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.
| WELLBRIDGE HEALTHCARE GREATER DALLAS | 4301 MAPLESHADE LANE PLANO, TX 75093 | June 18, 2020 |
| VIOLATION: PATIENT RIGHTS: PARTICIPATION IN CARE PLANNING | Tag No: A0130 | |
| Based on record review and interview, the facility failed to ensure patient participation in the development and implementation of his or her plan of care for 2 of 2 in-patients. (Patient #1 and #2) Findings included Patient #1's and #2's care plan did not indicate the patients participation in the development and implementation of his or her plan of care. During an interview and record review on 6/18/2020 from 9:00 to 10:58 AM, Personnel #3 reviewed the records and verified the findings. The December 2019 "Interdisciplinary Treatment Plan (ITP) Team Meetings" policy required, "Patient/Guardian/Caretaker Involvement...are considered active members of the treatment team...the physician, social worker, and nurse meet with the patient to discuss the initial formulation of the ITP...The patient then signs the ITP...The team shall repeat this process of discussing and eliciting the patient's signature after reasonably modifying the ITP to better meet the patient's needs...The social worker is responsible for contacting the patient's guardian or family/caretakers to update them following any qualifying event or no less frequently than every three days..." |
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| VIOLATION: PATIENT SAFETY | Tag No: A0286 | |
| Based on record review and interview, the facility failed to enforce its incident reporting system which includes a mechanism to ensure that all incidents are recorded in safety committee minutes, in that, 5 of 6 in-patient wounds (Patient #1, #2, #4, #5, and #6) were not recorded on an incident report to be evaluated, to show followed up and corrective actions. Findings included Patient #1, #2, #3, #4, #5, and #6 developed hospital acquired wound/injury during their admission. They were documented as: Patient #1 - Left dorsal foot ulcer, bilateral heel pressure ulcers Patient #2 - Stage 3 Pressure Ulcer (R) Right buttock; Stage 1 (L) Left Buttock Patient #3 - Decubitus ulcer on buttocks Patient #4 - Left Arm Skin tear Patient #5 - Diabetic ulcer on his feet Patient #6 - Wound right foot/Decubitus Redness, non-tender, Stage I Patient #1, #2, #3, #4, #5, and #6 had no indication documented that FAMILY was NOTIFIED of wound/injury development. There was no indication of RESOLVED wounds/injuries. Patient #1, #2, #3, #4, #5, and #6 did not have daily SKIN ASSESSMENTS documented to prevent and identify early signs of wounds/skin injuries. Patient #1, #2, #3, #4, #5, and #6 did not have PAIN and WOUND BED assessments documented with dressing changes. Patient #1, #2, #3, #4, #5, and #6 did not have PERIODIC PICTURES (dated/timed/patient identification) of wounds/injuries to show wound/healing progression. There were no facility wound prevention or wound care POLICIES. During an interview and record review on 6/17/2020 ending at 3:30 PM, Personnel #4 was asked if wounds were being tracked that did not receive antibiotics. Personnel #4 stated, "No. I am not. The previous DON would come to the meeting with the wound information. Since she left, we don't have a lot of information. We have started chart reviews for the last 2 weeks - Admin/DON/HIM/and myself. We found that skin assessments were not being documented. We are putting together some education. Just in the planning stages now." Personnel #4 was asked about wound care supplies the wound care doctor needed. Personnel #4 stated, "I was told that she gave them a list and they ordered them." Personnel #4 was asked for incident reports for the wounds that had been found. Personnel #4 supplied an incident report for one of the wounds identified (Patient #3) during the survey period. Personnel #4 stated, "I don't have one for the others." During an interview and record review on 6/18/2020 from 9:00 to 10:58 AM, Personnel #3 reviewed the records and verified the findings. During an interview on 6/18/2020 ending at 11:51 AM, Personnel #4 supplied requested policies. Personnel #4 stated, "We don't have wound policies." The February 2017 "Incident Reporting" policy required, "use the process as a means for quality improvement and risk management, and report all incidents to the appropriate internal and regulatory parties...Injury to patient - accidental or intentional...Employees must turn in completed incident reports to their supervisor by the end of the shift...The supervisor is to complete his or her brief investigation and submit to the Director...Per policy related to each specific potential event, the administrator on call and/or other parties may need to notified...Risk manager completes the investigation...Leadership supports a transparent environment in which staff is encouraged to complete incident reports for any unusual event...Events are analyzed for patterns and system failures...Aggregate data on events will be reported monthly in the Quality Committee..." The sample "Incident Report" required, "Physician Notified...Family of Guardian Notified...Client Care Incident...12 Recreational injury...13 Fall...21 Deviation from policy...23 Skin Breakdown...24 Brusing / Skin Tear/ Abrasion...32 Self inflicted Injury...38 Medical Complication___Delay in Results___Treatment refused...unanticipated death, significant injury, or allegation of sexual abuse or physical abuse/neglect involving staff...Please call the Risk Manager immediately..." |
