HospitalInspections.org

Based on policy review, facility document review, observation, and interview, the Governing Body failed to assume responsibility and provide oversight for the Patient Rights, Medical Staff, Nursing Services and the Infection Control Program.

The findings included:

1. The governing body failed to protect and promote patients' rights.
Refer to A 131, A 166, A 167, A 168 and A 175.

2. The Governing Body failed to appoint medical staff after considering the recommendations of the existing members of the medical staff.
Refer to A 046 and A 341.

3. The Governing Body failed to ensure current Medical Staff Bylaws were approved and adopted to provide oversight and direction to the practicing medical staff.
Refer to A 048, A 347, A 353 and A 354.

4. The Governing Body failed to consult directly with the individual assigned the responsibility for the organization and conduct of the hospital's medical staff.
Refer to A 053.

5. The Governing Body failed to ensure the hospital appropriately assessed pressure wounds and developed and implemented plans of care for patients with pressure wounds.
Refer to A 395 and A 396.

6. The Governing Body failed to ensure the hospital developed, implemented and maintained an active hospital-wide Infection Control Program for the prevention and control of infections.
Refer to A 747, A 748, A 749 and A 756.

Based on policy review, document review, observation, and interview, the facility failed to protect and promote each patient's rights when patients were denied the right to make informed decisions about their care, failed to ensure physician's orders were obtained prior to the use of restrains, and failed to monitor those patients in restraints while receiving care in the hospital.

The findings included:

1. The facility failed to ensure patients were allowed the right to make informed decisions regarding their care and treatment.
Refer to A 131

2. The facility failed to ensure the plan of care was updated to reflect the use of restraints.
Refer to A 166

3. The facility failed to ensure a face to face assessment was conducted according to policy.
Refer to A 167

4. The facility failed to ensure a physician order was obtained for restraints.
Refer to A 168

5. The facility failed to ensure patients in restraints were monitored by staff at intervals according to policy.
Refer A 175

Based on policy review, facility document review, observation, and interview, the Medical Staff (Medical Executive Committee [MEC]) failed to operate under bylaws approved by the governing body for the quality of medical care provided to patients receiving care in the facility.

The findings included:

1. The Medical Staff failed to protect and promote each patient's rights.
Refer to A131, A166, A167, A168 and A175.

2. The Medical Staff failed to reappoint or deny current medical providers, whose privileges were expiring, to continued membership of the Medical Staff .
Refer to A 046 and A 341.

3. The Medical Staff failed to ensure Medical Staff Bylaws were adopted and enforced by the medical staff to carry out its responsiblilities. The Medical Staff failed to ensure its current Bylaws were approved by the Governing Body to carry out its responsibilities to patients receiving care in the hospital.
Refer to A 048, A 347, A 353 and A 354.

4. The medical staff failed to consult directly with the Governing Body for the organization and conduct of the hospital's medical staff.
Refer to A 053

5. The Medical Staff failed to ensure the hospital developed, implemented and maintained an active hospital-wide Infection Control Program for the prevention and control of infections.
Refer to A 747, A 748, A 749 and A 756.

Based on policy review, facility document review, observation, and interview, the facility failed to ensure nursing services appropriately assessed wounds, developed inital plans of care and followed the plan of care for wounds.

The findings included

1. The facility failed to ensure pressure wounds were appropriately assessed.
Refer to A 395

2. The facility failed to develop an initial plans of care and failed to follow the plan of care for wounds.
Refer to A 396

Based on policy review, medical record review, observation, and interview the facility failed to provide a sanitary environment and failed to implement an active program for the prevention, control, and investigation of infections and communicable diseases.

The findings included:

1. The facility failed to designate a qualified person to serve as the Infection Control Officer.
Refer to A 748

2. The facility failed to implement measures to prevent the potential spread of infection.
Refer to A 749

3. The facility failed to ensure the Chief Executive Officer (CEO), Medical Staff, and Director of Nursing Services/Chief Clinical Officer (CCO) addressed identified problems with infection control and implemented successful corrective action plans.
Refer to A 756

Based on policy review, facility document review, credential file review and interview, the governing body failed to reappoint medical staff, whose privileges were expiring, after considering the recommendations of the existing members of the medical staff for 1 of 5 (Medical Provider #5) medical providers reviewed.

The findings included:

1. Review of the facility's "Governing Body" policy revealed, "...Each hospital will have its own Governing Body, which is responsible for overall operation of the hospital...Each Governing Body has its own set of Governing Body Bylaws under which it functions that are particular to the individual facility supervised...The Governing Body meets quarterly and more often as necessary...The Chief Quality Officer will be responsible for writing the Governing Body minutes..."

2. Review of the facility's "2017 MEDICAL STAFF BYLAWS" revealed, "...The Hospital is owned by the [named corporation]. [Named corporation] retains all authority and control over the business, policies, operations, and assets of the Hospital via the Governing Board. The Governing Board retains ultimate responsibility for the Hospital's compliance with all applicable Federal, State, and local laws and regulations...The primary function of the Governing Board shall be to assure that the Hospital and its Medical Staff provide quality medical care that meets the needs of the community...For this purpose, the Corporation has delegated to the Governing Board the authority to...make decisions in compliance with the Corporation's policies regarding Medical Staff Membership and the granting of Clinical Privileges...Advanced Practice Professionals are not Medical Staff Members, but are granted Clinical Privileges and permission to practice at the Hospital under a defined degree of direction from a Supervising/Collaborating Physician...PROCESS FOR CREDENTIALING AND PRIVILEGING...If the recommendation of the Medical Executive Committee is to grant Medical Staff Membership and/or Clinical Privileges, it will be forwarded to the Board for final action..."

The "2017 MEDICAL STAFF BYLAWS" were documented as reviewed October 2017, but there was no documentation of the bylaws had been adopted by the Medical Staff or approved by the Governing Board.
During an interview in the conference room on 8/14/18 at 3:58 PM, the Chief Executive Officer (CEO) stated the facility did not have a copy of the Medical Staff Bylaws signed as adopted by the Medical Staff or approved by the Governing Board.

3. Review of credentialing file for Medical Provider #5 revealed Medical Provider #5 is currently an active member of the Medical Stall. Review of the PHYSICIAN REAPPOINTMENT APPLICATION revealed Medical Provider #5's privileges expired on 3/02/18, and Medical Provider #5 requested reappointment to the Medical Staff. There was handwritten documentation the hospital's medical staff received the application 10/9/17.

Review of the "SUMMARY OF APPOINTMENT/REAPPOINTMENT VERIFICATION FORM" revealed, Medical Provider #5's request for reappointment was neither approved or denied. There was no documentation the form was signed by the President of the Medical Staff, the CEO or Designee, or the Governing Board Vice-Chair or Designee to indicate reappointment was approved or denied.

4. During a telephone interview on 8/13/18 at 3:35 PM, the Medical Director was questioned regarding Medical Provider #5's reappointment application. The Medical Director stated, "I don't remember us ever discussing her, but like I said, it's been at least 8 months since we've had a meeting..."

During an interview in the conference room on 8/14/18 at 8:25 AM, the CEO confirmed Medical Provider #5 had been practicing in the facility since March 2018 when her credentialing and privileges expired. The CEO stated that "it [her expired credentials and privileges] was brought to our attention last week."

Based on facility document review and interview, the Governing Body failed to approve medical staff bylaws and other medical staff rules and regulations.

The findings included:

1. Review of the facility's "Governing Body" policy revealed, "...Each hospital will have its own Governing Body, which is responsible for overall operation of the hospital...Each Governing Body has its own set of Governing Body Bylaws under which it functions that are particular to the individual facility supervised...The Governing Body meets quarterly and more often as necessary...The Chief Quality Officer will be responsible for writing the Governing Body minutes..."

2. The "2017 MEDICAL STAFF BYLAWS" were documented as reviewed October 2017, but there was no documentation of the bylaws had been adopted by the Medical Staff or approved by the Governing Board.

Review of the "2017 MEDICAL STAFF RULES AND REGULATIONS" revealed, "...Medical Staff Rules and Regulations Agreement...Allied Health Practitioners shall agree to abide by these policies. They shall, when so approved, be equally binding on the Medical Staff, Allied Health Practitioners and the Governing Board...The adoption and approval of these Rules/Regulations will constitute a repeal of all prior Rules/Regulations of the Medical Staff of the Hospital...Adopted by the Active Staff of [name of hospital] at a meeting duly and regularly called and held at [name of hospital] on...(Date) [blank]...APPROVED BY...President of Medical Staff [blank]...Chairperson of the Governing Board [blank]...Chief Executive Officer [blank]..."

3. During an interview in the conference room on 8/14/18 at 3:58 PM, the Chief Executive Officer stated the facility did not have a copy of the medical staff bylaws or the medical staff rules and regulations signed as approved by the Governing Board.

Based on policy review, facility document review and interview, the Governing Body failed to consult directly with the individual assigned the responsibility for the organization and conduct of the hospital's medical staff.

The findings included:

1. Review of the facility's "Governing Body" policy revealed, "...Each hospital will have its own Governing Body, which is responsible for overall operation of the hospital...Each Governing Body has its own set of Governing Body Bylaws under which it functions that are particular to the individual facility supervised...The Governing Body meets quarterly and more often as necessary...The Chief Quality Officer will be responsible for writing the Governing Body minutes..."

2. Review of the facility's Governing Body documents revealed documentation of a meeting occurring on 7/28/17. The facility provided a Governing Board Teleconference agenda for a meeting scheduled 11/7/17. The facility was unable to provide documentation the meeting was held as scheduled 11/7/17. The facility provided a document entitled, "Patient Care Meeting Minutes" dated 2/28/18 with the meeting called to order at 7:10 AM and adjourned at 9:12 AM. The facility was unable to provide documentation this was a meeting of the Governing Body. The facility was unable to provide documentation of an attendance record.

3. During a telephone interview on 8/13/18 at 3:35 PM, the Medical Director was asked to describe how the Medical Executive Committee (MEC) was informed of problems in the facility. The Medical Director stated he could not answer that adequately because they had only had 1 meeting since (named corporation) took over (in 2016). The Medical Director also stated the communication between the administration and the physicians was not good. He then stated that in the past, the MEC reported to the governing body, and it was done as a presentation by the Quality Assurance committee. The Medical Director stated he was taken off the Governing Body when (named corporation) took over but was informed by the current Chief Executive Officer (CEO) that he was back on the Governing Body.

During an interview in the conference room on 8/14/18 at 3:58 PM, the CEO confirmed there was no documentation of Governing Body meeting minutes since 7/28/17. The CEO stated the Governing Body met on 11/7/17 and 2/28/18 but confirmed there was no documentation of the Governing Body meeting on these dates.

Based on facility document review, medical record review, and interview the facility failed to ensure patients or their representatives were allowed the right to make informed decisions regarding their care and treatment for 3 of 30 (Patients #4, 21, and 23) sampled residents, and the facility failed to ensure a patient or his representative was informed of the risks involved when choosing to leave Against Medical Advice (AMA) for 1 of 1 (Patient #20) sampled residents that left AMA.

The findings included:

1. Review of the facility's "Compliance Handbook" revealed, "...Respecting Patient Rights-Freedom of Choice- Upon admission, [named hospital] must provide patients with a written statement of their rights...Patients must be given the opportunity to be involved in all aspects of their care and [named hospital] must obtain their informed consent for treatment..."

