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.

CEDAR HILLS HOSPITAL 10300 SW EASTRIDGE STREET PORTLAND, OR 97225 Feb. 28, 2019
VIOLATION: ORGANIZATION OF NURSING SERVICES Tag No: A0386
Based on observations including video recordings, interviews, review of medical record and incident/event documentation for 29 of 40 patients reviewed (Patients 59, 61, 63, 65, 66, 67, 68, 69, 70, 71, 72, 76, 77, 79, 81, 82, 83, 84, 85, 86, 87, 88, 89, 93, 94, 95, 97, 98 and 99), and review of policies and procedures and other documentation it was determined that nursing services had not been organized and managed by a director of nursing who was responsible to ensure the delivery of safe and appropriate care to patients who experienced skin alterations, changes of condition, falls, medication errors and other incidents that resulted in potential or actual harm.

Findings include:

1. Refer to the findings cited under Tag A395, CFR 482.23(b)(3), CoP Nursing Services - Standard: RN supervision and evaluation of nursing care for each patient.

2. Refer to the findings cited under Tag A396, CFR 482.23(b)(4), CoP Nursing Services - Standard: Development and maintenance of a nursing care plan for each patient.

3. Refer to the findings cited under Tag A405, CFR 482.23(c), CoP Nursing Services - Standard: Preparation and administration of drugs.

4. Refer to the findings cited under Tag A115, CFR 482.13, CoP Patient's Rights.
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
Based on observations including video recordings, interviews, review of medical record and incident/event documentation for 29 of 40 patients reviewed (Patients 59, 61, 63, 65, 66, 67, 68, 69, 70, 71, 72, 76, 77, 79, 81, 82, 83, 84, 85, 86, 87, 88, 89, 93, 94, 95, 97, 98 and 99), and review of policies and procedures it was determined that nursing services had not been organized and managed to ensure the delivery of safe and appropriate care to patients who experienced skin alterations, changes of condition, falls, medication errors and other incidents that resulted in potential or actual harm.

Findings include:

1. Refer to the findings cited under Tag A395, CFR 482.23(b)(3), CoP Nursing Services - Standard: RN supervision and evaluation of nursing care for each patient.

2. Refer to the findings cited under Tag A396, CFR 482.23(b)(4), CoP Nursing Services - Standard: Development and maintenance of a nursing care plan for each patient.

3. Refer to the findings cited under Tag A405, CFR 482.23(c), CoP Nursing Services - Standard: Preparation and administration of drugs.

4. Refer to the findings cited under Tag A115, CFR 482.13, CoP Patient's Rights.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Refer to the findings identified in the deficiency at Tag A395 related to Patients 59, 61 and 76 on the 90-day termination revisit survey, CMS 2567 with Survey Event ID OM1C12 dated 02/28/2019.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on interviews, review of medical record and incident/event documentation for 8 of 8 patients reviewed for the provision of nursing services (Patients 59, 61, 69, 76, 83, 84, 86 and 97) and review of policies and procedures it was determined that the hospital failed to develop and implement clear and complete nursing services policies and procedures to ensure the RN was responsible for the supervision and evaluation of safe and appropriate care to patients who experienced skin alterations, changes of condition, falls and other incidents that resulted in potential or actual harm and acute medical ED and inpatient hospitalization s:
* Patient's actual and potential problems and needs were not assessed, care planned and acted upon promptly to achieve resolution and prevent worsening of the problem.
* Changes of patient condition were not assessed, care planned and acted upon promptly to achieve resolution and prevent worsening of the problem.

Findings include:

1. a. The policy and procedure titled "Medical Precautions" dated as last revised 11/10/2017 included the following:
* "Should the individual be determined to have a medical condition that requires services/treatment beyond the scope/capability of Cedar Hills Hospital, they will be directed, referred, or as applicable, transferred to a facility/agency that can better meet their care needs."
* "Patients identified as having a co-occurring high risk medical condition, may, at the discretion of the [LIP] or Registered Nurse, be placed on Medical Precautions."
* "The Registered Nurse communicates directives regarding Medical Precautions to other members of the team."
* "The following interventions are considered when planning and providing care for a patient on Medical Precautions...Increase the frequency with which vital signs are obtained...Required Routine assessment / reassessment of condition and possible symptoms, Provide relevant medical equipment and treatments, Consider increased frequency of vital signs."* "Nursing team members working with the patient remain vigilant in observing the patient for changes in condition and immediately communicate significant observations of concern to the Registered Nurse. Factual observations are documented in the patient's medical record. The Registered Nurse assures that the attending/on-call provider is informed of these observations."

b. The policy and procedure titled "Medical Exclusionary Criteria" dated as last reviewed "02/2018" included the following:
* "Functional Exclusions: Inability to independently perform activities of daily living..."
* "Medical Instability Exclusions: Unstable vital signs. Temp [greater than] 103...SA O2 on room air less than 90%..."
* "Care exclusions:...Wounds that nursing intervention sterile dressings (sic)...Requires O2 therapy..."

