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Based on record review, observation, and interview, the hospital failed to meet the requirement for the Condition of Participation for Nursing Services as evidenced by the hospital failure to ensure the RN supervised and evaluated the care of each patient by:

1) failure to have a system in place to track and trend patients' weights and to notify physicians of significant weight loss for 4 (#1, #2, #3, #4) of 5 (#1-#5) patients sampled for weights; and

2) failure to ensure physician's orders were followed for weights for 4 (#1, #2, #3, #5) of 10 (#1-#10) sampled patients;

(See findings tag A-0395).

Based on record review and interview, the hospital failed to assure any incidents of abuse, neglect, and/or harassment were reported and analyzed, and the hospital was in compliance with applicable local, State, and Federal Laws and Regulations. This deficient practice was evidenced by the hospital's failure to report an allegation of patient (Patient #7) abuse by staff within 24 hours to LDH-HSS for 1 (#7) of 1 patient reviewed for allegations of abuse/neglect from a total patient sample of 10 ( #1-#10).

Findings:

Review of the Louisiana Revised Statutes, Title 40. Public Health and Safety, Chapter 11, State Department of Health and Hospitals revealed "Department" shall mean the Department of Health and Hospitals. "Unit" means the Medicaid fraud control unit created within the office of criminal law of the Department of Justice and which is certified by the secretary of the United States Department of Health, Education and Welfare. Regarding §2009.20. Duty to make complaints; penalty; immunity.

"Abuse" is the infliction of physical or mental injury or the causing of the deterioration of a consumer by means including but not limited to sexual abuse, or exploitation of funds or other things of value to such an extent that his health or mental or emotional well-being is endangered.

"Neglect" is the failure to provide the proper or necessary medical care, nutrition, or other care necessary for a consumer's well-being. Any person who is engaged in the practice of medicine, social services, facility administration, psychological or psychiatric services; or any registered nurse, ... having knowledge that a consumer's physical or mental health or welfare has been or may be further adversely affected by abuse, neglect, or exploitation shall, within twenty-four hours, submit a report to the department or inform the unit or local law enforcement agency of such abuse or neglect. When the department receives a report of sexual or physical abuse, whether directly or by referral, the department shall notify the chief law enforcement agency of the parish in which the incident occurred of such report. Such notification shall be made prior to the end of the business day subsequent to the day on which the department received the report.


Review of the hospital policy titled, "Abuse, Neglect and Exploitation", revealed the following, in part: Purpose: To protect patients under the care of this hospital staff. To comply with Federal and State guidelines. Definitions: Abuse: Deliberate acts designed to cause physical or mental harm to another person can include pushing, slapping, making inappropriate comments, and sexual abuse.

Procedure:

6. if at any time there is reason to believe that a patient has been abused, neglected or exploited, authorities (State Police Department, Adult Protective Services) will be contacted by hospital management and staff can expect to be questioned regarding any information they may have on the subject.

10. Allegations of abuse, neglect, or exploitation are reported to LDH utilizing the appropriate form and instructions put forth by LDH.


Review of Patient #7's medical record revealed the following narrative nursing note entries, in part:

08/14/2020 7:49 p.m.: Received a call from the front desk informing me the police were here to ensure Patient #7 was okay. The officer informed me the patient's relative (daughter) called them and informed them their father was being abused by the nurses as she heard them shouting at him. They asked how he was doing and were informed the patient was in his room, in bed, being maintained on oxygen. The officer then said okay and no further questions were asked.

08/14/2020 7:56 p.m.: S2DON was informed that the local police department was called and what transpired. We ( S2DON and writer) went to the front desk, however, the officers were not there.


In an interview on 12/11/2020 at 10:33 a.m. with S2DON, she confirmed the police had been to the hospital for a welfare check on Patient #7 because the patient's daughter had called them alleging her father was being abused by the nursing staff. S2DON reported Patient #7's daughter had called her with her concerns about potential staff abuse of her father. S2DON indicated she had reassured her that her father was fine. S2DON reported she had gone to interview the staff regarding this complaint. She confirmed she had no documentation of the investigation. S2DON further confirmed she had not self - reported the allegation of abuse of Patient #7 by nursing staff to LDH-HSS because she felt there had been no abuse and the allegation was unfounded.

