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.

COMANCHE COUNTY MEMORIAL HOSPITAL 3401 WEST GORE BLVD LAWTON, OK 73505 March 2, 2018
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
Based on record review and interview the hospital failed to ensure:
I. the Grievance Committee developed a grievance process that evaluated each event to identify program effectiveness, identify improvement opportunities, and reported their activities to the Executive Committee for five of five grievances submitted from 01/17 to 03/18.

II. staff understood the definitions of a complaint and a grievance for six (Staff A, Y, Z, AA, BB, and CC) of seven staff interviewed.

These failed practices had the potential for improvement opportunities to be missed, and for grievances to be under-reported due to the lack of understanding by the staff to identify a grievance.

Findings:
I. Process
A review of the policy titled, "Grievance Management Policy (01/17)" documented the responsibility for management and resolution of grievances that was delegated to the Grievance Committee. The policy documented the committee would meet quarterly. The policy documented the committee would provide a summary report to the Executive Council of all grievances filed by a patient or patient representative on a quarterly basis.

A review of "Grievance Management Committee (02/19/18)" minutes documented the following two grievances were submitted:
A. Minutes-Grievance #1560 regarded a procedural complication that warranted readmission. The minutes failed to document analysis regarding the investigation, actions taken, and the identification of any improvement opportunities needed.

A review of the corresponding grievance form and attachments dated 09/24/17 showed the medical record was sent for review, but no review was provided. The response letter documented staff were interviewed, but no interviews were provided.

B. Minutes-Grievance #1561 alleged an agency nurse was extremely rough and rude. The minutes documented the nurse did not get reassigned to the facility.

A review of the corresponding grievance form and attachments dated 10/16/17 showed other allegations that were not cited in the minutes. The allegations included skin was not prepped before injections and finger sticks, injection site bleeding was not managed, and medication and ventilator / CPAP (continuous positive airway pressure) issues. There was no documentation regarding the investigation of the allegations. The response letter documented staff was interviewed and the medical record was reviewed, but no interviews or medical record review was provided.

A review of "Grievance Management Committee (02/15/17)" minutes showed no grievances to report.

A review of "Grievance Management Committee (08/16/17)" minutes showed from 01/17-03/17 one grievance was submitted and 04/17- 06/17 no grievances.
Minutes-grievance [1556] regarded staff attitude, medical care, and physician care. The minutes documented there were "multiple issues" with the family and "everyone tried to relieve the situation".

A review of the corresponding grievance form and attachments dated 01/03/17 showed allegations regarding permission for intubation and documented nonspecific "complaints" and multiple "differences of opinion" with staff. The grievance form documented the medical record would be reviewed and that the patient had meetings with various administrative staff, but no documentation of the medical record review and meetings were provided. The response letter documented professional behavior and actions of physicians had been discussed, but no evidence of these discussions were provided. The letter documented the medical record was reviewed for accuracy, but no information was provided regarding the review. The letter documented the physician was educated regarding intubation, but no evidence of education was provided. The letter documented staff was educated including attitude, but no evidence of staff education was provided. The letter documented nursing schedules would be modified, but no evidence of schedule modifications were provided.

Two grievance forms #1557 and #1559 with corresponding attachments were provided to the surveyor, but were not documented in the Grievance Committee meeting minutes.
A. A review of Grievance Form #1557 dated 07/27/17 showed allegations regarding medical treatment, medication administration, and being moved due to "sewer backing up in room". The response letter documented the medical record was reviewed and summarized the findings regarding medication administration. No information was attached regarding a review of medical treatment. No information was provided regarding the investigation and response to the sewer issues.
B. A review of grievance response letter #1559, and correspondence from the Better Business Bureau dated 09/03/17 and attachments (no grievance form completed) showed allegations regarding medical treatment. The response letter documented staff and physician education, but no evidence of education was provided. No information was provided that peer medical record review was performed.

A review of the Executive Committee Meeting Minutes for 06/07/17, 07/06/17, 09/06/17, 10/02/17, 11/06/17, 12/04/17, 01/04/18 showed no documentation regarding grievances.

On 03/02/18 at 10:11 am, Staff B, Risk Manager, stated all issues were started out as complaints and some issues elevated to a grievance. Staff B stated the patient determined whether the grievance was resolved. Staff B stated he/she received all grievances. Staff B stated the grievances were reviewed by Staff C, and Staff GG, and were generally discussed in the "Board" meeting.