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| VIOLATION: RN SUPERVISION OF NURSING CARE | Tag No: A0395 | |
| Based on record review and interview, the facility failed to ensure a registered nurse must supervise and evaluate the nursing care for each patient, in that, A) 6 of 10 in-patients (Patient #1, #2, #3, #4, #5, and #6) developed hospital acquired wounds during their admission: There was no a skin assessment daily to prevent and identify wounds. There was no pain and wound assessment with dressing changes; and B) 1 of 10 in-patients (Patient #1) Initial Inpatient Nurse Assessment was not completed. Findings included A) Patient #1, #2, #3, #4, #5, and #6 developed hospital acquired wound/injury during their admission. They were documented as: Patient #1 - Left dorsal foot ulcer, bilateral heel pressure ulcers Patient #2 - Stage 3 Pressure Ulcer (R) Right buttock; Stage 1 (L) Left Buttock Patient #3 - Decubitus ulcer on buttocks Patient #4 - Left Arm Skin tear Patient #5 - Diabetic ulcer on his feet Patient #6 - wound right foot/Decubitus Redness, non-tender, Stage I Patient #1, #2, #3, #4, #5, and #6 had no indication documented that FAMILY was NOTIFIED of wound/injury development. There was no indication of RESOLVED wounds/injuries. Patient #1, #2, #3, #4, #5, and #6 did not have daily SKIN ASSESSMENTS documented to prevent and identify early signs of wounds/skin injuries. Patient #1, #2, #3, #4, #5, and #6 did not have PAIN and WOUND BED assessments documented with dressing changes. Patient #1, #2, #3, #4, #5, and #6 did not have PERIODIC PICTURES (dated/timed/patient identification) of wounds/injuries to show wound/healing progression. There were no facility wound prevention or wound care POLICIES. During an interview and record review on 6/18/2020 from 9:00 to 10:58 AM, Personnel #3 reviewed the records and verified the findings. During an interview on 6/18/2020 ending at 11:51 AM, Personnel #4 supplied requested policies. Personnel #4 stated, "We don't have wound policies." The November 2017 "Assessment Guidelines" required, "skin assessment...skin issues to be documented on daily RN Note and addressed on treatment plan...Impaired skin integrity..." The April 2020 "Medical Record Documentation" policy required, "adequately maintained in order to provide documentary evidence of the course of the patient'smedical evaluation, treatmentans change in condition...completion of each assessment requires that all areas on the respective form are completed or deferred with explaination, clinican signature, and date and time of completion...shift progress notes must include any observations related to care, treatment and services, and the patient's response, as well as recommendations for revisionsto the plan of care and a precise assessment of the patient's progress in treatment..." B) Patient #1's 4/29/2020 Initial Inpatient Nurse Assessment was not completed. Documented was "Patient Refuses" for each question. There was no indication documented of attempts to revisit the information when the patient improved or to contact the family for answers. Other interdisciplinary team members spoke to the daughter for input on their assessments. Patient #5's Initial Inpatient Nurse Assessment had no skin assessment completed/documented. During an interview and record review on 6/18/2020 from 9:00 to 10:58 AM, Personnel #3 reviewed the records and verified the findings. The November 2017 "Assessment Guidelines" policy required, "Inpatient Nursing Assessment...initiated within 1 hour of patients arrival to the inpatient unit; fully completed within 8 hours of admission..." The February 2017 "Integrated Assessment" policy required, "these assessments are conducted in their entirety. Every effort will be made to ascertain required information directly from the patient; however in situations where this is not possible, the patient's guardian, family, and/or caretakers will be included with appropriate consent." |
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| VIOLATION: NURSING CARE PLAN | Tag No: A0396 | |