Based on policy review, record review and interview, the hospital failed to ensure the use of restraint or seclusion was in accordance with the order of a physician or other licensed independent practitioner who is responsible for the care of the patient. This deficient practice was evidenced by failure to obtain orders for medical restraints every 24 hours, as per hospital policy, for 1 (#7) of 3 (#7, #8, #9) sampled patients reviewed for restraint use from a total patient sample of 10 (#1-#10).

Findings:

Review of the hospital policy titled, "Restraints", policy number PC.11.10, 12.10: revealed in part: Purpose: Intensive Specialty Hospital supports the limitation of restraint use to clinically appropriate and adequately justified situations. The guidelines for restraint use will only be initiated to protect the patient from injury to himself/others and to prevent serious disruption of their medical/surgical treatment. The least restrictive method will be initiated.

Definition: The word restraint is defined as a method for confining within bounds to place under restriction, to limit, or to keep under control by subduing or holding in, to hold back, to moderate, or limit the force of, or prevent doing, exhibiting or expressing.

Philosophy: Limiting the use of restrains to emergencies in which there is an imminent risk of an individual physically harming themselves or others, including staff; responsibility to facilitate the discontinuation of restraint as soon as possible.

Procedure: A time limited physician's order is required for the use of any restraint. g.time limit is 24 hours, h. telephone and verbal orders taken by the nurse will be timed, dated and counter signed by the physician within 24 hours. k... the physician will have a new order within no less than once each calendar day for the reorder/renewal.


Review of Patient #7's medical record revealed an admission date of 07/22/2020 with admission diagnoses including alcohol dependence withdrawal -toxic and metabolic, anxiety disorder, epilepsy, ataxic gait, Alzheimer's dementia, and encephalopathy.

Further review of Patient #7's medical record revealed the following nurses' notes documentation regarding restraint use:
08/13/2020 07:30 a.m.: Soft wrist restraints, Posey vest due to patient continuously taking off Vapotherm (Oxygen) and pulling at lines.

Review of Patient #7's medical record revealed no physician's order dated 08/13/2020 for physical restraints- soft wrist restraints and Posey vest ( a medical restraint to restrain a patient to a bed or chair).

09/05/2020 8:00 p.m.: Patient is in 4 point restraints, circulation intact. Continued use due to patient being non-complaint. Further review revealed restraint assessments were documented on both the day and night shift on 09/05/2020.

Review of Patient #7's physician's progress note, dated 09/05/2020: Patient was seen and examined, Patient has intermittent confusion that was worse overnight requiring Haldol and Ativan. Patient is currently in 4-point restraints and vest per protocol. Patient's confusion and combativeness did improve after medication administration. He is currently resting.

Review of Patient #7's physician's orders revealed there were no restraint orders for 08/13/2020 and 09/05/2020.


In an interview on 12/10/2020 at 10:28 a.m. with S3DOQ, she confirmed there was no physician's order in Patient #7's medical record for the vest and 4 point restraints in use on 09/05/2020. S3DOQ indicated 4 point restraints and a Posey vest can be used, but must be ordered by the physician.


In an interview on 12/10/2020 at 3:23 p.m. with S2DON, she confirmed there was no physician's order for the wrist restraints in use on 08/13/2020 for Patient #7. S2DON indicated the least restrictive interventions should be used prior to initiating restraints. She reported Patient #7 was kind of wild and could get himself out of restraints. S2DON further reported Patient #7 crawled over the rails, required constant watching, if they had enough staff, and COVID -19 had not been so prevalent at that time they would have possibly put him on 1:1 supervision so he wouldn't have to be restrained as much. S2DON reported she could not find any documented justification for the 4 point restraints and indicated they rarely used 4 point restraints.


In an interview on 12/14/2020 at 10:30 a.m. with S2DON and S3DOQ, they confirmed they had not identified failure to obtain restraint orders for each calendar day as a problem and had not put any corrective actions in place.

