4:00 PM, showed the patient had a Stage I (persistent redness that does not blanche) pressure sore measuring 3 centimeters (cm) by 2 cm (this documentation did not identify where).

Review of a wound care/Ostomy note dated 12/12/11 showed the patient had a Braden score of "14" and the wound care nurse (WCN) identified a DTI on the right foot/heel (deep blue with red edge), measuring 5 cm by 1.5 cm (indicating a deterioration in the size since 12/11/11). The WCN documented the DTI was suggestive of bed board (pressure against) involvement due to location, shape and size. The WCN recommeded waffle boots, and a dressing called Allevyn to the right foot.

Record review of an Event Report dated 12/13/11 showed the patient transferred from the medical intensive care unit (MICU) to the general medical/surgical unit on this date. During a Braden assessment at 12:00 midnight, staff found a DTI on the plantar (outer) surface of the right foot/heel (indicating this DTI was facility-acquired).

Observation and interview on 12/13/11 at 8:30 AM, showed Patient #13 lying in bed with both heels directly on a pillow (causing pressure to the heels). The patient did not have waffle boots on as recommended by the WCN. Staff II, RN, stated the patient did not have the waffle boots on at 7:00 AM when she arrived for the shift (and failed to put them on then). Staff QQ, WCN, stated that this DTI was not present on admission. Staff QQ stated it looked like this DTI was caused by pressure against the footboard while in the MICU. Staff failed to ensure the waffle boots were on the patient and the heels were floated (off of the bed or pillow surface to alleviate all pressure), after the development of the DTI.

During an interview on 12/13/11 at 1:35 PM, RN Staff II stated any recommendation made by the WCN was considered an order, and should be followed by the nurses.

During an interview on 12/13/11 at 2:08 PM, WCN Staff QQ stated recommendations were put into the computer as a clinical note and the nurse was verbally notified. Waffle boots didn't need an order. WCN Staff QQ stated that the patient should have been wearing waffle boots while in bed and would also suggest this patient's heels be floated (off of the bed or pillow surface to alleviate all pressure).

During an interview on 12/14/11 at 1:50 PM, WCN staff YY stated their recommendations are to be followed as if an order. Staff failed to follow the WCN's recommendations for Patient #13.
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, policy review and record review the facility failed to ensure the staff individualize and/or update the care plans for four patients (#9, #43, #44 and #13) of sixteen patients reviewed. The facility census was 212.

Findings included:

1. Record review of the facility policy titled "Interdisciplinary Plan of Care (IPOC)" dated February 14, 2011 showed the following direction:
-all inpatients will have an electronic plan of care which is interdisciplinary, individualized, current and comprehensive of all patient care conditions;
-the interdisciplinary plan of care will be individualized based on the patient's current and ongoing assessed needs and will consider physiological, psychological and psychosocial factors in developing interventions and therapeutic goals; and
-the interdisciplinary plan of care is reviewed, updated and prioritized each shift by the RN(Registered Nurse) to ensure that it is pertinent and addresses all issues.

2. Record review of Patient #9's History and Physical (H&P) dated 12/09/11 showed the patient spoke French Creole and did not speak English and that a blue phone (a telephone with dual-receivers which is held by the patient and the nurse in the facility and the interpreter proficient in French Creole) was used to communicate with him.

Record review of the "Patient Learning Assessment" (a part of the complete nursing assessment which assesses any difficulty the patient might have in being taught) dated 12/09/11, the day the patient was admitted to the facility, showed the patient had a barrier to learning which was identified as language because he spoke French Creole and did not understand the English language when spoken. There was no plan of care to address the communication needs of the patient when reviewed by the surveyor on 12/13/11.

During an interview on 12/13/11 at 10:30 AM Staff V, Director of 4 Gold unit, stated that the admitting nurse should have included the communication care plan including the specifics of the patient being unable to understand English and that the blue phones would be used for communication purposes and it could have been done by any nurse who was updating the care plan.

3. Record review of Patient #43's H&P dated 11/25/11 showed the patient had been admitted to the facility for a neurological work up (a series of tests which assess brain and nerve function) related to constant uncontrolled, purposeless body movements and was hearing impaired.