I. Staff Competency
A review of the policy titled, "Grievance Management Policy (01/17) documented the policy defined grievance as a formal or informal written or verbal complaint that is made to the hospital by a patient, or the patient's representative, regarding the patient's care (when the complaint is not resolved at the time of the complaint by staff present), abuse or neglect, issues related to the hospital's compliance with the CMS Hospital Conditions of Participation (CoPs), or a Medicare beneficiary billing complaint related to rights and limitations provided by 42 CFR 489. The policy failed to clearly explain that if a complaint was postponed for later resolution, was referred to other staff for later resolution, required investigation, and/or required further actions for resolution, then the complaint was a grievance.

A review of the document titled, "Nursing Service Orientation" documented the definition of a complaint as "an issue that can be resolved in one hour or less by appropriate personnel AND does not meet the criteria for being filed as a grievance. The document defined grievance as "an allegation of abuse or neglect of a patient or involves a report of negative or inadequate care of a patient."

On 03/02/18 at 8:43 am, Staff Y stated he/she did not know the difference between a complaint and a grievance.
On 03/02/18 at 8:45 am, Staff Z stated staff can address a complaint, but grievance must be submitted to administration.
On 03/02/18 at 8:55 am, Staff AA stated a complaint was when a patient was unhappy, and a grievance was a complaint filed against the hospital.
On 03/02/18 at 9:00am, Staff BB stated a complaint was an issue in which the patient was unhappy, but it could be resolved at the bedside, and a grievance was a formal written complaint filed with the hospital. Staff BB stated the grievance form was on the computer, and provided a blank copy.
On 03/02/18 at 9:04 am, Staff A stated if an issue could not be resolved during the shift, the complaint would be escalated to a grievance.
On 03/02/18 at 9:06 am, Staff CC stated a complaint could be a grievance, and occurred if someone was upset and wanted to file a grievance. Staff CC stated a grievance was an issue someone had on a unit in which something had occurred with patient care.
On 03/02/17 at 10:11 am, Staff B stated usually no staff nurse completed the complaint [and grievance] form.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on record review, interview, and observation, the hospital failed to:

I. maintain a safe, sanitary environment due to the occurrences of 24 plumbing issues in ICU from 10/05/17 to 03/02/18.

This failed practice negatively impacted the care of one (Patient #28) and had the potential to negatively impact 153 dialysis patients who received care in the ICU, and resulted in exposure of sewage water for ICU staff.

Findings:

I. Plumbing Occurrences

Review of a document titled "Bed Tracking/Bed History" showed from 10/05/17 to 02/13/18, nine rooms (120, 121, 123, 124, 125, 126, 127, 128 and 130) of the 12 ICU rooms were closed more than one time due to plumbing issues:
a. Room 120: 10/05/17, 10/17/17 (total two)
b. Room 121: 10/05/17,10/11/17, 10/17/17, 11/14/17, 11/30/17, 12/29/17 (total six)
c. Room 123: 10/10/17, 12/29/17, 02/05/18, 02/13/18 (total four)
d. Room 124: 10/11/17, 01/09/18 (total two)
e. Room 125: 11/05/17, 12/01/17 (total two)
f. Room 126: 11/29/17, 02/11/18 (total two)
g. Room 127: 11/26/17 (total one)
h. Room 128: 10/06/17, 11/04/17 (total two)
i. Room 130: 11/28/17 (total one)
j. Room 131: 11/26/17, 11/27/17 (total two)

A review of a medical record patient #21 showed on 12/28/17 at 11:20 am bedside dialysis was started by Staff BBB (RN). The record showed the toilet overflowed and the patient was moved due to "flooding". Staff BBB documented the toilet overflowed and the patient's treatment was paused while the patient and treatment equipment were moved to another room, and dialysis resumed at 12:52 pm.

Review of an untitled document showed from 10/01/17 to 01/31/18, 153 patients received dialysis in the ICU.

Review of a policy "Unusual Event/Occurrence Report (effective 03/17)", stated the Safety Committee was provided a monthly summary of the reports, key points, and the trends would be provided to managers/directors/supervisors in a daily safety huddle.

Review of a document "Facility Life Safety/Environment of Care minutes (01/17/18)", showed the plumbing capacity in ICU North was a "Risk Point" and there was no update on the estimated construction cost from 11/21/17. The minutes showed on 12/11/17 that Staff KKK stated a quote from an outside contractor had not been received. On 01/09/18 the document stated Staff KKK had ordered "flushed wipe catcher" (device utilized to retrieve hygienic wipes from plumbing).

On 03/01/18 at 8:30 am, Staff BBB stated dialysis staff "dreaded" doing dialysis at the facility due to "flooding" issues and that "flooding" issues did not occur in other facilities he/she had worked. He/she stated the ICU rooms at this hospital are known to "flood" and dialysis staff had to test the equipment and plumbing prior to starting dialysis to see if the room would "flood", which delayed patient care. He/she stated when the floor was "flooded" he/she turned the reserve osmosis on and had run "fluid" out the window in ICU, which delayed and interrupted patient care. Staff BBB stated the dialysate was stopped when it started overflowing, which caused it to bypass the patient and resulted in delayed/interrupted patient care. Staff BBB stated, "we only do this at this facility, we've evolved into this". Staff BBB stated he/she had informed Staff E and had not written Unusual Event/Occurrence Reports.