Based on record reviews and interviews, the hospital failed to ensure the RN supervised and evaluated the care of each patient as evidenced by:

1) Failing to have a system in place to track and trend patients' weights and to notify physicians of significant weight loss for 4 (#1, #2, #3, #4) of 5 (#1-#5) patients sampled for weights; and

2) Failure to ensure physician's orders were followed for weighing patients for 4 (#1, #2, #3, #5) of 5 (#1-#5) patients sampled for weights; and

3) Failing to accurately assess the wounds for 1 (#1) of 10 (#1-#10) sampled patients; and

4) Failing to ensure a wound consult had been obtained as ordered for 1 (#7) of 6(#1- #5, #7) patients sampled for wounds; and

5) Failing to ensure wounds were assessed with the appearance documented in descriptive terms for size, appearance, presence/absence of drainage, and presence/absence of odor for 1 (#7) of 6 (#1- #5, #7) patients sampled for wounds; and

6) Failing to ensure full body audits, re-assessment of fall risk, and incident reports were performed, per hospital policy, on a patient (#7) who had fallen twice in one day for 1(#7) of 3 (#6,#7,#9) sampled patients reviewed for falls.; and

7) Failing to ensure a patient's family (Patient #7) was notified timely of a change in condition. This deficient practice is evidenced by a patient found to be COVID-19 positive and moved to the COVID-19 floor and the family was not notified until 2 days after patient was diagnosed and moved for 1(#7) of 4 (#7, #8,#9, #10) sampled COVID-19 positive patients reviewed.


Findings:

1) Failing to have a system in place to track and trend patient's weights and to notify physicians of significant weight loss.

Patient #1

Review of the closed medical record for Patient #1 revealed the patient was admitted to the hospital on 06/04/2020 from a LTC facility for aggressive wound care and IV ATB therapy and was discharged on 07/24/2020. Patient #1 was an 87-year-old female with a history of Acute Respiratory Failure, Malnutrition, Anemia, and Multiple infected decubitus, Quadriplegia, Encephalopathy, Hypernatremia, Chronic Kidney Disease, and Venous Thrombosis.

Review of Patient #1's Admit Physician's Orders dated 06/04/2020 revealed orders for weekly weights. Admit weight was noted as 129.6 pounds.

Review of Patient #1's 24 Hour Care Record dated 07/19/2020 listed Patient #1's weight as 104.7 pounds.

Review of Patient #1's Weight/Calf Measurement record revealed documented weights:
06/26/2020 - 113.9 pounds
07/10/2020 - 109.2 pounds

Further review of the record revealed Patient #1 had a significant weight loss of 20.9 pounds in 45 days. There was no documentation of physician notification in the patient's record.

Interview on 12/10/2020 at 11:00 a.m. with S3DOQ confirmed there was no documentation that the physician was notified of Patient #1's significant weight loss weights in the medical record.


Patient #2

Review of the medical record for current Patient #2 revealed an admit date of 09/10/2020. Patient #2 was a 71-year-old male admitted to the hospital for Covid-19 and had a history of DM, Depression, Bipolar, OA, and Acute Hypoxic Respiratory Failure.

Patient #2's Physician's Order Sheet dated 09/10/2020 revealed an order to admit with weekly weights and a documented weight of 210.8 pounds.

Review of Patient #2's 24 Hour Care Record dated 10/08/2020 revealed documented weight of 167.6 pounds, which was a 43.2 pound weight loss in 28 days. There was no evidence of documentation that the physician was notified.

Interview on 12/10/2020 at 2:40 p.m. with S3DOQ confirmed that there were discrepancies in obtaining and documenting weights in Patient #2's medical record and that there was no evidence that the physician had been notified of the patient's weight loss. Further interview with S3DOQ confirmed that the hospital had discrepancies in obtaining and documenting weights in the patients' medical record. She further stated that the hospital during the beginning of the Covid-19 pandemic did away with the graphic sheet which was used for documenting patient weights. S3DOQ further stated that there had been no triggers or indicators in the QA system that indicated a problem with the weights not being obtained and documented in the hospital.


Interview on 12/11/2020 at 12:00 p.m. with S6NP revealed that he sees Patient #2 and was unaware of any weight loss issues. S6NP further stated that he was aware there was a system failure with issues obtaining weights and documenting them in the patient's chart, but had not brought it to the attention of administration.


