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Based on review of facility policies and procedures, review of medical records (MR), and interviews with staff (EMP), it was determined the facility failed to ensure patient's Notice of Rights (A-0117), failed to ensure patient's Informed Decision Notification for Advanced Directives (A-0132), failed to ensure patient's Admission Status Notification (A-0133), and failed to ensure patient's Restraint or Seclusion was discontinued in the earliest possible time (A-0174).

Cross Reference:

482.13(a)(1) Standard: Notice of Rights
482.13(b)(3) Standard: Informed Decision Notification, Advanced Directives
482.13(b)(4) Standard: Admission Status Notification
482.13(e)(9) Standard: Restraint or Seclusion, Discontinuation

Based on review of medical records (MR), review of facility documents and interviews with staff (EMP), it was determined that the facility failed to develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement (QAPI) program, failed to show measurable improvement in quality indicators, failed to show evidence that they were measured, analyzed and tracked to determine the effectiveness and safety of services provided by the hospital (A0273); failed to document the reason for conducting the selected performance improvement project (A0297); failed to implement interventions and changes that would ensure improvements were sustained (A0283); failed to ensure staff knowledge of the safety plan, and failed to analyze the cause of a patient death (A0286).

Cross Reference:
482.21(a)(1)(a)(2),(b)(1),(b)(2)(i),(b)(3)- Data Collection & Analysis
482.21(a)(2)(c)(2),(e)(3)-Patient Safety, Medical Errors & Adverse Events
482.21(b)(2)(ii),(c)(3)-Quality Improvement Activities
482.21(d)(3)-Performance Improvement Projects

The Physical Environment Condition was found to be out of compliance during a Life Safety Survey completed on April 3, 2017. Further details are outlined in that Division of Life Safety Survey Report.

Based on review of facility policy and procedures, review of medical records (MR), and interview with staff (EMP), it was determined the facility failed to provide Medicare beneficiaries with "An Important Message from Medicare (IMM)" within two days of admission for eight of ten medical records reviewed (MR20, MR22, MR23, MR24, MR25, MR26, MR27, and MR28).

Findings include:

Review on March 23, 2017, of facility policy, "Patient Admissions, Discharges and Transfers 2.0", undated, revealed, "Purpose ... To provide guidelines for obtaining proper admission documentation and timely admitting procedures to the hospital according to the hospital's established criteria ... Scope ... This policy applies to all patient admissions ... 2.1 ... Introduction ... Kindred's admission procedures are designed to collect admission and registration data for all patients treated by the hospital ... 2.6 Admissions Documents ...Virtual Patient File Folder (VPFF) ... The Virtual Patient File Folder allows users to access all Admissions Documents ... a) Required Inpatient Forms ... Important Message from Medicare/Champus ... c) Explanation of additional forms required for Medicare patients ... Inpatients ... An Important Message from Medicare/Champus ... This form shall be given to the patient within 2 calendar days of admission and be signed by the patient/representative."

Review of MR20, MR22, MR23, MR24, MR25, MR26, MR27, and MR28, on March 21 and 22, 2017, revealed no documented evidence that the patient (Medicare beneficiary), or patient representative, was provided with an IMM form within two calendar days of admission. All IMM forms had no patient/representative signature or acknowledgement from the facility that any attempt(s) were made to have the form signed by the patient/representative.

Interview with EMP1, on March 21, 2017, between 1:00 P.M. and 3:00 P.M., and March 22, 2017, between 9:15 A.M. and 11:30 A.M., confirmed, MR20, MR22, MR23, MR24, MR25, MR26, MR27, and MR28, had no documented evidence that the patient (Medicare beneficiary), or patient representative, was provided with an IMM form within two calendar days of admission. EMP1 further confirmed that all IMM forms had no patient/representative signature or acknowledgement from the facility that any attempt(s) were made to have the form signed by the patient/representative.

Interview with EMP6, on March 23, 2017, at 1:30 P.M., confirmed, MR20, MR22, MR23, MR24, MR25, MR26, MR27, and MR28, had no documented evidence that the patient (Medicare beneficiary), or patient representative, was provided with an IMM form within two calendar days of admission.