c. The policy and procedure titled "Medical Transfers" dated as last reviewed 11/09/2016 included the following:
* "Patients who have been admitted to Cedar Hills Hospital either via direct admission or transfer, who are subsequently found to have medical conditions that cannot be safety treated/managed at Cedar Hills Hospital or that are outside of the scope of services provided by Cedar Hills Hospital are to be transferred to another medical facility."
* "Attempt to contact the on-call medical provider before initiating a transfer for significant deviation from normal vital signs...Vital sign deviations that may warrant medical transfer are: Temperature [greater than] 102...SA O2 [less than] 90% on room air and symptomatic."
* "Patients who after admission are identified as having the following conditions are to be transferred to another medical facility in as timely manner as is possible so as not to compromise the welfare of the patient: Requires oxygen therapy and is unable to maintain SAO2 [greater than] 90% on room air. Has infectious process requiring isolation or contact precautions. Requires treatments, such as intravenous fluids/medications, that are outside of the scope of services available at Cedar Hills Hospital."

d. The policy and procedure titled "Daily Progress Notes / Re-assessment of Patients" dated as last reviewed 06/21/2018 included the following:
* "It is policy of Cedar Hills Hospital to assess patients at time of admission...Reassessment occurs on an ongoing basis via daily assessment by a Registered Nurse."
* "Evening Shift Nursing Progress Notes, documented daily, may be completed by an LPN. If completed by an LPN, the LPN is responsible to report any significant observations to the Registered Nurse. The Registered Nurse in turn is responsible to co-sign the note and document a narrative of his/her assessment of the significant observations."
* "Reassessment is conducted by Registered Nurse daily at a minimum. Additionally, reassessment occurs in the following circumstances: If there is a change in the patient's condition..."
* "A minimum of once each 24 hours the Registered Nurse completes the Daily Nursing Reassessment Form and places the completed form the (sic) patient's medical record. The reassessment consists of a brief face-to-face interview, clinical assessment, and observation."
* "If an LPN completes the Nursing Progress Note it is to be reviewed and co-signed by a Registered Nurse. The Registered Nurse is responsible to document a narrative note regarding any significant observations made by the LPN."
* "As indicated by the patient's condition, length of stay and level of care, the treatment team reassesses the patient in relation to progress toward treatment plan goal. These reassessments are documented on the Interdisciplinary Treatment Plan Update form."

e. The policy and procedure titled "Treatment Planning, IP" dated as revised "3/2017" reflected:
* "Each patient's care will be guided by an individualized Multidisciplinary Treatment Plan that is based on the needs of the individual, as identified in the clinical documentation of Cedar Hills Hospital...The RN completing the Nursing Assessment initiates the Treatment Plan by documenting on the 'Multidisciplinary Treatment Plan, Part 1' form. This documentation includes treatment goals and interventions reflecting the reason the patient admitted to Cedar Hills Hospital, as well as safety concerns and medical issues...For all active medical problems identified upon admission, the admitting RN will complete an individual 'Problem Sheet'...The admitting RN will review the treatment plan with the patient and give him/her the opportunity to provide input. This document will guide the patient's care until the patient's Treatment Team meets to develop the 'Multidisciplinary Treatment Plan, Part 2.'"
* "Within 72 hours of admission, the patient's treatment team will meet to reconcile all problems identified in the Nursing Assessment, Clinical Assessment, History and Physical, and Psychiatric Evaluation. The Multidisciplinary Treatment Plan, Part 2' will be completed along with individual 'Problem Sheets' indicated by the needs of the patient. All clinically significant findings identified in assessments will be incorporated in the Treatment Plan, with documented justification for issues not addressed during treatment at Cedar Hills."
* "The Multidisciplinary Treatment Plan will document individualized and measurable short- and long-term goals of the patient, which include time frames, settings, services, staff names and responsibilities required to meet the goals."
* "The Treatment Plan will be reviewed and/or updated weekly by the Treatment Team and will reflect changes in the patient's course of treatment."

f. The policy and procedure titled "Vital Signs" dates as last reviewed 05/14/2018 included the following:
* "Routine vital signs are obtained at 0700 and 1900 daily. Vital signs include: Blood pressure, Temperature, Heart Rate, Respirations, O2 Saturation."
* "The reference ranges for vital signs are defined as follows...Temperature = 97.8 - 100, O2 Sat = [greater than or equal to] 92% on room air."
* "Staff obtains vital signs from each patient per protocol, Physician's Order, and at direction of the licensed nurse. Vital signs are reported to the licensed nurse in a timely manner. Values outside of the reference range are reported to the nurse."
* "If values are obtained outside of the reference range, vital signs are retaken 30 minutes after RN notification or at an interval designated by the RN."
* "Each patient's vital signs are recorded on the Vitals Log in each patient's medical record...RNs must review and initial all vital signs on the Vitals Log."
* "The patient's provider and the Unit or Nursing Supervisor are notified if values do not significantly improve after retaking vital signs."

