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.

LAS PALMAS MEDICAL CENTER 1801 NORTH OREGON STREET EL PASO, TX 79902 Feb. 7, 2017
VIOLATION: CONTENT OF RECORD - DISCHARGE DIAGNOSIS Tag No: A0469
Based on review of clinical records and staff interview, the facility failed to ensure that medical records were completed with 30 calendar days following discharge.


Findings included:


The medical record for Patient #1 was not completed within 30 days as there were physician notes that were signed more than 30 days after written and after Patient #1 was discharged , to include the following:

Clinical Note 11/15/16 0705, not signed by physician until 12/28/16.

Internal Medicine Progress Note 11/16/16 0617, not signed by physician until 12/28/16.

Internal Medicine Progress Note 11/17/16 0618, not signed by physician until 12/28/16.

Internal Medicine Progress Note 11/18/16 0650, not signed by physician until 12/28/16.

Internal Medicine Progress Note 11/19/16 1459, not signed by physician until 12/28/16.

Internal Medicine Progress Note 11/20/16 1545, not signed by physician until 12/28/16.

Internal Medicine Progress Note 11/21/16 1634, not signed by physician until 12/28/16.

Discharge Summary 11/23/16 at 1525, not signed by physician until 12/28/16.


The above findings were confirmed in an interview with Staff #4 the afternoon of 2/7/17 in the administration office.
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
Based on review of documentation and interview, the nursing service did not ensure adequate number of licensed registered nurses and other personnel to provide nursing care to all patients in accordance with the "Staffing Table" for 5 South Medical/Surgical Unit. This deficient practice had the likelihood to cause harm to all patients admitted to 5 South.


Findings included:


Review of the medical record for Patient #1 on 5 South revealed that Patient #1 suffered a fall resulting in injuries. The only nursing note documenting the incident by Staff #13, RN on 11/18/16 stated, "At 0933 was called into Room 527. Maintenance had found patient on the floor. CNA [Staff #15] and RN [Staff #16] assisted patient back to bed. VS obtained and were WNL, see chart. No complaints of pain noted at this time. Patient had non slip footwear on, bed alarm was in place however did not go off. Informed Dr [Staff #17] at 0945. Around 1015, physical therapist went in to work with patinet (sic) and stated that patient had excruiating (sic) pain to left hip upon movement, even when elevating the HOB. [Staff #17] notified once again verbally and requested an xray."


CT scan on 11/18/16 at 1:38 pm for Patient #1 revealed "Left anterior sacral cortex fracture. Vertical Left obturator ring fracture ...." X-ray of Left hip with pelvis on 11/18/16 revealed "interval fracture off the medial left acetabulum. There is also irregularity of the left inferior pubic ramus not seen previously ...Impression: Left acetabular and inferior pubic rami fractures."


Review of the actual staffing for the day shift on 5 South for 11/18/16 revealed 1 Charge Nurse, 3 RNs, and 2 Nurse Assistants for 23 patients. The unit was short 1 RN and 1 nurse assistant per the Staffing Table.


Review of the actual staffing for the day shift for 2/5/17 revealed 1 Charge Nurse, 3 RNs, and 3.5 Nursing Assistants with a census of 20 patients. The unit was short 1 RN per the Staffing Table.


Review of the actual staffing for the day shift for 2/6/17 revealed 1 Charge Nurse, 3 RNs, and 2 Nursing Assistants with a census of 21 patients. The unit was short 1 RN per the Staffing Table.


Review of the actual staffing for the day shift for 2/7/17 revealed 1 Charge Nurse, 3 RNs, and 2 Nursing Assistants with a census of 20 patients. The unit was short 1 RN per the Staffing Table.


Review of the "Staffing Table" for 5 South Medical/Surgical Unit provided to the survey team on 2/7/16 in the Administrative Office revealed the following:

For a census of 20 patients:

1 Charge Nurse, 4 RNs, and 2 Nurse Assistants for the 7-3 pm day shift;

1 Charge Nurse, 4 RNs, and 2 Nurse Assistants for the 3-7 pm evening shift.


For a census of 21 patients:

1 Charge Nurse, 4 RNs, and 2 Nurse Assistants for the 7-3 pm day shift;

1 Charge Nurse, 4 RNs, and 2 Nurse Assistants for the 3-7 pm evening shift.


For a census of 23 patients:

1 Charge Nurse, 4 RNs, and 3 Nurse Assistants for the 7-3 pm day shift;

1 Charge Nurse, 4 RNs, and 2 Nurse Assistants for the 3-7 pm evening shift.


'The above findings were confirmed in an interview the afternoon of 2/7/17 with Staff #2 in the Administrative Office.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review, observation, and interviews, the hospital failed to;

1. ensure that nursing care was properly supervised, implemented, and evaluated;

2. ensure that assessments were conducted and documented; and

3. verify that patient care equipment was on and operational.

These practices were not in accordance with facility policy and standards of nursing practice and presents a risk to all patients admitted to the hospital.


Findings included:


Review of the medical record Plan of Care for Patient #1 revealed that she was an [AGE] year old female with a documented High Risk for Falls. Approximately a week before she was admitted to Del Sol hospital on [DATE], Patient #1 had fallen and suffered a wrist fracture.


On 11/18/16 a nursing shift assessment was completed at 0830 by Staff #13, RN which revealed the following:

"Fall Risk Elements: Fall HX (Last 3 Months) ...

Month/Year of Last Fall: [DATE] ...

Fall Risk Comment: HOURLY ROUNDING. CALL BELL AND PERSONAL BELONGINGS WITHIN REACH

High Risk for Falls: Y [Yes]

Fall Precautions Comment: NON SLIP FOOTWEAR"

There was no documented evidence that the nurse verified that the bed alarm was on and activated for Patient #1, or that Patient #1 had a yellow wristband or yellow gown per the hospital Fall Precautions Policy.


The morning of 11/18/16, Patient #1 suffered a fall in her patient room resulting in injuries, including left acetabular and inferior pubic rami fractures. The only nursing note documenting the incident by Staff #13, RN on 11/18/16 stated, "At 0933 was called into Room 527. Maintenance had found patient on the floor. CNA [Staff #15] and RN [Staff #16] assisted patient back to bed. VS obtained and were WNL, see chart. No complaints of pain noted at this time. Patient had non slip footwear on, bed alarm was in place however did not go off. Informed Dr [Staff #17] at 0945. Around 1015, physical therapist went in to work with patinet (sic) and stated that patient had excruiating (sic) pain to left hip upon movement, even when elevating the HOB. [Staff #17] notified once again verbally and requested an xray."