2. Review of the facility's "Condition Admission Authorization Treatment" document revealed, "...CONSENT FOR ADMISSION AND TREATMENT... I consent to receiving examinations and procedures that may be performed during this hospitalization...SIGNATURE AND CERTIFICATION... The undersigned certifies that he/she has read this document, has received a copy, and is either the patient or dully authorized by the patient as patient's general agent to execute the above and accept its terms..."

3. Medical record review for Patient #4 revealed an admission date of 8/3/18 at 4:40 AM with diagnoses which included Pneumonia, Status Post Tracheotomy, Atrial Fibrillation and Hypertension. Patient #4 was alert and oriented.

Review of the Admission Agreement revealed the telephone consent was obtained by the Quality Manager and witnessed by the Chief Executive Officer on 8/2/18 at 5:22 PM.

During an interview in the conference room on 8/8/18 at 3:30 PM, the Quality Manager verified that she had Patient #4 give consent for admission to the hospital by telephone before he was admitted. The Quality Manager further verified that Patient #4 was capable of signing his admission agreement in person once he was onsite at the hospital and that should have been the process.

4. Medical record review for Patient #21 revealed an admission date of 6/15/18 with diagnoses which included Status Post Motor Vehicle Accident, Acute Hypoxic and Hypercapnic Respiratory Failure with Tracheostomy, Methicillin-resistant Staphylococcus Aureus, Polyneuropathy, Oropharyngeal Dysphagia and Diabetes Mellitus. The Discharge Summary revealed, "DATE OF ADMISSION: June 15, 2018...DATE OF DISCHARGE: July 10, 2018 (25 day length of stay)..."

The Admission Agreement dated 6/15/18 revealed, "...The undersigned certifies that he/she has read this document, has received a copy, and is either the patient or duly authorized by the patient as patient's general agent to execute the above and accept its terms..." There was no documentation the patient or approved patient representative was informed of or agreed to the terms of the admission agreement.

The "INFORMED CONSENT FOR TRANSFUSION" dated 6/16/18 revealed, "...This consent form provides a written communication of the recommended transfusion of blood or blood products to be performed and information you have been given about your condition. It will allow you to give or withhold your consent to the proposed treatment(s)...PHYSICIAN CERTIFICATION: I hereby certify that I have discussed the treatment(s) described above with the patient (or patient's legal representative). The discussion was held prior to treatment and included the risks/benefits, consequences/alternatives and other pertinent information about the proposed treatment(s)...Printed Name/Signature of Physician...[signed by Physician #1]...Printed Name/Signature of Witness...[blank]..." There was no documentation the patient or approved patient representative was informed of or gave informed consent for the blood transfusion.

5. Medical record review for Patient #23 revealed an admission date of 7/28/18 with diagnoses which included Severe Peripheral Vascular Disease, Acute Respiratory Disease, Acute Renal Failure, Severe Sepsis with Septic Shock, Severe Protein-calorie Malnutrition, Coronary Artery Disease and Hypertension. The Transfer Summary revealed, "DATE OF ADMISSION: July 28, 2018...DATE OF TRANSFER: 07/31/2018 (3 day length of stay)..."

The Admission Agreement dated 7/28/18 revealed, "...The undersigned certifies that he/she has read this document, has received a copy, and is either the patient or duly authorized by the patient as patient's general agent to execute the above and accept its terms..." There was no documentation the patient or approved patient representative was informed of or agreed to the terms of the admission agreement.

6. Review of the facility's "MEDICAL STAFF RULES AND REGULATIONS" policy revealed, "...4. Should a patient leave the Hospital against the advice of the practitioner or without proper discharge, the practitioner shall request that the patient sign the Against Medical Advice (AMA) release form and an appropriate notation shall be made in the patient's medical record..."

7. Review of the facility's "Discharge Against Medical Advice" policy revealed, "...Competent patients who wish to leave the hospital against medical advice will be counseled on the decision to leave the hospital and asked to sign an against medical advice acknowledgement (the "AMA Form")...I. If the patient refuses to sign the AMA Form, the nurse will document the refusal, time, date and witness signature on AMA Form and place it in the patient's medical record..."

8. Medical record review for Patient #20 revealed an admission date of 6/25/18 with diagnoses which included Recent Hiatal Hernia Repair with of Esophageal Tear with Mediastinal Empyema with Acute Respiratory Failure Status Post Tracheostomy, Required Vent [ventilator] support, Acute Renal Failure, Septic Shock, Atrial Fibrillation, and Anemia.

The Discharge Summary dated 7/11/18 revealed Patient #20 left the facility AMA on 7/11/18 after patient "...did develop some muscle twitching, no altered mental status after twitching, unlikely is a seizure activity and it lasts about 1 second or so. The etiology of course uncertain at this time, but suspicious for possible toxin accumulation with recovering renal failure. He also has underline [underlying] eye muscle tone with tremors unable to distinguish if it is essential tremor or early stage of some Parkinson, but his need to be followed as an outpatient. I did request the patient's family to stay for another dialysis to see if any improvement of this spontaneous muscle movement, but the family wishes to leave AMA and be transferred to [named another hospital] for the evaluation of the tremor..."

The "PATIENT DECISIONS AGAINST MEDICAL ADVICE" form signed by the physician on 7/12/18 revealed no signature from the patient or his representative. There was no documentation noted in the medical record that the patient or his representative had been informed of the risks involved with leaving AMA or their refusal to sign the AMA form.

9. During an interview in the conference room on 8/8/18 at 12:52 PM, the Chief Clinical Officer (CCO) was asked what the process was when a patient left the facility AMA. The CCO stated, "Normally they [staff] would call the doctor and try to get them [the patient] to stay...should be documented in the nurse's notes...and have them sign the AMA form..."

Based on facility policy review, medical record review and interview, the facility failed to ensure each patient's care plan was updated for the use of restraints for 6 of 7 (Patients #1, 3, 7, 20, 26 and 30) sampled patients with use of restraints documented.

The findings included:

1. Review of the facility's "Restraints/Seclusion" policy revealed, "PURPOSE: To ensure the proper use of restraints, delineate the accountability of staff and ensure appropriateness of restraint use...PROCEDURE: C. Restraints may only be initiated after careful assessment of the patient and after alternative verbal and non-verbal interventions and after alternative or other less restrictive interventions have been attempted. F. Revision of the patient's Plan of Care will be made to reflect restraint use..."

2. Medical record review for Patient #1 revealed an admission date of 6/8/18 with diagnoses which included Acute Respiratory Failure with Hypoxemia, Acute on Chronic Diastolic Congestive Heart Failure, Acute Spontaneous Intraparenchymal Intracranial Hemorrhage and Basal Ganglia/Acute Ischemic Stroke, Severe Generalized Muscle Weakness and Debility/Left-sided Hemiplegia With All Flaccid Extremities and Oropharyngeal Dysphagia.

A "RESTRAINT INITIATION/ORDER" documented a mitten restraint was applied on the right hand on 8/11/18 at 6:00 AM. The physician's order was signed by Physician #1 on 8/11/18, but the order was not timed. Physician #1 did not document the reason(s) for the restraints.

A "RESTRAINT INITIATION/ORDER" documented a mitten restraint was applied to the right hand 8/12/18 at 6:00 AM by Nurse #4. The physician's order was signed by Physician #1 on 8/12/18 at 11:00 AM. There was no documentation of the reason for restraint usage.

There was no documentation the care plan was revised or updated to reflect restraint usage on 8/11/18 and 8/12/18.

3. Medical record review for Patient #3 revealed an admission date of 8/4/18 with diagnoses which included Surgical Wound Dehiscence and Wound Infection with Proteus Mirabilis, Aspiration Pneumonia, Paroxysmal Atrial Fibrillation, Seizure Disorder, and Acute Respiratory Failure Status Post Tracheostomy with Ventilator Support.

Medical record review revealed "RESTRAINT INITIATION/ORDERS" documented limb/soft restraints for right and left wrists for Patient #3 on 8/5/18, 8/6/18, 8/7/18, 8/8/18, 8/9/18, 8/11/18 and 8/12/18. The orders dated 8/6/18, 8/7/18, 8/8/18, 8/9/18, 8/11/18, and 8/12/18 were signed by the physician, but there was no documentation of the reason for restraint usage.

There was no documentation the care plan was revised or updated to reflect restraint usage 8/5/18, 8/6/18, 8/7/18, 8/8/18, 8/9/18, 8/11/18 and 8/12/18.

4. Medical record review for Patient #7 revealed an admission date of 7/19/18 with diagnoses which included Renal Failure, Pneumonia, Sepsis, Diabetes, Hypertension, Congestive Obstructive Pulmonary Disease, Anxiety, Morbid Obesity, and Acute Respiratory Failure Status Post Tracheostomy with Required Ventilator support.

A "DAILY NURSING ASSESSMENT" dated 8/3/18 documented: "Shift: 7a...Safety...Restraint in use...wrapped hands c (with) Kerlix bilat (bilaterally)..." There was no documentation of the reason for restraint usage. There was no documentation of physician's orders for restraints, no documentation of "RESTRAINT INITIATION/ORDERS," and no documentation of "RESTRAINT MONITORING."

During an interview in the conference room on 8/14/18 at 11:30 AM, when asked to explain the nursing entry on 8/3/18 for "...wrapped hands c Kerlix bilat..." and if this was a restraint, the Chief Clinical Officer stated, "I would take that as mittens, I have not seen this documentation before, it would be a restraint."

"RESTRAINT INITIATION/ORDERS" dated 8/11/18, 8/12/18, 8/13/18 and 8/14/18 documented limb/soft restraints for right and left wrists for Patient #7. There was no documentation of the reason for restraint usage on 8/11/18 or 8/12/18.

There was no documentation the care plan was revised or updated to reflect restraint usage 8/11/18, 8/12/18, 8/13/18 and 8/14/18.

5. Medical record review for Patient #20 revealed an admission date of 6/25/18 with diagnoses which included Recent Hiatal Hernia Repair with Complication of Esophageal Tear with Mediastinal Empyema with Acute Respiratory Failure Status Post Tracheostomy, Required Vent [ventilator] support, Acute Renal Failure, Septic Shock, Atrial Fibrillation, and Anemia.

A "RESTRAINT INITIATION/ORDERS" for limb/soft restraint to the right wrist for Patient #20 dated 7/10/18. Further review of the medical record revealed the "RESTRAINT MONITORING" form was completed for 7/10/18.

There was no documentation the care plan was revised or updated to reflect the restraint usage on 7/10/18.

6. Medical record review for Patient #26 revealed an admission date of 5/16/18 with diagnoses which included Chronic Obstructive Pulmonary Disease, Coronary Artery Disease, Diverticulitis, Gastroesophageal Reflux Disease, Cerebrovascular Accident, Hypertension, Migraines, Depression, Anxiety, and Bipolar Disorder.

Medical record review revealed "RESTRAINT INITIATION/ORDERS" for limb/soft restraints for right and left wrists for Patient #26 dated 5/16/18. Further review of the medical record revealed the "RESTRAINT MONITORING" forms were completed for 5/16/18, 5/17/18, 5/18/18, 5/19/18, 5/20/18, 5/21/18, 5/22/18, 5/23/18, 5/24/18, 5/25/18, 5/26/18, 5/27/18 and 5/28/18.

