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Based on observation, interview and review of documents, the staff did not effectively identify and treat a patient at risk for skin breakdown and the nursing plan of care was not kept current with the physician's plan for medical care; in situations involving constant observation staff were inconsistent in ensuring and documenting RN and physician actions; and staff were not effectively versed / trained in and were inconsistent in following the facilities Constant Observation For Suicidal, Violent/Combative Patients And/Or Patients With Other Behavioral Issues policy. These findings were noted in three of five medical records (MRs) reviewed.

Finding #1
On September 3rd 2014, patient #1, an [AGE] year old (y/o) female, was admitted to the facility with report of syncope and fall sustained while at home. The patient was admitted to medicine, it was determined that she had developed an intracrainial bleed as a result of hemorrhagic stroke. At the time of admission she was described as alert and oriented, however as the days went by, a decline in her mental abilities was evident. Nursing Progress Note for 9/6/14 stated "skin is intact" also noted was "skin protocol implemented". The patient at this time was on bedrest and was noted to be "turned and positioned" every two hours. By 9/12/14, the patient's Glasgow Coma Scale score was noted at 11, down from 14 from the previous days [Glasgow Coma Scale is a neurological scale that aims to give a reliable, objective way of recording the conscious state of a person. A patient score ranges between 3 (indicating deep unconsciousness) and 15 (fully awake person)]. She was noted to be "confused", had "generalized weakness". Skin was still "intact". A "potential problem" was identified on the Braden scale (a tool used to assess a patient's risk of developing a pressure ulcer) for that day, again, "skin protocol" was implemented.

Review of the nursing plan of care for September 6th and also September 15th, the day of discharge, showed staff did not identify skin integrity as a problem area and a treatment plan was not implemented. The patient was transferred to a nursing home. Survey Team obtained and reviewed the patient's nursing home medical record and it indicated that a stage III sacral decubitus ulcer was discovered on day one of patient's stay.

At interview with Staff #1 on 1/12/15, while on Unit 5W, Staff #1 stated that the initial skin assessment is made at the time of admission and on each shift thereafter. Patients with actual skin breakdown are treated per policy. Stage II ulcers are treated with a barrier cream, Stage I with a hydrocolloid gel. Additionally, all patients are placed on pressure relief mattresses.

In the case of patient #1 however, staff failed to comply with the facility policy on the identification and treatment of pressure ulcers.

Finding #2
(A) Review of the Electronic Medical Record (EMR) revealed this 87 y/o male, patient #2, was admitted to the facility on [DATE] with chief complaint of productive cough for 2 weeks, shortness of breath and difficulty breathing when lying flat. He was admitted to Medicine for Telemetry Monitoring.

Per the EMR, on 01/14/15 at 05:47 (5:47 AM) the Registered Nurse (RN) documented that at 4:30 AM patient #2 became increasingly agitated and was attempting to climb out of bed. The doctor was notified and he ordered 2.5 milligrams (mg) of Haldol. Although patient #2 received the medication as ordered, he remained agitated an hour later. At 5:30 AM patient #2 was ordered for one to one (1:1) observation and the order was implemented. The MD order is documented as follows: "14 Jan-2015 05:47; 1:1 Obs. for behavioral intervention. Prevent patient from falling, duration: 24hrs; Frequency: ONCE.

Staff #3, the Primary RN, during an interview on 01/15/15 at approximately 11:40 AM, acknowledged that the MD order for the 1:1 observation had expired that day (01/15/15) at 5:47 AM, and there was no order to continue monitoring the patient. Staff #2 stated that a physician's order is not needed to continue 1:1 observation for behavioral intervention and that the RN will assess the patient and document the need for continuation. However, this assessment had not been documented. The documentation in the nursing - progress note, dated 1/14/2015 11:17(AM) read: "patient very confused at night, patient is combative and trying to climb out of bed. 1:1 observation." Staff #4, who was also present, acknowledged expiration of the order for 1:1 observation. and stated a physician's order should be obtained.

The facility's policy title: Constant Observation For Suicidal, Violent/Combative Patients And Patients With Other Behavioral Issues, was presented to the surveyor at approximately 2:00 PM on 1/15/15. The process stated by Staff #2 is not stated in the policy.
Section 3.4 Constant observation may be ordered by a psychiatrist or physician or may be initiated under the supervision and at the direction of nurse manager/designee based on the patient's condition. The patient's physician must be notified immediately.
Section 3.7 For patients on constant observation, the physician must be actively involved in reassessing the status of constant coverage at least every day with the collaboration of psychiatry, as necessary.

On 1/15/15 at approximately 11:50 AM, during a tour of the 2N Unit it was observed that Patient #2 was cohorted in the same room with Patient #3, and Staff #2 was assigned 1:2 observation of both patients. Upon review of the facility's policy title Constant Observation For Suicidal, Violent/Combative Patients And/Or Patients With Other Behavioral Issues, which was last reviewed/revised on 12/2009, it was identified that "At the discretion of the nurse manger or designee, in collaboration with the physician, one employee may monitor the behavior and activity of one or two patients cohorted in the same room (1:1 or 1:2 observation) with the following conditions: high fall risk with confusion, diagnosis of Dementia or Alzheimer's, past history of wandering, confusion, alcohol withdrawal, and combative/aggressive patient."