Record review of the "Patient Learning Assessment" dated 11/25/11 showed that the patient had no barriers to learning and "Neurological" assessment showed the patient had a jerky and unsteady gait (the manner or style of walking).

Record review of the patient's "Interdisciplinary Plan of Care" initiated 11/25/11 showed the patient's "Communication" care plan did not identify the patient as hearing impaired and did not have interventions or goals to accommodate this need. The care plan had last been updated on 11/29/11.

During an interview on 12/13/11 at 12:15 PM Staff XXXX , Registered Nurse (RN), stated that the patient was very hard of hearing and heard best when spoken to loudly and to his left ear.

During an interview on 12/13/11 at 12:35 PM Staff V, Director of 4 Gold, stated that he would expect the impaired hearing to be on the care plan under communication because the care plan drives the plan of care.

4. Record review of Patient #44's H&P dated 11/16/11 showed the patient had been admitted to the facility on on that date with a diagnoses of dizziness and chest pain and was assigned a sitter (a staff member who is to stay with the patient at all times) due to his confusion.

Record review of the patient's "Comfort Measures" (a part of the complete nursing assessment which assesses level of pain) dated 11/17/11 showed the patient was confused/disoriented.

Record review of the "Interdisciplinary Plan of Care" (IPOC) dated 11/29/11 showed an intervention to provide a safe environment for the patient. This intervention was not specific to the sitter who stayed with the patient 24 hours a day.

During an interview on 12/13/11 at 12:50 PM Staff V stated that the nursing staff were to review and update the patient's care plan once a day usually at 4:00 PM and 4:00 AM. The system does not allow the staff to add specifics to a care plan other than the drop down boxes (computer generated care plan with options for interventions) that are available.

5. Record review of a facility policy titled, "Pressure Ulcer Prevention-Inpatient," dated 07/11/11 showed the following:
-The plan of care (IPOC) should be amended to reflect wound care as indicated;
-Patients will be classified as a skin risk if their Braden Scale (a tool used to identify risk for development of pressure sores) is less than 18;
-The RN will initiate pressure ulcer prevention for those with a Braden score less than 18.

6. Record review of Patient #13's H & P showed that the patient was admitted on [DATE] with a diagnosis of respiratory failure.

Record review of a wound care/Ostomy note dated 12/8/11 showed the patient had a Braden score of "10" and the wound care nurse (WCN) recommended waffle boots to relieve pressure on the feet/heels.

Record review of the patient's IPOC, dated 12/14/01 showed staff failed to include interventions regarding the waffle boots, or specific interventions to alleviate pressure to the patient's feet/heels.

During an interview on 12/14/11 at 1:50 PM, WCN, Staff YY stated that it was the facility policy to individualize the IPOC to the patient's needs. Staff YY stated the WCN's were involved in the update of the IPOC as needed.

During an interview on 12/14/11 at 2:20 PM, Staff ZZ, Information Technician, stated the IPOC computer program utilized would not currently allow this specificity regarding pressure relief/prevention devices. Staff failed to make Patient #13's IPOC specific to her needs.
VIOLATION: PATIENT RIGHTS: SECLUSION OR RESTRAINT Tag No: A0214
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, record review, and policy review the facility failed to notify the Centers for Medicare & Medicaid (CMS), by telephone, of patient deaths associated with the use of restraints for two (Patients #35 and #36) of two death records reviewed for restraints. The facility census was 212.

Findings included:

1. Record review of the facility's policy titled, "Management of Restraints, Health Promoting," dated10/12/11showed direction to facility staff for the Nurse Manager to report to CMS any death that occurs while a patient is restrained, or within 24 hours after removal from restraint or seclusion, or where it is reasonable to assume a patient's death is a result of restraint. The report was to be made by telephone.

2. Review of Patient #35's discharged medical record showed the patient expired on 08/10/11 at 9:16 AM related to [DIAGNOSES REDACTED]. The patient had bilateral soft wrist restraints ordered on that date and at the time of death.

