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.

TRUSTPOINT REHAB HOSPITAL OF LUBBOCK 4302 PRINCETON LUBBOCK, TX July 9, 2014
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on a review of medical records, hospital policies, nurse staffing/patient assignment sheets, the hospital failed to ensure that a patient's right to privacy and right to care in a safe setting were ensured, and that the hospital's grievance process was followed. These deficient practices had the potential for harm to all patients admitted to the hospital.

Findings included:

Review of the records of 4 out of 5 behavioral health patients (Patients #7, 6, 8 and 1) revealed that their right to personal privacy was restricted as they were monitored 1:1 without an active order from a physician. Cross Refer A0143

Review of the records of 3 out of 5 behavioral health patients (Patients #1, 5, and 7) revealed that their right to care in a safe setting was not ensured as they were not monitored 1:1 per active orders from a physician and documentation of patient monitoring was not included or completed in the medical record. Cross refer: A0144

Review of facility policy, patient records and staffing interview revealed that the hospital failed to provide a written response to patient grievances in accordance with hospital policy. Cross refer: A0118
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on a review of hospital policies and staff interviews, the facility failed to provide a written response to patient grievances.

Findings included:

Review of hospital policy #1.002 entitled, "Grievance, Patient/Family", last reviewed 12/13, stated, in part,

"1. The Governing Body for TrustPoint Hosptial is responsible for effective operation of the complaint process and has delegated the authority to review and resolve complaints to the Administration of the hospital ...i. All verbal or written complaints regarding abuse, neglect, patient harm, or TrustPoint Hospital compliance with regulations, are considered to be grievances ...

7. TrustPoint Hospital will provide the patient/representative with written notice of its decision in a language and manner the hospital can reasonable expect the patient/representative to understand."

In an interview with the Chief Nursing Officer the afternoon of 7/9/14, he stated that a meeting was held with the family of Patient #1 to discuss the family's concerns about the care of Patient #1, but that no written response had been sent to the patient/representative.

In a telephonic interview with the daughter and wife of Patient #1 the afternoon of 7/9/14, the daughter and wife both stated that a verbal complaint was made to the hospital administration and the hospital had not provided a written response.

In an interview with the Chief Nursing Officer the afternoon of 7/9/14, he stated that the family of Patient #2 "spoke to the nurse manager" about complaints related to the care and treatment of Patient #2. The Chief Nursing Officer stated that no written response had been sent to the patient/representative for the verbal complaint.

In an interview with Staff #4, Nurse Manager the afternoon of 7/9/14, she stated that the wife of Patient #2 requested to see records regarding the second fall, which occurred on 5/9/14, as the wife of Patient #2 had not been notified that Patient #2 had a second fall. Staff #4 stated that she told the wife of Patient #2 that the occurrence report related to the fall could not be released as it was an internal document. Staff #4 stated that the wife of Patient #2 asked to see the medical record and Staff #4 stated that she referred the wife of Patient #2 to the Medical Records Department.

Review of the medical record for Patient #2 revealed that he fell on [DATE] at 8:30 am. Nursing note entry of 5/9/14 at 1640 stating, "Family members asking to see the manager due to patient's fall." Patient was transferred to a higher level of care on 5/9/14 at the family's request.

The above findings were confirmed in an interview the afternoon of 7/9/14 in the facility conference room with the Chief Nursing Officer.
VIOLATION: PATIENT RIGHTS: PERSONAL PRIVACY Tag No: A0143
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on a review of medical records, hospital policies, nurse staffing/patient assignment sheets, the hospital failed to ensure that the patient right to personal privacy was ensured.

Findings included:

Review of the records of 4 out of 5 behavioral health patients (Patients #7, 6, 8 and 1) revealed that their right to personal privacy was restricted as they were monitored 1:1 by nursing staff or sitters without an active order from a physician.

Review of Behavioral Health facility policy #2.013, "Patient Monitoring", last revised 4/9/13, stated, in part,

"c. One-on-One Monitoring - Intensive level of observation reserved for patients who are an imminent risk for harming self or others whose psychiatric state is such that control/safety cannot be maintained otherwise.

i. One staff member is assigned to this patient and remains in physical proximity (elbow to fingertips) at all times ...

ii. The need for continued one on one monitoring should be assessed every day by the physician, and the order renewed as appropriate ...

