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.

ST CHARLES HOSPITAL 200 BELLE TERRE ROAD PORT JEFFERSON, NY 11777 Oct. 15, 2018
VIOLATION: NURSING CARE PLAN Tag No: A0396
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Based on observation, Medical Record review, document review and interview, the Nursing Staff did not document: (a) The daily priority goal for three (3) of eight (8) patients, and (b) the skin care treatment for three (3) of five (5) patients.

This failure to document a daily priority goal and skin care treatment may prevent patient involvement in their plan of care and achievement of their therapeutic goals.

Findings related to (a):

Observations in the facility's 3 East Unit during a tour between 10:45AM and 12:00PM on 10/10/18 identified the following:

Patient #5 did not have a daily goal documented on the white board in the patient's room.

Patient #6 did not have a daily goal documented on the patient white board.

Patient #8 did not have a daily goal documented on the patient white board.

These observations were made in the presence of Staff P (Nurse Manager), who confirmed the findings.

The facility Policy and Procedure titled "Plan of Care" last revised 05/16/17, stated, "The team works closely with the patient to establish a daily priority goal...This goal is written on the white board in the patient's room and is communicated several times throughout the day. Any changes in condition / status that occur during hospitalization ...are addressed in the Plan of Care....Patients' needs are re-assessed throughout the course of care, treatment and services."


Findings related to (b):

Patient #11's Medical Record identified missing care plan documentation on skin care on 09/07/18, 09/14/18, 09/23/18, 09/28/18 and 09/29/18.

The same lack of skin care plan documentation was found in the Medical Records for Patient #12 on 10/05/18, 10/07/18, 10/08/18 and 10/09/18; and for Patient #13 on 09/27/18, 10/01/18 and 10/10/18.

These records were reviewed on 10/11/18 from 1:30PM to 3:30PM in the presence of Staff E (Director of Nursing Services) and Staff O (Nurse Manager) who confirmed the findings.

The facility's Policy and Procedure titled "Wound Assessment and Pressure Ulcers" last revised 11/21/16, lacked direction on how often the Nursing Care Plan should be updated.

The facility's Policy and Procedure titled "Plan of Care" last revised 06/21/17 stated, "Care plan needs to be reviewed or updated, modified and/or documented on at least daily by the Registered Nurse (RN)."
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VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

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Based on Medical Record review, document review and interviews, facility staff did not ensure that an allegation of abuse was investigated as a Complaint or Grievance, as per facility Policy, in one (1) of four (4) Complaint Investigations reviewed.

This lack of an investigation could result in the facility not implementing corrective actions or resolving grievances and complaints.

Findings include:

The facility Policy and Procedure titled "Patient (Pt.) Complaint and Grievances", last revised July 19, 2018, stated the following: "Patient complaints that are considered grievances also include situations where...an authorized representative telephones the hospital with...an allegation of abuse or neglect....Complaints or grievances received post discharge...shall be processed as follows: Upon receipt of a Patient Care Inquiry (PCI) the individual receiving the PCI should complete the...Customer Relations Action Form (CRAF)...[and] record a brief description of the nature of the complaint...A copy of the CRAF should be faxed to the Quality Management Associate [and]...to the appropriate department manager...Within 48 hours of receipt of the CRAF, the responsible department manager...should ascertain specific facts...asses the circumstances and contact the involved individuals...Upon completion of the PCI assessment, the CRAF should be completed noting the final conclusion, recommendations, actions and follow-up."

The facility Policy and Procedure titled "Patient Abuse: Prevention Investigation and Reporting" last revised August 5, 2016, stated the following: "Every staff member is empowered to immediately report an allegation of...abuse...Once the patient complaint...is received the Nursing Supervisor, the Administrator on call is notified immediately...A timely and thorough investigation of the case will be conducted...This investigation must be initiated immediately....all involved staff members will be requested to participate in the interview process and documentation of the event will be obtained...The patient relations coordinator will record all complaints / allegations of abuse on a Patient Abuse Log."

Review of Patient #3's Medical Record identified the following information: This [AGE]-year-old female presented by ambulance to the emergency room on [DATE] with a change in mental status. The Nurse documented the patient was combative, screaming, kicking, punching the staff and that the patient appeared to be hallucinating. The patient was restrained, placed on 1:1 observation and medicated. The Nurse's Notes documented that the patient remained aggressive with delusional thoughts expressed and was unable to accept or understand what was reported. The patient was evaluated by Psychiatry who documented the patient had paranoid delusions with psychosis and needed inpatient psychiatric hospitalization . The patient was transferred as an involuntary admission to psychiatry at another facility.