Patient #3

Review of the medical record for current Patient #3 revealed an admit date of 08/11/2020. Patient #3 was an 82-year-old female admitted to the hospital for med-psych management, with a history of Metabolic Encephalopathy, Schizophrenia, Mood Disorder, Alzheimer's, Chronic Kidney Disease, and DM.

Review of Patient #3's Physician's Admit Orders dated 08/11/2020 revealed an order for weekly weights. Further review of the physician orders dated 08/18/2020 revealed an order for PEG tube placement on 08/18/2020 with feedings of Glucerna 1.5 at 25cc/hr.

Review of Patient #3's Nutritional Assessment dated 09/10/2020 listed diet as Glucerna 1.5 at 45cc/hr per PEG tube. Patients admit weight was documented as 186.6 pounds.

Review of Patient #3's 24 Hour Care Record dated 12/11/2020 revealed weight of 148.2 pounds.

Patient #3's current documented weight of 145.9 pounds was given to surveyor, by S3DOQ, on 12/14/2020 at 11:40 a.m. There was a 40.7 pound weight loss since admit.

Interview on 12/11/2020 at 12:10 p.m. with S3DOQ confirmed there was no documented evidence, in the patient's medical record, that the physician had been notified of Patient #3's weight loss.

Interview on 12/11/2020 at 12:00 p.m. with S6NP revealed that he sees Patient #3 and was unaware of any weight loss issues. S6NP further stated that he was aware of issues with inconsistent documentation of weights and there was a system breakdown in obtaining weights in the hospital.


Patient #4

Review of the medical record for current Patient #4 revealed an admit date of 12/01/2020. Patient #4 was a 93-year-old female admitted to the hospital for wound care, who had a history of CVA, expressive aphasia, HTN, DJD, and Osteomyelitis of right foot.

Review of Patient #4's 24 Hour Care Record Note dated 12/03/2020 revealed an admission weight of 150 pounds.

Review of Patient #4's 24 Hour Care Record Note dated 12/05/2020 revealed a weight of 144.6 pounds, a loss of 5.4 pounds in 5 days. There was no evidence of documentation that the physician was notified of the patient's weight loss.


Interview on 12/10/2020 at 11:55 a.m. S2DON stated that during the Covid-19 pandemic the hospital was very busy taking care of Covid-19 patients and that even administrative staff were working at the bedside because of staffing shortages due to Covid-19. During that time the graphic sheet that weights were documented was discontinued being used by the hospital staff. The weights should be documented on the 24 Hour Care form used daily by the nurses. There is a place for the admit weight and current weight to be documented. S2DON further stated that the nursing staff was not documenting the weights on the form and confirmed there were issues with consistently obtaining and documenting weights in the hospital.

Interview on 12/11/2020 at 12:30 p.m. with S9LPN revealed that she was currently taking care of Patient #4 and was unaware of any weight discrepancies for the patient and had not notified the physician of any weight loss. S9LPN further stated that hospital policy was to notify the physician of weight loss of 5 pounds in one week or 3 pounds in one day. S9LPN further stated that she usually weighs her own patients in their beds using one pillow, one sheet, and one blanket for an accurate weight.

Interview on 12/10/2020 at 1:45 p.m. with S3DOQ confirmed that there was no policy for weight loss to be used as guidance for nurses. She further stated that the nurse should have contacted the physician about patients' significant weight loss.

In an interview on 12/11/2020 at 12:40 p.m. with S17Physician, he reported the nursing staff obtains patient weights. He further reported the nursing staff notifies the physicians/NPs of patient weight losses and if there are concerns identified regarding weight losses the physicians/NPs order a consult for evaluation by the dietician. He indicated he has noticed there can be large variances in patients' weights and methods used for obtaining weights.

Interview on 12/11/2020 at 1:25 p.m. with S9CNA revealed that she had been working at the hospital approximately two years. She further stated that she receives each shift a list of patients that need to be weighed that day. The patients are weighed in their own bed using the bed scales. She further stated that patients are weighed either daily or weekly. She stated when she weighs a patient the bed is in the flat position with only one sheet one blanket and one pillow on the bed. S9CNA confirmed that weights are given to the nurse.