PROCEDURE

1. Obtain a written physician's order for the specific level of monitoring needed ...

2. The physician's order includes the designated level of monitoring ...

4. A physician's order is necessary to discontinue or change the level of monitoring ...

8. Document patient monitoring
a. From the time of admission to the unit, a staff member will note and document on the Patient Monitoring Form the location of the patient at a minimum of fifteen (15) minute intervals."

Review of the "Trust Point Hospital Job Description & Performance Evaluation" for the job title of "Sitter" revealed the following:

"Job Summary: A sitter provides support to the patient care team by providing direct (line-of-sight) supervisor of patients requiring 1:1 supervision for safety under the direction and supervision of nurses ...

Qualifications, Knowledge & Ability: ...
Provides 1:1 constant supervision/observation and monitoring to patient assigned to ensure safety and prevention of injury ...

Maintains appropriate precautionary measures for designated patients (i.e., respiratory, contact, suicide precautions) ...

Does not leave patient unless relieved by another staff member."

Review of the "TrustPoint Hospital Patient's Bill of rights for Mental Health Services" provided to the surveyor on 7/9/14, stated, in part,

"Basic Rights for All Patients ...
3. You have the right to a clean and humane environment from which you are protected from harm, have privacy with regard to personal needs, and are treated with respect and dignity."

Review of the TrustPoint Hospital Behavioral Health Policy and/or Procedure #2.022, "Rights, Patient" last revised 4/11/13, stated, in part,

"No patient shall be deprived of any rights, benefits, or privileges guaranteed by law."

Review of the medical record for Patient #1 revealed the following:

Patient #1 was admitted on [DATE] on every 15 minutes observation and discharged on [DATE]. There was no documented evidence of any order for 1:1 observation during the patient's stay.

Review of the nurse staffing/patient assignment sheets revealed that Patient #1 was assigned to be monitored 1:1 on the following 7 dates: 5/3/14, 5/4/14, 5/5/14, 5/6/14, 5/7/14, 5/8/14 and 5/9/14.

Review of the nursing notes revealed that Mr. Townsend had a 1:1 sitter on 5/3/14, 5/4/14, 5/5/14, 5/6/14, 5/7/14, 5/8/14, and 5/9/14 without an order.

Review of the medical record for Patient #7 revealed the following:

Patient #7 had orders for 1:1 observation on 7/6/14 and 7/7/14.

Review of nurse staffing sheets revealed that Patient #7 was assigned to be monitored 1:1 on 7/8/14 and 7/9/14 without an order for 1:1 observation.

Review of the medical record for Patient #6 revealed the following:

Patient #6 had Orders for 1:1 on the following dates: 6/4/14, 6/5/14, 6/9/14, 6/10/14, 6/11/14, 6/13/14, 6/14/14, 6/15/14 and 6/16/14.

Per the Nurse Staffing/patient assignments sheets, Patient #6 was assigned to be monitored 1:1 every day between 6/4/14 and 6/15/14.

Patient #6 was monitored 1:1 without an active physician order for the following 4 dates: 6/6/15, 6/7/14, 6/8/14, and 6/12/14.

Review of the medical record for Patient #8 revealed the following:

Patient #8 had orders for 1:1 on the following dates: 6/6/14, 6/10/14, 6/12/14, 6/13/14, 6/14/14, an undated entry between other entries dated 6/15/14 and 6/16/14, 6/16/14, 6/17/14, and 6/19/14.

Per the nurse staffing/patient assignment sheets, Patient #8 was assigned to be monitored 1:1 every day between 6/6/14 and 6/19/14.

Patient #8 was monitored 1:1 without an active physician order for the following 6/7/14, 6/8/14, 6/9/14, and 6/11/14. One physician order was not dated.

The above findings were confirmed in an interview with the Chief Nursing Officer the afternoon of 7/9/14 in the facility conference room.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on a review of patient records, hospital policies, and staff interview, the facility failed to ensure the patient's right to care in a safe setting as behavioral health patients were not monitored according to physician orders.

Findings included:


Review of the records of 3 out of 5 behavioral health patients (Patients #1, 5, and 7) revealed that their right to care in a safe setting was not ensured as they were not monitored 1:1 per active orders from a physician and documentation of patient monitoring was not included or completed in the medical record.