Based on review of facility policy and procedures, review of medical records (MR), and interview with staff (EMP), it was determined the facility failed to facilitate assisting the patient with formulating an advanced directive, or failed to acknowledge on admission, that the patient has an existing advanced directive for eight of ten medical records reviewed (MR20, MR22, MR23, MR24, MR25, MR26, MR27, and MR28).

Findings include:

Review on March 23, 2017, of facility policy, "Patient Admissions, Discharges and Transfers 2.0", undated, revealed, "Purpose ... To provide guidelines for obtaining proper admission documentation and timely admitting procedures to the hospital according to the hospital's established criteria ... Scope ... This policy applies to all patient admissions ... 2.1 ... Introduction ... Kindred's admission procedures are designed to collect admission and registration data for all patients treated by the hospital ... 2.6 Admissions Documents ...Virtual Patient File Folder (VPFF) ... The Virtual Patient File Folder allows users to access all Admissions Documents ... a) Required Inpatient Forms ... Advance Directives ... Form should be utilized by the Social Service Manager/designee to ensure the patient has necessary information and assistance to establish and advance directive if desired. Follow-up action is required to obtain copies of Advanced Directives identified on this form (See State specific guidelines)."

Review of MR20, MR22, MR23, MR24, MR25, MR26, MR27, and MR28, on March 21 and 22, 2017, revealed, no documented evidence that the patient was provided with assistance in formulating an advanced directive, or acknowledgment on admission, that the patient/representative had an existing advanced directive. All advanced directive facility forms, within the admission forms section of the MR, were incomplete/blank.

Interview with EMP1, on March 21, 2017, between 1:00 P.M. and 3:00 P.M., and March 22, 2017, between 9:15 A.M. and 11:30 A.M., confirmed, MR20, MR22, MR23, MR24, MR25, MR26, MR27, and MR28, had no documented evidence that the patient was provided with assistance in formulating an advanced directive, or acknowledgment on admission, that the patient/representative had an existing advanced directive. EMP1 further confirmed that all advanced directive facility forms, within the admission forms section of the MR, were incomplete/blank.

Interview with EMP6, on March 23, 2017, at 1:30 P.M., confirmed, MR20, MR22, MR23, MR24, MR25, MR26, MR27, and MR28, had no documented evidence that the patient was provided with assistance in formulating an advanced directive, or acknowledgment on admission, that the patient/representative had an existing advanced directive.

Based on review of medical records (MR) and interview with staff (EMP), it was determined the facility failed to ensure that the primary care physician (PCP) was notified of the patients respective admission to the facility for ten of ten medical records reviewed (MR20, MR21, MR22, MR23, MR24, MR25, MR26, MR27, MR28, and MR29).

Findings include:

Review of MR20, MR21, MR22, MR23, MR24, MR25, MR26, MR27, MR28, and MR29, on March 21 and 22, 2017, revealed, no documented evidence that the patient's PCP was notified of the patient's respective admission to the facility.

Interview with EMP1, on March 21, 2017, between 1:00 P.M. and 3:00 P.M., and March 22, 2017, between 9:15 A.M. and 11:30 A.M., confirmed, MR20, MR21, MR22, MR23, MR24, MR25, MR26, MR27, MR28, and MR29, had no documented evidence that the patient's PCP was notified of the patient's respective admission to the facility. EMP1 further confirmed that the facility does not routinely contact the patient's PCP unless there is medical necessity to do so or at the request of a facility physician caring for the patient.

Interview with EMP6, on March 23, 2017, at 11:15 A.M., confirmed that the facility does not currently have a policy that requires notification to the PCP of the patient's admission to the facility.

Based on review of facility policy and procedures, review of medical records (MR), and interview with staff (EMP), it was determined the facility failed to document that the use of restraints was discontinued at the earliest possible time for two of two restraint medical records reviewed (MR23 and MR24).