2) Failure to ensure physician's orders were followed for weighing patients.

Review of the hospital policy titled "Weekly Weights", dated 12/29/92 revealed in part: To provide an accurate record of patient's weight. Weights are used to calculate drug dosages, monitor nutritional status and provide the best overall picture of the patient's fluid status. All patients will be weighed weekly, on designated days, with their baths unless otherwise ordered. Every patient's weight will be documented on the graphic sheet.


Patient #1

Review of the Admit Physicians Orders dated 06/04/2020 revealed an order for weekly weights. Patient #1's admit weight was noted as 129.6 pounds.

Review of the 24 Hour Care Record dated 07/19/2020 listed Patient #1's weight as 104.7 pounds.

Review of the Weight/Calf Measurement record revealed the following documented weights:
06/26/2020 - 113.9 pounds.
07/10/2020 - 109.2 pounds.

Review of Patient #1's Nutritional Assessment dated 06/04/2020 revealed a current weight of 135 pounds, and indicated the patient was at risk nutritionally - "severe", plan to monitor weights, labs, and intake.

Interview on 12/10/2020 at 11:35 a.m. with theS2DON confirmed that there were no other documented weights in Patient #1's medical record other than the ones mentioned above. She verified the weights had not been taken weekly as ordered.


Patient #2

Review of Patient #2's Physician Order Sheet dated 09/10/2020 revealed an order to admit with weekly weights, and an admit weight of 210.8 pounds.

Review of the 24 Hour Care Record dated 10/08/2020 revealed a documented weight of 167.6 pounds.

Review of the 24 Hour Care Record dated 11/26/2020 revealed a documented weight of 173.2 pounds.

Review of the 24 Hour Care Record dated 12/08/2020 revealed a documented weight of 175.9 pounds.

Interview on 12/10/2020 at 2:40 p.m. with S3DOQ confirmed that there were discrepancies in obtaining and documenting weights in the patients' medical records and that there were no other documented weights for Patient #2 other than the above mentioned weights.


Patient #3

Review of Patient #3's Physician's Admit Orders dated 08/11/2020 revealed an order for weekly weights.

Review of the 24 Hour Care Record dated 12/11/2020 revealed a documented weight of 148.2 pounds.

The current weight for Patient #3, given to surveyor on 12/14/2020 by S3DOQ, revealed a weight of 145.9 pounds.

Interview on 12/14/2020 at 12:10 p.m. with S3DOQ confirmed there were no documented weights in Patient #3's medical record other than the weight on 12/11/2020 weight given to surveyor on 12/14/2020.



Patient #5

Review of Patient #5's medical record on 12/10/2020 revealed an order dated 12/05/2020 at 11:50 p.m. to weigh daily starting tonight and to notify the physician if there was a weight gain greater than 5 pounds. Further review revealed the only weight documented in the medical record was on admission on 12/03/2020.

In an interview on 12/10/2020 at 1:45 p.m. with S5LPN, he verified there were no weights in the medical record for Patient #5 other than on admission on 12/03/2020. He verified the physician's order on 12/05/2020 was to weigh daily.

Interview on 12/11/2020 at 10:30 a.m. with S7DT revealed that she was contracted with the hospital for dietary services. She did confirm that there were inconsistencies in obtaining weights in the hospital.

Interview on 12/11/2020 at 12:00 p.m. with S6NP revealed that he sees patients for S15Physician and S16Physician. He did state that he was aware of issues in the patient's chart with documentation of weights, but said he had not brought the issue to any of the administration of the hospital.

Interview on 12/11/2020 at 2:40 p.m. with S3DOQ confirmed that that the hospital had discrepancies in obtaining and documenting weights in the patients' medical records. She further stated that the hospital during the beginning of the Covid-19 pandemic did away with the graphic sheet, which was used, for documenting patient weights. She further stated that there had been no triggers or indicators in the QA system that indicated a problem in the hospital with the weights not being obtained as ordered and documented.