On 03/01/18 at 11:15 am, Staff L stated a sink had been removed and new plumbing installed to accommodate hemodialysis in an ICU room. Staff KKK also stated he/she had not submitted the project for approval to the Oklahoma State Plan of Review.

On 03/01/18 at 11:15 am, surveyors observed a sink in an ICU room had been removed, construction was ongoing, including plumbing pipes with two faucets installed.
VIOLATION: PATIENT CARE ASSIGMENTS Tag No: A0397
Based on record review and interview, the hospital failed to ensure nursing staff :
I. performed consistent patient risk assessments for pressure ulcers and skin breakdown utilizing the Braden Scale, and
II. generated a timely Wound Team (Enterostomal Therapy) consult for Braden Scores of 15 or lower according to hospital policy.

These failed practices had the potential to result in the development of wounds for high risk and/ or worsening wounds for seven (Patients # 3, 12, 16, 17,18, 20 and 21) of nine patients with wounds out of a total sample of 22 patients' medical record review from 10/01/17 to 03/01/18.


Findings:

A review of the policy titled," Pressure Injury Survey (09/16)" documented the hospital was committed to provide consistent evidence based quality care in the prevention of pressure injury.

A review of hospital document titled, "Operational Report for Reduction of Hospital Acquired Pressure Injury (HAPI) at CCMH 11/11/17" showed an increased incidence rate of HAPI from 2nd quarter 2017 (rate 1.31) to 3rd quarter 2017 (rate 1.94). The report defined the incidence measured as the number of patients developing new pressure ulcers after 24 hours of admission.

A review of the policy titled, "Pressure Injury Prevention and Managing Skin Integrity (date 09/16)" documented an automatic Enterostomal Therapy wound consult for pressure injury prevention would be generated at any time during hospitalization when a patient's Braden Score was 15 or less. The document showed the program's purpose was to promote prompt evaluation and intervention of any changes in skin integrity during the hospital stay. (The Braden Risk Assessment Scale is an assessment tool which consists of six categories: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. The total score can range from 6 to 23 with a lower score indicating a higher risk of skin breakdown to the patient. The level of risk indicates the intervention strategies that should be used.)

A review of hospital document titled, "Inservice 2S/4W Staff Meeting 05/15/17 and 05/17/17" documented when a patient had a Braden Score of 15 or less, an Enterostomal Therapy consult should be "considered".

A review of the medical records of the following patients showed Braden Assessments were inconsistently scored by multiple different nursing staff:

Patient #3
From 01/23/18 to 02/07/18, 19 of 23 Braden Scores were 15 or less which by policy would generate a Wound Team consult. Wound Care intervention occurred 17 days after the identification by staff of a Braden Score which would qualify Patient #3 for an Enterostomal Consult.

01/23/18 at 10:45 am, Staff JJJ documented a Braden Score of 17, and at 5:57 pm, Staff TTT documented a score of 15.
01/24/18 at 8:49 am, Staff TTT documented a score of 16.
01/25/18 at 9:52 am, Staff TTT documented a score of 17, and at 8:31 pm and 10:15 pm, Staff UUU and Staff VVV documented scores of 20.
01/26/18 at 7:00 am, Staff K documented a score of 15 and at 6:30 pm, Staff RR documented a score of 14.
01/27/18 at 7:00 am, Staff K documented a score of 15 and at 6:52 pm, Staff WWW documented a score of 13.
01/28/18 at 6:50 am, Staff XXX documented a score of 18.
01/29/18 at 6:50 am, Staff XXX documented a score of 18.
01/30/18 at 7:43 am and 10:58 am, Staff LL documented a score of 13 and 12.
01/31/18 at 6:05 am and 2:48 pm, Staff LL documented scores of 12 and 11, and at 7:17 pm, Staff YYY documented a score of 13.
02/01/18 at 6:30am, Staff ZZZ documented a score of 14.
02/02/18 at 6:41 pm, Staff J documented a score of 12.
02/03/18 at 7:00 am, Staff AAAA documented a score of 15 and at 6:47 pm, Staff J documented a score of 13.
02/04/18 at 7:00 am, Staff AAAA documented a score of 12 and at 6:47 pm and 7:49 pm, Staff J documented a score of 13.
02/05/18 at 7:00 pm, Staff J documented a score of 16.
02/06/18 at 6:45 am, Staff ZZZ documented a score of 14.
02/07/18 at 7:00 am and at 7:00 pm, Staff BBBB and Staff II, respectively documented scores of 14 and 12.
02/08/18 at 7:28 am, Staff LL documented a score of 12 and at 9:57 am, Staff CCCC, Wound Care nurse, assessed and measured the wound of Patient #3, and recommended foam heel cup for prevention and Calazime Cream to buttocks. 19 of 23.