g. The policy and procedure titled "Skin Check / Body Search" dated as last reviewed 11/15/2016 included the following:
* "Patients admitted to Cedar Hills Hospital are to...comply with an unclothed physical examination to ascertain the presences/absence of injuries, wounds, infections, scars, tattoos, and other identifying marks."
* "The purpose of this skin check/body search is to insure a safe and healthy clinical environment for all patients."
* "During the visual body search the licensed staff will be assessing, and documenting, the patient's current skin condition, assessing specifically for open wounds, bruising, rashes, parasites or bites. The staff will also note the presence of scars, tattoos and piercings."

h. The review of policies and procedures revealed no evidence of such related to nursing care and management of open wounds, burns, lacerations, rashes and other skin alterations. This was confirmed during repeated requests for such policies and procedures throughout the survey. During interview with the CEO on 02/25/2019 at 1730 he/she confirmed that the hospital did not have policies and procedures related to wound care and management and stated that they did not have a skin care process and program.

i. The policy and procedure titled "Fall Prevention Program" dated as revised "02/2019" reflected:
* "In keeping with our mission to provide a safe and injury free environment CHH engages in a Fall Preventive Program. Patients are screened during the nursing assessment for fall potential and to identify those patients who need to be placed on fall precautions. Fall precautions may be initiated at any time during hospitalization if the patient's condition changes. Using the Edmonson Psychiatric Fall Risk Assessment."
* "All patients will be screened for fall potential during the initial nursing assessment."
* "Those patients who score 90 or above are placed on fall precautions."
* "Any staff that observes a patient anywhere within the facility who may be at risk for a fall will alert nursing staff and will provide immediate assistance.
* "Once identified as a fall risk the patient's fall precautions are initiated by the nurse with instruction given to MHT and patient."
* "A fall kit is obtained...Patient is issues (sic) yellow no slip socks...A yellow wristband is placed loosely on the patients wrist...A pair of Non-skid shoes is given to patients that admit with shoes that increase risk for falls...A bedside bed bell for patients as appropriate."
* "Communication will take place at the completion of the nursing assessment between the RN and the other nursing staff when a patient is identified as a fall risk. The daily rounds sheet will be immediately marked to indicate fall precautions."
* "All patients on fall precautions will be reported at change of shift to assure that oncoming staff is aware of the patient on fall precautions. This report will include information about what places that individual at risk."
* "Patients assessed at risk for falling are assessed daily using the fall risk assessment tool. Nursing staff will also assess the footwear of patients on Fall Precautions to determine if they are appropriate and not likely to contribute to falls."
* "The care plan will be reviewed and updated following each assessed change in condition as evidence (sic) by the fall risk assessment tool."
* "Fall Risk Care plan will indicate the individual patients need."
* "A patient may be placed on fall precautions at any time that a fall potential is identified by nursing staff. RNs will initiate fall precautions based on the patient's fall assessment or reassessed needs including but not limited to change in medications, changes in mental status, change in self-care ability, or the patient has a fall or near fall."
* "These interventions are considered the minimum preventive measures for fall potential and do not take the place of professional judgment. More intensive interventions may be implemented as the patient requires by nursing judgment or physician order."
* "All staff in the facility are responsible to be aware of any safety issues that a patient may be placed upon, and to communicate risk to other team members who have contact with the patient, this may include patient's visitors...These include but are not limited to...Recent history of falls...Confusion/disorientation...Dizziness...Unsteady gait...Environmental hazards...Requires assistance with standing or walking...Assistive equipment is obtained if needed for the patient safety...If patient...should fall the first priority is to assess for any obvious injury and to provide immediate medical assistance. A patient's fall status will be documented in the medical record."
* "Based on the cause of the fall any immediate environmental issue will be addressed and actions taken to increase patient or environmental safety."
* "Incident reports will be completed on all falls and reviewed by leadership in the Safety Huddle each day. Data will be tracked and analyzed to identify trends or issues that need further action. Data will be reported thru the safety committee to the Performance Improvement Committee...The Fall Prevention Committee will meet monthly to review all fall documentation, analyze data, aggregate fall rates, look for trends, make recommendations related to staff training need, equipment available for fall prevention and update interventions in place to prevent or reduce falls...Environmental safety walk-a-rounds are completed at least one times (sic) weekly by the COO/CNO and Environment of Care Manager/Director to assure ongoing monitoring of any potential fall hazards. Incident reports are completed for any safety issues...The EOC manager/director computes monthly Safety/Security rounds that are documented and reported to PI."
* "(Note: The fall assessment screening is based on the Edmonson Psychiatric Fall Risk Assessment)."