3) Failing to accurately assess wounds.

Review of the hospital policy titled "Assessment, Wound/Skin/Risk", Policy Number PC.2.1, 2.2, 5.5 revised 12/19 revealed in part: To provide a process for assessment and reassessment of skin integrity, risk for skin breakdown, and wounds. To provide accurate data for determining appropriate interdisciplinary skin/wound care management. A. Skin Assessment/Reassessment. 1. Patients admitted with skin conditions will have skin assessments: a.) By the floor staff admit nurse within 4 hours of admission to the facility. B.) Verified by the Wound Care Professional within 72 hours of Wound Care Program receipt of consult. 2. Skin assessment includes: a.) Viewing/inspecting bare skin ...patient must be undressed and in bed. B.) Inspection is from head to toes, viewing entire posterior of body initially and continues with anterior head to toes inspection. C.) Emphasis of inspection is over bony prominences. D.) Documentation of skin disruption is recorded on the admission assessment.


Patient #1

Review of the closed medical record for Patient #1 revealed the patient was admitted to the hospital on 06/04/2020 from a LTC facility for aggressive wound care and IV ATB therapy and was discharged on 07/24/2020.

Wound Care Evaluation Form dated 06/05/2020 revealed sacral wound measurements 11 cm x 8 cm with total score of 47.

Wound Care Evaluation Form dated 07/07/2020 revealed sacral wound measurements 5.5 cm x 8.5 cm with total score of 32.

Review of Patient #1's Progress Note dated 06/16/2020 revealed Patient #1 was being treated for a Stage 4 Sacral pressure ulcer and an Unstageable left heel ulcer. Further review of the patient's record did not reveal any assessment and/or documentation of an assessment to the left heel area. There were no photographs of the area.

Interview on 12/10/2020 at 10:30 a.m. with S5LPN confirmed there was no documentation of an assessment for Patient #1's left heel. S5LPN further stated that there should have been an initial assessment and photographs taken upon admit and/or discovery of the wound.

Review of Patient #1's Multi Wound Chart Details form dated 07/21/2020 given to surveyor by S5LPN as the last documented wound assessment for Patient #1 listed sacral pressure ulcer not healed with dimensions as the only documented wound.

Upon discharge, Patient #1 was admitted to Nursing Facility (a). Review of Patient #1's Registered Nurse Assessment dated 07/23/2020 obtained from Nursing Facility (a) revealed skin assessment as follows:
Non-blanchable area inner right knee
Left heel eschar
Left lateral eschar
Right heel stage 1
Right lateral calf eschar
Right trochanter open area
Right inner thigh open area
Coccyx unstageable

Interview on 12/14/2020 at 10:00 a.m. with S5LPN revealed that the 07/21/2020 wound document was the last assessment done on Patient #1. He stated that the wound care nurses that documented findings were no longer employed by the hospital. Surveyor discussed findings reported by the Nursing Facility (a) skin assessment form with S5LPN. S5LPN stated that he did not have an answer for the discrepancies in the accuracy of the documentation.

Interview on 12/14/2020 at 11:30 a.m. with S3DOQ confirmed that the hospital's QA had not identified any issues concerning wound care in the hospital's QA reports.


4) Failing to ensure a wound consult had been obtained as ordered.

Review of Patient #7's medical record revealed an admission date of 07/22/2020. Further review revealed the patient had been transferred to the hospital's COVID-19 unit on 08/10/2020 after testing positive for COVID-19.

Review of Patient #7's COVID Unit admit physician's orders revealed an order requesting a wound care consult on 08/10/2020.

Further review of Patient #7's entire medical record, assisted by S5LPN, certified wound care nurse, revealed no documented evidence a wound care consult had been obtained and there were no wound care notes.

In an interview on 12/11/2020 at 12:40 p.m. with S17Physician, he reported the nursing staff assessed patients' skin for changes/wounds. He indicated the hospital has a wound care team that assesses and manages patients' wounds. S17Physician explained the physician/independent practitioners ordered wound care consults when patients were in need of an assessment by the wound care team.