Findings include:

Review on March 23, 2017, of facility policy, "Physical Restraints (Violent and Non-Violent Behavior) and Seclusion", effective, "06/2016", revealed, "Policy ... To delineate responsibilities and procedural steps for clinical/nursing staff and Physician/Licensed Independent Practitioners (LIP)/Allied Health Practitioners (AHPs) regarding physical restraint and/or seclusion of a patient. These requirements support Kindred Healthcare's philosophy to protect the patient's health and safety, and preserve the patients dignity, rights and well-being ... Components ... 7. Criteria for release of Restraint(s) ... The clinical team (Physicians/LIP, RNs, and all direct care staff) work collaboratively to observe the patient and remove the restraints (or discontinue seclusion) as soon as possible, based on an assessment. This includes documentation that indicates ... a. The unsafe situation is resolved ... b. Determination is made that the patient's behavior is no longer a threat to the patient's safety and/or safety of others."

Review of MR23, on March 22, 2017, revealed the patient was admitted on February 19, 2017. Further review of the medical record revealed the patient was placed in bilateral soft limb restraints on March, 9, 2017. Further review of the medical record revealed no documented evidence that the restraints were removed from the patient in the earliest possible time, that the unsafe situation requiring the use of restraints was resolved, and that the patient's behavior, requiring the use of restraints was no longer a threat to the patient and/or the safety of others.

Review of MR24, on March 22, 2017, revealed the patient was admitted on March 17, 2017. Further review of the medical record revealed the patient was placed in bilateral mitt restraints on March 17, 2017. Further review of the medical record revealed no documented evidence that the restraints were removed from the patient in the earliest possible time, that the unsafe situation requiring the use of restraints was resolved, and that the patient's behavior, requiring the use of restraints, was no longer a threat to the patient and/or the safety of others.

Interview with EMP1, on March 22, 2017, between 9:15 A.M. and 11:30 A.M., confirmed, MR23 and MR24, had no documented evidence that the restraints were removed on the patient in the earliest possible time, that the unsafe situation requiring the use of restraints was resolved, and that the patients behavior, requiring the use of restraints, was no longer a threat to the patient and/or the safety of others.

Based on review of facility documents and interviews with staff (EMP), it was determined the facility failed to establish an ongoing Quality Assessment Performance Improvement (QAPI) program that showed measurable improvement in quality indicators, failed to show evidence that these indicators were measured, analyzed and tracked to determine the effectiveness and safety of services provided by the hospital and failed to identify the frequency of data collection for performance improvement indicators for the hospital -wide QAPI program, for one of one quality indicators reviewed (Blood Product Transfusion Paperwork).

Findings include:

Review on March 21, 2017, of the facility document "2017 Strategic Quality Operational Plan," approved by the Governing Board January 2016, revealed "Kindred Strategic Quality Plan, Section 1, Quality, Aims: is the roadmap to excellence ... Clinical programs, patient care processes and practices are evidence-based and focus on reducing variation and improving outcomes ... Section ll, Scope, Authority and Responsibilities: Quality Council coordinates the improvement process by: Establishing a planned, systematic, organization-wide approach to performance measurement, analysis, and improvement ... Setting priorities for improvement, systematically measuring, analyzing and directing performance improvement. Implementing improvement activities based on assessment conclusions. Section lll, Quality Framework: Integrating Performance Improvement methodologies and tools is essential to a systematic approach to continuous improvement ... The PDCA (Plan, Do, Check, Act) cycle goes from problem identification to implementation of the solution. P: Plan, determine what the improvement will be and the method for data collection. D: Do, implement the plan. C: Check, review, and analyze the results. A: Act, hold the gain and continue with the improvement ... Appendix D: Data Reporting Procedures ... Benchmark data must be entered into the Data Entry Application in the Business Warehouse by the 8th of the month. After the 8th you will no longer have access to key your data. "

Review on March 22, 2017, of facilty document "Quality Council Agenda Meeting Minutes" dated January 25, 2016, revealed "Quality Council Meeting Dashboard Report ... Blood Product Transfusion Paperwork" for reported dates October, November, and December 2015, revealed no documented evidence data was reported, measured, analyzed and tracked.