An interview was conducted with Staff #5, Mechanic from Maintenance Department the afternoon of 2/717 in the Administration Office. When asked about the incident involving a patient fall on November 18, 2016 on 5 South, Staff #5 stated, "I was walking in the hallway, checking the floor, I heard one voice screaming 'help, help.' I think it was afraid." Staff #5 stated, through a translator, "The cry for help sounded like she was scared, versus in pain." Staff #5 stated he looked into the patient room through the door from the hall and saw a patient on the floor. He went to the nurse's station and told them the patient was on the floor. The staff got up and responded.


At 1005 on 11/18/16, Staff #14, PT, DPT entered the room of Patient #1 for scheduled physical therapy treatment and assessed Patient #1. Staff #14 determined at that time that Patient #1 was in pain with limited range of motion of the left leg and bruising. Staff #14 notified the nursing staff of the injury to Patient #1 and informed the nursing staff that Patient #1 needed an x-ray to rule out a fracture.


At 1328 on 11/18/16, Staff #14. PT, documented that at 1005, "Patient presents in supine and upon arrival into room she indicates she has some pain. She refuses to get OOB [out of bed]. PROM [Passive Range of Motion]: RLE [right lower extremity] WFL [within functional limits]. However LLE [left lower extremity] is extremely painful with all PROM. Palpation: No TTP [thrombotic[DIAGNOSES REDACTED] purpura tender to palpation] over RLE, but bruising noted and TTP over L knee and hip. A: Patient demonstrates post fall reported by nursing this morning. She was found by Maintenance on the floor. She exhibits bruising and TTP over L knee and hip. She also indicates pain with bringing HOB [head of bed] up past 70 degrees, flinching towards L LE. Nursing notified that x-ray needs to be ordered to rule out fracture."


CT scan on 11/18/16 at 1:38 pm for Patient #1 revealed "Left anterior sacral cortex fracture. Vertical Left obturator ring fracture ...." X-ray of Left hip with pelvis on 11/18/16 revealed "interval fracture off the medial left acetabulum. There is also irregularity of the left inferior pubic ramus not seen previously ...Impression: Left acetabular and inferior pubic rami fractures."


There was no documented evidence in the medical record of an immediate assessment for evidence of injury after the fall, before Patient #1 was moved, in accordance with facility policy.

There was no medical record entry or nursing assessment documented related to the fall by Staff #16, RN, who was the RN that assisted the patient back to bed from the floor after the fall.

There was no documented evidence of a Post Fall Assessment by nursing for injuries after the fall as required by facility policy.

There was no documented evidence of a neurological assessment conducted by nursing after the fall as required by facility policy.

There was no documented evidence that Patient #1 was wearing a yellow wristband or yellow gown to indicate high risk for falls per policy.

There was no documented evidence of a Fall Risk Assessment conducted on Patient #1 after her fall on 11/18/16 at 0933, as required by facility policy; a Fall Risk Assessment was not conducted until the following shift at 2130.

As stated in the nurses note, the bed alarm did not sound and there was no documented evidence the bed alarm was on and functioning.

Review of the hospital report of the incident revealed that Patient #1 was not wearing a yellow falls precautions wristband or was wearing a yellow gown at the time of the fall, in accordance with facility policy.


A fall risk assessment was also not conducted in accordance with facility policy after Patient #1 returned to her room after a surgical intervention in the OR to repair the fracture on 11/22/16.

On 11/16/16 at 1100, Patient #1 was transferred to a different patient room. A Fall Risk Assessment was not conducted after the move in accordance with facility policy until 2235 on 11/16/16. A medical record entry was made at 1500 on 11/16/16 (4 hours after the patient was moved to the new room) which stated, "Fall Risk Precautions, View Only, Default from Fall Risk Assessment."


An interview was conducted the afternoon of 2/7/17 in the administration office with Staff #4. Staff #4 was asked by the survey team about the bed alarm not going off when Patient #1 got out of bed and fell . Staff #4 stated that she had spoken about the bed alarm to Staff #13, RN, the registered nurse assigned to Patient #1 when she fell and was injured. Staff #4 stated that Staff #13 told her that she had been in the room of Patient #1 earlier in the morning, working with her and moving her around on the bed. Staff #13 said that the bed alarm should have gone off during the time she was working with Patient #1, but it didn't occur to Staff #13 at the time that the alarm was not alarming. Per Staff #4, Staff #13 stated that she should have realized that when she was moving Patient #1 around on the bed, the bed alarm should have been going off, but it didn't occur to her until later, after the fall that the bed alarm wasn't working. Staff #4 stated that the bed alarm didn't alarm with the movement earlier in the morning or when Patient #1 got out of bed and fell at 9:33 am."


During the hospitalization of Patient #1 (11/14/16 - 11/23/16), there were only 3 instances of nursing documentation that the bed alarm for Patient #1 was on and verified. This documentation occurred on 11/15/16 at 1919, on 11/16/16 at 1500, on 11/19/16 at 1925.


Review of the medical record for Patient #1 revealed that a Fall Risk Assessment was not conducted each shift in accordance with policy for a patient with a high fall risk. There was no Fall Risk Assessment documented on the following shifts:

11/19/16 - no AM Fall Risk Assessment documented

11/20/16 - no AM Fall Risk Assessment documented

11/21/16 - no AM Fall Risk Assessment documented

11/22/16 - no AM Fall Risk Assessment documented

11/22/16 - no PM Fall Risk Assessment documented


A Fall Risk Assessment is required every shift in accordance with facility policy for a patient designated as a High Risk of Falls. Review of the medical record for Patient #1 revealed no documented evidence in the Fall Risk Assessment required every shift that the nurse verified that the bed alarm was on or activated on the following dates:

11/15/16 at 0910 No statement that the nurse verified the bed alarm was on or activated, only the words, "Bed Alarm"

11/16/16 at 0910 No statement that the nurse verified the bed alarm was on or activated

11/16/16 at 2100 No statement that the nurse verified the bed alarm was on or activated, only the words, "Bed Alarm"

11/16/16 at 2235 No statement that the nurse verified the bed alarm was on or activated, only the words, "Bed Alarm in place"

11/17/16 at 0730 No statement that the nurse verified the bed alarm was on or activated, only the words, "Bed Alarm in place"

11/17/16 at 2135 No statement that the nurse verified the bed alarm was on or activated, only the words, "Bed Alarm in place"

11/18/16 at 0830 No statement that the nurse verified the bed alarm was on or activated

11/18/16 at 0933 Patient #1 fell and bed alarm did not alarm

11/18/16 at 2130 No statement that the nurse verified the bed alarm was on or activated

11/19/16 at 2100 No statement that the nurse verified the bed alarm was on or activated

11/20/16 at 2155 No statement that the nurse verified the bed alarm was on or activated

11/21/16 at 2130 No statement that the nurse verified the bed alarm was on or activated

11/23/16 at 0800 No statement that the nurse verified the bed alarm was on or activated


There were 7 text nursing notes during the hospitalization of Patient #1 (11/14/16 - 11/23/16) which stated "Bed alarm in place"; however there was no statement that the nurse verified that the bed alarm was on or activated. (11/18/16 at 0632, 11/18/16 at 1900, 11/18/16 at 2055, 11/19/16 at 0639, 11/20/16 at 0612, 11/20/16 at 1900, 11/23/16 at 0830).