In an interview on 12/14/2020 at 8:05 a.m. with S5LPN, he confirmed there were no documented wound care assessments and no wound care had been performed on Patient #7. He reported there was a change in the process for requesting wound consults in late July 2020 and the requests were made using a paper consult request instead of the electronic requests through Meditech. He indicated he felt they had not been receiving all of the wound consult requests at that time due to the change in the ordering process and acknowledged some of them may have been missed like this request had been missed.


5) Failing to ensure wounds were assessed with the appearance documented in descriptive terms for size, appearance, presence/absence of drainage, and presence/absence of odor for 1 (#7) of 6 (#1- #5, #7) patients sampled for wounds.


Review of Patient #7's medical record revealed the patient was admitted on 07/22/2020 from another area acute care hospital. Further review of the transferring hospital's discharge documentation, dated 07/22/2020, indicated the patient had the following wounds on discharge: Sight #1: right heel - blister partial thickness and Site # 5: left heel - partial thickness wound.

Additional review of Patient #7's medical record revealed the following nursing note entries addressing the patient's skin:

07/22/2020 07:54 a.m.(Admit): integumentary: warm, dry, heels red bilaterally.

08/24/2020 07:35 a.m. integumentary: warm, dry, bruised, sacral wound- see wound care notes;

08/24/2020 08:00 p.m. integumentary: warm, dry skin, sacral wound;

08/25/2020 07:00 a.m.: integumentary: warm, dry thin, sacral wound;

09/04/2020 08:00 a.m.: integumentary: sacral wound

09/06/2020 07:00 a.m. integumentary: sacral wound noted.

The entries referenced above failed to include descriptions of Patient #7's wounds that noted the size of the wounds, appearance, presence/absence of drainage, and presence/absence of odor.

In an interview on 12/14/2020 at 8:05 a.m. with S5LPN, certified wound care nurse, he reported skin assessments should be performed on admit - a full body audit, every shift, after falls and with changes. S5LPN confirmed there were no descriptive nursing assessments indicating appearance, size, presence/absence of drainage, presence/absence of odor of the bilateral heel wounds present on admit (per documentation from transferring hospital) and the sacral wounds noted in nurses' notes on 08/24/2020, 08/25/2020, 09/04/2020, and 09/06/2020. He further confirmed Patient #7 had not been followed by wound care and there were no wound care assessments/notes.

In an interview on 12/14/2020 at 12:27 p.m. with S11LPN, she reported head to toe skin assessments should be performed on admit, with changes, and after falls. She indicated the assessments were documented in the nurses' notes. She reported the staff nurses could not assess and document stages of wounds. She further reported patients with wounds should have a wound assessment performed by the wound care team and the assessments were documented in wound care team notes.


6) Failing to ensure full body audits, re-assessment of fall risk, and incident reports were performed/documented, per hospital policy.

Review of the hospital policy titled, "Fall Prevention Program", Policy Number NPSG. 9A, revealed the following, in part Procedure: 9.Any time a patient falls the following actions are to be taken: a. assess the patient's physical condition; do not attempt to move if a traumatic injury is suspected. E. Re-assess fall risk 14. Complete the following interventions: a. Document the specifics of the fall in the patient record. b. Complete an incident report form and send to quality management department with the patient's current medication record.

Review of Patient #7 medical record revealed an admission date of 07/22/2020. Further review revealed the patient had been admitted to the COVID Unit on 08/10/2020. Further review revealed Patient #7 was on fall precautions.

Review of Patient #7's nursing notes revealed the following entries, in part, regarding Patient #7's falls:

09/02/2020 08:00 a.m.: Patient on floor, no injury sustained, NP and daughter (power of attorney) notified. Entry signed by: S12LPN. Further review revealed no documented evidence that a head to toe body audit had been performed after the patient's fall and no re-assessment of the patient's fall risk had been performed post fall.

09/02/2020 10:00 a.m.: Patient on floor again. Quarter sized superficial abrasion to right arm. Entry signed by S12LPN. Further review revealed no documented evidence that a head to toe body audit had been performed after the patient's fall and no re-assessment of the patient's fall risk had been performed post fall.