Review of Behavioral Health facility policy #2.013, "Patient Monitoring", last revised 4/9/13, stated, in part,

"1. All patients are monitored as to their location and activity at regular intervals ...

2. A physician order is required to change the level of patient monitoring based on patient condition ...b. The clinical need for this level of monitoring is addressed on the Treatment Plan.

3.a. Standard patient monitoring i. All patients are monitored a minimum of once every fifteen (15) minutes upon admission and until discharge ...

c. One-on-One Monitoring - Intensive level of observation reserved for patients who are an imminent risk for harming self or others whose psychiatric state is such that control/safety cannot be maintained otherwise.

i. One staff member is assigned to this patient and remains in physical proximity (elbow to fingertips) at all times ...

ii. The need for continued one on one monitoring should be assessed every day by the physician, and the order renewed as appropriate ...

PROCEDURE
1. Obtain a written physician's order for the specific level of monitoring needed ...

2. The physician's order includes the designated level of monitoring ...

4. A physician's order is necessary to discontinue or change the level of monitoring ...

8. Document patient monitoring

a. From the time of admission to the unit, a staff member will note and document on the Patient Monitoring Form the location of the patient at a minimum of fifteen (15) minute intervals."

Review of the medical record for Patient #1 revealed the following:

Patient #1 was admitted on [DATE] on every 15 minutes observation and discharged on [DATE].

Review of the "Q 15 Minute Checklist" forms in the medical record revealed only 3 forms for 24 hour documentation of monitoring. Two forms were dated, with dates of 5/7/15 and 5/8/14. The other form was undated, and there was no means to determine conclusively the date the sheet and the monitoring were completed. There was no documented evidence of Q 15 monitoring sheets for 5/2/14, 5/3/15, 5/4/14, 5/5/14, 5/6/14, and 5/9/14. There was no means to determine that patient #1 was monitored Q 15 minutes as ordered.

Review of the medical record for Patient #7 revealed the following:

Review of the "Q 15 Minute Check List" sheets for Patient #7 revealed one completed, but undated check list; there was no means to determine conclusively the date the sheet and the monitoring were completed. There was no checklist for 7/1/14, and there was no checklist for 7/4/14. There was no observation or 15 minute checks documented on 7/5/14 for 10:00 am and 10:15 am, as the space for documentation of those checks was left blank.

Review of the medical record for Patient #5 revealed the following:

Admission orders for Patient #5 included 1:1 level of observation at 2100 at 7/8/14. Observation level was changed to Q 15 minute checks on 7/9/14 at 1445. There was no documented evidence that Patient #5 was monitored 1:1 from admission until 6 am on 7/9/14, as there was no observation checklist sheet from the time of his admission until 6 am on 7/9/14. The nurse staffing sheets do not list Patient #5 or any staff assigned to him on 7/8/14.

Review of the TrustPoint Hospital Behavioral Health Policy and/or Procedure #2.022, "Rights, Patient" last revised 4/11/13, stated, in part, "No patient shall be deprived of any rights, benefits, or privileges guaranteed by law."

The above findings were confirmed in an interview with the Chief Nursing Officer the afternoon of 7/9/14 in the facility conference room, who stated that he was unable to find the missing documentation or checklists.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on a review of patient records, hospital policies, Charge Nurse Meeting minutes, and staff interview, the hospital:

1. failed to ensure that a registered nurse properly supervised and evaluated the nursing care for each patient including not completing or accurately documenting assessments and patient monitoring, and

2. failed to ensure the patients were monitored according to physician orders.

These deficient practices have the likelihood to cause harm to all patients admitted to the inpatient rehabilitation and the behavioral health units of the hospital.

Findings included:

A. Review of the records of 4 out of 5 behavioral health patients (Patients #7, 6, 8 and 1) revealed that their right to personal privacy was restricted as they were monitored 1:1 by nursing staff or sitters without an active order from a physician for 1:1 monitoring.

Cross refer: A0395

B. Review of the medical record for 3 out of 3 inpatient rehabilitation patients (Patients #2, 3, and 4) revealed no documented evidence of CNA rounding every even hour. The records for Patients #2, 3, and 4 revealed a single "Bedside Care Flowsheet" completed with one general entry per shift. There was no documented evidence that the CNA conducted rounds on Patients #2, 3, and 4 during their stay.