Review of the medical records for 9 current patients the afternoon of 2/7/17 that were admitted to the 5 South unit of Vista Del Sol Medical Center revealed the following:

Patient #2 revealed no statement the bed alarm was on or activated for 02/02/17.

Patient #5 revealed no statement the bed alarm was on or activated for 02/06/17.

Patient #6 revealed no statement the bed alarm was on or activated for 02/05/17.

Patient #7 revealed no statement the bed alarm was on or activated for 01/31/17.

Patient #9 revealed no statement the bed alarm was on or activated for 02/06/17.

In an interview on the afternoon of 2/7/17 at the 5 South nurses station, the clinical coordinator, Staff #10, confirmed the findings.


Review of the medical record for Patient #1 on 11/18/16 at 0830 revealed the assessing nurse documented, "N" [No] to the fall risk assessment indicator, "Pt has 3 or more meds in drug classes known to be indicator of fall risk". Patient #1 was taking Clonazepam, Enalapril and Gabapentin routinely, all of which are labeled in the hospital electronic eMAR system, "**CAUTION: MEDICATION ASSOCIATED WITH FALLS**". Patient #1 was also taking Morphine for her wrist fracture pain. 7 out of 11 shifts where fall risk assessments were documented had an incorrect response to the question regarding 3 or more medications, as below.

11/16/16 at 0910 documented "N" [No] for 3 or more medications

11/16/16 at 2100 documented "N" [No] for 3 or more medications

11/16/16 at 2235 documented "N" [No] for 3 or more medications

11/17/16 at 0730 documented "N" [No] for 3 or more medications

11/18/16 at 0830 documented "N" [No] for 3 or more medications

11/18/16 at 2130 documented "N" [No] for 3 or more medications

11/23/16 at 0800 documented "N" [No] for 3 or more medications


The "Unit Activity Report" for Patient #1 provided to the survey team revealed a "Detailed record of all activities per Unit/Team in date order". This report included a timed report of every nurse or nurse assistant entering and exiting the room of Patient #1 between 11/17/16 and 11/23/16. Patient #1, a high risk for falls, would require rounding every hour, according to hospital policy. Review of the Unit Activity Report revealed that nursing staff did not make rounds every hour in accordance with facility policy for Patient #1 at least 24 times between 11/17/16 and 11/23/16.

11/17/16
No rounds between 1:39 am and 3:07 am
No rounds between 3:33 am and 4:38 am
No rounds between 7:13 pm and 9:15 pm

11/18/16
No rounds between 4:53 am and 6:20 am
No rounds between 6:24 am and 8:24 am

11/19/16
No rounds between 4:18 pm and 5:39 pm
No rounds between 7:35 pm and 9:12 pm

11/20/16
No rounds between 1:03 pm and 2:19 pm
No rounds between 8:13 pm and 9:54 pm

11/21/16
No rounds between 00:16 am and 2:11 am
No rounds between 2:11 am and 3:20 am
No rounds between 4:04 am and 5:10 am
No rounds between 5:18 am and 6:48 am
No rounds between 4:13 pm and 5:24 pm

11/22/16
No rounds between 00:45 am and 3:43 am
No rounds between 3:53 am and 5:16 am
No rounds between 3:20 pm and 5:20 pm

11/23/16 - returned from OR at 2309 on 11/22/16
No rounds between 00:53 am and 3:34 pm
No rounds between 3:36 am and 5:30 am
No rounds between 5:45 am and 7:21 am
No rounds between 8:53 am and 11:39 am
No rounds between 1:57 pm and 3:14 pm
No rounds between 7:56 pm and 9:28 pm
No rounds between 9:49 pm and 11:06 pm


In an interview with Staff #2 the afternoon of 2/7/17 in the Administration Office, she stated that rounds are not made every hour during the night shift. Review of the document provided to the survey team entitled, "In-Patient Hourly Rounding Log" revealed a form used on the unit to track hourly rounding. The form had a line for every hour until 10 pm-12am, 12-2 am, 2-4 am, and 4-6 am. Staff #2 stated that the form was not a part of the medical record and was thrown away after each shift.


The personnel folder was reviewed for Staff #13, RN, who was the Registered Nurse assigned to Patient #1 on 11/18/16 when she sustained a fall resulting in injury. Review of the personnel record revealed a Position Description and Competency Evaluation, Annual Evaluation Effective Date May 2016. The Annual Evaluation, signed by Staff #13 on 6/16/16 documented a specific goal which stated, "State specific steps with deadline dates to accomplish goals ...3. Check bed/wheelchair alarms during hourly rounding (7/1/16)." 2016 Mandatory Fair Requirement Record dated 5/31/16 revealed "Fall Prevention" training for Staff #13 (completed before the annual evaluation). The In-service Record document dated November 29 -30, 2016 revealed Staff #13 attended a Power Point presentation dated 5/25/16 and 5/26/16 that included a section on preventing falls. There was no documented follow-up on the 6/16/16 goal for Staff #13 to check bed/wheelchair alarms during hourly rounding with a due date of 7/1/16. Staff #13 was and continues to be licensed as an RN in the state of Texas. All other required training, including CPR certifications were current on 11/18/16 and as of 2/7/17. The above was confirmed in an interview the afternoon of 2/7/17 with Staff #2 in the Administration Office.


Review of facility policy "PC 237_Patient Fall Prevention" stated, in part, "PURPOSE: To identify patients at risk for falls, to assess fall potential, and to provide a maximum level of patient protection and safety without compromising mobility and functional independence. POLICY: Upon admission, patients are assured of assessment of their risk for falls; manipulation of the environment to prevent falls, and appropriate management of those who experience a fall. Most falls do not lead to serious injury; however, moderate to severe injuries reduce mobility and independence and increase the risk for premature death ...Of all fall-related fractures, hip fractures are the most serious and lead to the greatest number of health problems and death. Patients who fall once during their outpatient stay are more likely to fall again, increasing the risk for more injury.