| Based on record review and interview, the facility failed to ensure nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient's goals and the nursing care to be provided to meet the patient's needs, in that, A) 6 of 10 in-patients (Patient #1, #2, #3, #4, #5, and #6) developed hospital acquired wounds/injuries during their admission and they had no wound care plan; B) 2 of 2 in-patients (Patient #1 and #2 had no individualized nursing care plan for their current needs/co-morbidities; and C) 2 of 2 in-patients (Patient #1 and #2) care plans did not reflect collaboration from each team member. Findings included A) Patient #1, #2, #3, #4, #5, and #6 developed hospital acquired wound/injury during their admission and had no care plan for wounds/skin integrity. The wounds/injuries were documented as: Patient #1 - Left dorsal foot ulcer, bilateral heel pressure ulcers Patient #2 - Right check Decubitus Patient #3 - Decubitus ulcer on buttocks Patient #4 - Left Arm Skin tear Patient #5 - Diabetic ulcer on his feet Patient #6 - wound right foot/Decubitus Redness, non-tender, Stage I There were no facility wound prevention or wound care policies. During an interview and record review on 6/18/2020 from 9:00 to 10:58 AM, Personnel #3 reviewed the records and verified the findings. During an interview on 6/18/2020 ending at 11:51 AM, Personnel #4 supplied requested policies. Personnel #4 stated, "We don't have wound policies." The November 2017 "Assessment Guidelines" required, "skin assessment...skin issues to be documented on daily RN Note and addressed on treatment plan...Impaired skin integrity..." The April 2020 "Medical Record Documentation" policy required, "adequately maintained in order to provide documentary evidence of the course of the patient's medical evaluation, treatment and change in condition...completion of each assessment requires that all areas on the respective form are completed or deferred with explanation, clinician signature, and date and time of completion...shift progress notes must include any observations related to care, treatment and services, and the patient's response, as well as recommendations for revisions to the plan of care and a precise assessment of the patient's progress in treatment..." B) Patient #1 had Hypertension, Pacemaker, Coronary Artery Disease, Diabetes, and Atrial Fibrillation. The patient was on Warfarin and needed INR results. (The international normalised ratio (INR) is a laboratory measurement of how long it takes blood to form a clot. It is used to determine the effects of oral anticoagulants on the clotting system.) There was no individualized nursing care plan (Cardiac, INR/Warfarin, and Diabetic) for these. Patient #2 had Diabetes. There was no individualized nursing care plan. During an interview and record review on 6/18/2020 from 9:00 to 10:58 AM, Personnel #3 reviewed the records and verified the findings. The December 2019 "Interdisciplinary Treatment Plan Team Meetings" policy required, "organized and systemic process to plan and implement patient care...Nursing: provides an overall overview of the patient's medical condition including risk factors such as fall risk, infections, substance abuse or detox, pending labs, and pending consults..." C) ~ Patient #1's 4/29/2020 "Inpatient Master Treatment Plan" was not filled in and signed by the social worker, dietitian, pharmacy, discharge planning, physician, and the patient to reflect collaboration from each team member. Patient #1's 5/29/2020 "Master Treatment Plan Update" was not filled in and signed by dietician, physician, psychiatrist, discharge planning, and the patient to reflect collaboration from each team member. Sections left blank included social services, discharge planning, participation in group therapy, Progress towards goals, and patient participation. Patient #1's 6/05/2020 "Master Treatment Plan Update" was not filled in and signed by dietician, physician, and the patient to reflect collaboration from each team member. Sections left blank included social services, discharge planning, participation in group therapy, Progress towards goals, and patient participation. Each "Master Treatment Plan Update" has hand written note that stated, "Wife wants a nursing home..." (Wife was deceased .) ~ Patient #2's 5/18/2020 "Inpatient Master Treatment Plan" was not filled in and signed by the social worker, dietitian, discharge planning, physician, psychiatrist, and the patient to reflect collaboration from each team member. Patient #2's 6/03/2020 "Master Treatment Plan Update" was not filled in and signed by dietician, physician, psychiatrist, and the patient to reflect collaboration from each team member. Sections left blank included social services, discharge planning, participation in group therapy, Progress towards goals, and patient participation. Patient #2's 6/10/2020 "Master Treatment Plan Update" was not filled in and signed by dietician, discharge planning, physician, psychiatrist, and the patient to reflect collaboration from each team member. Sections left blank included social services, discharge planning, Progress towards goals, and patient participation to reflect collaboration from each team member. During an interview and record review on 6/18/2020 from 9:00 to 10:58 AM, Personnel #3 reviewed the records and verified the findings. The December 2019 "Interdisciplinary Treatment Plan Team Meetings" policy required, "Within 72 hours of the patient's admission, the master treatment plan is reviewed including a minimum of: The patient...The patient's attending psychiatrist...a registered nurse...the patient's assigned social worker...The recreational therapist...the utilization review RN (registered nurse)...any other clinicians directly involved in the patient care. This may include mental health technician (MHT), internal medicine provider, or any other clinician directly involved in care...initial discharge date is discussed and reviewed...all members present in the master treatment team review meeting will sign the Master Treatment Plan at the time it is reviewed..." |
