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.

BRYNN MARR HOSP 192 VILLAGE DRIVE JACKSONVILLE, NC 28540 Aug. 24, 2017
VIOLATION: PATIENT RIGHTS: PARTICIPATION IN CARE PLANNING Tag No: A0130
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of facility policy and procedures, nursing staff meeting minutes review, closed medical record review, bed census review, health department staff and staff interviews, the facility staff failed to notify a guardian of a change in condition and treatment provided for 1 of 1 patients (#9) and the presence of bed bugs in the patients' room for 3 of 3 patients (#5, #8, #9).

Findings include:

Review on 08/23/2017 of the policy and procedure titled "Nursing Assessment" (last reviewed 04/01/2017) revealed, "PURPOSE: To define the process used to identify patient needs and /or problems assessed by the Registered Nurse....Policy:...A Registered Nurse completes the nursing assessment on each newly admitted patient."

Review on 08/23/2017 of the policy and procedure titled "Medical Response to Changes in Patient's Condition Assessment/Reassessment" (last reviewed 01/27/2017) revealed, "POLICY STATEMENT:...The purpose of this policy is to establish guidelines for assessment/reassessment for medical response to changes in patient's condition....Policy:...Nurses assess and reassess patients on a 24-hour continuum throughout the patient's hospitalization to identify changes physical/medical status that inform timely and effective care decisions....Procedure:..In all situations, the nurse shall:...Continue to monitor and assess the situation and provide any care ordered by the physician and as clinically indicated."

Review on 08/23/2017 of the document titled "Nursing Staff Meeting" dated 07/17/2017 and 07/18/2017 revealed "...Communication...Keep families informed of patient changes in condition, i.e.. UTI (Urinary Tract Infection), Strep, fever, rash, injuries, etc."

1. Closed medical record review on 08/22/2017 revealed Patient #9 was a [AGE] year old male admitted on [DATE] IVC (Involuntary Commitment) because he exhibited behaviors as being a danger to himself and others. Review of a "Progress Note:" dated 07/28/2017 revealed Patient #9 "...has a prior mental health diagnosis of Intermittent Explosive Disorder, Bipolar Disorder and Oppositional Defiance Disorder....The patient admits to having self-injurious behaviors of cutting himself as well as allowing others to cut him." Further review revealed Patient #9 did not have any allergies or "...no other abnormal physical exam findings on admission." Review of the "NURSING ADMISSION ASSESSMENT" dated 07/17/2017 at 1651 revealed a front and back anatomical human diagram that displayed the skin assessment accompanied with a skin assessment key (guide). The documented skin assessment included the following: scars to front and back of bilateral upper arms, back of bilateral forearms, front of bilateral thighs, bilateral knees, back of bilateral hands, front of bilateral chest, upper back and umbilicus; self-inflicted wounds to bilateral forearms and discoloration to the left hip. Review of "Physician's Order Form" dated 07/24/2017 at 1010 revealed a medication order for Mycostatin powder to be applied to the groin two times a day for jock itch. Review of the MAR (Medication Administration Record) dated 07/24/2017 revealed Mycostatin powder was administered at 1700. Review of the "NURSING ASSESSMENT /REASSESSMENT " documentation by a RN #7(Registered Nurse) dated 07/24/2017 revealed Patient #9 had itching in the groin area. Review of the "Physician's Order Form" dated 07/25/2017 revealed orders to discontinue the Mycostatin powder and a new order for Nyststatin cream to be applied to the groin two times a day for tinea or jock itch and Benadryl fifty milligrams by mouth every six hours as needed for itching. Review of the MAR dated 07/25/2017 revealed administration of the Nystatin cream 1 gram was refused at the scheduled 0900 medication administration time but was administered 1700. Further review of the MAR revealed the Nystatin cream 1 gram was administered on the following dates and times: 07/26/2017 0900 and 1700; 07/28/2017 at 0900. Review revealed Patient #9 was discharged to home at 1028.

Interview on 08/23/2017 at 1019 with the FNP (Family Nurse Practitioner) revealed Patient #9 complained he was having to scratch himself in his genital area. Interview revealed the FNP observed Patient #9's pubic and groin area and noticed darker pigmentation to the areas. Interview revealed treatment was ordered for jock itch. The FNP stated "....He was not shy about letting me know what was going on with him."

Interview on 08/23/2017 at 1104 with the RN #7 that documented the jock itch in the skin assessment note revealed the treatment for the jock itch had been ordered the shift prior to her shift. Interview revealed she did not remember calling the guardian. Interview revealed if the change in condition occurred on her shift she would call the guardian and give the type treatment but if it was a day or two old she would assume the guardian had been called.

Interview on 08/23/2017 at 0841 with the DON (Director Of Nursing) revealed Patient #9's guardian was not notified of his change in condition - jock itch. Interview revealed Patient #9's change in condition should have been reported to the guardian.

Interview with the RN #6, Nurse Manager, on 08/23/2017 at 0925 revealed there is not any available documentation of the guardian having been notified of Patient #9's change in condition. RN #6 stated "Should have attempted to contact parent and documented. We encourage them to report any medical condition and give the guardian an update. Changes in patient condition policy in RN orientation packet. Not noted in policy to contact guardian of medical changes. Not in our policy it is standard practice here." Interview revealed "Nursing monthly meeting discussed process of notify parent or guardian as soon as possible...anything to make sure giving treatment."