The Falls Prevention Program Includes ...2. Basic safety considerations/interventions for all patient. 3. Screening to identify patients at risk for falls or injury. 4. Use of recommended interventions for patients assessed "at Risk." 5. Post-fall management, documentation and follow-up.

PROCEDURE:

GENERAL ...C. Patient at a high risk for falls will be identified with a YELLOW wristband and YELLOW socks. D. Patients that have one or more of the following criteria (confused, impulsive or history of falls) will be identified with a YELLOW gown in addition to the YELLOW wristband and YELLOW socks. E. Hourly rounding will be performed on all patients.
RISK ASSESSMENT:

A. A Fall evaluation is defined as an assessment that includes the following: a history of all circumstances, medications, acute or chronic medical problems, and mobility levels; an examination of vision, gait and balance, and lower extremity joint function; an examination of basic neurological function, including mental status, muscle strength; and assessment of basic cardiovascular status including heart rate and rhythm, and blood pressure ...

D. A Fall Risk Assessment will be completed in Meditech as part of the Nursing Admission Assessment and every shift ...

E. All adult and geriatric patients on the nursing units will have a fall risk assessment performed on:

1. Admission

2. Once a shift

3. Transfer (be receiving unit)

4. After receiving IV sedation

5. A change of condition or LOC

6. Change in medications that may contribute to falls risk

7. After any surgical intervention/procedure and

8. After any fall ...

E. The fall assessment will determine whether a fall risk exists for the patient, and if so, whether it is low, moderate, or high risk. Based on the assessment, fall precautions will be initiated and documented.

a. Score of 0-8 = Low Risk
b. Score >9 = High Risk

Interventions and Preventive Strategies

A. Implement the following interventions according to the Fall Risk Assessment scores.

1. Low Risk Intervention Score of 0-8 ...

Hourly rounds using the 4-P's - Pain, Potty, Positioning, and Possessions

Call Bell within reach; room is free of clutter, nightlight it on; bed is in the lowest position and locked; and all personal items are within reach ...

Both side bedrails are up X2 ...

Evaluate medication regime: Medication categories determined to potentiate risk of falls include narcotics, sedatives, tranquilizers, psychotropic's, cardiovascular, diuretics, anticonvulsives, laxatives, and antidepressants.

2. High Risk Interventions (Score at or greater than 9)

Implement all intervention for Low Risk
Alert: Apply yellow armband
Bed Alarm on bed ...
Provide non-slip footwear
Assist: Mobility
Assist: ADL"


Review of facility policy "PC 237_Patient Fall Prevention stated, in part,

"POST-FALL-WHENEVER A FALL OCCURS

1. Assess immediately for evidence of injury before moving the patient.

2. Post Fall Assessment. The physician, family/legal representative, manager, and nursing supervisor are notified.

3. The nurse documents the fall data and all persons notified in the Nursing Notes ...

DOCUMENTATION: ...

2. Complete a Post Fall Assessment and re-evaluate the Plan of Care and adjust interventions accordingly. Follow-up should consist of implementing and documenting the following in the nurses notes:

Vitals: Blood pressure, Pulse, Respirations

Neurological: Level of consciousness, Headache, Glascow Coma Score, Pupils (size/reaction) (If medicated with narcotics or sedatives in the last 12 hrs, consider that head injury may be masked because of medications)

Motor Strength: Arms and legs, Bilateral hand grasp

Musculoskeletal: Bilateral Upper & lower Extremities, Gait, ROM & Muscle tone

Skin Integrity: Skin intact & location, Bruising/contusions (location), Laceration/abrasions (location), Lines/tubes intact

Pain: Location, level, radiates to ..."


Facility policy, "PC 201_Assessment/Reassessment" stated, in part, "2. Focused assessment (Shift Reassessment) ...For all patients reassessment is at specified, regular intervals which may be related to: ...f. Risk for falling when appropriate and action taken to reduce risk.

NURSING ...9 ...The patient's health status will determine the frequency of assessment; however, an R.N. will perform a reassessment to include an update of the Plan of Care in at least the following situations ...

a. Prior to, upon arrival, and discharge from special procedures (i.e. Endo, OR, Cath lab) area.

b. Any time there is a significant change in the patient's condition ...

e. When the patient is transferred from one unit to another unit ...

i. Focused re-assessment, at least, once a shift."


Review of the Texas Nurse Practice Act 217.11, Standards of Nursing Practice, states, in part,

"(1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: (A) Know and conform to the Texas Nursing Practice Act and the board's rules and regulations as well as all federal, state, or local laws, rules or regulations affecting the nurse's current area of nursing practice;

(B) Implement measures to promote a safe environment for clients and others; ...

(D) Accurately and completely report and document:

(i) the client's status including signs and symptoms;

(ii) nursing care rendered; ...

(v) client response(s); and

(vi) contacts with other health care team members concerning significant events regarding client's status;"


The above findings were confirmed in an interview the afternoon of 2/7/16 with Staff #2 in the Administration Office.
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
Based on review of documentation and interview, the facility failed to ensure that a patients were informed of their patient rights as there was no documented evidence that patient rights documents were received or provided to the patient or legally authorized representative.


Findings included:


The medical record for Patient #1 was reviewed. The "Conditions of Admission and Consent for Outpatient Care" in the medical record for Patient #1, an 8 page document, was not signed by the patient or the legally authorized representative of the patient. The document included:

1. Consent to Treatment ...

9. Medicare Patient Certification and Assignment of Benefit ...

12. Communications About My Healthcare ...

15. Other Acknowledgements, including information about Personal Valuables, Patient Visitation Rights, Records Retention, Patient Self Determination Act (Advance Directives), Notice of Privacy Practices, and Acknowledgement of Notice of Patient Rights and Responsibilities.
The spaces on the form for patient or legally authorized representative initials were left blank, including the acknowledgement of receipt the Notice of Patient Rights and Responsibilities. The form was not dated. The form was left blank/no signature in the space for "Patient/Patient Representative Signature". The space for "Witness Signature and Title" had a hand-written signature (illegible) and the space for "Additional Witness Signature and Title: (required for Patients unable to sign without a representative or Patients who refuse to sign)" had a hand-written signature (also illegible). The signatures were not dated or timed.