Cross refer: A0395

C. Review of the records of 3 out of 5 behavioral health patients (Patients #1, 5, and 7) revealed that their right to care in a safe setting was not ensured as they were not monitored 1:1 per active orders from a physician and documentation of patient monitoring was not included or completed in the medical record.

Cross refer: A0395

D. Review of the medical record for Patient #2 revealed nursing documentation of Stage I pressure ulcers on his right hip and coccyx. There was no documented evidence of pictures or physician notification in the medical record for Patient #2 for the nursing assessments as required by hospital policy.

Cross refer: A0395

E. Review of 1 out of 1 patient record (Patient #2) with a medically indicated restraint ordered revealed no documented evidence of a Restraint Log for the dates of 4/5/14, and 4/6/14.

Cross refer: A0395

F. Review of the records for 2 out of 2 patients (Patients #1 and 2) experiencing falls at the hospital revealed that family notification of falls was not documented per hospital policy.
Cross refer: A0395

The above findings were confirmed in an interview with the Chief Nursing Officer the afternoon of 7/9/14 in the facility conference room.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on a review of patient records, hospital policies, Charge Nurse Meeting minutes, and staff interview, the hospital failed to ensure that a registered nurse properly supervised and evaluated the nursing care for each patient including not completing or accurately documenting assessments and patient monitoring, and failed to ensure the patients were monitored according to physician orders.

These deficient practices have the likelihood to cause harm to all patients admitted to the inpatient rehabilitation and the behavioral health units of the hospital.

Findings included:

A. Review of the records of 4 out of 5 behavioral health patients (Patients #7, 6, 8 and 1) revealed that their right to personal privacy was restricted as they were monitored 1:1 by nursing staff or sitters without an active order from a physician for 1:1 monitoring.

Review of Behavioral Health facility policy #2.013, "Patient Monitoring", last revised 4/9/13, stated, in part,

"c. One-on-One Monitoring - Intensive level of observation reserved for patients who are an imminent risk for harming self or others whose psychiatric state is such that control/safety cannot be maintained otherwise.

i. One staff member is assigned to this patient and remains in physical proximity (elbow to fingertips) at all times ...

ii. The need for continued one on one monitoring should be assessed every day by the physician, and the order renewed as appropriate ...

PROCEDURE
1. Obtain a written physician's order for the specific level of monitoring needed ...

2. The physician's order includes the designated level of monitoring ...

4. A physician's order is necessary to discontinue or change the level of monitoring ...

8. Document patient monitoring

a. From the time of admission to the unit, a staff member will note and document on the Patient Monitoring Form the location of the patient at a minimum of fifteen (15) minute intervals."

Review of the "Trust Point Hospital Job Description & Performance Evaluation" for the job title of "Sitter" revealed the following:

"Job Summary: A sitter provides support to the patient care team by providing direct (line-of-sight) supervisor of patients requiring 1:1 supervision for safety under the direction and supervision of nurses ...

Qualifications, Knowledge & Ability: ...
Provides 1:1 constant supervision/observation and monitoring to patient assigned to ensure safety and prevention of injury ...

Maintains appropriate precautionary measures for designated patients (i.e., respiratory, contact, suicide precautions) ...

Does not leave patient unless relieved by another staff member."

Review of the medical record for Patient #1 revealed the following:

Patient #1 was admitted on [DATE] on every 15 minutes observation and discharged on [DATE]. There was no documented evidence of any order for 1:1 observation during the patient's stay.

Review of the nurse staffing/patient assignment sheets revealed that Patient #1 was assigned to be monitored 1:1 on the following 7 dates: 5/3/14, 5/4/14, 5/5/14, 5/6/14, 5/7/14, 5/8/14 and 5/9/14.

Review of the nursing notes revealed that Mr. Townsend had a 1:1 sitter on 5/3/14, 5/4/14, 5/5/14, 5/6/14, 5/7/14, 5/8/14, and 5/9/14 without an order.

Review of the medical record for Patient #7 revealed the following:

Patient #7 had orders for 1:1 observation on 7/6/14 and 7/7/14.

Review of nurse staffing sheets revealed that Patient #7 was assigned to be monitored 1:1 on 7/8/14 and 7/9/14 without an order for 1:1 observation.