There was no documentation the care plan was revised or updated to reflect restraint usage on 5/16/18, 5/17/18, 5/18/18, 5/19/18, 5/20/18, 5/21/18, 5/22/18, 5/23/18, 5/24/18, 5/25/18, 5/26/18, 5/27/18 and 5/28/18.

7. Medical record review for Patient #30 revealed the patient was admitted 6/21/18 with diagnoses which included Spontaneous Bacterial Peritonitis with Ascites, Ileus, Acute on Chronic Anemia, Hepatic Encephalopathy Secondary to Liver Failure, Methicillin-resistant Staphylococcus Aureus (MRSA) with multiorgan dysfunction, Pericolonic/intra-abdominal abscess, Acute renal failure, Delirium tremens, Left breast abscess, and Bipolar disorder with depression and anxiety.

"RESTRAINT INITIATION/ORDERS" Limb/Soft restraints for the right and left wrists for Patient #30 dated 6/21/18, 6/25/18, 6/26/18, 6/27/18, 6/28/18, 7/2/18 and 7/3/18. Medical record review revealed "RESTRAINT MONITORING" forms were completed for 6/23/18, 6/24/18, 6/25/18, 6/26/18, 6/27/18, 6/28/18, 6/29/18, 6/30/18, 7/1/18, 7/3/18, 7/14/18 and 7/15/18.

The Interdisciplinary Patient Care Conference Record dated 7/5/18 revealed "Restraints Type: Wrist @ [at] HS [bedtime]." There was no documentation the care plan was revised or updated to reflect restraint usage.

There was no documentation the care plan was revised or updated to reflect restraint usage on 6/21/18, 6/23/18, 6/24/18, 6/25/18, 6/26/18, 6/27/18, 6/28/18, 6/29/18, 6/30/18, 7/1/18, 7/2/18, 7/3/18, 7/14/18 and 7/15/18.

8. During an interview in the conference room on 8/14/18 at 9:25 AM, when asked if she had been updating care plans to reflect restraint use, the Interim Nurse Manager stated, "I have not."

Based on policy review, medical record review and interview, the facility failed to ensure 7 of 7 (Patient #1, 3, 7, 20, 23, 26 and 30) sampled patients with restraints received a face to face assessment in accordance with facility policy and procedure.

The findings included:

1. Review of the "Restraints/Seclusion" policy revealed, "...E. Patients will have a face to face assessment within one hour after initiation of a restraint by an RN [Registered Nurse] who did not initiate the restraint..."

2. Medical record review for Patient #1 revealed an admission date of 6/8/18 with diagnoses which included Acute Respiratory Failure with Hypoxemia, Acute on Chronic Diastolic Congestive Heart Failure, Acute Spontaneous Intraparenchymal Intracranial Hemorrhage and Basal Ganglia/Acute Ischemic Stroke, Severe Generalized Muscle Weakness and Debility/Left-sided Hemiplegia With All Flaccid Extremities and Oropharyngeal Dysphagia.

A "RESTRAINT INITIATION/ORDER" documented Nurse #4 applied a mitten restraint to the right hand 8/12/18 at 6:00 AM. There was no documentation Patient #1 received a face to face assessment within 1 hour after initiation of a restraint by an RN who did not initiate the restraint.

3. Medical record review for Patient #3 revealed an admission date of 8/4/18 with diagnoses which included Surgical Wound Dehiscence and Wound Infection with Proteus Mirabilis, Aspiration Pneumonia, Paroxysmal Atrial Fibrillation, Seizure Disorder, and Acute Respiratory Failure Status Post Tracheostomy with Ventilator Support.

A "RESTRAINT INITIATION/ORDER" documented Nurse #9 applied Limb/Soft restraints to Left and Right Wrists on 8/5/18 at 8:30 AM. There was no documentation Patient #3 received a face to face assessment within 1 hour of initiation of a restraint by an RN who did not initiate the restraint.

A "RESTRAINT INITIATION/ORDER" documented Nurse #8 applied Limb/Soft restraints to Left and Right Wrists on 8/6/18 at 8:00 AM, and on 8/7/18 at 8:30 AM. There was no documentation Patient #3 received a face to face assessment within one hour of initiationof a restraint by an RN who did not initiate the restraint.

A "RESTRAINT INITIATION/ORDER" documented Nurse #8 applied Limb/Soft restraints to Left and Right Wrists on 8/8/18 at 8:30 AM. There was no documentation Patient #3 received a face to face assessment within one hour of initiation of a restraint by an RN who did not initiate the restraint.

A "RESTRAINT INITIATION/ORDER" documented Nurse #4 applied Limb/Soft restraints to Left and Right Wrists on 8/10/18 at 9:50 PM and on 8/12/18 at 6:00 AM. There was no documentation Patient #3 received a face to face assessment within 1 hour of initiation of a restraint by an RN who did not initiate the restraint.

4. Medical record review for Patient #7 revealed an admission date of 7/19/18 with diagnoses which included Renal Failure, Pneumonia, Sepsis, Diabetes, Hypertension, Congestive Obstructive Pulmonary Disease, Anxiety, Morbid Obesity and Acute Respiratory Failure Status Post Tracheostomy with Ventilator Support.

A "RESTRAINT INITIATION/ORDER" documented Nurse #4 applied Limb/Soft restraints to Left and Right Wrists 8/12/18 at 6:00 AM. There was no documentation Patient #7 received a face to face assessment within 1 hour of initiation of a restraint by an RN who did not initiate the restraint.

A "DAILY NURSING ASSESSMENT" dated 8/3/18 documented: "Shift: 7a...Safety...Restraint in use...wrapped hands c (with) Kerlix bilat (bilaterally)..." The 8/3/18 nursing assessment documented no explanation and no other documentation of the patient's hands restrained. There was no physician's order for restraints, no "RESTRAINT INITIATION/ORDERS," and no "RESTRAINT MONITORING" on 8/3/18.

During an interview in the conference room on 8/14/18 at 11:30 AM, the Chief Clinical Officer verified this was a restraint. There was no documentation an order was obtained, no documentation a face to face assessment occurred within 1 hour after initiation of a restraint by an RN who did not initiate the restraint and no documentation the patient was monitored.

5. Medical record review for Patient # 20 revealed an admission date of 6/25/18 with diagnoses which included Recent Hiatal Hernia Repair with Complication of Esophageal Tear with Mediastinal Empyema with Acute Respiratory Failure Status Post Tracheostomy, Required Vent [ventilator] support, Acute Renal Failure, Septic Shock, Atrial Fibrillation, and Anemia.

A "RESTRAINT INITIATION/ORDER" documented Limb/Soft restraints were applied to the right wrist on 7/10/18 at 12:00 by Nurse #8. There was no documentation the resident received a face to face assessment within 1 hour of initiation by a Registered Nurse who did not initiate the restraint.

6. Medical record review for Patient #23 revealed an admission date of 7/28/18 with diagnoses which included Severe Peripheral Vascular Disease, Acute Respiratory Disease, Acute Renal Failure, Severe Sepsis with Septic Shock, Severe Protein-calorie Malnutrition, Coronary Artery Disease and Hypertension.

A "RESTRAINT INITIATION/ORDER" documented Nurse #5 applied Limb/Soft restraints to left and right wrists on 7/30/18 at 9:35 PM. There was no documentation Patient #23 received a face to face assessment within 1 hour of initiation by a nurse who did not initiate the restraint.

7. Medical record review for Patient #26 revealed an admission date of 5/16/18 with diagnoses which included Chronic Obstructive Pulmonary Disease, Coronary Artery Disease, Diverticulitis, Gastroesophageal Reflux Disease, Cerebrovascular Accident, Hypertension, Migraines, Depression, Anxiety, and Bipolar Disorder.

A "RESTRAINT INITIATION/ORDER" documented Limb/Soft restraints were applied to left and right wrists 5/16/18 at 10:00 PM by Nurse #7. There was no documentation Patient #26 received a face to face assessment within 1 hour of initiation by a nurse who did not initiate the restraint.

8. Medical record review for Patient #30 revealed the patient was admitted 6/21/18 with diagnoses which included Spontaneous Bacterial Peritonitis with Ascites, Ileus, Acute on Chronic Anemia, Hepatic Encephalopathy Secondary to Liver failure, Methicillin-Resistant Staphylococcus Aureus (MRSA) with Multiplan Dysfunction, Pericolonic/Intra-abdominal Abscess, Acute Renal Failure, Delirium Tremens, Left Breast Abscess, and Bipolar Disorder with Depression and Anxiety.

A "RESTRAINT INITIATION/ORDER" documented Nurse #7 applied Limb/Soft restraints to left and right wrists on 6/21/18 at 10:00 PM. There was no documentation Patient #30 received a face to face assessment within 1 hour of initiation by a nurse who did not initiate the restraint.

A "RESTRAINT INITIATION/ORDER" documented Nurse #8 applied Limb/Soft restraints to left and right wrists on 6/25/18 at 7:00 AM. There was no documentation Patient #30 received a face to face assessment within 1 hour of initiation by a nurse who did not initiate the restraint.

A "RESTRAINT INITIATION/ORDER" documented Nurse #7 applied Limb/Soft restraints to left and right wrists on 6/26/18 at 8:00 PM. There was no documentation Patient #30 received a face to face assessment within 1 hour of initiation by a nurse who did not initiate the restraint.

A "RESTRAINT INITIATION/ORDER" documented Nurse #7 applied Limb/Soft restraints to left and right wrists on 6/27/18 at 8:00 PM. There was no documentation Patient #30 received a face to face assessment within 1 hour of initiation by a nurse who did not initiate the restraint.

A "RESTRAINT INITIATION/ORDER" documented Nurse #7 applied Limb/Soft restraints to left and right wrists on 6/28/18 at 8:00 PM. There was no documentation Patient #30 received a face to face assessment within 1 hour of initiation by a nurse who did not initiate the restraint.

A "RESTRAINT INITIATION/ORDER" documented Nurse #5 applied Limb/Soft restraints to left and right wrists on 7/2/18 at 7:00 PM. There was no documentation Patient #30 received a face to face assessment within 1 hour of initiation within 1 hour after initiation of a restraint by an RN who did not initiate the restraint.

A "RESTRAINT INITIATION/ORDER" documented Nurse #7 applied Limb/Soft restraints to left and right wrists on 7/3/18 at 7:00 PM by Nurse #7. There was no documentation Patient #30 received a face to face assessment within 1 hour of initiation within 1 hour after initiation of a restraint by an RN who did not initiate the restraint.

9. During an interview in the conference room on 8/14/18 at 9:35 AM, the Interim Nurse Manager verified that the nurse that applied the restraints could not perform the post restraint assessment according to the facility policy.

Based on policy review, medical record review, observation, and interview the facility failed to ensure physician's orders were obtained prior to the initiation of restraints and completed for restraint usage for 6 of 7 (Patients #1, 3, 7, 23, 26 and 30) sampled residents with restraints.