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| VIOLATION: MEDICAL RECORD SERVICES | Tag No: A0450 | |
| Based on record review and interview, the facility failed to ensure the completion of the record entries were legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures for 1 of 1 in-patients (Patient #1). Findings included Patient #1 had an order for being weighed on admission and weekly thereafter. Patient#1's "Graphic Record Flowsheet" had no weights documented. Patient #1 had an order for CMP (Comprehensive Metabolic Panel), Lipid Profile, and CBC (Complete Blood Count) on admission. There were no results for the CMP and Lipid Profile in the record. Patient #1's 4/30/2020 "Nutrition Consultation" for Cardiac diet reflected the height, weight, pertinent nutritional labs, nutrition assessment were left blank. There was no Estimated Calorie/PRO/Fluid needs determined. There were unreadable scribbles on some areas of the consult. There is no indication documented that family was called to attempt to gain information. Patient #1's 4/29/2020 Initial Inpatient Nurse Assessment was not completed. Documented was "Patient Refuses" for each question. It was not signed, dated, and timed by whomever completed it (Page 10 of 10). There was no indication documented of attempts to revisit the information when the patient improved or to contact the family for answers. Other interdisciplinary team members spoke to the daughter for input on their assessments. Patient #1's nursing, physician, psychiatric and group therapy notes contained written notes that were not legible. During an interview and record review on 6/18/2020 from 9:00 to 10:58 AM, Personnel #3 reviewed the records and verified the findings. The November 2017 "Assessment Guidelines" policy required, "Inpatient Nursing Assessment...initiated within 1 hour of patients arrival to the inpatient unit; fully completed within 8 hours of admission..." The February 2017 "Integrated Assessment" policy required, "these assessments are conducted in their entirety. Every effort will be made to ascertain required information directly from the patient; however in situations where this is not possible, the patient's guardian, family, and/or caretakers will be included with appropriate consent."During an interview and record review on 6/18/2020 from 9:00 to 10:58 AM, Personnel #3 reviewed the records and verified the findings. The November 2017 "Assessment Guidelines" policy required, "comprehensive assessment and reassessment of the patient's bio-psycho-social needs such that clinically appropriate interventions can be designed and carried out in a manner that supports recovery...Nutritional Consult...72 hours after time of order..." The April 2020 "Medical Record Documentation" policy required, "adequately maintained in order to provide documentary evidence of the course of the patient's medical evaluation, treatment change in condition...completion of each assessment requires that all areas on the respective form are completed or deferred with explanation, clinician signature, and date and time of completion...shift progress notes must include any observations related to care, treatment and services, and the patient's response, as well as recommendations for revisions to the plan of care and a precise assessment of the patient's progress in treatment...Social work - every three (3) days regarding the status of discharge planning and/or any other social services needs..." |
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| VIOLATION: DIETS | Tag No: A0630 | |
| Based on record review and interview, the facility failed to ensure the completion of the Nutrition Assessment for 1 of 1 in-patients (Patient #1). Findings included Patient #1 had an order for being weighed on admission and weekly thereafter. Patient#1's "Graphic Record Flowsheet" had no weights documented. Patient #1 had an order for CMP (Comprehensive Metabolic Panel), Lipid Profile, and CBC (Complete Blood Count) on admission. There were no results for the CMP and Lipid Profile in the record. Patient #1 had hypercholesterolemia, diabetes and developed wounds during his admission. Patient #1's "Nutrition Consultation" for Cardiac diet reflected the height, weight, pertinent nutritional labs, nutrition assessment were left blank. There was no Estimated Calorie/PRO/Fluid needs determined. There were unreadable scribbles on some areas of the consult. There is no indication documented that family was called to attempt to gain information. During an interview and record review on 6/18/2020 from 9:00 to 10:58 AM, Personnel #3 reviewed the records and verified the findings. The November 2017 "Assessment Guidelines" policy required, "comprehensive assessment and reassessment of the patient's bio-psycho-social needs such that clinically appropriate interventions can be designed and carried out in a manner that supports recovery...Nutritional Consult...72 hours after time of order..." |
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