Patient # 12
From 02/24/18 to 02/25/18, three of three Braden Scores were 15 or less which by policy would generate a Wound Team consult. Wound Care intervention occurred two days after the identification by staff of a Braden Score which would qualify Patient #12 for an Enterostomal Consult.

02/24/18 at 4:20 pm, Staff RRR documented a Braden Score of 10.
02/25/18 at 9:12 am and 10:47 pm, Staff CCC and Staff SSS, respectively documented scores of 14 and 12 .
02/26/18 at 9:57 am, Staff X, Wound Care nurse, assessed and measured wounds of Patient #12, and recommended Alevyn heel cups, Maxorb dressing, Vashe wound cleaner, dolphin bed, changed Braden score that the nurses had assigned, concerns regarding NPO (nothing to eat by mouth) status, low albumin blood value, and surgery consult.

Patient 16
From 02/05/18 to 02/11/18, four of 10 Braden Scores were 15 or less which by policy would generate a Wound Team consult. Wound Care intervention occurred four days after the identification by staff of a Braden Score which would qualify Patient #16 for an Enterostomal Consult.

02/05/18 at 7:53am, Staff ZZ documented a Braden Score of 20 and at 8:49 pm Staff AAA documented a score of 16.
02/06/18 at 8:30 am, Staff Q documented a score of 20.
02/07/18 at 8:10 am, Staff PP documented a score of 16.
02/08/18 at 9:18 am, Staff DDD documented a score of 16, and at 8:34 pm, Staff EEE documented a score of 13.
02/09/18 at 8:32 am, Staff FFF documented a score of 19, and 10:41 pm, Staff GGG documented a scores of 14. (which by policy would generate a Wound Team consult).
02/10/18 at 10:01 pm, Staff GGG documented a scores of 14.
02/11/18 at 8:50 am, Staff TT and Staff GGG documented a scores of 10.
02/12/18 at at 10:39 Staff X, Wound Care nurse assessed and measured wounds of Patient #16, and noted an atypical wound to the right buttock and recommended re-evaluation in tw- three days, pericare, and moisturizing of bilateral lower extremities.

Patient # 17
From 01/28/18 to 02/07/18, 17 of 17 Braden Scores were 15 or less which by policy would generate a Wound Team consult. Wound Care intervention occurred 11 days after the identification by staff of a Braden Score which would qualify Patient #17 for an Enterostomal Consult.

01/28/18 at 3:30 pm and 6:25 pm, Staff QQ and Staff NN, respectively, documented Braden Scores of 15 and 13.
01/29/18 at 6:35 am, Staff HHH documented a score of 13.
01/30/18 at 6:35 am, Staff HHH documented a score of 13.
01/31/18 at 6:45 am, Staff III documented a score of 14.
02/01/18 at 6:58 am Staff JJJ documented a score of 14.
02/02/18 at 7:35 am Staff III documented a score of 13.
02/03/18 at 7:00 and 11:00 am , Staff MMM documented a score of 15.
02/04/18 at 7:00 am, 5:15 pm, and 7:00 pm, Staff MMM, Staff KK, and Staff NNN respectively documented scores of 14, 14, and 15.
02/05/18 at 3:00 am, 6:48 am, and 6:50 pm, Staff NNN, Staff MMM, and Staff OOO respectively, documented scores of 15, 15, and 14. .
02/06/18 at 7:00 am and 6:30 pm , Staff PPP and Staff OOO respectively documented a scores of 10 and 12.
02/07/18 at 7:00 am Staff PPP documented a score of 10 , and Staff W, Wound Care Nurse, assessed Patient #17, measured wounds, and recommended granufoam, sureprep wands, and wound cleaner.

Patient # 18
From 02/12/17 to 02/15/18, three of seven Braden Scores were 15 or less which by policy would generate a Wound Team consult. Wound Care intervention occurred four days after the identification by staff of a Braden Score which would qualify Patient #18 for an Enterostomal Consult.

02/12/18 at 10:30 am, Staff QQ documented a Braden Score of 14 , and at 6:45 pm, Staff RR documented 17 as a score.
02/13/18 at 10:30 am, Staff VV documented a score of 20, and at 12:00 pm, Staff WW documented a score of 13.
02/14/18 at 07:46 am, Staff XX documented a score of 13, and at 6:19 pm, Staff YY documented a score of 17.
02/15/18 at 6:57 pm, Staff YY documented a score of 16.
02/16/18 at 10:39 am, Staff X, Wound Care nurse, assessed and measured Patient #18's wounds and recommended Calazime Cream, Vashe wound cleaner, waffle mattress, measurement.