The findings included:

1. Review of the facility's "Restraints/Seclusion" policy revealed, "...PROCEDURE...D. An LIP [Licensed Independent Practitioner] must provide an order per the requirements listed below...1. Medical/Surgical Restraint a. Applicability- used for the medical/surgical settings for patients that require intervention to promote health and safety. b. Justification- limited to use when alternatives, such as distraction, proximity to nurse/staff members are ineffective. c. Assessment- daily by LIP; daily by RN; data collection by educated trained staff members d. Order renewal- clinical justification requires LIP to reorder every calendar day; may be initiated by RN [Registered Nurse] with notification to the LIP as soon as possible, but within 1 hour; telephone orders must be signed within 24 hours...H. Orders for Restraints: 1. The physician or his designee...responsible for the care of the patient is authorized to order a restraint. a. each order for the use of restraints should be related to a specific episode and not a unspecified future or episode. b. all telephone orders must be countersigned within 24 hours...2...a. continued use of restraint beyond the first 24 hours is authorized by the physician after examination of the patient and renewing the original order or issuing a new order. This is done no less than once each calendar day. 3. Each episode of restraint must be initiated in accordance with an order by a physician or other LIP. IF a patient was recently released from restraint and exhibits behavior that can only be handled by reapplication of restraint, a new order is required..."

2. Medical record review for Patient #1 revealed an admission date of 6/8/18 with diagnoses which included Acute Respiratory Failure with Hypoxemia, Acute on Chronic Diastolic Congestive Heart Failure, Acute Spontaneous Intraparenchymal Intracranial Hemorrhage and Basal Ganglia/Acute Ischemic Stroke, Severe Generalized Muscle Weakness and Debility/Left-sided Hemiplegia With All Flaccid Extremities and Oropharyngeal Dysphagia.

A "RESTRAINT INITIATION/ORDER" documented a mitten restraint was applied to the right hand 8/11/18 at 6:00 AM by Nurse #4. There was no documentation Nurse #4 contacted the physician within 1 hour of initiation of the restraint to obtain an order. The order was signed by Physician #1 on 8/11/18, but Physician #1 did not document the time the order was signed.

3. Medical record review for Patient #3 revealed an admission date of 8/4/18 with diagnoses which included Surgical Wound Dehiscence and Wound Infection with Proteus Mirabilis, Aspiration Pneumonia, Paroxysmal Atrial Fibrillation, Seizure Disorder, and Acute Respiratory Failure Status Post Tracheostomy with Ventilator Support.

A "RESTRAINT INITIATION/ORDER" documented Limb/Soft Restraint were applied to the right and left wrists 8/5/18 at 8:30 AM by Nurse #9. There was no documentation Nurse #9 contacted the physician within 1 hour of initiation of the restraint to obtain an order. The Physician's order was not obtained or completed per facility policy.

A "RESTRAINT INITIATION/ORDER" documented Limb/Soft Restraints were applied to the right and left wrists 8/6/18 at 8:00 AM by Nurse #8. The Physician's order was not obtained or completed per facility policy.

A "RESTRAINT INITIATION/ORDER" documented Limb/Soft Restraints were applied to the right and left wrists 8/7/18 at 8:30 AM by Nurse #8. The Physician's order was not obtained or completed per facility policy.

A "RESTRAINT INITIATION/ORDER" documented Limb/Soft Restraints were applied to the right and left wrists 8/8/18 at 8:30 AM by Nurse #8. The Physician's order was not obtained or completed per facility policy.

During a telephone interview on 8/9/18 at 1:13 PM, Medical Provider #5 revealed that she had signed 3 restraint orders for Patient #3 on the morning of 8/8/18. Medical Provider #5 verified she did not date the orders so that Nurse #8 could use them for the dates she needed.

A "RESTRAINT INITIATION/ORDER" documented Limb/Soft Restraints were applied to left and right wrists on 8/9/18 by Nurse #7, but did not document the time the restraints were applied. The Physician's order was not obtained or completed per facility policy.

A "RESTRAINT INITIATION/ORDER" documented Limb/Soft Restraints were applied to left and right wrists on 8/10/18 at 9:50 PM by Nurse #4. The Physician's order was not obtained or completed per facility policy.

A "RESTRAINT INITIATION/ORDER" documented Limb/Soft Restraints were applied to left and right wrists on 8/11/18 at 6:00 AM by Nurse #4. The Physician's order was not obtained or completed per facility policy.

A "RESTRAINT INITIATION/ORDER" documented Limb/Soft Restraints were applied to left and right wrists on 8/12/18 at 6:00 AM by Nurse #4. The Physician's order was not obtained or completed per facility policy.

4. Medical record review for Patient #7 revealed an admission date of 7/19/18 with diagnoses that included Renal Failure, Pneumonia, Sepsis, Diabetes, Hypertension, Congestive Obstructive Pulmonary Disease, Anxiety, Morbid Obesity and Acute Respiratory Failure Status Post Tracheostomy with Ventilator Support.

Medical record review revealed a "DAILY NURSING ASSESSMENT" dated 8/3/18 documented, "Restraints in use...wrapped hands c [with] Kerlix bilat [bilaterally]." There was no other documentation related to the patient's hands wrapped with Kerlix. There was no order for the Kerlix or for a restraint. There was no care plan for the patient's hands to be wrapped withe Kerlix.

During an interview in the conference room on 8/14/18 at 11:30 AM when asked about the documentation, the Chief Clinical Officer reviewed the nursing assessment and stated, "Would take that as mittens...I have not seen this documentation before, There should be an order for a restraint..."

5. Medical record review for Patient #23 revealed an admission date of 7/28/18 with diagnoses which included Severe Peripheral Vascular Disease, Acute Respiratory Disease, Acute Renal Failure, Severe Sepsis with Septic Shock, Severe Protein-calorie Malnutrition, Coronary Artery Disease and Hypertension.

A "RESTRAINT INITIATION/ORDER" documented Limb/Soft Restraints were applied to left and right wrists on 7/30/18 at 9:35 PM by Nurse #5. The Physician's order was not obtained or completed per facility policy.

6. Medical record review revealed Patient #26 was admitted to the facility on 5/16/18 with diagnoses which included Chronic Obstructive Pulmonary Disease, Coronary Artery Disease, Diverticulitis, Gastroesophageal Reflux Disease, Cerebrovascular Accident, Hypertension, Migraines, Depression, Anxiety, and Bipolar Disorder.

A "RESTRAINT INITIATION/ORDERS" documented bilateral wrist restraints were applied to Patient #26 on 5/16/18 at 8:00 PM by Nurse #7 after a telephone order was obtained from the physician. Further review of the "RESTRAINT INITIATION/ORDERS" revealed the physician failed to sign the order until 7/4/18, a total of 49 days after the order was obtained.

Review of the completed "RESTRAINT MONITORING" forms revealed restraints were used on Patient #26 from 10:00 PM on 5/16/18 until 5/18/18 at 4:00 PM.

The restraints were applied on 5/18/18 at 6:00 PM and remained in use until 10:00 PM on 5/24/18.

There were no physician's orders written to initiate or continue the restraint use.

The restraints were applied on 5/25/18 at midnight and remained in use until 2:00 PM on 5/26/18.

There were no physician's orders written to initiate or continue the restraint use.

The restraints were applied at 8:00 PM on 5/26/18 and remained in use until 2:00 PM on 5/28/18.

There were no physician's orders written to initiate or continue the restraint use.

7. Medical record review for Patient #30 revealed the patient was admitted 6/21/18 with diagnoses which included Spontaneous Bacterial Peritonitis with Ascites, Ileus, Acute on Chronic Anemia, Hepatic Encephalopathy Secondary to Liver Failure, Methicillin-resistant Staphylococcus Aureus (MRSA) with Multiorgan Dysfunction, Pericolonic/Intra-Abdominal Abscess, Acute Renal Failure, Delirium Tremens, Left Breast Abscess, and Bipolar Disorder with Depression and Anxiety.

A "RESTRAINT INITIATION ORDERS" documented Limb/Soft Restraints were applied to left and right wrists on 6/21/18 at 10:00 PM. The Physician's order was not complete per facility policy.

A "RESTRAINT INITIATION ORDERS" documented Limb/Soft Restraints were applied to left and right wrists on 6/25/18 at 7:00 AM. The Physician's order was documented 6/26/18 at 11:10 AM, 25 hours after the restraint was initiated.

A "RESTRAINT INITIATION/ORDERS" documented Limb/Soft restraints were applied to left and right wrists at 8:00 PM on 6/26/18. A telephone order was obtained at 8:00 PM on 6/26/18. The physician signed the order on 7/6/18 at 11:27 AM, 10 days after the telephone order.

A "RESTRAINT INITIATION/ORDERS" documented Limb/Soft restraints were applied to left and right wrists to Patient #30 at 8:00 PM on 6/27/18. A telephone order was obtained 6/27/18 at 8:00 PM. The physician signed the order on 7/6/18 at 11:27 AM, 9 days after the telephone order.

A "RESTRAINT INITIATION ORDERS" documented Limb/Soft restraints were applied to left and right wrists at 8:00 PM on 6/28/18. A telephone order was obtained on 6/28/18 at 8:00 PM. The physician signed the order on 7/3/18. The physician's order was incomplete per facility policy.

A "RESTRAINT INITIATION ORDERS" documented Limb/Soft restraints to left and right wrists were applied at 7:00 PM on 7/2/18.
The "RESTRAINT INITIATION ORDERS" was incomplete per facility policy.

A "RESTRAINT INITIATION ORDERS" documented Limb/Soft restraints to left and right wrists were applied at 7:00 PM on 7/3/18. A telephone order was written 7/3/18 at 7:00 PM. No physician's signature was obtained. The "RESTRAINT INITIATION ORDERS" was incomplete per facility policy.

Review of the completed "RESTRAINT MONITORING" forms revealed restraints were used from 12:00 AM on 6/23/18 until 6/25/18 at 6:00 AM with no telephone or documented order.

Review of the completed "RESTRAINT MONITORING" forms revealed restraints were used from 12:00 AM on 6/29/18 until 6/29/18 at 6:00 PM with no telephone or documented order.

Review of the completed "RESTRAINT MONITORING" forms for 7/14/18 and 7/15/18 revealed restraints were used from 8:00 PM on 7/14/18 until 7/15/18 at 6:00 PM with no telephone or documented order.

8. During an interview in the conference room on 8/8/18 at 11:20 AM, the Chief Clinical Officer (CCO) confirmed the facility's policy required an order for restraint use from a physician. The CCO further stated that the order must be signed by the physician within 24 hours and that a new order or renewal order must be written every 24 hours that restraints were used.

9. During a telephone interview on 8/13/18 at 3:35 PM, the Medical Director confirmed physician's orders should be obtained for restraint use on a daily basis.

10. During an interview on 8/14/18 at 9:25 AM, the Interim Nurse Manager verified restraint orders had to be renewed every 24 hours and a new order had to be written if restraints were removed and reapplied.

Based on policy review, facility document review, medical record review and interview, the facility failed to ensure patients with restraints were monitored by trained staff at an interval determined by hospital policy for 6 of 7 (Patient #1, 3, 7, 23, 26 and 30) sampled patients with restraints.

The findings included:

1. Review of the facility's "Restraints/Seclusion" policy revealed, "...To ensure the proper use of restraints, delineate the accountability of staff and ensure appropriateness of restraint use...Monitoring and care - When restraints are used there is an increased need for patient monitoring and assessment to assure patient safety, that least restrictive methods are used when possible, and use is discontinued as soon as possible...1. A qualified nurse must monitor the patient a [at] least every two (2) hours...a. signs of injury associated restraint...b. nutrition/hydration...c. releasing the restraint to check circulation and provide range of motion...d. hygiene and elimination...e. readiness for a less restrictive method..."