However, Patient #1 did have a Power of Attorney, per the Surgical Consent to Treatment for Patient #1 for surgery on 11/22/16 related to a pelvic ring fracture sustained during a fall on 11/18/16. This consent was signed on 4 separate pages on 11/21/16 at 2000 PM by the daughter of Patient #1, who documented her relationship to the patient with each of the 4 signatures as "Daughter/POA".


There was no documented evidence in the record or provided to the survey team that Patient #1 or the legally authorized representative for Patient #1 were provided with or advised of their Patient Rights.


In an interview with Staff #2 the afternoon of 2/8/17 in the Administration Office, the above findings were confirmed. Staff #2 stated that Patient #1 came in through the ER via EMS and therefore consent was not obtained, which included providing or advising the patient of their Patient Rights.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of documentation and interview, it was determined that the facility did not always provide patient care in a safe setting as the hospital did not supply an adequate number of licensed registered nurses and other personnel to provide nursing care to all patients in accordance with the "Staffing Table" for 5 South Medical/Surgical Unit. The hospital failed to ensure that nursing care was properly supervised, implemented, and evaluated, failed to ensure that assessments were conducted and documented and failed to verify that patient care equipment was on and operational. This was not in accordance with facility policy and standards of nursing practice and presents a risk to all patients admitted to the hospital.

Findings included:

Review of the medical record Plan of Care for Patient #1 revealed that she was an [AGE] year old female with a documented High Risk for Falls. Approximately a week before she was admitted to Del Sol hospital on [DATE], Patient #1 had fallen and suffered a wrist fracture.

On 11/18/16 a nursing shift assessment was completed at 0830 by Staff #13, RN which revealed the following:
"Fall Risk Elements: Fall HX (Last 3 Months) ...
Month/Year of Last Fall: [DATE] ...
Fall Risk Comment: HOURLY ROUNDING. CALL BELL AND PERSONAL BELONGINGS WITHIN REACH
High Risk for Falls: Y [Yes]
Fall Precautions Comment: NON SLIP FOOTWEAR"
There was no documented evidence that the nurse verified that the bed alarm was on and activated for Patient #1, or that Patient #1 had a yellow wristband or yellow gown per the hospital Fall Precautions Policy.

The morning of 11/18/16, Patient #1 suffered a fall in her patient room resulting in injuries, including left acetabular and inferior pubic rami fractures. The only nursing note documenting the incident by Staff #13, RN on 11/18/16 stated, "At 0933 was called into Room 527. Maintenance had found patient on the floor. CNA [Staff #15] and RN [Staff #16] assisted patient back to bed. VS obtained and were WNL, see chart. No complaints of pain noted at this time. Patient had non slip footwear on, bed alarm was in place however did not go off. Informed Dr [Staff #17] at 0945. Around 1015, physical therapist went in to work with patient (sic) and stated that patient had excruiating (sic) pain to left hip upon movement, even when elevating the HOB. [Staff #17] notified once again verbally and requested an xray."

An interview was conducted with Staff #5, Mechanic from Maintenance Department the afternoon of 2/7/17 in the Administration Office. When asked about the incident involving a patient fall on November 18, 2016 on 5 South, Staff #5 stated, "I was walking in the hallway, checking the floor, I heard one voice screaming 'help, help.' I think it was afraid." Staff #5 stated, through a translator, "The cry for help sounded like she was scared, versus in pain." Staff #5 stated he looked into the patient room through the door from the hall and saw a patient on the floor. He went to the nurse's station and told them the patient was on the floor. The staff got up and responded.

At 1005 on 11/18/16, Staff #14, PT, DPT entered the room of Patient #1 for scheduled physical therapy treatment and assessed Patient #1. Staff #14 determined at that time that Patient #1 was in pain with limited range of motion of the left leg and bruising. Staff #14 notified the nursing staff of the injury to Patient #1 and informed the nursing staff that Patient #1 needed an x-ray to rule out a fracture.

At 1328 on 11/18/16, Staff #14. PT, documented that at 1005, "Patient presents in supine and upon arrival into room she indicates she has some pain. She refuses to get OOB [out of bed].
PROM [Passive Range of Motion]: RLE [right lower extremity] WFL [within functional limits]. However LLE [left lower extremity] is extremely painful with all PROM.
Palpation: No TTP [thrombotic[DIAGNOSES REDACTED] purpura tender to palpation] over RLE, but bruising noted and TTP over L knee and hip.
A: Patient demonstrates post fall reported by nursing this morning. She was found by Maintenance on the floor. She exhibits bruising and TTP over L knee and hip. She also indicates pain with bringing HOB [head of bed] up past 70 degrees, flinching towards L LE. Nursing notified that x-ray needs to be ordered to rule out fracture."

CT scan on 11/18/16 at 1:38 pm for Patient #1 revealed "Left anterior sacral cortex fracture. Vertical Left obturator ring fracture ...." X-ray of Left hip with pelvis on 11/18/16 revealed "interval fracture off the medial left acetabulum. There is also irregularity of the left inferior pubic ramus not seen previously ...Impression: Left acetabular and inferior pubic rami fractures."

There was no documented evidence in the medical record of an immediate assessment for evidence of injury after the fall, before Patient #1 was moved, in accordance with facility policy.
There was no medical record entry or nursing assessment documented related to the fall by Staff #16, RN, who was the RN that assisted the patient back to bed from the floor after the fall.
There was no documented evidence of a Post Fall Assessment by nursing for injuries after the fall as required by facility policy.
There was no documented evidence of a neurological assessment conducted by nursing after the fall as required by facility policy.
There was no documented evidence that Patient #1 was wearing a yellow wristband or yellow gown to indicate high risk for falls per policy.
There was no documented evidence of a Fall Risk Assessment conducted on Patient #1 after her fall on 11/18/16 at 0933, as required by facility policy; a Fall Risk Assessment was not conducted until the following shift at 2130.
As stated in the nurses note, the bed alarm did not sound and there was no documented evidence the bed alarm was on and functioning.
Review of the hospital report of the incident revealed that Patient #1 was not wearing a yellow falls precautions wristband or was wearing a yellow gown at the time of the fall, in accordance with facility policy.

A fall risk assessment was also not conducted in accordance with facility policy after Patient #1 returned to her room after a surgical intervention in the OR to repair the fracture on 11/22/16.
On 11/16/16 at 1100, Patient #1 was transferred to a different patient room. A Fall Risk Assessment was not conducted after the move in accordance with facility policy until 2235 on 11/16/16. A medical record entry was made at 1500 on 11/16/16 (4 hours after the patient was moved to the new room) which stated, "Fall Risk Precautions, View Only, Default from Fall Risk Assessment."