Review of the medical record for Patient #6 revealed the following:

Patient #6 had Orders for 1:1 on the following dates: 6/4/14, 6/5/14, 6/9/14, 6/10/14, 6/11/14, 6/13/14, 6/14/14, 6/15/14 and 6/16/14.

Per the Nurse Staffing/patient assignments sheets, Patient #6 was assigned to be monitored 1:1 every day between 6/4/14 and 6/15/14. Patient #6 was monitored 1:1 without an active physician order for the following 4 dates: 6/6/15, 6/7/14, 6/8/14, and 6/12/14.

Review of the medical record for Patient #8 revealed the following:

Patient #8 had orders for 1:1 on the following dates: 6/6/14, 6/10/14, 6/12/14, 6/13/14, 6/14/14, an undated entry between other entries dated 6/15/14 and 6/16/14, 6/16/14, 6/17/14, and 6/19/14.

Per the nurse staffing/patient assignment sheets, Patient #8 was assigned to be monitored 1:1 every day between 6/6/14 and 6/19/14. Patient #8 was monitored 1:1 without an active physician order for the following 6/7/14, 6/8/14, 6/9/14, and 6/11/14. One physician order was not dated.


The above findings were confirmed in an interview with the Chief Nursing Officer the afternoon of 7/9/14 in the facility conference room.


B. Review of the medical record for 3 out of 3 inpatient rehabilitation patients (Patients #2, 3, and 4) revealed no documented evidence of CNA rounding every even hour. The records for Patients #2, 3, and 4 revealed a single "Bedside Care Flowsheet" completed with one general entry per shift. There was no documented evidence that the CNA conducted rounds on Patients #2, 3, and 4 during their stay.

Review of the TrustPoint Hospital Charge Nurse Meeting Minutes dated May 21st, 2014 revealed the following:

"REMINDERS ...D. Rounding expectation is every 4 hours for Team Leaders
C.N.A. should be rounding every even hour and floor nurses should be rounding every odd hour."

In an interview with Staff #4, Nurse Manager, she stated that the expectation is that patient rounds are conducted every hour, in addition to any specific orders for monitoring that a patient may have. When asked, Staff #4 stated that the nurses and the CNAs documented their rounds in the patient medical records. When asked for the hospital policy on conducting rounds on inpatient rehabilitation patients, Staff #4 was unable to produce a policy, stating that there was a policy for monitoring on the behavioral health unit, but not the inpatient rehabilitation unit. Staff #4 stated that it was the expectation that rounds would be conducted.

The above findings were confirmed in an interview with Staff #4, Nurse Manager, in the facility conference room the afternoon of 7/9/14.


C. Review of the records of 3 out of 5 behavioral health patients (Patients #1, 5, and 7) revealed that their right to care in a safe setting was not ensured as they were not monitored 1:1 per active orders from a physician and documentation of patient monitoring was not included or completed in the medical record.

Review of Behavioral Health facility policy #2.013, "Patient Monitoring", last revised 4/9/13, stated, in part,

"1. All patients are monitored as to their location and activity at regular intervals ...

2. A physician order is required to change the level of patient monitoring based on patient condition ...b. The clinical need for this level of monitoring is addressed on the Treatment Plan.

3.a. Standard patient monitoring i. All patients are monitored a minimum of once every fifteen (15) minutes upon admission and until discharge ...

c. One-on-One Monitoring - Intensive level of observation reserved for patients who are an imminent risk for harming self or others whose psychiatric state is such that control/safety cannot be maintained otherwise.

i. One staff member is assigned to this patient and remains in physical proximity (elbow to fingertips) at all times ...

ii. The need for continued one on one monitoring should be assessed every day by the physician, and the order renewed as appropriate ...

PROCEDURE

1. Obtain a written physician's order for the specific level of monitoring needed ...

2. The physician's order includes the designated level of monitoring ...

4. A physician's order is necessary to discontinue or change the level of monitoring ...

8. Document patient monitoring
a. From the time of admission to the unit, a staff member will note and document on the Patient Monitoring Form the location of the patient at a minimum of fifteen (15) minute intervals."