2. Review of the facility's "RESTRAINT MONITORING" document revealed the following safety checks would be performed at least every two hours for a patient in restraints: "...Initial when intervention performed...Range of motion offered/provided, Food/fluids offered/provided, Toileting offered/provided, Dignity/comfort/hygiene maintained, Managed safety/no injury, Mental status unchanged, Skin integrity unchanged, Temporary release during care giving [given] (direct observation maintained), Geri chair/4 Side Rails in use, Circulatory status of restrained extremities unchanged, Pain managed per policy..."

3. Medical record review for Patient #1 revealed an admission date of 6/8/18 with diagnoses which included Acute Respiratory Failure with Hypoxemia, Acute on Chronic Diastolic Congestive Heart Failure, Acute Spontaneous Intraparenchymal Intracranial Hemorrhage and Basal Ganglia/Acute Ischemic Stroke, Severe Generalized Muscle Weakness and Debility/Left-sided Hemiplegia With All Flaccid Extremities and Oropharyngeal Dysphagia.

A "RESTRAINT INITIATION/ORDER" documented a Mitten Restraint was applied to the right hand 8/11/18 at 6:00 AM by Nurse #4.

A "RESTRAINT INITIATION/ORDER" documented a Mitten Restraint was applied to the right hand 8/12/18 at 6:00 AM by Nurse #4.

A "RESTRAINT MONITORING" form dated 8/11/18 revealed no documentation safety checks and monitoring were performed for Patient #1 after 6:00 PM on 8/11/18. There was no documentation the restraint was ever removed.

3. Medical record review for Patient #3 revealed an admission date of 8/4/18 with diagnoses which included Surgical Wound Dehiscence and Wound Infection with Proteus Mirabilis, Aspiration Pneumonia, Paroxysmal Atrial Fibrillation, Seizure Disorder, and Acute Respiratory Failure Status Post Tracheostomy with Ventilator Support.

A "RESTRAINT INITIATION/ORDER" documented a Limb/Soft Restraint was applied to Patient #3's left and right wrists on 8/5/18 at 8:30 AM by Nurse #8.

A "RESTRAINT MONITORING" form dated 8/5/18 revealed no documentation of temporary release during care given from 8:30 AM-6:30 PM.

A "RESTRAINT INITIATION/ORDER" documented a Limb/Soft Restraint was applied to Patient #3's left and right wrists on 8/11/18 at 6:00 AM by Nurse #4.

A "RESTRAINT MONITORING" form dated 8/11/18 revealed no documentation of safety checks and monitoring from 4:00 PM-8:00 PM.

A "RESTRAINT INITIATION/ORDER" documented a Limb/Soft Restraint was applied to Patient #3's left and right wrists on 8/12/18 at 6:00 AM by Nurse #4.

A "RESTRAINT MONITORING" form dated 8/12/18 revealed documentation of safety checks and monitoring from 12:00 PM-6:00 PM.

4. Medical record review for Patient #7 revealed an admission date of 7/19/18 with diagnoses which included Renal Failure, Pneumonia, Sepsis, Diabetes, Hypertension, Congestive Obstructive Pulmonary Disease, Anxiety, Morbid Obesity and Acute Respiratory Failure Status Post Tracheostomy with Ventilator Support.

A "DAILY NURSING ASSESSMENT" dated 8/3/18 documented, "Restraints in use...wrapped hands c [with] Kerlix bilat [bilaterally]." There was no other documentation related to the patient's hands wrapped with Kerlix. There was no order for the Kerlix or for a restraint. There was no documentation of restraint monitoring and no documentation of a care plan for the patient's hands to be wrapped with Kerlix.

During an interview in the conference room on 8/14/18 at 11:30 AM when asked about the documentation, the Chief Clinical Officer reviewed the nursing assessment and stated, "Would take that as mittens...I have not seen this documentation before, There should be an order for a restraint..."

5. Medical record review for Patient #23 revealed an admission date of 7/28/18 with diagnoses which included Severe Peripheral Vascular Disease, Acute Respiratory Disease, Acute Renal Failure, Severe Sepsis with Septic Shock, Severe Protein-calorie Malnutrition, Coronary Artery Disease and Hypertension.

A "RESTRAINT INITIATION/ORDER" documented Limb/Soft Restraints were applied to left and right wrists 7/30/18 at 9:35 PM by Nurse #5.

A "RESTRAINT MONITORING" form dated 7/31/18 revealed no documentation Patient #23's circulation was checked or pain managed from 12:00 PM-8:00 PM.

7. Medical record review for Patient #26 revealed an admission date of 5/16/18 with diagnoses which included Chronic Obstructive Pulmonary Disease, Coronary Artery Disease, Diverticulitis, Gastroesophageal Reflux Disease, Cerebrovascular Accident, Hypertension, Migraines, Depression, Anxiety, and Bipolar Disorder.

A "RESTRAINT INITIATION/ORDER" dated 5/16/18 revealed bilateral wrist restraints were applied to Patient #26 at 8:00 PM by Nurse #7.

A "RESTRAINT MONITORING" form dated 5/24/18 revealed no documentation safety checks were performed at 8:00 AM.

8. Medical record review for Patient #30 revealed the patient was admitted 6/21/18 with diagnoses which included Spontaneous Bacterial Peritonitis with Ascites, Ileus, Acute on Chronic Anemia, Hepatic Encephalopathy Secondary to Liver Failure, Methicillin-Resistant Staphylococcus Aureus (MRSA) with Multiplan Dysfunction, Pericolonic/Intra-Abdominal Abscess, Acute Renal Failure, Delirium Tremens, Left Breast Abscess, and Bipolar Disorder with Depression and Anxiety.

A "RESTRAINT INITIATION/ORDER" dated 6/21/18 revealed Limb/Soft Restraints were applied to left and right wrists 6/21/18 at 10:00 PM by Nurse #7.

A "RESTRAINT MONITORING" form dated 6/23/18 revealed no documentation safety checks were performed 6:00 PM-12:00 AM 6/24/18.

A "RESTRAINT INITIATION/ORDER" dated 6/26/18 revealed Limb/Soft Restraints were applied to left and right wrists 6/25/18 at 8:00 PM by Nurse #7.

A "RESTRAINT MONITORING" form dated 6/27/18 revealed no documentation safety checks were performed 2:00 AM-6:00 PM.

A "RESTRAINT INITIATION/ORDER" dated 6/27/18 revealed Limb/Soft Restraints were applied to left and right wrists 6/27/18 at 8:00 PM by RN #7.

A "RESTRAINT MONITORING" form dated 6/28/18 revealed no documentation safety checks were performed 6:00 AM-6:00 PM.

A "RESTRAINT INITIATION/ORDER" dated 6/28/18 revealed Limb/Soft Restraints were applied to left and right wrists 6/28/18 at 8:00 PM by RN #7.

A "RESTRAINT MONITORING" form dated 6/29/18 revealed no documentation safety checks were performed from 6:00 PM to 8:00 AM on 6/30/18.

A "RESTRAINT INITIATION/ORDER" documented Limb/Soft Restraints were applied to left and right wrists 7/2/18 at 7:00 PM by RN #5.

There was no documentation of a "RESTRAINT MONITORING" form dated 7/2/18 for Patient #30.

9. During an interview in the conference room on 8/14/18 at 9:23 AM, the Interim Nurse Manager stated nurses should initial each safety check on the "RESTRAINT MONITORING" form when performed. The Interim Nurse Manager stated she could not confirm a safety check was performed if a nurse did not initial the check on the monitoring form.

Based on policy review, document review, medical record review and interview, the facility failed to measure, analyze and track quality indicators for restraint use to ensure an effective Quality Assurance and Performance Improvement (QAPI) program.

The findings included:

1. Review of the facility's "Restraints/Seclusion" policy revealed, "...Restraint Use Monitoring and Evaluation - Evaluation and measurement regarding the use of restraints will be performed at least quarterly to include...1. 100% review of all restraint use...2. data reviewed by patient unit, shift, and ordering LIP [licensed independent practitioner]...3. reasons for the restraint...4. identification of trends in type of restraint, condition/diagnosis of patient and frequency of injury related to restraint use..."

2. Review of the facility's Quality Indicators for 2018 revealed the facility failed to monitor and evaluate restraint use as indicated in their policy including auditing 100% of all restraint use, reviewing all data by patient unit, shift, and ordering LIP, reasons for the restraint, and identification of trends in type of restraint, condition/diagnosis of patient and frequency of injury related to restraint use.

3. Medical record review revealed 6 of 7 sampled patients with restraint use with no physician's order for the restraint and 7 of 7 no face to face assessment within an hour of initiation of a restraint by a registered nurse who did not initiate the restraint. There was no revision to the plan of care for restraint use for 6 of 7 of the sampled patients with restraints. Refer to A 166, A 167 and A 168.

4. During an interview in the conference room on 8/8/18 at 3:20 PM, the Quality Manager stated the facility did not review patient's medical records who had restraints. The Quality Manager confirmed the facility did not monitor and evaluate the information designated in the facility's policy about restraint use or incorporate the information into the QAPI program.

Based on facility document review, credential file review and interview, the Medical Staff failed to make recommendations to the Governing Body on the reappointment to the Medical Staff for 1 of 5 (Medical Provider #5) medical providers reviewed.

The findings included:

1. Review of the facility's "2017 MEDICAL STAFF BYLAWS" revealed, "...Advanced Practice Professionals are not Medical Staff Members, but are granted Clinical Privileges and permission to practice at the Hospital under a defined degree of direction from a Supervising/Collaborating Physician...PROCESS FOR CREDENTIALING AND PRIVILEGING...If the recommendation of the Medical Executive Committee is to grant Medical Staff Membership and/or Clinical Privileges, it will be forwarded to the Board for final action..."

Review of the "2017 MEDICAL STAFF BYLAWS" revealed there was no documentation the bylaws had been adopted by the Medical Staff or approved by the Governing Board.

During an interview in the conference room on 8/14/18 at 3:58 PM, the Chief Executive Officer (CEO) verified the 2017 Medical Staff Bylaws were currently in use but he did not have a copy of the Medical Staff Bylaws signed as adopted by the Medical Staff or approved by the Governing Body.

2. Review of credentialing file for Medical Provider #5 revealed Medical Provider #5 is currently an active member of the Medical Stall. Review of the PHYSICIAN REAPPOINTMENT APPLICATION revealed Medical Provider #5's privileges expired on 3/02/18, and Medical Provider #5 requested reappointment to the Medical Staff. There was handwritten documentation the hospital's medical staff received the application 10/9/17.

The "SUMMARY OF APPOINTMENT/REAPPOINTMENT VERIFICATION FORM" revealed, no documentation the form was signed by the President of the Medical Staff, the CEO or Designee, or the Governing Board Vice-Chair or Designee to indicate reappointment was approved or denied.

3. During a telephone interview on 8/13/18 at 3:35 PM, the Medical Director was questioned regarding Medical Provider #5's reappointment application. The Medical Director stated, "I don't remember us ever discussing her, but like I said, it's been at least 8 months since we've had a meeting..."