An interview was conducted the afternoon of 2/7/17 in the administration office with Staff #4. Staff #4 was asked by the survey team about the bed alarm not going off when Patient #1 got out of bed and fell . Staff #4 stated that she had spoken about the bed alarm to Staff #13, RN, the registered nurse assigned to Patient #1 when she fell and was injured. Staff #4 stated that Staff #13 told her that she had been in the room of Patient #1 earlier in the morning, working with her and moving her around on the bed. Staff #13 said that the bed alarm should have gone off during the time she was working with Patient #1, but it didn't occur to Staff #13 at the time that the alarm was not alarming. Per Staff #4, Staff #13 stated that she should have realized that when she was moving Patient #1 around on the bed, the bed alarm should have been going off, but it didn't occur to her until later, after the fall that the bed alarm wasn't working. Staff #4 stated that the bed alarm didn't alarm with the movement earlier in the morning or when Patient #1 got out of bed and fell at 9:33 am."

During the hospitalization of Patient #1 (11/14/16 - 11/23/16), there were only 3 instances of nursing documentation that the bed alarm for Patient #1 was on and verified. This documentation occurred on 11/15/16 at 1919, on 11/16/16 at 1500, on 11/19/16 at 1925.

Review of the medical record for Patient #1 revealed that a Fall Risk Assessment was not conducted each shift in accordance with policy for a patient with a high fall risk. There was no Fall Risk Assessment documented on the following shifts:
11/19/16 - no AM Fall Risk Assessment documented
11/20/16 - no AM Fall Risk Assessment documented
11/21/16 - no AM Fall Risk Assessment documented
11/22/16 - no AM Fall Risk Assessment documented
11/22/16 - no PM Fall Risk Assessment documented

A Fall Risk Assessment is required every shift in accordance with facility policy for a patient designated as a High Risk of Falls. Review of the medical record for Patient #1 revealed no documented evidence in the Fall Risk Assessment required every shift that the nurse verified that the bed alarm was on or activated on the following dates:
11/15/16 at 0910 No statement that the nurse verified the bed alarm was on or activated, only the words, "Bed Alarm"
11/16/16 at 0910 No statement that the nurse verified the bed alarm was on or activated
11/16/16 at 2100 No statement that the nurse verified the bed alarm was on or activated, only the words, "Bed Alarm"
11/16/16 at 2235 No statement that the nurse verified the bed alarm was on or activated, only the words, "Bed Alarm in place"
11/17/16 at 0730 No statement that the nurse verified the bed alarm was on or activated, only the words, "Bed Alarm in place"
11/17/16 at 2135 No statement that the nurse verified the bed alarm was on or activated, only the words, "Bed Alarm in place"
11/18/16 at 0830 No statement that the nurse verified the bed alarm was on or activated
11/18/16 at 0933 Patient #1 fell and bed alarm did not alarm
11/18/16 at 2130 No statement that the nurse verified the bed alarm was on or activated
11/19/16 at 2100 No statement that the nurse verified the bed alarm was on or activated
11/20/16 at 2155 No statement that the nurse verified the bed alarm was on or activated
11/21/16 at 2130 No statement that the nurse verified the bed alarm was on or activated
11/23/16 at 0800 No statement that the nurse verified the bed alarm was on or activated

There were 7 text nursing notes during the hospitalization of Patient #1 (11/14/16 - 11/23/16) which stated "Bed alarm in place"; however there was no statement that the nurse verified that the bed alarm was on or activated. (11/18/16 at 0632, 11/18/16 at 1900, 11/18/16 at 2055, 11/19/16 at 0639, 11/20/16 at 0612, 11/20/16 at 1900, 11/23/16 at 0830).

Review of the medical records for 9 current patients the afternoon of 2/7/17 that were admitted to the 5 South unit of Vista Del Sol Medical Center revealed the following:
Patient #2 revealed no statement the bed alarm was on or activated for 02/02/17.
Patient #5 revealed no statement the bed alarm was on or activated for 02/06/17.
Patient #6 revealed no statement the bed alarm was on or activated for 02/05/17.
Patient #7 revealed no statement the bed alarm was on or activated for 01/31/17.
Patient #9 revealed no statement the bed alarm was on or activated for 02/06/17.
In an interview on the afternoon of 2/7/17 at the 5 South nurses station, the clinical coordinator, Staff #10, confirmed the findings.

Review of the medical record for Patient #1 on 11/18/16 at 0830 revealed the assessing nurse documented, "N" [No] to the fall risk assessment indicator, "Pt has 3 or more meds in drug classes known to be indicator of fall risk". Patient #1 was taking Clonazepam, Enalapril and Gabapentin routinely, all of which are labeled in the hospital electronic eMAR system, "**CAUTION: MEDICATION ASSOCIATED WITH FALLS**". Patient #1 was also taking Morphine for her wrist fracture pain. 7 out of 11 shifts where fall risk assessments were documented had an incorrect response to the question regarding 3 or more medications, as below.
11/16/16 at 0910 documented "N" [No] for 3 or more medications
11/16/16 at 2100 documented "N" [No] for 3 or more medications
11/16/16 at 2235 documented "N" [No] for 3 or more medications
11/17/16 at 0730 documented "N" [No] for 3 or more medications
11/18/16 at 0830 documented "N" [No] for 3 or more medications
11/18/16 at 2130 documented "N" [No] for 3 or more medications
11/23/16 at 0800 documented "N" [No] for 3 or more medications