Review of a facsimile (FAX) cover sheet provided by facility staff on 12/14/11, showed staff failed to report the patient's death by telephone, instead it was reported by FAX on 08/10/11 at 2:07 PM.

3. Review of Patient #36's discharged medical record showed the patient expired on [DATE] at 11:37 PM related to an intracranial bleed (bleeding in the brain). The patient had bilateral soft wrist restraints ordered on that date and at the time of death.

Review of a FAX cover sheet provided by facility staff on 12/14/11, showed staff failed to report the patient's death by telephone, instead it was reported by FAX on 12/12/11 at 6:23 AM.

4. During an interview on 12/14/11 at 10:55 AM, Staff HHHH, Patient Safety and Accreditation, stated that patient deaths were reported to CMS, and confirmed staff failed to report these deaths via telephone. Staff HHHH stated she was unaware of the telephone requirement.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review the facility failed to:

- Terminate an employee per their policy (Staff TTT) even though they had confirmed physical abuse of one patient (Patient #53) -placing all Emergency Department (ED) patients at risk for further abuse from August 08, 2011 through December 13, 2011, or four months. The facility had not terminated the employee as of 12/17/11, and stated they had no intention of terminating her;
-Failed to report a suspected, and substantiated, case of physical abuse (on 08/08/11) to the State agency (Statute states that any health care worker is a mandated reporter of suspected abuse);
-Failed to train Staff TTT as stated in their plan to address the physical abuse, after the substantiation of the abuse, and Staff TTT had not completed this training (ProAct-a specific training to assist in the care of patients exhibiting behaviors) as of 12/17/11. One patient was identified with abuse/neglect allegations out of seven grievances chosen, one of which was Patient #53. The facility census was 212.

Findings included:

1. Review of facility policies titled, "Abuse and Neglect Reporting," initiated on 11/05/03, and "Abuse, Neglect or Exploitation at Truman Medical Centers," initiated on 11/12/07, showed the following:
-Physical abuse includes slapping;
-The facility will intervene in situations in which abuse or neglect is likely to occur;
-Patients in treatment for health conditions are considered vulnerable, including those with mentation (thinking process) disorders and those that are restrained;
-All individuals will be protected against harm during and following the investigation. Suspected employee may be suspended during the complaint investigation;
-All substantiated violations will be reported to the appropriate agency as required;
-Any employee witnessing or suspecting abuse is required to report it verbally and in writing to their supervisor immediately;
-The supervisor receiving this report should notify the Patient Care Manager with responsibility for the area in which the incident allegedly occurred;
-If abuse is confirmed, the employee will be terminated;
-Physicians and staff shall address the safety needs of the patients;
-Staff confirmed the above to be the current practice of the facility.

2. Review of Patient #53's ED record showed the following:
-The patient (MDS) dated [DATE] at 7:06 AM via ambulance;
-The patient was anxious and combative, stating he was suicidal;
-Staff put the patient in 4-point restraints, but the patient continued to kick and grab staff;
-Laboratory results showed the patient had multiple drugs in his system;
-The patient was transferred to an inpatient psychiatric unit at 4:38 PM.
Review of an Incident Report (a tool utilized by facility staff to report unusual or out of the ordinary instances), dated 08/08/11, showed the following:
-On 08/08/11 at 1:30 PM, Security Officer, Staff UUUU, responded to POD S (a unit within the ED that is utilized for patients with behavioral/psychiatric problems) in the ED because Patient #53 was being disruptive by attempting to remove medical monitors, being verbally abusive, and attempting to grab medical staff;
-Staff UUUU witnessed Patient Care Technician (PCT), Staff TTT, strike Patient #53 on the left side of the head, with an open hand.

During an interview on 12/15/11 at 11:47 AM, Staff UUUU stated that he was assigned to POD S on 08/08/10 and nurses in the ED requested he come and assist with patient #53 because he was pulling his monitors off. Staff UUUU heard Staff TTT yell out and saw her take her hand across the top of patient #53's head (probably left side). Staff UUUU asked Staff TTT later what happened and she said the patient grabbed her in the groin so she slapped him. Staff UUUU failed to report this incident to the ED Director, or Manager of the ED as directed in the policy.