During an interview on 8/14/18 at 8:25 AM, in the facility conference room, the Chief Executive Officer (CEO) confirmed Medical Provider #5 had been practicing in the facility since March 2018 when her credentialing and privileges expired. The CEO stated that "it [her expired credentials and privileges] was brought to our attention last week."

Based on facility document review and interview, the Medical Staff failed to be well organized and accountable to the Governing Body for the quality of the medical care provided to the patients.

The findings included:

1. Review of the "2017 MEDICAL STAFF BYLAWS" revealed, "...The purposes and responsibilities of the Medical Staff are...to provide a formal organizational structure through which the Medical Staff shall carry out its responsibilities and govern the professional activities of its Members and other Practitioners and to provide mechanisms for accountability of the Medical Staff to the Governing Board...to serve as a primary means for accountability to the Governing Board concerning professional performance of practitioners and others with Clinical Privileges authorized to practice at the Hospital with regard to the quality and appropriateness of health care...to provide a means of communication with regard to issues of mutual concern to the Medical Staff, Administration, and Governing Board..."

2. During an interview in the conference room on 8/13/18 at 2:42 PM, Infectious Disease Physician #1 stated he used to be the Chairman of the Infection Control Committee, but now the committee was defunct. Infectious Disease Physician #1 stated he could not remember the last time the Infection Control Committee met and was unsure if the committee was presently in existence. Infectious Disease Physician #1 stated he was the only infectious disease physician at the hospital. Infectious Disease Physician #1 stated he was on the Medical Executive Committee (MEC), but he was unable to remember the last time the committee met.

3. During a telephone interview on 8/13/18 at 3:35 PM, the Medical Director was asked to describe the how the Medical Executive Committee (MEC) was informed of problems in the facility. The Medical Director stated he could not answer that adequately because they had only had 1 meeting since (named corporation) took over (October 2016). The Medical Director also stated the communication between the administration and the physicians was not good. He then stated that in the past, the MEC reported to the governing body, and it was done as a presentation by the Quality Assurance committee. The Medical Director stated he was taken off the Governing Body when [named corporation] took over but was informed by the current Chief Executive Officer (CEO)that he was back on the Governing Body. The Medical Director stated the MEC was scheduled to meet in July 2018 but the meeting was canceled by the CEO. The Medical Director stated he was unsure why the meeting was canceled. When asked about the credentialing of Medical Provider #5, the Medical Director stated he had deferred to the CEO for emergency privileging.

4. During an interview in the conference room on 8/14/18 at 3:58 PM, the CEO stated the facility's privileging had been outsourced to [Named company] in February 2018. The CEO denied the emergency privileging and stated he was unaware Medical Provider #5 had not been reappointed until it was brought to his attention by the surveyors.

5. During an interview in the conference room on 8/14/18 at 3:58 PM, the CEO confirmed there was no Medical Executive Committee meeting minutes since 11/1/17 and no Governing Body meeting minutes since 7/28/17.

6. Interview with the CEO, Medical Director, and Infectious Disease Physician #1 revealed they were unsure of the current status of the MEC and of the collaboration between the MEC and Governing Body. The facility failed to conduct meetings for the Governing Body and the MEC per policy to review the medical care provided to the patients.

Based on facility document review and interview, the Medical Staff failed to approve medical staff bylaws and other medical staff rules and regulations.

The findings included:

1. Review of the "2017 MEDICAL STAFF BYLAWS" revealed no documentation the bylaws were adopted by the Medical Staff.

Review of the "2017 MEDICAL STAFF RULES AND REGULATIONS" revealed, "...Medical Staff Rules and Regulations Agreement...Allied Health Practitioners shall agree to abide by these policies. They shall, when so approved, be equally binding on the Medical Staff, Allied Health Practitioners and the Governing Board...The adoption and approval of these Rules/Regulations will constitute a repeal of all prior Rules/Regulations of the Medical Staff of the Hospital...Adopted by the Active Staff of [name of hospital] at a meeting duly and regularly called and held at [name of hospital] on...(Date) [blank]...APPROVED BY...President of Medical Staff [blank]...Chairperson of the Governing Board [blank]...Chief Executive Officer [blank]..."

2. During an interview in the conference room on 8/14/18 at 3:58 PM, the Chief Executive Officer stated the facility did not have a copy of the medical staff bylaws or the medical staff rules and regulations signed as approved by the Medical Staff.

Based on policy review, facility document review and interview, the Medical Staff failed to ensure medical staff bylaws and other medical staff rules and regulations were approved by the Governing Body.

The findings included:

1. Review of the facility's "Governing Body" policy revealed, "...Each hospital will have its own Governing Body, which is responsible for overall operation of the hospital...Each Governing Body has its own set of Governing Body Bylaws under which it functions that are particular to the individual facility supervised...The Governing Body meets quarterly and more often as necessary..."

2. Review of the "2017 MEDICAL STAFF BYLAWS" revealed no documentation the bylaws were approved by the Governing Body.

Review of the "2017 MEDICAL STAFF RULES AND REGULATIONS" revealed, "...Medical Staff Rules and Regulations Agreement...Allied Health Practitioners shall agree to abide by these policies. They shall, when so approved, be equally binding on the Medical Staff, Allied Health Practitioners and the Governing Board...The adoption and approval of these Rules/Regulations will constitute a repeal of all prior Rules/Regulations of the Medical Staff of the Hospital...Adopted by the Active Staff of [name of hospital] at a meeting duly and regularly called and held at [name of hospital] on...(Date) [blank]...APPROVED BY...President of Medical Staff [blank]...Chairperson of the Governing Board [blank]...Chief Executive Officer [blank]..."

3. During an interview in the conference room on 8/14/18 at 3:58 PM, the Chief Executive Officer stated the facility did not have a copy of the medical staff bylaws or the medical staff rules and regulations signed as approved by the Governing Body.

Based on review of "The Tennessee Board of Nursing Rules and Regulations of Licensed Practical Nurses," review of "Tennessee Board of Nursing Position Statements," policy review, medical record review, personnel file review and interview, the hospital failed to ensure pressure wounds were appropriately assessed for 4 of 22 (Patient #2, 10, 11 and 29) sampled patients with wounds.

The findings included:

1. Review of "The Tennessee Board of Nursing Rules and Regulations of Licensed Practical Nurses" dated June 2015 revealed, "...1000-02-.14(1)(a) Standards Related to the Licensed Practical Nurse's Contribution to and Responsibility for the Nursing Process - The Licensed Practical Nurse shall: 1. Contribute to the nursing assessment by collecting, reporting and recording objective and subjective data in an accurate and timely manner. 2. Participate in the development of the plan of care/action in consultation with a Registered Nurse..."

2. Review of "Tennessee Board of Nursing Position Statements" dated February 2012 revealed, "...POLICY...It is apparent from these rules [Rules and Regulations of Licensed Practical Nurses (LPN)] the interpretation of the standard of care for the licensed practical nurse in terms of assessment is that the individual is not prepared educationally in the basic vocational program with the requisite scientific skills to expand his or her practice to assessment of patients (page 31)..."

3. Review of the facility's "Wound Assessment" policy revealed, " ...Wound Care RN [Registered Nurse] completes an initial assessment of major wounds within the Admission Reference Date (admission + 2 calendar days)...Reassess & [and] document (major and minor) wound characteristics with each scheduled or prn [as needed] dressing change for initial, weekly follow-up, new wound, change in wound status & [and] discharge..."

Review of the facility's "Photography Of Wounds Guidelines" policy revealed, "...Wound photos will be obtained with the admission process: all pressure ulcer stages to include unstageable and sDTI [suspected deep tissue injury], diabetic wounds, venous ulcers, arterial wounds, surgical wounds or other complex/atypical wounds...Identification information to be included on the measuring guide in the photograph should include: Required-patient MR# [medical record number], date, location of the wound and optional-wound measurements. Use a marker and write legibly so the information can be read in the photo...Photographs should be retaken at a minimum as the wound(s) change(s), monthly, and within 48 hours prior to discharge..."

4. Medical record review for Patient #2 revealed an admission date of 7/16/18 with diagnoses which included Stage IV Sacral Decubitus, Right Hip Stage IV Decubitus, Left Stump Unstageable Wound, Left Buttock Deep Tissue Injury, Diabetes Mellitus, Hypertension, Neurogenic Bowel and Bladder, T [thoracic]9 Paraplegia and History of Left Above the Knee Amputation.

The "WOUND CARE STATUS REPORT" dated 7/16/18 revealed Patient #2 had a total of 7 wounds. There was no documentation an assessment of the wounds was completed by an RN after 7/16/18.

The "WOUND CARE STATUS REPORT" dated 7/16/18 revealed, " ...WOUND #2...DATE FIRST OBSERVED: 7/16/18...Location/Anatomic site: R [right] buttocks...Etiology...Pressure..." There was an admission assessment of the wound to the right buttock dated 7/16/18 which designated the wound as a suspected deep tissue injury with nonviable tissue. There were three other assessments of the wounds documented on this form. The first assessment failed to document the date or type of assessment. The second and third assessments failed to document the date or type of assessment or the stage of the wound. The three assessments were performed by the Licensed Practical Nurse (LPN),

The "WOUND PHOTOGRAPHIC DOCUMENTATION" dated 7/16/18 revealed, "...2x1: Size: (L [length] X W [width])..." The photograph did not include a measuring guide or location of the wound.

The "WOUND PHOTOGRAPHIC DOCUMENTATION" dated 7/16/18 revealed, "...3x3: Size: (L X W)..." The photograph did not include a measuring guide or location of the wound.

5. Medical record review for Patient #10 revealed an admission date of 6/1/18 with diagnoses which included Stage IV Pressure Ulcer Bilateral Hip/Ischium, Acute Anemia on Chronic Microcytic Anemia, Sepsis, Severe Protein-calorie Malnutrition, Neurogenic Bowel and Bladder, Paraplegia, Osteoarthritis and Neuropathy. The "DISCHARGE SUMMARY" dated 5/24/18 revealed, "...DATE OF DISCHARGE: May 24, 2018..."

The "WOUND CARE STATUS REPORT" dated 6/2/18 revealed, "...WOUND #1...DATE FIRST OBSERVED: 6/2/18...Type of Assessment...Adm [Admission]...Stage...IV..." There was no documentation of the location, shape or etiology of the wound. There was no photograph of the wound.

The "WOUND CARE STATUS REPORT" dated 6/2/18 revealed, "...WOUND #2...DATE FIRST OBSERVED: 6/2/18...Location/Anatomic site...Left...Trochanter...Shape/Overall Wound Pattern...Round/Oval...Etiology...Pressure...Type of Assessment...Adm [Admission]..." There was no staging of the wound documented on the assessment dated 6/2/18. There was no photograph of the wound.

The "WOUND CARE STATUS REPORT" dated 6/2/18 revealed, "...WOUND #3...DATE FIRST OBSERVED: 6/2/18...Location/Anatomic site...Sacrum & [and] Coccyx...Shape/Overall Wound Pattern...Round/Oval...Type of Assessment...Adm [Admission]...Stage...IV..." There was no documentation of the etiology of the wound. There was no photograph of the wound.

There was no documented assessment of Patient #10's wounds by a RN (except on 6/22/18 for Wound #2 and 3).

6. Medical record review for Patient #11 revealed an admission date of 4/25/18 with diagnoses which included Stage IV Sacral Pressure Ulcer, End Stage Renal Disease and Diabetes Mellitus. The "DISCHARGE SUMMARY' dated 5/24/18 revealed, "...DATE OF DISCHARGE: May 24, 2018..."