Patient #20
From 10/23/17 to 11/01/17, six of 15 Braden Scores were 15 or less which by policy would generate a Wound Team consult. Wound Care intervention occurred five days after the identification by staff of a Braden Score which would qualify Patient #20 for an Enterostomal Consult.

10/23/17 at 9:19 am, Staff HH documented a Braden Score of 20.
10/24/17 at 9:26 am, Staff HH documented a score of 18, at 7:45 pm Staff II documented a score of 17.
10/25/17 at 6:00 am, Staff JJ documented a score of 16.
10/26/17 at 7:00 am, Staff KK documented scores of 17 and 18.
10/27/17 at 7:00 am, Staff KK documented scores of 17.
10/28/17 at 6:10 am, Staff LL documented a scores of 13 and 14.
10/29/17 at 7:02 am, 11:56 am, Staff MM documented a score of 18, and at 7:00 pm, Staff SS documented a score of 15 .
10/30/17 at 7:00 am, Staff RR documented a score of 20, and at 3:32 pm, Staff TT documented a score of 13.
10/31/17 at 10:15 am and at 10:01 pm, respectively, Staff OO and Staff UU documented a score of 12, and Staff OO documented the presence of a sacral wound.
11/01/17 at 8:15 am, Staff OO documented a score of 11, and at 10:14 am Staff PP, Wound Care Nurse, assessed and measured Patient# 2's wounds and recommended foam heel cups, low air matrress, Puracol to wound beds, Border foam to buttocks and coccyx, Calazime to scrotum, and clean with Vashe.

Patient #21
From 11/26/17 to 11/30/17, four of five Braden Scores were 15 or less which by policy would generate a Wound Team consult. Wound Care intervention occurred four days after the identification by staff of a Braden Score which would qualify Patient #21 for an Enterostomal Consult.

11/26/17 at 7:00 pm, Staff EE documented a Braden Score of 15.
11/27/17 at 6:00 pm, Staff EE documented a score of 13.
11/28/17 at 6:45 am, Staff FF and Staff J documented a score of 13, and the use of perineal cleaner, Alevyn Dressing, and an absorbent bed pad.
11/29/17 at 7:00 am, Staff K documented a score of 14.
11/30/17 at 7:00 am, Staff K documented a score of 16, and at 1:56 pm, Staff X, Wound Care Nurse, assessed Patient 21 and recommended foam heel cups, waffle mattress, Calazime to scrotum, and Sanyl Ointment (an enzyme ointment for debridement).

On 02/28/18 at 12:33 pm, Staff K stated staff nurses should contact the physician when a wound was identified, and the phsyician would order an ET consult. Staff K did not state a Braden Score of 15 or less would generate an ET consult. Staff W said staff nurses did not measure wounds, and wound measurement was performed by the ET nurses. Staff K said he/she was not given wound care training by the hospital, had done wound care for 17 yrs, and utilized the Wound Care team as a resource.

On 03/01/18 at 8:31am, Staff X stated staff nurses perform skin assessments, which included a Braden Score and may contact the patient's physician to initiate a Enterostomal Therapy (ET)(Wound) consult. Staff X identifed the policy titled, "Pressure Injury Prevention and Managing Skin Integrity (date 09/16)" as the "protocol" for skin/wound management and included ET would be contacted for Braden Scores of 15 or less. Staff X stated no quality improvement audits were conducted to verify the consistency of the nursing evaluation of the Braden Scores prior to an ET consult. Staff X stated staff were trained to perform Braden Scoring. Staff X stated the Wound Care team had begun a new initiative in 10/17 which included, but was not limited to Braden Scale scoring improvement strategies.


On 03/01/18 at 9:07 am, Staff W reviewed the electronic medical record for Patient # 20 and stated Wound Care team documentation was contained within the "Wound" tab and the nursing staff utilized the "Wound-Nurse" tab. Staff W stated the Wound Care team's first consult occurred on 11/01/17 and the staff nurses identified a wound on 10/31/17.

On 03/01/18 at 9:33 am, Staff W reviewed the electronic medical record for Patient # 21 and stated the Wound Care team's first consult occurred on 11/30/17.
VIOLATION: FORM AND RETENTION OF RECORDS Tag No: A0438
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review and interview the hospital failed to ensure nursing staff documented accurately and completely into the patient's EMR necessary for continuity of care, patient safety and quality of care as evidenced by:

A. Inconsistent documentation of turning and positioning for seven (Patient #3, 12, 15, 16, 18, 19, and 20) out of a total sample of 22 patients medical records according to hospital policy, procedure and current evidence based practice.