Review on March 22, 2017, of facility document "Quality Council Agenda Meeting Minutes" dated July 25, 2016, revealed "Quality Council Meeting Dashboard Report ... Blood Product Transfusion Paperwork" for reported dates April, May, and June 2016, revealed no documented evidence data was reported, measured, analyzed and tracked.
Review on March 22, 2017, of facility document "Quality Council Agenda Meeting Minutes" dated October 24, 2016, revealed "Quality Council Meeting Dashboard Report ... Blood Product Transfusion Paperwork" for reported dates July, August, and September 2016, revealed no documented evidence data was reported, measured, analyzed and tracked A request was made to EMP13 on March 22, 2017, for the documentation. None was provided.
Interview on March 22, 2017, at 10:55 AM, with EMP13 confirmed there was no documented evidence of ongoing data collection for the performance indicator, Blood Product Transfusion Paperwork and no documented evidence the data was measured, analyzed and tracked or reported for the months of October, November and December 2015, and April, May, June, July, August and September 2016. Further interview with EMP13 confirmed there was no provision for the frequency of data collection in the hospital-wide QAPI program.

Based on review of facility documents and interviews with staff (EMP), it was determined that the facility failed to implement interventions and changes that would ensure that improvements were sustained for one of one quality indicators reviewed (Blood Product Transfusion Paperwork.)
Findings include:
Review on March 21, 2017, of the facility's "2017 Strategic Quality Operational Plan," approved by the Governing Body January 2016, revealed "Kindred Strategic Quality Plan ... Sectionll, Scope, Authority and Responsibilities: Quality Council coordinates the improvement process by: Establishing a planned, systematic, organization-wide approach to performance measurement, analysis, and improvement ... Setting priorities for improvement, systematically measuring, analyzing and directing performance improvement. Implementing improvement activities based on assessment conclusions ... Sectionlll, Quality Framework: Integrating Performance Improvement methodologies and tools is essential to a systematic approach to continuous improvement ... The PDCA (Plan, Do, Check, Act) cycle goes from problem identification to implementation of the solution. P: Plan, determine what the improvement will be and the method for data collection. D: Do, implement the plan. C: Check, review, and analyze the results. A: Act, hold the gain and continue with the improvement. PDCA should be repeated for continuous improvement. If the solution does not remove the process, it is removed and the cycle is repeated with a different plan."
Review on March 22, 2017, of facility document "Quality Council Agenda Meeting Minutes" dated January 25, 2016, revealed "Quality Council Meeting Dashboard Report ... Blood Product Transfusion Paperwork" for reported dates October, November, and December 2015, revealed no documented evidence of ongoing data collection reported at the quarterly council meeting ... Futher review of the Dashboard Report revealed "Recommendations, actions, and follow-up ... Request Nurse Manager to submit documentation of remediation with nurses. Corrective action plan for Lab Medical Director by February 15, 2016."
A request was made on March 22, 2017, to EMP13 for evidence of staff remedial training and the Performance Improvement (PI) plan for Lab Medical Director due February 15, 2016. None was provided.
Interview with EMP13, at 2:10 PM, confirmed no documented evidence of a PI plan submitted to the Lab Medical Director.
Review on March 22, 2017, of facilty document "Quality Council Agenda Meeting Minutes" dated April 25, 2016, revealed "Quality Council Meeting Dashboard Report ... Blood Product Transfusion Paperwork," goal was set for 95% accurate paperwork completion ... Futher review of the Dashboard Report revealed the following: January 2016, goal: 52%, February 2016, goal: 71%, March 2016, goal: 49% ... Findings/Analysis: January: goal not met, February: goal not met, March: goal not met ... Recommendations, Actions, and Follow up: Nurse manager to submit a PI (no date specified) to the Lab Medical Director."
A request was made on March 22, 2017, to EMP13 for evidence of PI plan submitted to the Lab Medical Director. None was provided.
Review on March 22, 2017, of facilty document "Quality Council Agenda Meeting Minutes" dated July 25, 2016, revealed "Quality Council Meeting Dashboard Report ... Blood Product Transfusion Paperwork" for reported dates April, May, June 2016 revealed "... Recommendations, Actions, and Follow-up: ... Nurse Manager to submit a PI plan to Lab Medical Director. Nurse Manager to respond by May 15, 2016."
A request was made on March 22, 2017, to EMP13 for evidence PI plan submitted to Lab Medical Director. None was provided.
Interview on March 22, 2017, at 2:10 PM, with EMP13 confirmed there was no documented evidence a PI plan was submitted to the Lab Director.
Review on March 22, 2017, of facility document "Quality Council Meeting Dashboard Report ... Blood Product Transfusion Paperwork" for April, May, June, July, August, September, October, November, and December 2016, revealed no documented evidence of goal compliance data collection and no documented evidence a new PI plan was submitted for a new cycle and repeated with a different plan for improvement for one of one quality indicator, Blood Product Transfusion Paperwork.
Review on March 22, 2017, of facility document "Quality Council Agenda Meeting Minutes" dated January 23, 2017 revealed "Quality Council Meeting Dashboard Report ... Blood Product Transfusion Paperwork, ... Recommendations, Actions, and Follow-up: Unit tags ... sent to CCO for staff remedial training ... CCO/Nurse Manager to submit a PI plan to Lab Medical Director."
A request was made on March 22, 2017, to EMP13 for evidence of staff remedial training and the PI plan for Lab Medical Director. None was provided.
Interview on March 22, 2017, at 2:10 PM, with EMP13 confirmed no documented evidence of goal compliance data collection and no documented evidence a new PI plan was submitted for a new cycle and repeated with a different plan for improvement for one of one quality indicator, Blood Product Transfusion Paperwork.