The "WOUND CARE STATUS REPORT" revealed, "...WOUND #1...DATE FIRST OBSERVED: 4/25/18...Location/Anatomic site...Coccyx...Shape/Overall Wound Pattern...Round/Oval...Type of Assessment...Adm [Admission]...Stage...IV..." There was no assessment of the coccyx wound from 5/2/18 to 5/18/18 (16 days).

The "WOUND PHOTOGRAPHIC DOCUMENTATION" dated 4/25/18 and 4/26/18 revealed two photographs of the coccyx wound which were blurry, and the writing of the wound characteristics (patient name, date, location, size and depth) in the photograph were illegible. The "WOUND PHOTOGRAPHIC DOCUMENTATION" with the camera date stamp of 5/1/16 revealed a picture of the coccyx wound with an illegible date on the measuring guide in the photograph. There was no nurse signature on any of the four photographs taken of the coccyx wound. There was no photograph within 48 hours of Patient #11's discharge on 5/24/18.

There was no documented assessment of Patient #11's wound by a RN after the initial assessment on 4/25/18.

7. Medical record review for Patient #29 revealed an admission date of 4/26/18 with diagnoses which included Stage IV Sacral Pressure Ulcer, Proteus Bacteremia, Severe Protein-calorie Malnutrition, Oropharyngeal Dysphagia and Iron Deficiency Anemia. The "DISCHARGE SUMMARY' dated 5/29/18 revealed, "...DATE OF DISCHARGE: May 29, 2018..."

The "WOUND CARE STATUS REPORT" revealed, "...WOUND #1...DATE FIRST OBSERVED: 4/27/18...Location/Anatomic site...Sacrum & Coccyx...Shape/Overall Wound Pattern...Round/Oval...Etiology...Pressure...Stage...IV...Undermining > 4 cm [centimeters] or tunneling in any area...Tunnels 4 cm @ [at] 5 o'clock...Tunnels 5.5 cm @ 3 o'clock..." There were no other assessments of the sacral wound documented on the "WOUND CARE STATUS REPORT."

The "WOUND PHOTOGRAPHIC DOCUMENTATION" revealed three photographs (2 dated 4/27/18 and 1 dated 5/19/18) of the sacral wound. There was no nurse signature on any of the three photographs. There was no photograph within 48 hours of Patient #29's discharge on 5/29/18.

There was no documented assessment of Patient #29's wound by a RN after the initial assessment on 4/27/18.

8. Review of the personnel file for the Wound Care Nurse revealed a current LPN license. There was no documentation the Wound Care Nurse had received special training in wound care.

9. During an interview in the conference room on 8/8/18 at 11:00 AM, the Wound Care Nurse confirmed she had received no formal training for wound care. The Wound Care Nurse stated she did not always use a measuring guide when photographing a patient's wounds and did not always document the patient's name, location and wound characteristics when using the measuring guide.

During an interview in the conference room on 8/8/18 at 11:15 AM, the Chief Clinical Officer stated the nurse should always use a measuring guide when photographing a patient's wounds, and the patient's name, location and wound characteristics should always be documented on the guide.

Based on policy review, medical record review and interview, the facility failed to develop an initial plan of care for 12 of 30 (Patient #3, 4, 10, 11, 17, 19, 21, 23, 24, 26, 28 and 29) sampled patients and failed to follow the plan of care for wound care treatment for 1 of 22 (Patient #29) sampled patients with wounds.

The findings included:

1. Review of the facility's "Nursing Patient Care Plan" policy revealed, "...The Patient Care Plan starts as soon as the patient is admitted to the hospital and is continually updated throughout the patient's stay...Initiating/Updating the Patient Care Plan...The Plan of Care will be initiated by an RN [registered nurse] after completion of the Admission Assessment...Problems will be addressed and resolved as the patient progresses through their treatment plan..."

Review of the facility's "Wound Assessment" policy revealed, "...Determine strategies based on goals...Healable: moist wound using advanced wound care products...These strategies are tried before adding or changing to adjuvant therapy. If the wound is stalled despite optimal local care and patient condition optimized, adjuvant therapies may be appropriate...Maintenance: the goal is to remove or minimize deterrents to wound healing, reduce the risk of infection and/or wound deterioration, and optimize patient condition...Non-healing/Palliative wound: the goal is to reduce the risk of infection, prevent/minimize deterioration and promote patient comfort and function..."

2. Medical record review for Patient #3 revealed an admission date of 8/4/18 with diagnoses which included Surgical Wound Dehiscence and Wound Infection with Proteus Mirabilis, Aspiration Pneumonia, Paroxysmal Atrial Fibrillation, Seizure Disorder, and Acute Respiratory Failure Status Post Tracheostomy with Ventilator Support.

There was no documentation of a plan of care was initiated by an RN after the admission assessment was completed.

3. Medical record review for Patient #4 revealed an admission date of 8/3/18 with diagnoses which included Pneumonia, Status Post Tracheotomy, Atrial Fibrillation and Hypertension.

There was no documentation of a plan of care was initiated by an RN after the admission assessment was completed.

4. Medical record review for Patient #10 revealed an admission date of 6/1/18 with diagnoses which included Stage IV Pressure Ulcer Bilateral Hip/Ischium, Acute Anemia on Chronic Microcytic Anemia, Sepsis, Severe Protein-calorie Malnutrition, Neurogenic Bowel and Bladder, Paraplegia, Osteoarthritis and Neuropathy.

There was no documentation of a plan of care was initiated by an RN after the admission assessment was completed.

5. Medical record review for Patient #11 revealed an admission date of 4/25/18 with diagnoses which included Stage IV Sacral Pressure Ulcer, End Stage Renal Disease and Diabetes Mellitus.

There was no documentation of a plan of care was initiated by an RN after the admission assessment was completed.

6. Medical record review for Patient #17 revealed an admission date of 4/16/18 with diagnoses which included Acute Hypoxic Respiratory Failure, Severe Sepsis with Septic Shock, Pneumonia with Haemophilus Influenza, Alchohol Abuse/Withdrawal, Chronic Hepatitis C/Alcoholic Cirrhosis, Atrial Fibrillation, Severe Bilateral Lower Extremity Edema and Bilateral Hip and Knee Osteoarthritis.

There was no documentation of a plan of care was initiated by an RN after the admission assessment was completed.

7. Medical record review for Patient #19 revealed an admission date of 5/18/18 with diagnoses which included Acute Respiratory Failure with Recent Tracheostomy, Subarachnoid Hemorrhage, Cerbral Artery Vasospasm, Sepsis Secondary to Pneumonia/Urinary Tract Infection/Clostridium difficile Colitis, Anemia, Methicillin-resistant Staphylococcus aureus Colonization, Oropharyngeal Dysphagia and Aspiration Pneumonia.

There was no documentation of a plan of care was initiated by an RN after the admission assessment was completed.

8. Medical record review for Patient #21 revealed an admission date of 6/15/18 with diagnoses which included Status Post Motor Vehicle Accident, Acute Hypoxic and Hypercapnic Respiratory Failure with Tracheostomy, Methicillin-resistant Staphylococcus aureus, Polyneuropathy, Oropharyngeal Dysphagia and Diabetes Mellitus.

There was no documentation of a plan of care was initiated by an RN after the admission assessment was completed.

9. Medical record review for Patient #23 revealed an admission date of 7/28/18 with diagnoses which included Severe Peripheral Vascular Disease, Acute Respiratory Disease, Acute Renal Failure, Severe Sepsis with Septic Shock, Severe Protein-calorie Malnutrition, Coronary Artery Disease and Hypertension.

There was no documentation of a plan of care was initiated by an RN after the admission assessment was completed.

10. Medical record review for Patient #24 revealed an admission date of 5/2/18 with diagnoses which included Acute on Chronic Hypercapnic and Hypoxemic Respiratory Failure, Acute on Chronic Systolic and Diastolic Heart Failure, Acute Renal Failure, Chronic Obstructive Pulmonary Disease, Diabetes Mellitus and Morbid Obesity.

There was no documentation of a plan of care was initiated by an RN after the admission assessment was completed.

11. Medical record review for Patient #26 revealed an admission date of 5/16/18 with diagnoses which included Chronic Obstructive Pulmonary Disease, Coronary Artery Disease, Diverticulitis, Gastroesophageal Reflux Disease, Cerebrovascular Accident, Hypertension, Migraines, Depression, Anxiety, and Bipolar Disorder.

There was no documentation of a plan of care was initiated by an RN after the admission assessment was completed.

12. Medical record review for Patient #28 revealed an admission date of 4/23/18 with diagnoses which included Acute Respiratory Failure, Acute Renal Faliure, Pneumonia Secondary to Pseudomonas, Recent Multifocal Ischemic Cerebrovascular Accidents with Right Upper Extremity Weakness, Acute Deep Venous Thrombosis of the Right Common Femoral Vein, Paroxysmal Atrial Fibrillation and Bilateral Lower and Upper Extremity Gangrene.

There was no documentation of a plan of care was initiated by an RN after the admission assessment was completed.

13. Medical record review for Patient #29 revealed an admission date of 4/26/18 with diagnoses which included Stage IV Sacral Pressure Ulcer, Proteus Bacteremia, Severe Protein-calorie Malnutrition, Oropharyngeal Dysphagia and Iron Deficiency Anemia.

There was no documentation of a plan of care was initiated by an RN after the admission assessment was completed.

A physician's order dated 4/27/18 revealed, "...Clean wound c [with] wound cleanser. Pat dry apply Therahoney [wound gel] to sterile 4x4 gauze. Apply to wound and gently pack. Cover with 4x4s and ABD [abdominal pad] and [symbol for change] daily and PRN [as needed]..."

The "WOUND CARE TREATMENT RECORD" dated 4/27/18-5/4/18 documented the wound care treatment for 4/27/18 was signed as completed. There was no documentation Patient #29 received wound care treatment from 4/28/18-5/4/18.

The "PHYSICIAN DEBRIDEMENT NOTE" dated 5/4/18 revealed, "...Wound 1...Wound Type...Pressure...Wound measurements...Length...10 [cm]...Width...10...Depth...3...Physician conclusion/recommendation...Pt [patient] doing well...cont [continue] WTD [wet to dry dressing] DAILY [underlined twice]..."

There was no documentation Patient #29 received wound care treatments after 4/27/18.

The "DISCHARGE SUMMARY" dated 5/29/18 revealed, "...DATE OF DISCHARGE: May 29, 2018...DISCHARGE DIAGNOSES...Stage IV sacral pressure ulcer with possible sacral osteomyelitis..."

14. During an interview in the conference room on 8/7/18 at 10:04 AM, the Quality Manager stated the plan of care should be initiated immediately after the admission assessment was completed. The Quality Manager stated the initial plan of care should be documented on the form entitled, "PLAN OF CARE."

Based on review of the Medical Staff Rules and Regulations, policy review, medical record review and interview, the facility failed to ensure all physician orders were dated, time and authenticated for 14 of 30 (Patient #3, 8, 9, 10, 12, 14, 15, 18, 20, 21, 23, 26, 27 and 30) sampled patients.