2. a. The medical record of Patient 59 reflected a lack of appropriate, and timely, initial and ongoing RN assessment, care planning and intervention for burn wounds the patient was admitted with. Those failures resulted in significant harm to the patient as the wounds worsened and the patient experienced increased inability to perform ADLS, pain, numbness, infection, debridement, acute care inpatient hospitalization , IV antibiotics and possible amputation. The medical record contained the following documentation related to the patient's burn wounds:
* On 01/05/2019 at 0851 faxed records were received from PSVMC ED that reflected Patient 59 had presented to the ED with "Burn, hands, second degree, left" and "Burn, hands, second degree, right" secondary to a suicide attempt. "The patient...tore open the sheet rock wall and removed electrical wires that [he/she] intentionally electrocuted [him/herself] with...describes holding the electrical wire in both hands and shocking [him/herself] for [as] long at 10 minutes..." ED documentation related to the wounds included: "Bilateral blister/burns to palms...may require surgical debridement of wounds...Bilateral hand blister(s) Assessment...several popped blisters bilat...moist drainage..."
* On 01/06/2019 at 1811 the patient was admitted to CHH.
* On 01/06/2019 at 1838 a QMHP completed and signed the "Clinical Intake Screen" form. The "Chief Complaint" was recorded as "Pt was admitted to [PSVMC] on [01/05/2019] following a suicide attempt via electrocuting [him/herself]. Pt lives in a group home (from October 2018)."
* On 01/06/2019 at 1850 an RN completed and signed the "Medical Screen" form. Under the "Reasons for Assessment/Admission" the RN recorded "transferred from Providence, try (sic) to commit suicide by electrical shocks, fingers burned...on both hands." Under "Medical Issues" the RN checked the boxes for "Skin Problems" and "Current." The "Body...Skin Check" section of the form contained a diagram of a body on which both hands had been circled. The description written in the "Other" space was "[positive] burns" and under the "Details of Issues Noted in Skin Check" the RN recorded "hands bilateral - burns. self-inflicted burns. wrapped in 4 x 4 dressings." There was no documentation to reflect that the RN visualized the patient's wounds and there was no descriptive information by the RN to include the specific locations, extent and severity of the burns, drainage, etc.
* On 01/06/2019 at "21[illegible]" an RN completed and signed the admission "Nursing Assessment" form. The RN recorded the "Reason for admission" was "Suicidal attempt, I tied two wires on the thumbs." The RN recorded under "Physical Health Screening" that the patient's "Skin" was "Denies problems." The RN recorded under "Pain Screening" that the patient experienced "burning" pain however, the space for the "Location" of the pain was blank and not completed. The RN recorded under the "Initial Nursing Treatment Plan" that the patient problems to be addressed were "[Inpatient suicidal ideation's]" and "[Inpatient elopement]" There were no other problems identified, including none related to burns. Under "Immediate Actions Taken by RN" the "Medical Precautions" section was blank and not completed. There was no documentation on the RN's assessment to reflect that the patient had burns, no documentation to reflect that the RN visualized the patient's wounds and no descriptive information to confirm the locations, extent and severity of the burns, drainage, etc.
* On 01/06/2019 at 2112 the RN dated and signed the "Master Treatment Plan" form. Although the RN had not identified or assessed wounds on the admission nursing assessment, under "Skin Problems" on the treatment plan the RN underlined "Cellulitis" and wrote "Burns bilateral thumbs." The care plan was incomplete and did not address such things as interventions for contact precautions or assisting the patient with ADLs when both of his/her hands were wounded and dressed. It was further unclear how the RN obtained the diagnosis of [DIAGNOSES REDACTED]."
* On 01/06/2019 at an illegible time an RN recorded " Patient has bilateral thumb blisters between 1" and 2", hands are edematus (sic)."
* On 01/07/2019 at 0205 an RN recorded "Following the 2:00 rounds the MHT reported the dressing coming loose on this patient. I took 4" paper tape and small Telfa Pads & reinforced the existing dressing with instructions to have the morning Nurse redress with Silver Silvadeen (sic) in the morning." However, there was no orders for dressing changes or topical ointment at that time.
* On 01/07/2019 at 1100 an MD completed and signed the "Medical History and Physical Examination" form. The MD recorded that the patient's "History or Present Illness" was "...psych [treatment]. [Patient] has [chief complaint] of shoulder pain...has [positive auditory verbal hallucinations]." The MD recorded under the review of systems that the patient's "Integument" was "Negative." The MD recorded under the physical examination that the patient's "Skin" was "OK [illegible]." Under "Problems to be Addressed in Treatment Plan" the MD recorded "Burns, finger - [illegible] dressing changes, Daily Silvadene, and consult 1/9." The documentation about the patient's burns was unclear and lacked descriptive information to confirm the locations, extent and severity of the patient's burns, drainage, etc.
* On 01/07/2019 at 1145 the MD signed a physician's order for "Medical Consult evaluate for possible [antibiotic] treatment."
* On 01/07/2019 at 1147 the MD signed a physician's order for "silver sulfadiazine topical 1% Topical cream 1 app TOP DAILY...hand burns...please apply after daily dressing changes." There were no other physician orders related to treatment of the burns, including what kind of "dressing changes" were to occur. For example: Sterile, type of product, where to apply the ointment, how to wrap, etc.