B. No documentation of an initial physical assessment by the RN within 24 hours of the patient's admission for two (Patient #12 and 20) out of a total sample of 22 patient medical records reviewed.

C. Inconsistent documentation of an assessment by the registered nurse (RN) every 24 hours per hospital policy for two (Patient #12 and 20) out of a total sample of 22 patient medical records reviewed.

D. Inconsistent documentation of nursing shift assessments for two (Patient #12 and 16) out of a total sample of 22 patients medical records reviewed.

These failed practices had the potential for increased risk to patient safety due to the unavailability of pertinent information to make timely medical and nursing decisions among health care providers and adverse health outcomes for seven (Patient #3, 12, 15, 16, 18, 19, and 20) of a total sample 22 patients from 10/01/17 to 03/01/18.

Findings:

A. Turning and Positioning

Review of a hospital policy titled "Policy Requirements" dated 10/16 showed the purpose was to standardize practices and promote evidence based practices within the policies and procedures across the organization. Procedures without a specific policy were to refer to "Smith, Duell, Martin,. Clinical Nursing Skills Base (sic) to Advanced Skills, Eighth Edition, 2012".

Review of textbook titled "Clinical Nursing Skills Basic to Advanced Skills Eighth Edition" (2012) showed body position should be changed (turned) at minimum every two hours by rotating weight bearing areas using right and left lateral (side lying), prone (horizontally on back), supine (flat on stomach) and swimming type positions in an effort to prevent skin breakdown and injury caused by friction and shear forces. Bedridden patients should be repositioned every one to two hours. Pressure reducing devices such as foam, static-air, and specialized mattresses for patients at risk for pressure ulcers.

Review of hospital policy titled "Skin care and Pressure Injury Prevention" dated 5/17showed risk reduction strategies included systematic turning and repositioning of patients to reduce prolonged direct contact of bony prominences. Patients at risk should be repositioned every two hours.

Review of hospital policy titled "Pressure Injury Prevention and Managing Skin Integrity" dated 2017 showed patients with pressure injuries (stage I, II and deep tissue) should be turned every two hours while in bed.

Patient #3 a [AGE] year old female admitted with supratheraupetic (above the theraupetic level) INR (International Normalized Ratio - blood test designed to help diagnosis bleeding and clotting disorders) and severe anemia who went into septic shock requiring intubation and ventilator support. Review of Patient #3's medical record showed from 01/23/18 to 02/05/18 there was no documentation of repositioning for:
*01/24/18 1:00 am, 7:04 am to 6:00pm
*01/26/18 7:00 am to 6:00 pm and 11:00 pm
*01/27/18 8:00 am and 10:00 am to 6:00 pm
*01/28/18 10:00 am, 12:00 pm, 4:00 pm, 7:08 pm and 10:00 pm to 12:00 am
*01/29/18 8:00 am, 9:00 am, 1:00 pm and 7:06 pm
*01/30/18 6:20 am, 8:20 am, 10:10 am, 12:07 pm, and 4:23 pm
*01/31/18 7:15 am, 9:15 am to 11:05 am, 2:30 pm, 4:19 pm to 6:20 pm and 11:10 pm
*02/01/18 11:00 pm
*02/02/18 3:00 am to 4:00 pm
*02/03/18 7:00 am to 5:00 pm
*02/04/18 9:00 am to 5:00 pm

Patient #12 was a [AGE] year old male admitted with sepsis secondary to chronic UTIs (urinary tract infection) and a stage III sacral decubitus ulcer on arrival. Attending physician ordered repositioning every hour on admission. Review of Patient #12's medical record showed from 02/24/18 to 02/28/18 there was no evidence turning and repositioning was documented every hour as ordered by the physician.

Patient #15 was a [AGE] year old male admitted with necrotizing infection of the perineum. Review of Patient #15's medical record showed from 02/25/18 to 03/01/18 there was no documentation of repositioning for:
*02/25/18 10:30 am to 7:00 pm, 8:00 pm and 10:00 pm
*02/26/18 3:00 am to 7:00 pm
*02/27/18 10:20 am to 6:58 pm, and 8:00 pm
*03/01/18 6:00 am to 10:00 am

Patient #16 was a [AGE] year old male admitted with progressive hematuria, supratherapeutic INR and severe anemia. On admission assessment showed no wounds. At discharge patient had a stage III pressure ulcer to the left buttock. Review of Patient #16's medical record showed from 02/05/18 to 02/21/18 there was no documentation of repositioning for:
*02/08/18 3:56 am to 9:04 pm
*02/09/18 4:25 am, and 10:44 am to 7:18 pm
*02/10/18 7:32 am to 4:45 pm, 6:07 pm, and 11:12 pm to ...
*02/11/18 ... 7:23 am, 12:54 pm to 7:24 pm
*02/20/18 5:30 am to 3:01 pm, 4:00 pm to 7:56 pm