Review of Hospital Policy 11.229, "Documentation in the Medical Record, Nursing", last revised 1/6/14, stated, in part,

"3. All paper forms in the medical record will be dated, each entry time and a patient identification label will be included. Forms that are specific to one day-of-care can be dated at the top and each entry timed ..."

Review of the medical record for Patient #1 revealed the following:

Patient #1 was admitted on [DATE] on every 15 minutes observation and discharged on [DATE].

Review of the "Q 15 Minute Checklist" forms in the medical record revealed only 3 forms for 24 hour documentation of monitoring. Two forms were dated, with dates of 5/7/15 and 5/8/14. The other form was undated, and there was no means to determine conclusively the date the sheet and the monitoring were completed. There was no documented evidence of Q 15 monitoring sheets for 5/2/14, 5/3/15, 5/4/14, 5/5/14, 5/6/14, and 5/9/14. There was no means to determine that patient #1 was monitored Q 15 minutes as ordered.

Review of the medical record for Patient #7 revealed the following:

Review of the "Q 15 Minute Check List" sheets for Patient #7 revealed one completed, but undated check list; there was no means to determine conclusively the date the sheet and the monitoring were completed. There was no checklist for 7/1/14, and there was no checklist for 7/4/14. There was no observation or 15 minute checks documented on 7/5/14 for 10:00 am and 10:15 am, as the space for documentation of those checks was left blank.

Review of the medical record for Patient #5 revealed the following:

Admission orders for Patient #5 included 1:1 level of observation at 2100 at 7/8/14. Observation level was changed to Q 15 minute checks on 7/9/14 at 1445. There was no documented evidence that Patient #5 was monitored 1:1 from admission until 6 am on 7/9/14, as there was no observation checklist sheet from the time of his admission until 6 am on 7/9/14. The nurse staffing sheets do not list Patient #5 or any staff assigned to him on 7/8/14.

Review of the TrustPoint Hospital Behavioral Health Policy and/or Procedure #2.022, "Rights, Patient" last revised 4/11/13, stated, in part,

"No patient shall be deprived of any rights, benefits, or privileges guaranteed by law."

The above findings were confirmed in an interview with the Chief Nursing Officer the afternoon of 7/9/14 in the facility conference room, who stated that he was unable to find the missing documentation or checklists.

D. Review of TrustPoint Hospital Policy 11.276, "Pressure Sores, Prevention and Treatment" last revised 12/30/13, stated, in part,

"b. Upon admission and at least once every shift, all patients will be assessed for their risk of pressure ulcer development using the Braden Risk Assessment Scale ...

c. For patients at risk for pressure ulcer development, a pressure ulcer prevention plan of care will be initiated by a Registered Nurse (RN) ...

i. Pictures of any wounds or pressure ulcers will be taken at the time of admission, when changes occur throughout the hospitalization , and at discharge. Pictures will include a completed pressure ulcer measurement guide.

ii. All pictures will be placed on a physician progress note, labeled with a "sign here" sticker, and placed under the progress note section of the chart. The physician or designated provider is then required to sign the pictures ...

Wounds are to be addressed in nursing documentation each shift."

Review of the medical record for Patient #2 revealed nursing documentation of Stage I pressure ulcers on his right hip and coccyx. There was no documented evidence of pictures or physician notification in the medical record for Patient #2 for the following nursing assessments:

? 3/29/14 - impaired skin integrity.."coccyx redened (sic) from pressure; pt refuses to allowe (sic) staff to turn 2q"

? 3/30/14 - impaired skin integrity ..."coccyx redened from pressure; pt refuses to allowe staff to turn 2q"

? 4/1/14 - impaired skin integrity ..."coccyx redened from pressure; pt refuses to allowe staff to turn 2q"

? 4/2/14 - impaired skin integrity ..."coccyx redened from pressure; pt refuses to allowe staff to turn 2q"

? 4/20/14 - Impaired skin integrity ...number of wounds: 6, including left eyebrow abrasion, right eyebrow scab, right knee [DIAGNOSES REDACTED] and edema, left knee [DIAGNOSES REDACTED] and edema, right hip reddened Stage I pressure wound, and coccyx reddened Stage I pressure wound.

? 4/23/14 - Impaired skin integrity ...number of wounds: 6, including left eyebrow abrasion, right eyebrow scab, right knee [DIAGNOSES REDACTED] and edema, left knee [DIAGNOSES REDACTED] and edema, right hip reddened Stage I pressure wound, and coccyx reddened Stage I pressure wound.