* On 01/08/2019 at 0922 an RN recorded "Pt wound change completed by Med RN...Pt currently on...medical (wounds on both hands) precautions." However, it was unclear what type of dressing change occurred on this occasion and throughout the hospitalization .
* On 01/08/2019 at 2240 an RN recorded "burns to both hands has clean, dry and intact dressing."
* On 01/09/2019 at 2314 the MD dictated a "Medical Consultation" that reflected the "Date of Visit" was 01/09/2019. The MD recorded "Just before [patient] came to the hospital, [he/she] electrocuted in both hands and had blisters. [He/she] is not complaining of increased pain, but the blisters are not healing, skin is open at few places with some redness around it and some discharge from it...Both hand palms have bake blisters with redness at the ______ (sic) around the blisters and some tenderness. Left arm blisters are open with some sticky discharge and redness...Bilateral hand electric burn with some infection...Wound care was done by debriding the blisters and then by draining debriding blisters and applying Silvadene cream and redressing it...Continue all other treatment as it is."
* On 01/10/2019 at 1100 an RN recorded a description of the patient's behaviors and referred to the patient as a "[AGE] year [opposite gender of Patient 59]." Neither was Patient 59's [AGE] years.
* On 01/10/2019 at 2045 an RN recorded "dressing to hands was done earlier."
* On 01/11/2019 at 1050 an RN recorded "Pt reports that [he/she] has not showered, pt states that [he/she] did not want to comprimise (sic) the dressings on [his/her] hand wounds. Pt had dressings on both hands changed."
* On 01/13/2019 at 0810 an RN recorded "Pt requested [his/her] bandages on [his/her] hands be changed a little earlier than noon. This RN changed wound changes (sic) per physician protocols. Pt's wound blister opened and silvedine (sic) applied. Will continue to monitor."
* On 01/14/2019 at 0825 an RN recorded "Pt...[complains of] numbness in [his/her right] thumb. Pt has burns on hands bilaterally. Pt put on medical board for possible infection on [his/her] hands d/t electrical burns."
* On 01/14/2019 at 2015 an unsigned "Daily Nurse Progress Note" reflected "Patient [complains] of a new onset of pain 8/10 to both thumbs, has wounds on both hands from burns, dressing saturated, patient refuses wound dressing. On call [physician] notified increase ibuprofen 400 mg to 800mg TID prn pain, order transcribed, patient put on medical consult."
* On 01/14/2019 at 2028 the MD gave a "telephone" order for "Medical Consult New onset of pain to bilateral thumbs and saturated wounds to both hands."
* On 01/15/2019 at 1704 an RN recorded "This RN did wound dressing this morning at around 1035 am in the pt hands (sic) both left and right hands. This RN applied siver (sic) sulfadiazine topically 1% cream (Silvadene) as ordered for the patient burn hands. Pt hands was (sic) wrapped with nonadhesive gauze. Pt advised (sic) to keep [his/her] hands clean and dry."
* On 01/15/2019 at 1925 the MD signed a physician's order for "cephalexin 250 mg 500 mg PO QID...Bilaterl (sic) hand infected burn wound/cellulitis."
* On 01/15/2019 at 1929 the MD signed a physician's order for "Wound care at Providence wound care."
* On 01/15/2019 at 2035 an RN recorded "[He/she] started antibiotic, Keflex tonight, [his/her] wounds are not progressing well per [physician's] report. [He/she] redressed the wounds near shift change tonight. Burns are full thickness bilateral on palms of [his/her] hands."
* On 01/15/2019 at 2151 the MD dictated a "Medical Consultation" that reflected the "Date of Visit" was 01/15/2019. The MD recorded "Just before [patient] came to the hospital, [he/she] self-electrocuted [him/herself] with both hands and developed deep electric burns and blisters. Some of the blisters " (sic) are open and then debrided last week and was placed on a Silvadene cream. Today, [he/she] was complaining of increased pain in [his/her] thumb and hand ______, (sic) but [he/she] denied having [DIAGNOSES REDACTED].Bilateral hand electric burn with some infection...We will start antibiotics now. Keflex 500 mg 4 times a day for 7 days. Continue wound care...We will also get a wound care consult from Providence Wound Care Department and for further management of [his/her] open wound."
* On 01/16/2019 at 0930 a staff person with an illegible signature recorded on a "Daily Nurse Progress Note" that "Appt. made for pt at [LEMC] [tomorrow] the 17th at 1430...Pt reports pain in hand."
* On 01/17/2019 at 1330 an RN recorded "Pt went to appt at Ore. wound/Burn clinic accompanied by MHT. Pt went by cab."
* On 01/17/2019 at 1500 the RN recorded "Received call from wound clinic reporting that pt was going to be admitted to hospital for possible amputation of part of hands D/T wound/bone infection."
* On 01/17/2019 at 1550 a QMHP completed and signed a "Communication Log" form and recorded that "Pt was admitted to the Oregon Burn Center at Legacy Emmanuel (sic)."
* Although the MAR, on which treatments were documented, reflected that the "silver sulfadiazine topical 1% cream" was applied once a day from 01/08/2019 through 01/17/2019, there was no documentation on those occasions to reflect an assessment of the patient's burns, including clear descriptive information about locations, extent and severity.
* The MAR reflected that the patient's PRN ibuprofen pain medication usage increased daily from one time per day, 400 mg., on 01/07/2019 to five times per day on 01/14/2019 for which he/she received the maximum allowed by the physician's order of 2400 mg. in one day.
* The patient was discharged from CHH on 01/17/2019 at 1737.