Patient #18 was a [AGE] year old male admitted with shortness of breath and persistent bronchitis secondary to squamous cell [DIAGNOSES REDACTED] in the right upper lobe of the chest. On admission skin assessment showed no wounds. At discharge patient had a sacral pressure ulcer. Review of Patient #18's medical record showed from 02/12/18 to 02/19/18 there was no documentation of repositioning for:
*02/12/18 11:45 am to 3:00 pm, and 6:45 pm to 11:00 pm
*02/13/18 4:00 am to 8:59 am, 12:00 pm to 6:00 pm
*02/15/18 7:00 am to 5:00 pm
*02/16/18 2:39 am, 4:54 pm to ....
*02/17/18 ....2:00am, 4:00 am to 11:38 am and 3:42 pm to ....
*02/18/18 ...7:27am, 8:44am to 2:28 pm to 6:35 pm
*02/19/18 12:00 am to 8:52 am

Patient #19 was a [AGE] year old male admitted with hematuria and anemia requiring blood transfusions. On admission skin assessment noted a non-blanchable redness stage I sacral ulcer. At discharge patient had progressed to a stage II sacral ulcer and developed a deep tissue injury on the left heel. Review of Patient #19's medical record showed from 01/23/18 to 01/30/18 there was no documentation of repositioning for:
*01/23/18 7:05 pm to 11:43pm
*01/24/18 12:00 am to 8:33 am, 6:15 pm to 8:33 pm, 9:30 pm to 11:43pm
*01/25/18 1:30 am to 2:30 pm
*01/26/18 2:00 am, 4:17 pm to 6:24 pm
*01/27/18 10:22 am, 2:44 pm, 4:39pm to 8:36 pm
*01/28/18 3:30 am, 7:21 am, 9:45 am to 10:55 pm
*01/29/18 5:30 am to 12:05 pm, 6:14 pm to 3:46 am (01/30/18)
*01/30/18 5:49 am to 11:20 am, 7:44 pm to 10:54 pm

Patient #20 was an [AGE] year old male admitted with abdominal pain, vomiting and diarrhea. On admission skin assessment showed no wounds. At discharge patient had developed stage II pressure ulcers to right, left buttocks, coccyx and scrotum. Review of Patient #20's medical record showed from 10/24/17 to 11/01/17 there was no documentation of repositioning for:
*10/26/17 4:39 am to 1:00 pm, 1:50 pm to 8:49 pm
*10/27/17 10:40 am to 7:51 pm
*10/28/17 5:44 am to 10:40 am, 3:40 pm to 10:50 pm
*10/29/17 1:02 am to 4:12 am, 5:28 am to 7:00 pm
*10/30/17 5:00 am to 2:00 pm, 3:32 pm ...
*10/31/17 ...4:00 pm
*11/01/17 5:01 am to 9:00 am

On 02/28/18 at 11:46 am, Staff J stated he/she repositioned or turned patients every two hours. Staff J stated he/she was unaware of a specific policy or procedure for repositioning patients and his/her practice would be to reposition the patient based on their preference. Staff J stated he/she would document the repositioning of the patient under the rounding tab in the electronic medical record (EMR).

On 02/28/18 at 12:33 pm, Staff K stated he/she repositioned or turned patients every two hours. Staff K stated he/she documented the position he/she positioned the patient under the rounding tab in the patient's EMR.

B. Initial Assessment by RN

Review of hospital policy titled "Initial Assessment/History of Patients" dated 02/17showed the admitting nurse would complete a head to toe assessment "on admission" of the patient.

Two (Patient #12 and 20) of 14 medical records reviewed showed no evidence of an RN initial assessment within 24 hours of hospital admission per hospital policy.

On 02/28/18 at 11:46 am, Staff J stated generally the RN would complete an initial head to toe assessment as soon as possible after the patient arrived.

03/01/18 at 11:30 am, Staff E stated the RN had 24 hours to complete a full assessment once a patient arrived, but practice generally would be to perform the assessment as soon as possible.

C. RN 24 Hour Assessment

Review of hospital policy titled "Assessment of Patients/Nursing" dated 11/16 showed the initial assessment and a daily assessment every 24 hours must be completed by the RN.

Patient #12 a [AGE] year old male admitted on [DATE] had no evidence of daily RN assessments for 02/25/18, 02/26/18 and 02/28/18.

Patient #20 an [AGE] year old male admitted on [DATE] had no evidence of RN assessments for 10/23/18 and 10/24/17.