? 4/24/14 - Impaired skin integrity ...number of wounds: 6, including left eyebrow abrasion, right eyebrow scab, right knee [DIAGNOSES REDACTED] and edema, left knee [DIAGNOSES REDACTED] and edema, right hip reddened Stage I pressure wound, and coccyx reddened Stage I pressure wound.

The above findings were confirmed in an interview the afternoon of 7/9/14 in an interview with Staff #4, Nurse Manager in the facility conference room.


E. Review of TrustPoint Hospital policy, #11.256, entitled, "Restraint, Use of" last revised 5/2/14, stated, in part, "Procedure 1. Obtain physician order for the restraint as per policy ...
6. Monitor the patient on an ongoing basis per policy guidelines ...
8. Loosen restraints to ensure adequate circulation and to observe skin condition at least every two (2) hours.
9. Change patients position a minimum of every two (2) hours to maintain comfort and skin integrity ...
10. Offer toileting and hydration a minimum of every two (2) hours ...
12. Document all monitoring, patient condition and response, and all observations ...
Documentation
1. Nursing documentation on the Restraint Log will include the assessment, monitoring, and evaluation of a patient in restraint ..."

Review of 1 out of 1 patient record (Patient #2) with a medically indicated restraint ordered revealed no documented evidence of a Restraint Log for the dates of 4/5/14, and 4/6/14. There was no documented evidence of patient monitoring, skin condition monitoring and position changing every 2 hours, toileting and hydration offered or any other documentation for patient #1 on a Restraint Log for 4/5/14 and 4/6/14. Review of the record indicated an active order for rear fastening seat belt on 4/5/14 and 4/6/14, however there was no documentation of monitoring or care provided on 4/5/14 and 4/6/14.

The above findings were confirmed in an interview the afternoon of 7/9/14 with the Chief Nursing Officer in the facility conference room.

F. Review of the records for 2 out of 2 patients (Patients #1 and 2) experiencing falls at the hospital revealed that family notification of falls was not documented per hospital policy.
? Patient #2 had a fall on 4/12/14. The box for "Patient/Family notified" was left blank on the occurrence report for the event.
? Patient #2 also had a fall on 4/19/14. The box for "Patient/Family notified" was checked "No" on the occurrence report for the event.
? Patient #1 had a fall on 5/9/14 at 8:30 am in his bedroom. The box for "Patient/Family notified" was checked "yes" on the occurrence report for the event; however there was no documented evidence of the name of person contacted and no date and time documented as required by policy.

Review of the TrustPoint Hospital Policy #11.235 entitled, "Fall Prevention" stated, in part, "If Patient Falls ...6. Documentation should include: ...e. Notification of family - name of person contacted as well as date and time."

The above findings were confirmed in an interview with the Chief Nursing Officer the afternoon of 7/9/14 in the facility conference room.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on a tour of the facility, review of hospital policies, and staff interview, the facility failed to ensure an environment to prevent cross contamination as the patient clothing washing machine was in need of cleaning and disinfection.

Findings included:

During a tour of the GeroPsych Unit the morning of 7/9/14, accompanied by the Chief Nursing Officer, Staff #4 and Staff #5, the patient clothing washing machine was observed in need of cleaning and disinfection. The lip at the top of the tub was dirty with a raised layer of black-ish sticky substance, which appeared to be soap residue and dirt. The rim of the washing machine lid and the top of the washing machine were also dirty with a raised layer of black sticky substance with appeared to be soap residue and dirt. This creates a risk for cross contamination. There was no flow sheet observed with a procedure outlining the procedures for cleaning and disinfecting the washing machine. The above findings were confirmed with the CNO, Staff #4 and Staff #5 during the tour.

Review of facility policy #10.023, "Washer/Dryer Disinfection", last revised 2/14, stated, in part,

"2. The patient washing machine and dryer outer surface will be wiped with disinfectant between each patient use...

4. The procedure outlined will be documented on a flow sheet attached to the side of the washing machine."

The above findings were confirmed in an interview with the Chief Nursing Officer, Staff #4 and Staff #5 during the tour of the GeroPsych Unit the morning of 7/9/14.