b. Review of an unsigned CHH "Hospital Transfer Tracking" form dated 01/23/2019 at 1600 reflected that a report about the patient had been received from PSVMC (although the faxed documents attached were from LEMC Burn Center.) The report reflected that on 01/21/2019 CHH received an initial request to readmit Patient 59 and on 01/23/2019 the patient was denied a readmission to CHH secondary to "medically excluded d/t wound care needs & IV [antibiotics]." The attached LEMC Oregon Burn Center "Admission History & Physical" signed and dated by the MD on 01/17/2019 reflected "Bilateral Ischemic Necrosis of Thumbs...edematous." Photographs attached to the 01/18/2019 LEMC Oregon Burn Center "Progress Note" demonstrated the severity of the wounds on both the patient's hands.

c. An "Incident Investigation Summary" form and corresponding documentation was dated 01/18/2019 at 0955. The "Investigation Summary / Outcome" section of the form was dated 01/18/2019 at 0955 by the DPI and reflected "Pt needing medical care for injury from suicide attempt. Med consult occurred & recommendations made for ER visit. Policies reviewed & staff[illegible] followed policy. Investigation report filed with [Washington] County. Pt was treated for burns at PSV. PSV requested to return patient one week later for continued treatment. Transfer was not accepted due to level of medical care [he/she] would need was beyond CHH scope."

This note was not accurate as evidenced by the findings about Patient 59 above as there had not been a recommendation for an ER visit but rather a wound clinic consult; Patient 59 was not sent to PSVMC but another hospital for treatment of the burns; and PSVMC did not request that the patient be returned to CHH as the patient had not been sent to PSVMC but another hospital. In addition, the request for readmission to CHH was initially received on 01/21/2019 and the transfer was denied by CHH on 01/23/2019, five days after the investigation summary note was dated by the DPI on 01/18/2019. Further, the RNs had not followed the hospital's nursing services policies and procedures related to patient assessment / reassessment and management of patient's changes of condition, incomplete as they were; and there were no nursing services policies and procedures related to care and management of wounds.

An attachment to the incident documentation was titled "Below is the timeline we established for Patient [59]" and it included "1/6/19 admitted with existing burns on hands...1/10/19 - 1/14/19 Daily wound care and dressing changes; poor documentation by nurses."

3. a. The medical record of Patient 76 reflected he/she was admitted on [DATE] at 1745 secondary to schizophrenia. The record reflected the following:
* A "Clinical Intake Screen" form with "Start Date/Time: 2/4/2019" at 1900 reflected the patient's chief complaint was "...disorganization, SI [with] plan to OD, confusion, AH..." The form reflected the patient had a history of falls where the "Fall" section reflected "...Past Dates: 'I slipped...3-4 weeks ago."
* The "Body (Completed By Nursing Staff)/Skin Check" form signed by a RN and dated 02/04/2019 at 2000 was reviewed and reflected "...[Left] Hand - Pointer finger escoriation (sic) from bandaid...[no] open areas Extremities X4 covered in scars from Hx of vascularitis." There was no further assessment of the identified skin conditions. For example, there was no description of the size of the skin conditions, presence or absence of signs/symptoms of [DIAGNOSES REDACTED]. There was no documentation that reflected the care plan was developed based on a nursing assessment that addressed the identified skin conditions including the "Master Treatment Plan, Part 1" signed by the RN on 02/04/2019 at 2030 and the "Multidisciplinary Master Treatment Plan, Part 2" signed by the RN on 02/06/2019 at 1000.
* An "Edmondson Psychiatric Fall Risk Assessment" form on the 5-page untimed "Nursing Assessment" dated 02/04/2019 was reviewed. The form had columns for calculating fall risk factors for determining a numeric fall risk score. A total score of 90 or greater indicated the patient was at risk for falls. The form reflected the patient's risk factors included a history of falls, he/she had a total fall risk score of 90, and was therefore at risk for falls. However, subsequent "Daily Edmondson Psychiatric Fall Risk Assessment" forms dated 02/05/2019 at 1125 and 02/06/2019 at 0900 unclearly reflected the patient had no history of falls and had a lower fall risk score of 84.
* On 02/06/2019 at 0834 the "Daily Nurse Progress Note" reflected "Pt reports pain but doesn't disclose where...Appears disorganized [and] confused...Reports not sleeping well..." There was no further nursing assessment of the patient's confusion, and reports of pain and not sleeping well. The next entry was at 1815 and reflected "Pt slipped [and] fell in hall in front of NS. Vitals obtained. VWNL's. Pt helped to a chair [and] a wheelchair was brought in after pt gait was observed [and] found to be shaky [and] slightly unsteady. Pt educated on how to use and asked to use for now...report filled out." There was no further nursing assessment of the patient after the fall. For example, there was no assessment of the patient's range of motion, signs and symptoms of [DIAGNOSES REDACTED]"VWNL's," no vital signs were recorded until 02/06/2019 at 1854, 39 minutes after the fall. The next entry was undated and untimed and reflected "Addendum...Patient was given education to utilize non-skid footwear to prevent falls. Writer made sure footwear was placed properly on patient's feet."
* On 02/06/2019 at 2207 the "Daily Nurse Progress Note" re
VIOLATION: NURSING CARE PLAN Tag No: A0396
Based on interviews, review of medical record and incident/event documentation for 8 of 8 patients reviewed for the provision of nursing services (Patients 59, 61, 69, 76, 83, 84, 86 and 97) and review of policies and procedures it was determined that the hospital failed to develop and implement clear and complete nursing services policies and procedures to ensure the development and maintenance of an individualized nursing care plan for each patient based on patient assessment.