3. Review of a Comment/Grievance Case Detail Report, dated 08/08/11, untimed, showed the following:
-Patient #53 reported to Guest Services, Staff EEEE, that Staff TTT slapped him across the face.

During an interview on 12/15/11 at 10:13 AM, Staff EEEE stated Patient #53 requested to speak with someone so he could file a complaint. That complaint was made to Staff EEEE. Staff EEEE stated Patient #53 said a staff member in red scrubs slapped him across the face. Staff EEEE documented this report and said he verbally reported the event to the ED Director; however, the ED Director stated she did not get notified of the event by Staff EEEE.

4. Review of an Adverse Response Administrator on-call form, dated 08/09/11, showed the following:
-Staff placed patient #53 in 4-point restraints (restraint of arms and legs), but was still kicking, and kicked Staff TTT in the crotch twice. Upset, Staff TTT slapped the patient and said, "Don't do that again;"
-The ED Director, Staff RRR, documented that she was not notified of this event until 08/09/11 at 3:43 PM, and indicated the facility policy for reporting had not been followed;
-The Supervisor of the ED, The Assistant Patient Care Manager or Director of Shift Operations were not notified as was directed in the facility policy;
-Staff RRR interviewed Staff TTT and Staff TTT admitted to hitting the patient.

During an interview on 12/15/11 at 9:18 AM, Staff RRR stated she was the Director of the ED and she did not know of the incident until 08/09/11. She said staff failed to report via proper channels resulting in a delayed investigation and response. Staff RRR stated Staff TTT did work the remainder of the shift on 08/08/11 and again on 08/09/11. Staff RRR stated Staff TTT was not terminated since there were no previous similar incidents. Staff RRR stated they had no intention, to date, to terminate Staff TTT. Staff TTT was scheduled to attend ProAct training in 10/11; however, this training was canceled. Staff TTT had not attended to this date, and was not scheduled until 01/18/12.

During an interview on 12/15/11 at 2:12 PM, Staff TTT stated she was taking care of Patient #53 on 08/08/11. The patient was violent, verbally and physically abusive. Patient #53 put his feet in her crotch and pinched her breast. Staff TTT stated she was upset and just reacted by smacking him on the side of the head. Staff TTT stated Staff RRR sent her home during her routine shift the next day (08/09/11), but was suspended about two days later and then returned to work (08/12/11).

Review of Staff TTT's timecard from 08/08-12/13/11, showed Staff TTT was suspended and was scheduled off work from 08/10/11 and 08/11/11 and was scheduled off work from 12/13/11 through 12/17/11. However, Staff TTT did work on a regular basis from 08/12/11 through 12/12/11. The facility allowed Staff TTT to work until 12/12/11 (she was scheduled off 12/13/11 through 12/17/11) which placed patients at risk from 08/12/11 through 12/12/11. Staff TTT remained in the employ of this facility up to, and through 12/17/11.

During an interview on 12/15/11 at approximately 2:30 PM, Staff XXXX, Vice President, stated the facility intended to keep the Staff TTT in their employ.

Facility staff failed to begin the investigation immediately, which lead to a failure to suspend Staff TTT from further patient care until 3:00 PM on 08/09/11, or approximately 14 hours after the abuse allegation. This resulted in a potential harm to all patients on POD S in the ED.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on interview and record review the facility failed to:

-Terminate an employee per their policy (Staff TTT) even though they had confirmed physical abuse of one patient (Patient #53) -placing all Emergency Department (ED) patients at risk for further abuse from August 08, 2011 through December 13, 2011, or four months;
- Report a suspected, and substantiated, case of physical abuse (on 08/08/11) to the State agency (Statute requires health care workers, mandated reporters to report any cause to believe abuse/neglect has occurred);
-To train Staff TTT as recommended, after the substantiation of the abuse, Staff TTT had not completed this training (ProAct-a specific training to assist in the care of patients exhibiting behaviors) as of 12/17/11.

The severity and cumulative effect of these systemic practices resulted in the facility's non-compliance with 42 CFR (Code of Federal Regulations) 482.13 Condition of Participation: Patient Rights.

The facility census was 212.