Incident reports for the above referenced falls were requested for review on 12/10/2020 from S2DON and S3DOQ. S2DON confirmed there were no incident reports for the above referenced falls sustained by Patient #7 on 09/02/2020.

In an interview on 12/10/2020 at 3:23 p.m. with S2DON, she confirmed it was hospital policy to complete incident reports for all falls and a head to toe body audit should be performed and documented after a fall. She also confirmed a re-assessment of the patient's fall risk should have been performed post fall for both falls.

In an interview on 12/11/2020 at 11:00 a.m. with S12LPN, she confirmed she had been Patient #7's nurse on 09/02/2020. She indicated she had not completed incident reports for the patient's falls on 09/02/2020 and reported she was not sure if she had been told what the hospital's policy was regarding completion of incident reports. She indicated she had documented the patient's injury on the second fall and had performed neurological checks because the fall had been unwitnessed.


7) Failure to ensure a patient's family (Patient #7) was notified timely of a change in condition.

Review of Patient #7's medical record revealed the patient had been admitted on 07/22/2020.

Further review of Patient #7's medical record revealed the patient had developed a cough and symptoms consistent with COVID-19 on 08/10/2020. The patient was swabbed and tested positive for COVID-19 on 08/10/2020 (patient was negative on admit on 07/22/2020- tested at the transferring hospital on 07/16/2020).

Additional review revealed an order to admit Patient #7 to the COVID Unit on 08/10/2020 and to initiate COVID protocols.

Review of Patient #7's medical record revealed the following nurses' note entry, in part, dated 08/12/2020 at 11:27 a.m.: (2 days after the patient's COVID-19 diagnosis and move to the COVID Unit): Writer spoke to Patient #7's family - daughter, and informed her of patient's status and why patient was transferred to this floor.

Further review of Patient #7's entire medical record revealed there was no prior notification provided to the family related to the patient's COVID-19 diagnosis and transfer to the COVID Unit except for the entry referenced above on 08/12/2020.

In an interview on 12/10/2020 at 3:23 p.m. with S2DON, she indicated the physician and the patient's family should be notified when there is a change in the patient's condition. She reported staff should notify the physician of a patient condition change first, should obtain orders, move the patient if the patient's condition is critical and then family (whomever is on the face sheet in Meditech) should be notified within the first half hour of changes in the patient's condition. When S2DON was informed Patient #7's family was not notified he was COVID-19 positive and had been moved to the COVID Unit for 2 days, she responded it was very sad and unacceptable that Patient #7's family was not notified for 2 days. She indicated the nurse assigned to the patient at the time of the transfer was responsible for notifying the family.


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Based on observation, policy review and interview, the hospital failed to ensure methods for preventing and controlling the transmission of infections within the hospital were followed. This deficient practice is evidenced by employees failing to sanitize their hands after removing gloves or between glove changes for 1 (#5) of 1 (#5) patient observed receiving wound care.

Findings:

Review of Patient #5's medical record revealed he had been admitted on 12/03/2020 with diagnosis including Sepsis status post shock with Bacteremia, Candidemia, Blood Loss Anemia, Multiple Decubitus and Paraplegia. Further review revealed an initial wound assessment dated 12/04/2020 which listed and described Patient #5's 14 wounds.

Review of the hospital's policy titled Hand Hygiene revealed in part:
Hand hygiene is the single most important strategy for preventing nosocomial infections.
The use of gloves does not negate the need for handwashing before and after glove use.

An observation was made of Patient #5's wound care beginning at 9:20 a.m. on 12/10/2020. Patient #5 had multiple wounds including stage 4 pressure ulcers to his left trochanter, left ischial tuberosity, sacrum, right ischial, and right anterior ischial tuberosity. During the removal of dressings, assessments, measurements, cleaning and redressing of wounds S5LPN doffed and donned new gloves 29 times. With the exception of washing prior to beginning, S5LPN did not wash or sanitize his hands during the entire observation. Further observation revealed S18CNA was assisting with wound care. She removed her gloves and left the room to obtain clean supplies. She did not wash or sanitize her hands.

In an interview on 12/11/2020 at 9:34 a.m. with S4ICO, she verified employees should wash or sanitize between glove changes or before leaving a room after removing gloves.