Findings include:

1. Refer to the findings cited under Tag A395, CFR 482.23(b)(3), CoP Nursing Services - Standard: RN supervision and evaluation of nursing care for each patient that reflects a lack of individualized nursing care plans.
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
Refer to the findings identified in the deficiency at Tag A123 related to Patient 85 on the 90-day termination revisit survey, CMS 2567 with Survey Event ID OM1C12 dated 02/28/2019.
VIOLATION: PATIENT RIGHTS: ADVANCED DIRECTIVES Tag No: A0132
Refer to the findings identified in the deficiency at Tag A132 related to Patients 61, 70, 76 and 85 on the 90-day termination revisit survey, CMS 2567 with Survey Event ID OM1C12 dated 02/28/2019.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Refer to the findings identified in the deficiency at Tag A144 related to Patients 59, 61, 70 and 76 on the 90-day termination revisit survey, CMS 2567 with Survey Event ID OM1C12 dated 02/28/2019.
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
Based on review of medical record and incident/event documentation for 7 of 9 patients who experienced medication errors (Patients 68, 71, 77, 81, 87, 93 and 95) and review of policies and procedures it was determined that the hospital failed to develop and implement nursing services policies and procedures to ensure the provision of safe and appropriate care to prevent medication errors.

Medication practices did not conform with the "six rights of medication administration" to ensure that patients received care in a safe setting. Recognized standards of practice for the "rights of correct medication administration" are referenced on the Lippincott Nursing Center website on 08/06/2018 and are identified as the "Right patient...Right medication...Right dose...Right route...Right time...Right documentation."

This is a repeat deficiency previously cited at Tag A144 on the original survey completed on 12/13/2018.

Findings include:

1. There were no nursing services policies and procedures related to medication administration. The only related policy and procedure provided was titled "Medication Administration" dated as last revised "01/2019." That policy was identified as a "Pharmacy" policy and the "owner" was the "Pharmacy Manager." This two-page document contained broad language for the following three sections of the policy: Labeling and Dispensing; Controlled (Scheduled) Medications; and Medication Adminsitration Details. The "Medication Administration Details" section of the policy was incomplete and included no specific procedures or directions for how nursing services personnel were to administer medications. Under item "IV. Medication Administration - Nurse must check all 'five rights,'" the only language was "- Right Patient (must use two patient identifiers, ie. picture, DOB, name) - Right Drug - Right Dose - Right Time - Right Route." Other unclear and incomplete language in that section included "VI. When medication bar code is available for unit dose medications, medications will be scanned via HCS system to be documented on the MAR." and "VII. Check to ensure that each patient has swallowed his/her medications."

2. A progress note in the medical record of Patient 68 dated 01/31/2019 by an RN reflected "At 0635 this morning pt received a Zantac that was not ordered." A "Medication Occurrence (sic) Report" was dated and signed by the RN on 01/31/2019 at 0648 and reflected the Zantac 150 mg was administered to Patient 68 and "Staff was pulling morning meds. Had a med cup for a pt to bring to room. This pt walked up asking for things and morning meds. Stimulus on unit. Staff placed this pt (sic) morning med in the same cup as other pt."

The investigation of the error was inaccurate and incomplete. In the "Pharmacy Dispensing" section of the form the documentation inaccurately reflected that the pharmacy dispensed the "Wrong Medication." The "Administering" errors section of the form was blank and reflected there were no errors related to administration of the medication. The "Contributing factors" section was incomplete and although four items were checked such as "Last 2 hours of 12 hour shift" and "Stimulus on Unit," the item "5 rights not done before administering medication" was not checked for this case where the patient received the wrong medication. The "Patient Effect Severity Rating" was inaccurately identified as "0" and was "0-Patient not effected (occurrence did not reach patient - no missed doses or incorrect therapy)." The only "Action Taken" was "Had nurse return to educated (sic) and finish documentation" initialed by an unknown author and dated 01/31/2019 at 1700. Further, an "Incident Investigation Summary" form contained a note dated 01/31/2019 at 1700 that referred to an "override" failure of the "Medispense" machine that did not clearly correspond with the RN's description of how the error occurred.