The "Unit Activity Report" for Patient #1 provided to the survey team revealed a "Detailed record of all activities per Unit/Team in date order". This report included a timed report of every nurse or nurse assistant entering and exiting the room of Patient #1 between 11/17/16 and 11/23/16. Patient #1, a high risk for falls, would require rounding every hour, according to hospital policy. Review of the Unit Activity Report revealed that nursing staff did not make rounds every hour in accordance with facility policy for Patient #1 at least 24 times between 11/17/16 and 11/23/16.
11/17/16
No rounds between 1:39 am and 3:07 am
No rounds between 3:33 am and 4:38 am
No rounds between 7:13 pm and 9:15 pm
11/18/16
No rounds between 4:53 am and 6:20 am
No rounds between 6:24 am and 8:24 am
11/19/16
No rounds between 4:18 pm and 5:39 pm
No rounds between 7:35 pm and 9:12 pm
11/20/16
No rounds between 1:03 pm and 2:19 pm
No rounds between 8:13 pm and 9:54 pm
11/21/16
No rounds between 00:16 am and 2:11 am
No rounds between 2:11 am and 3:20 am
No rounds between 4:04 am and 5:10 am
No rounds between 5:18 am and 6:48 am
No rounds between 4:13 pm and 5:24 pm
11/22/16
No rounds between 00:45 am and 3:43 am
No rounds between 3:53 am and 5:16 am
No rounds between 3:20 pm and 5:20 pm
11/23/16 - returned from OR at 2309 on 11/22/16
No rounds between 00:53 am and 3:34 pm
No rounds between 3:36 am and 5:30 am
No rounds between 5:45 am and 7:21 am
No rounds between 8:53 am and 11:39 am
No rounds between 1:57 pm and 3:14 pm
No rounds between 7:56 pm and 9:28 pm
No rounds between 9:49 pm and 11:06 pm

In an interview with Staff #2 the afternoon of 2/7/17 in the Administration Office, she stated that rounds are not made every hour during the night shift. Review of the document provided to the survey team entitled, "In-Patient Hourly Rounding Log" revealed a form used on the unit to track hourly rounding. The form had a line for every hour until 10 pm-12am, 12-2 am, 2-4 am, and 4-6 am. Staff #2 stated that the form was not a part of the medical record and was thrown away after each shift.

The personnel folder was reviewed for Staff #13, RN, who was the Registered Nurse assigned to Patient #1 on 11/18/16 when she sustained a fall resulting in injury. Review of the personnel record revealed a Position Description and Competency Evaluation, Annual Evaluation Effective Date May 2016. The Annual Evaluation, signed by Staff #13 on 6/16/16 documented a specific goal which stated, "State specific steps with deadline dates to accomplish goals ...3. Check bed/wheelchair alarms during hourly rounding (7/1/16)." 2016 Mandatory Fair Requirement Record dated 5/31/16 revealed "Fall Prevention" training for Staff #13 (completed before the annual evaluation). The In-service Record document dated November 29 -30, 2016 revealed Staff #13 attended a Power Point presentation dated 5/25/16 and 5/26/16 that included a section on preventing falls. There was no documented follow-up on the 6/16/16 goal for Staff #13 to check bed/wheelchair alarms during hourly rounding with a due date of 7/1/16. Staff #13 was and continues to be licensed as an RN in the state of Texas. All other required training, including CPR certifications were current on 11/18/16 and as of 2/7/17. The above was confirmed in an interview the afternoon of 2/7/17 with Staff #2 in the Administration Office.

Review of facility policy "PC 237_Patient Fall Prevention" stated, in part, "PURPOSE: To identify patients at risk for falls, to assess fall potential, and to provide a maximum level of patient protection and safety without compromising mobility and functional independence. POLICY: Upon admission, patients are assured of assessment of their risk for falls; manipulation of the environment to prevent falls, and appropriate management of those who experience a fall. Most falls do not lead to serious injury; however, moderate to severe injuries reduce mobility and independence and increase the risk for premature death ...Of all fall-related fractures, hip fractures are the most serious and lead to the greatest number of health problems and death. Patients who fall once during their outpatient stay are more likely to fall again, increasing the risk for more injury.
The Falls Prevention Program Includes ...2. Basic safety considerations/interventions for all patient. 3. Screening to identify patients at risk for falls or injury. 4. Use of recommended interventions for patients assessed "at Risk." 5. Post-fall management, documentation and follow-up.
PROCEDURE:
GENERAL ...C. Patient at a high risk for falls will be identified with a YELLOW wristband and YELLOW socks. D. Patients that have one or more of the following criteria (confused, impulsive or history of falls) will be identified with a YELLOW gown in addition to the YELLOW wristband and YELLOW socks. E. Hourly rounding will be performed on all patients.
RISK ASSESSMENT:
A. A Fall evaluation is defined as an assessment that includes the following: a history of all circumstances, medications, acute or chronic medical problems, and mobility levels; an examination of vision, gait and balance, and lower extremity joint function; an examination of basic neurological function, including mental status, muscle strength; and assessment of basic cardiovascular status including heart rate and rhythm, and blood pressure ...
D. A Fall Risk Assessment will be completed in Meditech as part of the Nursing Admission Assessment and every shift ...
E. All adult and geriatric patients on the nursing units will have a fall risk assessment performed on:
1. Admission
2. Once a shift
3. Transfer (be receiving unit)
4. After receiving IV sedation
5. A change of condition or LOC
6. Change in medications that may contribute to falls risk
7. After any surgical intervention/procedure and
8. After any fall ...
E. The fall assessment will determine whether a fall risk exists for the patient, and if so, whether it is low, moderate, or high risk. Based on the assessment, fall precautions will be initiated and documented.
a. Score of 0-8 = Low Risk
b. Score >9 = High Risk
Interventions and Preventive Strategies
A. Implement the following interventions according to the Fall Risk Assessment scores.
1. Low Risk Intervention Score of 0-8 ...
Hourly rounds using the 4-P's - Pain, Potty, Positioning, and Possessions
Call Bell within reach; room is free of clutter, nightlight it on; bed is in the lowest position and locked; and all personal items are within reach ...
Both side bedrails are up X2 ...
Evaluate medication regime: Medication categories determined to potentiate risk of falls include narcotics, sedatives, tranquilizers, psychotropic's, cardiovascular, diuretics, anticonvulsives, laxatives, and antidepressants.
2. High Risk Interventions (Score at or greater than 9)
Implement all intervention for Low Risk
Alert: Apply yellow armband
Bed Alarm on bed ...
Provide non-slip footwear
Assist: Mobility
Assist: ADL"

Review of facility policy "PC 237_Patient Fall Prevention stated, in part,
"POST-FALL-WHENEVER A FALL OCCURS
1. Assess immediately for evidence of injury before moving the patient.
2. Post Fall Assessment. The physician, family/legal representative, manager, and nursing supervisor are notified.
3. The nurse documents the fall data and all persons notified in the Nursing Notes ...
DOCUMENTATION: ...
2. Complete a Post Fall Assessment and re-evaluate the Plan of Care and adjust interventions accordingly. Follow-up should consist of implementing and documenting the following in the nurses notes:
Vitals: Blood pressure, Pulse, Respirations
Neurological: Level of consciousness, Headache, Glascow Coma Score, Pupils (size/reaction) (If medicated with narcotics or sedatives in the last 12 hrs, consider that head injury may be masked because of medications)
Motor Strength: Arms and legs, Bilateral hand grasp
Musculoskeletal: Bilateral Upper & lower Extremities, Gait, ROM & Muscle tone
Skin Integrity: Skin intact & location, Bruising/contusions (location), Laceration/abrasions (location), Lines/tubes intact
Pain: Location, level, radiates to ..."