Based on review of facility documents and interviews with staff (EMP), it was determined the facility failed to ensure staff were knowledgeable of the facility's Patient Safety Plan and failed to analyze reported events for one of two patient adverse events. (MR40).
Findings include:
Review on March 23, 2017, of facility document "Patient Safety Plan," approved by the "Patient Safety Committee" on January 2016, revealed "... Principles: ... Communication about the importance of patient safety must be well conceived, repeated, and consistent across the entire organization ... Responsibility and accountability for patient safety must be clearly articulated to physicians, managers, and employees ... All employees and medical staff members must review the self-learning module ..."
Interview on March 23, 2017, at 10:40 AM, with EMP15 confirmed lack of knowledge of the facility's safety plan and identification of the Patient Safety Officer.
Interview on March 23, 2017, at 10:52 AM, with EMP16 confirmed lack of knowledge of adverse events that were to be reported to the Patient Safety Officer, the facility's safety plan and identification of the Patient Safety Officer.
Interview on March 23, 2017, at 10:54 AM, with EMP 17 confirmed lack of knowledge of patient adverse events that were to be reported to the Patient Safety Officer, the facility's safety plan and identification of the Patient Safety Officer.
Interview on March 23, 2017, at 10:56 AM, with EMP18 confirmed lack of knowledge of the facility's patient safety plan and were unable to identify the Patient Safety Officer.
Interview on March 23, 2017, at 10:58 AM, with EMP19 confirmed lack of knowledge of the types of adverse events that were to be reported to the Patient Safety Officer.

_____________

Review on March 23, 2017, of facility document "Patient Safety Plan," approved by the "Patient Safety Committee" on January 2016, revealed "Establishment of a Patient Safety Committee: Functions ... provides the insight and management of the patient safety program ... Establishes appropriate mechanisms for the review and analysis of incidents, ... sentinel events ... Reviews summaries of all serious and sentinel event root cause analyses to determine whether the review has been thorough and credible in ascertaining the casual factors for the event ..."
Findings include:
Review on March 23, 2017, of MR 40 admitted January 14, 2016, revealed the patient expired twenty four hours after admission.
A request was made on March 23, 2017, regarding the outcome of a root cause analysis to ascertain the causal factors for the unexpected death in MR40. None was provided.
Review on March 23, 2017, of the facility's patient safety report of adverse events "Nature of Event Totals, Event date: January 1, 2016 to December 31, 2016, Nature of Event: death (unexpected)" revealed no documented evidence unexpected deaths were identified and reported.
Review on March 23, 2017, of facility document "Patient Safety Committee Meeting Minutes" dated January 20, 2016, February 17, 2016, March 16, 2016, and April 20, 2016, "Topic: Sentinel Events/Near Misses/Sentinel Event Alerts/Summary Report," revealed no documented evidence the unexpected death in MR40 was reported as a sentinel event.
Review on March 23, 2017, of facility document "Patient Safety and Reliability Committee Meeting Minutes" dated July 21, 2016, revealed "2016 Patient Safety and Reliability Dashboard Report, Topic: Sentinel Events/Near Misses/Sentinel Event Alerts/Summary Report, January 2016 to June 2016," revealed serious events and unexpected deaths were not reported.
Interview on March 23, 2017, at 10 AM with EMP 13 confirmed no documented evidence the (unexpected) deaths were reviewed and analyzed at the Patient Safety Committee.