3. A "Medication Occurrence (sic) Report" was dated and signed by the RN on 02/02/2019 at 1810 and reflected that three nurses had administered excess dosages of Lorazepam to Patient 71 on four occasions on 02/01/2019 and 02/02/2019 as "Four orders of medication given to pt from 2/1 - 2/2 as scheduled without CIWA being greater than 15. 0040, 0553 - [Nurse 1]. 1324, 1807 - [Nurse 2, Nurse 3]."

The "Contributing Factors" section of the form did reflect that the "5 rights not done before administering medication." However, other parts of the investigation of the error were inaccurate and incomplete. For example, in the "Administering" errors section of the form it reflected that the medication was given at the "Wrong Time" versus "Wrong Dose." There was no other evaluation of how three nurses made the same error on four consecutive occasions. The "Incident Investigation Summary" form contained an undated and unsigned note that reflected "Ativan scheduled for Q6 Hours for CIWA [greater than] 15. Pt scoring CIWAs less than 5. Four doses of Ativan given per this order...New order for PRN Ativan. Confusing order D/C'd." The "Investigation Summary / Outcome" section of the form reflected that "explained and educated staff that reading the entire order would've kept the error from happening....Nurse was confused by way that order is written on MAR by HCS (delete order)." The documentation did not clearly reflect that the investigation was adequate to identify all causes that resulted in three nurses making the same error consecutively or how three nurses failed to follow the "5 rights." Review of an attached copy of the MAR on which the medication order was documented reflected the order was clearly written and electronically printed as "Lorazepam tablet...1 mg...every six hours 0600, 1200, 1800, and 2345 for Lorazepam Protocol for CIWA greater than 15."

4. A "Medication Occurrence Report" reflected that Patient 87 received Tramadol 50 mg on 02/13/2019 at 0117 that was not ordered.

The investigation of the error was unclear, incomplete and not timely. The report was dated and signed on 02/17/2019 at 1251, four days after the error. An undated and unsigned "comment" was recorded as "Spoke to [Nurse 4]. [He/she] remembers calling for 1 time order. Told [him/her] to come in and correct the order." The "Administering" section of the form reflected the error was "Unordered Drug given" and "Controlled Substance Discrepancy." There was no "Contributing Factors" section on the report that had been on previously reviewed reports and there were no contributing factors otherwise identified. The "Incident Investigation Summary" form contained an undated and unsigned note that reflected "[Nurse 4] called, [he/she] denied giving any meds that night." However, another entry on that same form reflected "Reviewed cameras noted [Nurse 4] giving the med at time of incident and observed error screen on medispense. F/U call to follow today. Pt did get med. Will educate [Nurse 4] [he/she] is coming in tonight to correct order." Another note on the same form by a different author reflected "...spoke [with Nurse 4] 2/15/19 1915 believes [he/she] called for order." The "Investigation Summary / Outcome" section of the form further reflected a failure to thoroughly investigate this error as the DPI recorded on 02/15/2019 at 1120, prior to completion of the other entries, that "RN did not recall giving the pt the med, but video footage review confirmed that the RN did give the medication to the patient...Cause of error was unable to be determined as RN could not remember giving the med or any details about its administration." This entry was not consistent with the other documentation that reflected the RN "remembers calling for 1 time order" and "[he/she] is coming in tonight to correct order." Those additional concerning pieces of information were not investigated nor was there a final resolution of the error.

5. Medication error, progress note and MAR documentation reflected that Patient 95 received IM Ativan on 02/16/2019 at 0158 and IM Zyprexa on 02/16/2019 at 0159 inconsistent with physician orders that Ativan and Zyprexa were not to be given within one hour of each other.

Investigation documentation reflected that "Unfamiliar with the patients" and "Unit disruption" were the contributing factors but failed to identify the "5 rights not done before administering medication" entry on the medication error form. "Investigation Summary / Outcome" documentation by the DPI on 02/19/2019 at an illegible time reflected 'Pt was administered 2 PRN meds within an hour of each other when they should have been separated by 1 hour. Issue caused when one RN remain logged into HCS, causing the other RN to not recognize one PRN had already been administered." However, this investigation did not clearly explain or resolve how two different nurses could have accessed the medication dispensing machine, removed the IM medication, prepared the IM medication for injection, and administered the IM injection to the same patient within the span of one minute without each other being aware.

6. Medication error and MAR documentation reflected that Patient 93 received an excess dosage of SQ insulin on 02/15/2019 at 1105. Investigation documentation did not identify failure to follow the "5 rights" as a contributing factor and concluded that the error was "just an accident" as stated by the RN who administered the insulin.

7. Medication error and progress note documentation reflected that Patient 77 received a double dose of Oxycodone on 02/09/2019 at 0950 and investigation documentation reflected that "5 rights not done before administering medication."

8. Medication error, progress note and MAR documentation reflected that Patient 81 received Ativan two hours late on 02/10/2019 at 1955, and investigation documentation reflected there were no contributing factors to consider and "it must have been an oversight."