On 03/01/18 at 10:39 am, Staff B stated RN staff were assigned to a shift or units had free RN charge nurses who were responsible for performing the daily RN assessment.

D. Nursing Shift Assessment

Review of hospital policy titled "Assessment of Patients/Nursing" dated 11/16 showed a focused assessment should be completed every shift by an RN or LPN (licensed practical nurse).

Patient #12 was a [AGE] year old male admitted with sepsis secondary to chronic UTIs and a stage III sacral decubitus ulcer on arrival. Review of Patient #12's medical record showed no evidence of nursing assessment for the 7:00 am to 7:00 pm shift on 02/26/18.

Patient #16 was a [AGE] year old male admitted with progressive hematuria, supratherapeutic INR and severe anemia. Review of Patient #16's medical record showed no evidence of a nursing assessment for 7:00 am to 7:00 pm shift on 02/13/18 and the 7:00 pm to 7:00 am shift on 02/14/18.

On 02/28/18 at 11:46 am, Staff J stated he/she would perform an assessment at the beginning of the shift and document the findings as soon as possible into the patient's EMR.

On 02/28/18 at 12:33 pm, Staff K stated his/her practice was to perform a focused assessment on each patient at the beginning of the shift. Staff K stated he/she would document the findings from his/her assessment into the patient's EMR.
VIOLATION: PHYSICAL ENVIRONMENT Tag No: A0700
Based on review of documentation, interview, and observation, the hospital failed to:

I. ensure plumbing issues were reported consistently.


These failed practices negatively impacted the care of one (patient #28) and had the potential to negatively impact 153 dialysis patients who received care in the ICU, with compromised patient safety, delayed and/or disrupted care and resulted in the potential exposure of sewage water for ICU patients.

Findings:


I. Reporting

A review of a document titled, "Facility Life Safety/ Environment of Care" Committee minutes (dated 02/06/18) showed no updates since 11/21/17 for construction cost estimates for the plumbing capacity in ICU North. On 02/06/18, the action documented that Staff would investigate "flushed wipe catchers", obtain a bid, evaluate the system, and give the quote to retrofit the plumbing in ICU North. On 02/08/18, there was a delay in getting the "flushed wipe catcher". The minutes showed discussion regarding moving dialsysis patients to two rooms on ICU North. The minutes documented ICU nurses preferred not to move patients to those rooms [that had pluming issues]. The minutes documented that the removal of two sinks in ICU patient rooms would help resolve the "flooding" issues.

The following three documents were reviewed to ascertain the hospital's reporting of plumbing issues. No single report documented the plumbing issues in a comprehensive manner.
1. A review of document titled, "Bed Tracking /Bed history" showed from 10/05/17 to 02/13/18, 12 of 12 Intensive Care Unit (ICU) patient rooms (rooms 120-133) were closed due to plumbing issues.

2. A review of document titled, "Nursing Administration Shift Report (dated 12/09/17) showed rooms 124 and 125 overflowed from dialysis and engineering was notified.

3. A review of document titled, "Unusual Event / Occurrence Report (date 12/28/17)" showed Patient #21 in ICU room 132, was receiving dialysis, and had dialysis paused due to the toilet in ICU room 133 backing up and "flooding" the room. Patient #21 was transferred to room 140 and dialysis was resumed. The same document showed ICU room 133's toilet backed up and "flooded" the room. The patient in room 133 was moved to another room due to a wet floor. Engineering instructed Staff BBB to continue dialysis, but "place the dialysis maching drainage tube out the window", and this action prevented the window from closing and it was snowing outside. After notification of Staff I and Staff G, ICU rooms 132 and 133 were closed for maintenance.

On 03/01/18 at 7:00 am, Staff VV stated he/she had not completed an "Unusual Event / Occurrence Report" each time a plumbing problem had occurred in ICU. Staff VV stated he/she was not aware of the policy to document each event.


On 03/01/18 at 7:00 am, Staff I stated he/she had not completed an "Unusual Event / Occurrence Report" each time a plumbling problem had occurred in ICU. Staff I stated he/she was not aware of the policy to document each event.

On 03/01/18 at 8:45 am, Staff VV stated he/she he/ she was aware of each time there had been plumbing issues in ICU because the ICU staff completed an "Unusual Event / Occurrence Report".

On 03/02/18 at 10:10 am, Staff B stated Staff D stated "Unusual Event / Occurrence Report" were utilized for "everything", including but not limited to: falls, faulty equipment, and lost/stolen property. Staff B stated Staff D stated the expectation was that staff would complete the occurrence form on the same shift of the event/occurrence. Staff B stated he/she would log the event/occurrences into the computer program and route the form to the "appropriate people."