Based on review of facility documents and interviews with staff (EMP), it was determined that the facility failed to document the reason for conducting the selected performance improvement project for one of one quality indicator reviewed (Blood Product Transfusion Paperwork).

Findings include:

Review on March 22, 2017, of facility document "2017 Strategic Quality Operational Plan," approved by the Governing Board 2016, revealed "Kindred Strategic Quality Plan, Section ll. Scope, Authority and Responsibilities: ... utilization of the committee standardization process facilitates integration of quality and patient safety throughout the hospital through self-identification of issues, development of interdisciplinary action plans ... and monitoring for rapid cycle improvement ... SectionIV, Using Outcomes to Drive Performance: ... The single best indicator of the effectiveness of the QAPI is the ability of a hospital to self-identify quality issues ..."

Review on March 22, 2017, of facility document "Quality Council Agenda Meeting Minutes" dated January 25, 2016, April 25, 2016, July 25, 2016, and January 23, 2017, revealed the lack of documentation to indicate the reason for conducting the selected performance improvement project, Blood Product Transfusion Paperwork.

A request was made on March 22, 2017, to EMP4 and EMP13 for documented evidence that identified the reason for conducting the selected PI project. None was provided.

An interview on March 22, 2017, at 11:30 AM with EMP4 and EMP13 confirmed no prior knowledge of the reason for conducting the selected PI project and further confirmed the meeting minutes failed to include the reason the quality performance indicator was selected.

Based on review of facility policies and procedures, medical records (MR), and interviews with staff (EMP), it was determined that the facility failed to follow its established policy on the standards for the physical assessment of a patient, during/post blood transfusion, on four of four blood transfusion medical records reviewed (MR21, MR23, MR24, and MR25).

Findings include:

Review on March 23, 2017, of the facility policy "Transfusion Therapy", dated, "05/2015", revealed, "Rationale ... To provide guidelines for safe blood and blood product transfusion ... Procedure ... 8. ... c. Observe patient continuously for signs of transfusion reaction during the first 15 minutes, then every hour during the transfusion ... 10. Post-Transfusion ... b. Because patients can experience delayed transfusion reactions, caregivers should continue to monitor the patient for signs and symptoms of reaction during the first hour post transfusion.

Review of MR21, on March 22, 2017, revealed, the patient was admitted on March 3, 2017. Further review of the medical record revealed the patient did receive a blood transfusion on March 20, 2017. Further review of the medical record revealed no documented evidence that the patient was continuously assessed/monitored for signs of a transfusion reaction during the first fifteen minutes of the transfusion, every hour during the transfusion, and during the first hour, post-transfusion.

Review of MR23, on March 22, 2017, revealed, the patient was admitted on February 19, 2017. Further review of the medical record revealed the patient did receive a blood transfusion on February 20, 2017 and March 18, 2017. Further review of the medical record, for both transfusion dates, revealed no documented evidence that the patient was continuously assessed/monitored for signs of a transfusion reaction during the first fifteen minutes of the transfusion, every hour during the transfusion, and during the first hour, post-transfusion.

Review of MR24, on March 22, 2017, revealed, the patient was admitted on March 17, 2017. Further review of the medical record revealed the patient did receive a blood transfusion on March 20, 2017. Further review of the medical record revealed no documented evidence that the patient was continuously assessed/monitored for signs of a transfusion reaction during the first fifteen minutes of the transfusion, every hour during the transfusion, and during the first hour, post-transfusion.

Review of MR25, on March 22, 2017, revealed, the patient was admitted on February 18, 2017. Further review of the medical record revealed the patient did receive a blood transfusion on March 8, 2017. Further review of the medical record revealed no documented evidence that the patient was continuously assessed/monitored for signs of a transfusion reaction during the first fifteen minutes of the transfusion, every hour during the transfusion, and during the first hour, post-transfusion.