(B) On 01/12/15, patient #3, a 72 y/o male, was admitted from the Emergency Department to the Inpatient unit, with a chief complaint of new onset seizure. The physician / medical doctor (MD) ordered 1:1 observation on 1/12/15 when the patient was assessed to be "alert, confused, agitated, and repeatedly tried to get out of bed." The MD order is documented as follows: 12 Jan -2015 17:48; 1:1 Obs. for behavioral intervention. Prevent physical harm to self. Duration: 24hrs; Frequency: ONCE. Patient's 1:1 observation continued on 1/13/15, 1/14/15 and 1/15/15, and there was no MD order to continue the 1:1 observation. This finding was acknowledged by Staff #2 and Staff #3.

There is no documentation that the physician was actively involved in reassessing the patient's status of constant coverage or that the 1:1 observation was to be continued after 24 hours, in the response to the assessment of patient's need .

On 1/15/15 at approximately 11:50 AM, during a tour of the 2N Unit it was observed Patient #3 was cohorted in the same room with Patient #2 and Staff #2 was assigned 1:2 observation of both patients.
Based on review of medical records and documents, it was determined the facility failed to ensure that the standard of care was met for patient with a traumatic amputation injury. Specifically: (1) Staff failed to provide and document an accurate triage and evaluation of a traumatic injury, (2) Staff failed to communicate the need for timely intervention of a traumatic injury to other members of the health care team, (3) Staff failed to provide timely intervention and treatment to prevent potential harm to the patient with a traumatic injury. This finding was evident in Patient #4.


Review of closed medical record conducted on 1/9/15 and 1/12/15 found that on November 28, 2014 at 13:07 (1:07 PM), this 3 year 7 month (3y7m) old female, patient #4, arrived at the facility with her family, with a Chief Complaint of Finger Injury, and received a Triage/Evaluation by the RN at 13:07 (1:07 PM).

The evaluation documented in the ED Nursing Primary Evaluation Note states: Chief Complaint: Finger Injury; Pediatric Behavior Assessment: Patient does not display inappropriate sleepiness, irritability, lethargy/confusion, or a reduced response to pain; Vital Signs: Temperature 98.5 degrees Fahrenheit (F), Blood Pressure 111/72, Heart Rate 123, Respiration 20, Weight 15 kilograms (kg); Pain Assessment: No pain present. The Patient was assigned a Triage Acuity Level: 3 - Acute, and the record indicates the patient was triaged to the Pediatric Treatment Area. The documentation of the Finger Injury is unspecified.

At 14:39 (2:39 PM), there is documentation in the ED Nursing Disposition Note that the patient "walked out prior to the LIP Exam"; patient left without being seen. Note 2: LIP Exam is an examination conducted by a Licensed Independent Practitioner.

There is no other documented assessment in the medical record, and there is no documentation in the medical record to substantiate the allegation that the patient's fingertip and nail were amputated as a result of the injury.

During a telephone interview on 01/21/15, at approximately 1:30 PM, patient's father stated that when he arrived at the Emergency Department (ED), the patient's finger was wrapped in tissue, and there was bleeding, and the fingertip was in his pocket, wrapped in tissue. The nurse removed the tissue and put a dressing on the finger and he was sent to Pediatrics. While the patient was in the Pediatric area, there were doctors present and he tried to get them to look at the finger that was in his pocket but they kept asking him to wait. He left the facility and took the patient to another facility (facility #2), which the patient's father identified by name.

Review of the facility's policy titled: Triage of the Emergency Patient, received by the surveyor on 1/09/15, reveals there are no established guidelines and process for the triage nurse assessment and assignment of an acuity category, and there is no description of the acuity categories and actions to be taken.

A request for the facility's policy for treatment of traumatic injury was made on 01/21/15 to Staff #3, but this policy was not received by the surveyor.

Review of the medical record from facility #2, was conducted on 1/22/15 and revealed:

On November 28, 2014, at approximately 14:58 (2:58 PM), the patient arrived at facility #2 with a Chief Complaint of Right Pinky Injury, was triaged to a Level 3 at 15:01 (3:01 PM) and was taken for Pediatric Assessment. The ED Pediatric Pre-Assessment by the RN, states: "Right 5th Finger Injury; as per patient's father, patient's brother slammed wood door on patient's Right 5th finger, cutting tip off around 12:45 PM today: bleeding controlled." Comprehensive Pain Assessment: Occasional grimace or frown, lying quietly, moans or whimpers, reassured by occasional touching, hugging/distractible; Pain Score: 3. Vital Signs: Temperature 37.6 degrees Celsius (C), Heart Rate 101, Respiratory Rate 18, Blood Pressure 136/73, Weight 15.6 kilograms (kg).

At approximately 15:28 (3:28 PM), the Medical Screening Exam was initiated and the patient received evaluation and treatment to include: X-ray Finger 5th Digit and Ortho ED Consult.
ED diagnosis indicated: Fingertip Amputation; Presented 5 hours (hrs) sp (status post) tip/nail avulsion. "Father states brought initially to NYH Queens, waited for some time, but wasn't seen so left and came here." Father has tip. Distal tip 5 hrs dry on gauze attached to nail.
Medical care included: Tip immediately cleaned of gross debris and after irrigation was placed in Normal Saline (NS). Fingertip re-attachment done by hand team - may not attach permanently - father informed.
Discharge: From (facility #2) ED at 19:44 (7:44 PM) on November 28, 2014.