Facility policy, "PC 201_Assessment/Reassessment" stated, in part, "2. Focused assessment (Shift Reassessment) ...For all patients reassessment is at specified, regular intervals which may be related to: ...f. Risk for falling when appropriate and action taken to reduce risk.
NURSING ...9 ...The patient's health status will determine the frequency of assessment; however, an R.N. will perform a reassessment to include an update of the Plan of Care in at least the following situations ...
a. Prior to, upon arrival, and discharge from special procedures (i.e. Endo, OR, Cath lab) area.
b. Any time there is a significant change in the patient's condition ...
e. When the patient is transferred from one unit to another unit ...
i. Focused re-assessment, at least, once a shift."

Review of the Texas Nurse Practice Act 217.11, Standards of Nursing Practice, states, in part,
"(1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: (A) Know and conform to the Texas Nursing Practice Act and the board's rules and regulations as well as all federal, state, or local laws, rules or regulations affecting the nurse's current area of nursing practice;
(B) Implement measures to promote a safe environment for clients and others; ...
(D) Accurately and completely report and document:
(i) the client's status including signs and symptoms;
(ii) nursing care rendered; ...
(v) client response(s); and
(vi) contacts with other health care team members concerning significant events regarding client's status;"

The above findings were confirmed in an interview the afternoon of 2/7/16 with Staff #2 in the Administration Office.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on review of documentation and interview, the nursing service did not supply an adequate number of licensed registered nurses and other personnel to provide nursing care to all patients in accordance with the "Staffing Table" for 5 South Medical/Surgical Unit. This deficient practice had the likelihood to cause harm to all patients admitted to 5 South.
Cross refer: CFR 482.23(b) A0392 Staffing and Delivery of Care

Based on document review, observation, and interviews, the hospital failed to ensure that nursing care was properly supervised, implemented, and evaluated, failed to ensure that assessments were conducted and documented and failed to verify that patient care equipment was on and operational. This was not in accordance with facility policy and standards of nursing practice and presents a risk to all patients admitted to the hospital.
Cross refer: CFR 482.23(b)(3) A0395 RN Supervision of Nursing Care
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
Based on review of documentation and interview, the facility failed to ensure that a patient was afforded the right to informed consent to treatment and provided their patient rights as there was no documented evidence that patient rights were received or consent to inpatient treatment was provided by the patient or legally authorized representative.

Findings included:

Facility policy, "Legal Authority for Consent" RI 120.2, stated, in part, "3. In an emergency, consent is implied by law, but such consent exists only during the immediate emergency and is limited to treatment necessary to resolve the emergency.
4. When an adult patient is comatose, incapacitated or otherwise mentally or physically incapable of communication, another adult may consent to the medical treatment for the patient (Consent to Medical Treatment Act (1993).
4.1 In order of priority, the following individuals may consent to treatment of an incapacitated adult patient.
4.1.1 Agent designated by Medical Power of Attorney ..."

The medical record for Patient #1 was reviewed. The "Conditions of Admission and Consent for Outpatient Care" in the medical record for Patient #1, an 8 page document, was not signed by the patient or the legally authorized representative of the patient. The document included:
1. Consent to Treatment ...
9. Medicare Patient Certification and Assignment of Benefit ...
12. Communications About My Healthcare ...
15. Other Acknowledgements, including information about Personal Valuables, Patient Visitation Rights, Records Retention, Patient Self Determination Act (Advance Directives), Notice of Privacy Practices, and Acknowledgement of Notice of Patient Rights and Responsibilities.
The spaces on the form for patient or legally authorized representative initials were left blank, including the acknowledgement of receipt the Notice of Patient Rights and Responsibilities. The form was not dated. The form was left blank/no signature in the space for "Patient/Patient Representative Signature". The space for "Witness Signature and Title" had a hand-written signature (illegible) and the space for "Additional Witness Signature and Title: (required for Patients unable to sign without a representative or Patients who refuse to sign)" had a hand-written signature (also illegible). The signatures were not dated or timed.

However, Patient #1 did have a Power of Attorney, per the Surgical Consent to Treatment for Patient #1 for surgery on 11/22/16 related to a pelvic ring fracture sustained during a fall on 11/18/16. This consent was signed on 4 separate pages on 11/21/16 at 2000 PM by the daughter of Patient #1, who documented her relationship to the patient with each of the 4 signatures as "Daughter/POA".

There was no documented evidence of a Consent to Treatment for Inpatient Care in the medical record for Patient #1 provided to the survey team for the inpatient admission of Patient #1.

There was no documented evidence in the record or provided to the survey team that Patient #1 or the legally authorized representative for Patient #1 was provided with the Conditions of Admission or provided Consent for Treatment. There was no documented evidence in the medical record that Patient #1 or the legally authorized representative for Patient #1 were advised of their Patient Rights.

In an interview with Staff #2 the afternoon of 2/8/17 in the Administration Office, the above findings were confirmed. Staff #2 stated that Patient #1 came in through the ER via EMS and therefore consent was not obtained.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on review of documentation and interview, the facility failed to ensure that patients were informed of their rights as there was no documented evidence to show that patient rights documents were received or provided to the patient or legally authorized representative.

Cross refer: CFR 482.13(a)(1) Patient Rights: Notice of Rights


Based on review of documentation and interview, the facility failed to ensure that a patient was afforded the right to informed consent to treatment and provided their patient rights as there was no documented evidence that patient rights were received or consent to inpatient treatment was provided by the patient or legally authorized representative.

Cross refer: CFR 482.13(b)(2) A0131 Patient Rights: Informed Consent


Based on review of documentation and interview, it was determined that the facility failed to provide patient care in a safe setting as the hospital did not supply an adequate number of licensed registered nurses and other personnel to provide nursing care to all patients in accordance with the "Staffing Table" for 5 South Medical/Surgical Unit. The hospital failed to ensure that nursing care was properly supervised, implemented, and evaluated; failed to ensure that assessments were conducted and documented; failed to verify that patient care equipment was operational. This was not in accordance with facility policy and standards of nursing practice and presents a risk to all patients admitted to the hospital.

Cross refer: CFR 482.13(c)(2) A0144 Patient Rights: Care in Safe Setting