Interview with EMP1, on March 22, 2017, between 9:15 A.M. and 11:30 A.M., confirmed, MR21, MR23, MR24, and MR25 had no documented evidence that the patient was continuously assessed/monitored for signs of a transfusion reaction during the first fifteen minutes of the transfusion, every hour during the transfusion, and during the first hour, post-transfusion.

Based on review of facility policies and procedures and medical record review (MR), and interviews with staff (EMP), it was determined the facility failed to ensure it followed its own established policy regarding documenting in the patients' medical record the proper indications for continued use of an indwelling urinary catheter for three of three medical records reviewed (MR32, MR33, and MR34))

Findings include:

Review on March 22, 2017, of facility policy, "Indwelling Urinary Catheter Standards and Practice", dated June 2016, revealed "Components ... 3. Patients with urinary catheters will be assessed each shift by a registered nurse according to the facility indwelling urinary catheter discontinuation protocol."

Review on March 22, 2017, of facility policy, "Indwelling Urinary Catheter Discontinuation Protocol", dated June 2016, revealed "Procedure ... 7. If the removal criteria to remove the urinary catheter is not met the nurse will: a. Document in the medical record "urinary catheter not removed" related to one or more of the following indicators: i. Urologist or nephrologist on the case ii. Patient has an open sacral or perineal wound (stage III & IV) iii. Patient is on comfort and/or hospice care iv. Patient admitted with chronic indwelling catheter with written indication v. Critical care patient is hemodynamically unstable, is chemically paralyzed, sedated or requires hourly output measurement vi. Physician has written an order with an appropriate indication to maintain the urinary catheter in situ vii. Urinary catheter is being used for continuous or intermittent bladder irrigation."

Review on March 22, 2017, of MR32, revealed the patient was admitted to the facility on March 15, 2017, with a Foley catheter present on admission. Further review of MR32 revealed there were no documented nursing shift assessments that indicated "urinary catheter not removed" related to one or more of the following indicators: i. Urologist or nephrologist on the case ii. Patient has an open sacral or perineal wound (stage III & IV) iii. Patient is on comfort and/or hospice care iv. Patient admitted with chronic indwelling catheter with written indication v. Critical care patient is hemodynamically unstable, is chemically paralyzed, sedated or requires hourly output measurement vi. Physician has written an order with an appropriate indication to maintain the urinary catheter in situ vii. Urinary catheter is being used for continuous or intermittent bladder irrigation."

Review on March 22, 2017, of MR33, revealed the patient was admitted to the facility on March 9, 2017, with a Foley catheter present on admission. Further review of MR33 revealed there were no documented nursing shift assessments that indicated "urinary catheter not removed" related to one or more of the following indicators: i. Urologist or nephrologist on the case ii. Patient has an open sacral or perineal wound (stage III & IV) iii. Patient is on comfort and/or hospice care iv. Patient admitted with chronic indwelling catheter with written indication v. Critical care patient is hemodynamically unstable, is chemically paralyzed, sedated or requires hourly output measurement vi. Physician has written an order with an appropriate indication to maintain the urinary catheter in situ vii. Urinary catheter is being used for continuous or intermittent bladder irrigation."

Review on March 22, 2017, of MR34, revealed the patient was admitted to the facility on March 3, 2017. The Foley catheter was inserted on March 7, 2017. Further review of MR34 revealed there were no documented nursing shift assessments that indicated "urinary catheter not removed" related to one or more of the following indicators: i. Urologist or nephrologist on the case ii. Patient has an open sacral or perineal wound (stage III & IV) iii. Patient is on comfort and/or hospice care iv. Patient admitted with chronic indwelling catheter with written indication v. Critical care patient is hemodynamically unstable, is chemically paralyzed, sedated or requires hourly output measurement vi. Physician has written an order with an appropriate indication to maintain the urinary catheter in situ vii. Urinary catheter is being used for continuous or intermittent bladder irrigation."

Interview with EMP7 on March 22, 2017, at 11:15 AM, confirmed it was facility policy that nurses conduct shift assessments for the continued use of indwelling urinary catheters. EMP7 confirmed there was no documented nursing shift assessments for continued use of Foley catheters in MR32, MR33, and MR34. EMP7 confirmed the patients in MR32, 33, and 34 all had Foley catheters in place and the nursing shift assessments were required.