2. Closed medical record review on 08/23/2017 revealed Patient #5 was a [AGE] year old male admitted IVC on 07/12/2017 with a diagnosis of "Bipolar disorder, unspecified" Review of the "Patient Observation Record" revealed Patient #5 room assignment changed from room 345 bed "B" to room 337 bed "A". Review revealed no available documentation to Patient #5's guardian pertaining to the presence of bed bugs his room, 345. Review revealed Patient #5 was discharged from the facility on 08/15/2017.

Review of the bed census for 07/17/2017 revealed Patient #5 had been assigned to room 345 bed "B" for the past five days through 07/26/2017. Further review revealed room 345 did not have any patients assigned to room 345 from 07/26/2017 through 07/31/2017.

Interview on 08/23/2017 at 1156 with an EHDPS (Environmental Health Department Program Specialist) revealed the department received a complaint on 07/25/2017. Interview revealed the EHDPS entered the facility on 07/26/2017 and it was confirmed that dead bed bugs were present in room 345.

Interview on 08/23/2017 at 0841 with the DON (Director Of Nursing) revealed there was a dead bug found in room 345 on 07/24/2017 by the charge nurse performing rounds. The dead bug was not identified as a bed bug until 07/26/2017 when the HDS (Health Department Staff) came to the facility for an inspection

Interview on 08/23/2017 at 1608 with the DON revealed the guardians of the patients in room 345 were not notified of bed bugs being in the room. The DON stated "Every patient in room 345 guardians should have been notified."

Interview with the RN #6, Nurse Manager, on 08/23/2017 at 0925 revealed "...Nursing monthly meeting discussed process of notify parent or guardian as soon as possible...lice, bed bugs anything to make sure giving treatment."

3. Closed medical record review on 08/23/2017 revealed Patient #8 was a [AGE] year old male admitted IVC on 07/18/2017 because Patient #8 could not sleep and could not tell if he was awake of asleep. Patient #8 went to the ED (Emergency Department) and he exhibited aggressive behavior towards others. Review revealed Patient #8 was discharged on [DATE] at 1626. Review revealed no available documentation of time the dead bug was found in room 345 or Patient #8's guardian being notified that bed bugs were present in the room.

Review of the bed census revealed Patient #8 was assigned to room 345 bed "A" on 07/18/2017 through 07/24/2017.

Interview on 08/23/2017 at 1156 with an EHDPS (Environmental Health Department Program Specialist) revealed the department received a complaint on 07/25/2017. Interview revealed the EHDPS entered the facility on 07/26/2017 and it was confirmed that dead bed bugs were present in room 345.

Interview on 08/23/2017 at 0841 with the DON (Director Of Nursing) revealed there was a dead bug found in room 345 on 07/24/2017 by the charge nurse performing rounds. The dead bug was not identified as a bed bug until 07/26/2017 when the HDS (Health Department Staff) came to the facility for an inspection.

Interview on 08/23/2017 at 1608 with the DON revealed the guardians of the patients in room 345 were not notified of bed bugs being in the room. The DON stated "Every patient in room 345 guardians should have been notified."

Interview with the RN #6, Nurse Manager, on 08/23/2017 at 0925 revealed "Bug was found in bed A.....Nursing monthly meeting discussed process of notify parent or guardian as soon as possible...lice, bed bugs anything to make sure giving treatment."

4. Closed medical record review on 08/22/2017 revealed Patient #9 was a [AGE] year old male admitted on [DATE] IVC (Involuntary Commitment) because he exhibited behaviors as being a danger to himself and others. Review of a "Progress Note:" dated 07/28/2017 revealed Patient #9 "...has a prior mental health diagnosis of Intermittent Explosive Disorder, Bipolar Disorder and Oppositional Defiance Disorder...."

Review of the bed census for 07/17/2017 revealed Patient #9 had been assigned to room 345 bed "C" from 07/17/2017 through 07/26/2017. Review revealed Patient #9 was reassigned to room 333 bed "OA". Further review revealed room 345 did not have any patients assigned to the room from 07/26/2017 through 07/31/2017. Review revealed Patient #9 was discharged home on 07/28/2017.

Interview on 08/23/2017 at 1156 with an EHDPS (Environmental Health Department Program Specialist) revealed the department received a complaint on 07/25/2017. Interview revealed the EHDPS entered the facility on 07/26/2017 and it was confirmed that dead bed bugs were present in room 345.

Interview on 08/23/2017 at 0841 with the DON (Director Of Nursing) revealed there was a dead bug found in room 345 on 07/24/2017 by the charge nurse performing rounds. The dead bug was not identified as a bed bug until 07/26/2017 when the HDS (Health Department Staff) came to the facility for an inspection.

Interview on 08/23/2017 at 1608 with the DON revealed the guardians of the patients in room 345 were not notified of bed bugs being in the room. The DON stated "Every patient in room 345 guardians should have been notified."

Interview with the RN #6, Nurse Manager, on 08/23/2017 at 0925 revealed "...Nursing monthly meeting discussed process of notify parent or guardian as soon as possible...lice, bed bugs anything to make sure giving treatment."

NC 301