An Addendum Nursing Note dated 08/16/18 at 1:21PM stated, "Pt. [patient] also brought up claim that after having her underwear cut off there was a possibility she was abused...pt. started claiming that security officer was taping her with cell phone...". The Nurse documented that an explanation of the hospital's Policies was given but the patient would not accept the explanations. There is no other information about these allegations documented in the Medical Record.

Electronic mail from Staff Q (Nursing Director) to Staff E (Chief Nursing Officer) and Staff F (Risk Management Director) on Friday, August 17, 2018 at 3:15PM stated the following: "...[nurse] called from the psych unit and wanted to know if we had done a rape kit or any other investigation regarding Patient #3...transferred there yesterday. She is making allegations there now...that she was raped or assaulted...She (the patient) started saying that she will not agree to be transferred ...and also will say she was sexually assaulted because her clothes were cut off."

After Staff Q received the call about the PCI, no documented evidence was found that a CRAF or Patient Abuse Log had been completed, or an investigation related to the allegation had been initiated.

The findings were acknowledged by Staff E and Staff F at 10:30AM on 10/15/18.
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VIOLATION: CONTENT OF RECORD - OTHER INFORMATION Tag No: A0467
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Based on observation, Medical Record review, document review and interview, the facility did not ensure that: (a) staff assigned to 1:1 suicide observations consistently documented the hand off communication to oncoming staff; and (b) Nursing Staff consistently documented the turning and positioning of patients with decubitus ulcers every two (2) hours as ordered by the Physician.

This failure to document the patient's condition may place patients at risk for injury.

Findings related to (a):

Review of the Suicide Precautions Flow Record for Patient #5, who had been admitted for an overdose, identified the following:

On 07/31/18 from 7:00PM to 6:30AM, no documentation of the handoff / change of shift communication by Security Staff was found.

On 08/02/18 from 12:30AM to 6:30AM, no documentation of the handoff / change of shift communication by Security Staff was found.

On 08/21/18 from 7:00PM to 6:30AM, no documentation of the handoff / change of shift communication by Security Staff was found.

Similar findings of the lack of documentation for handoff / change of shift communication by Security Staff were noted on 08/24/18, 08/25/18, 08/29/18, 08/30/18, 08/31/18, 09/01/18 and 09/02/18.

During an interview with Staff P (Nurse Manager) and Staff F (Director of Risk Management) on 10/15/18 at 3:00PM, both staff members acknowledged that all sections including the handoff / change of staff / shift section of the Suicide Precautions Flow Record should have been completed by Security Staff.

The facility Policy and Procedure titled "Patient Observation: 1:1/ 2:1" last revised 01/29/18, contained the following statements: "...communication of the patient's present status (including the patient's behavioral characteristics and care needs) must be communicated to any staff member providing the observation, including times of shift change, staff relief and patient transfers to another unit or department."


Findings related to (b):

Medical Record reviews in the facility's Intensive Care Unit (ICU) and 3 North Units during a tour on 10/11/18 between 1:30PM and 3:30PM identified the following:

Patient #11 had "full thickness pressure injury to the right lower sacrum, Stage 4". The original Physician Order dated 08/28/18 ordered Turning and Positioning (T&P) "Now, then every 2 hours." The Order was renewed daily except for on 09/16/18 and 10/01/18.

The Nursing Flow Sheet for Patient #11 identified that Turning and Positioning was only documented two (2) or three (3) times per day for forty-two (42) days, out of the twelve (12) times per day required.

Patient #12 had a "Stage 2 pressure ulcer on the left buttock." The Physician's Order for Turning and Positioning every two (2) hours was dated 10/09/18 at 6:11PM.

The Nursing Flow Sheets identified the following: On 10/09/18, Turning and Positioning was documented once out of the required three (3) times; on 10/10/18, Turning and Positioning was documented once out of the required twelve (12) times; and on 10/11/18, Turning and Positioning was not documented the first four (4) of the required twelve (12) times.

The same problems in Turning and Positioning documentation were also found in the Medical Record for Patient #13 for the review period of 08/08/18 to 08/13/18.

These records were reviewed in the presence of Staff E (Director of Nursing Services) and Staff O (Nurse Manager) who confirmed that the Nursing Staff should have followed the Physician's Orders.

The facility's Policy and Procedure titled "Wound Assessment and Pressure Ulcers" last revised 11/21/16 stated, "Reposition and turn bed and chair bound patients" but lacked direction on the frequency of Turning and Positioning.