The findings included:

1. Review of the "2017 MEDICAL STAFF RULES AND REGULATIONS" reviewed September 2017 revealed, "...ORDERS...All telephone/verbal orders shall be transcribed in the medical record and shall be countersigned by the practitioner within 48 hours..."

2. Review of the facility's "General Documentation Guidelines" policy revealed, "...All clinical entries in the patient's medical record will be accurately dated, timed and authenticated and their authors identified...Medical Staff will follow the documentation guidelines as specified in the Medical Staff Bylaws and Rules and Regulations of the facility, and in accordance with State and Federal regulations...Orders...Verbal and telephone orders must be authenticated by the responsible practitioner within the time frame defined in the Medical Staff Rules and Regulations..."

Review of the facility's "Restraints/Seclusion" policy revealed, "...PROCEDURE...An LIP [licensed independent practitioner] must provide an order per the requirements listed below. Should the ordering physician not be the treating physician, then the treating physician should be notified of the use of the restraint as soon as possible...Medical/Surgical Restraint...Applicability - used for the medical/surgical settings for patients that require intervention to promote health and safety...Justification - limited to use when alternatives, such as distraction, proximity to nurse/staff members are ineffective...Assessment - daily by LIP; daily by RN; data collection by educated/trained staff members...Order renewal - clinical justification requires LIP to reorder every calendar day; may be initiated by RN [registered nurse] with notification to the IIP [LIP] as soon as possible, but within 1 hour; telephone orders must be signed within 24 hours; if initiation due to significant change in the patient condition; the LIP must be notified immediately...Content of order/renewal - type of restraint and reason for restraint..."

3. Medical record review for Patient #3 revealed an admission date of 8/4/18 with diagnoses which included Surgical Wound Dehiscence and Wound Infection with Proteus Mirabilis, Aspiration Pneumonia, Paroxysmal Atrial Fibrillation, Seizure Disorder, and Acute Respiratory Failure Status Post Tracheostomy with Ventilator Support.

Review of "RESTRAINT INITIATION/ORDER" on 8/8/18 revealed a Limb/Soft Restraint was applied to the right and left wrists by Nurse #8 on 8/6/18 at 8:00 AM, 8/7/18 at 8:30 AM and on 8/8/18 at 8:30 AM. There was no documentation of the date and time Medical Provider #5 signed the orders.

During a telephone interview on 8/9/18 at 1:13 PM, Medical Provider #5 revealed that she had signed 3 restraint orders for Patient #3 on the morning of 8/8/18. Medical Provider #5 further revealed she did not date the orders so that Nurse #8 could use them for the dates she needed.

Review of "RESTRAINT INITIATION/ORDER" on 8/13/18 revealed a Limb/Soft Restraint was applied to the right and left wrists by Nurse #8 on 8/6/18 at 8:00 AM, 8/7/18 at 8:30 AM and on 8/8/18 at 8:30 AM. There was no documentation of the date and time Physician #1 co-signed the restraint orders.

4. Medical record review revealed Patient #8 was admitted to the facility on 7/26/18 with diagnoses which included Acute Respiratory Failure, Wound Care of Left Jaw/Mandible Surgery and Left Mandibulectomy with Pectoral Flap Reconstruction and Management of Complex Medical History.

Physician's orders dated 7/28/28, 7/30/18, 8/3/18, 8/7/18 and 8/8/18 were not signed and dated by the physician.

5. Medical record review revealed Patient #9 was admitted to the facility on 7/26/18 with diagnoses which included Diabetes Mellitus Type 2, Peripheral Neuropathy, Hypertension, Peripheral Artery Disease, Stasis Dermatitis with Ulcer on the Lower Extremity, History of Deep Vein Thrombosis, Chronic Obstructive Pulmonary Disease and Chronic Atrial Fibrillation.

Physician's orders dated 7/27/18, 8/7/18 and 8/8/18 were not signed and dated by the physician.

6. Medical record review for Patient #10 revealed an admission date of 6/1/18 with diagnoses which included Stage IV Pressure Ulcer Bilateral Hip/Ischium, Acute Anemia on Chronic Microcytic Anemia, Sepsis, Severe Protein-calorie Malnutrition, Neurogenic Bowel and Bladder, Paraplegia, Osteoarthritis and Neuropathy.

Physician's orders dated 6/1/8, 6/15/18 and 6/29/18 were not signed and dated by the physician.

7. Medical record review for Patient #12 revealed an admission date of 6/27/18 with diagnoses which included Quadriplegia, Diabetes Mellitus Type II, Multiple Chronic Decubitus Ulcers, Bilaterally Upper Extremity Lymphedema, and Methicillin Resistant Staphylococcus Aureus Colonization.

Physician's orders dated 6/28/18, 6/29/18, 6/30/18, 7/1/18, 7/2/18, 7/4/18, 7/9/18, 7/10/18, 7/11/18, 7/15/18, 7/16/18, 7/17/18, 7/18/18, 7/20/18, 7/22/18, and 7/24/18 that were not signed and dated by the physician.

8. Medical record review for Patient #14 revealed an admission date of 6/27/18 with diagnoses which included Hematuria, Acute Coronary Syndrome, Acute Renal Failure, Ischemic Cardiomyopathy, Diabetes Mellitus Type II, Hypertension, Chronic Obstructive Pulmonary Disease, and Acute Systolic Heart Failure.

A physician's order dated 6/28/18 that was not signed and dated by the physician.

9. Medical record review for Patient #15 revealed an admission date of 6/2/18 with diagnoses which included Chronic Systolic Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, Paroxysmal Atrial Fibrillation/Atrial Flutter, Schizophrenia, Hepatitis C, and Hypertension.

The admission physician's orders dated 6/3/18 and physician's orders dated 6/26/18, 6/28/18, 6/29/18, 6/30/18, 7/1/18, 7/2/18, and 7/3/18 were not signed and dated by the physician.

10. Medical record review for Patient #18 revealed an admission date of 6/9/18 with diagnoses which included Stage IV sacral decubitus ulcer, Diabetes Mellitus type 2, Osteomyelitis, Recurrent Methicillin-resistant Staphylococcus aureus infection with abscess, Hypertension, Obesity, Acute on chronic anemia and Acute kidney injury.

Physician's orders dated 6/24/18, 6/25/18 and 7/5/18 were not signed and dated by the physician.

11. Medical record review for Patient #20 revealed an admission date of 6/25/18 with diagnoses which included Recent Hiatal Hernia Repair with Complication of Esophageal Tear with Mediastinal Empyema with Acute Respiratory Failure Status Post Tracheostomy, Required Vent [ventilator] support, Acute Renal Failure, Septic Shock, Atrial Fibrillation, and Anemia.

Physician's orders dated 6/25/18 and 6/29/18 were not signed and dated by the physician.

12. Medical record review for Patient #21 revealed an admission date of 6/15/18 with diagnoses which included Status Post Motor Vehicle Accident, Acute Hypoxic and Hypercapnic Respiratory Failure with Tracheostomy, Methicillin-resistant Staphylococcus aureus, Polyneuropathy, Oropharyngeal Dysphagia and Diabetes Mellitus.

Physician's orders dated 7/5/18 and undated discharge orders were not signed and dated by the physician.

13. Medical record review for Patient #23 revealed an admission date of 7/28/18 with diagnoses which included Severe Peripheral Vascular Disease, Acute Respiratory Disease, Acute Renal Failure, Severe Sepsis with Septic Shock, Severe Protein-calorie Malnutrition, Coronary Artery Disease and Hypertension.

Physician's orders dated 7/30/18 and 7/31/18 were not signed and dated by the physician.

14. Medical record review for Patient #26 revealed an admission date of 5/16/18 with diagnoses which included Chronic Obstructive Pulmonary Disease, Coronary Artery Disease, Diverticulitis, Gastroesophageal Reflux Disease, Cerebrovascular Accident, Hypertension, Migraines, Depression, Anxiety, and Bipolar Disorder.

A "RESTRAINT INITIATION/ORDER" dated 5/16/18 revealed a telephone order for restraints was obtained on 5/16/18 at 10:00 PM. The order was not signed by the physician until 7/4/18; a total of 49 days after the telephone order was obtained.

During an interview on 8/14/18 at 9:35 AM, in the facility conference room, when asked when the physician signed the order, the Interim Nurse Manager stated, "According to the documentation, July 4."

15. Medical record review for Patient #27 revealed an admission date of 7/3/18 with diagnoses which included Acute on Chronic Hypoxemic and Hypercapnic Respiratory Failure, Acute Renal Failure, Severe Sepsis with Septic Shock, Chronic Obstructive Pulmonary Disease, Chronic Atrial Fibrillation, Systolic Heart Failure, Severe Protein-calorie Malnutrition and General Debility.

Physician's orders dated 7/5/18, 7/6/18, 7/8/18, 7/9/18, 7/11/18, 7/12/18, 7/13/18 and 7/14/18 were not signed and dated by the physician.

16. Medical record review for Patient #30 revealed an admission date of 6/21/18 with diagnoses which included Spontaneous bacterial peritonitis with ascites, Ileus, Acute on chronic anemia, Hepatic encephalopathy secondary to liver failure, Methicillin-resistant Staphylococcus aureus (MRSA) with Multiplan dysfunction, Pericolonic/intra-abdominal abscess, Acute renal failure, Delirium tremens, Left breast abscess, and Bipolar disorder with depression and anxiety.

A "RESTRAINT INITIATION/ORDER" dated 6/26/18 revealed a telephone order for restraints was obtained on 6/26/18 at 8:00 PM. The order was not signed by the physician until 7/6/18, a total of 10 days after the telephone order was obtained.

A telephone order for restraints received 6/27/18 at 8:00 PM was not signed by the physician until 7/6/18, a total of 9 days after the telephone order was obtained.

A telephone order for restraints received 6/28/18 at 8:00 PM was not signed until 7/3/18, a total of 5 days after the telephone order was obtained.

Physician's orders dated 7/3/18, 7/11/18, 7/12/18, 7/13/18 and 7/15/18 were not signed and dated by the physician.

17. During an interview on 8/14/18 at 3:27 PM, in the facility conference room, the Health Information Manager (HIM) confirmed charts were reviewed to ensure physician's orders were legible, signed, dated, and timed. She stated if she found any issues or problems with the orders, she would bring it to the doctor's attention to be addressed.

Based on policy review and interview, the facility failed to ensure 1 of 1 designated Infection Control Officers was qualified through education, training, experience or certification and failed to implement an effective Infection Control Program.

The findings included:

1. Review of the facility's "Infection Control Plan" policy revealed, "I. Purpose...III. Authority: A qualified individual will be appointed as the Infection Control Preventionist (ICP). The ICP has clinical authority over the infection control program. The ICP is responsible for the daily management of infection control activities and developing/implementing policies governing control of infection and communicable diseases. The ICP is responsible for the system of identifying, reporting, investigating and controlling infections and communicable diseases...The Infection Control Plan will be evaluated, revised as necessary, and approved for surveillance, prevention, and control of infections...The CEO [Chief Executive Officer], Medical Staff, CCO [Chief Clinical Officer] and ICP [Infection Control Preventionist] will be responsible for surveillance, prevention, and control of infections..."

2. During the an interview in the conference room on 8/6/18 at 10:00 AM, the CEO named the CCO as the ICP and stated she has been in that position since early June 2018.

During an interview in the waiting room on 8/7/18 at 10:00 AM, the CCO stated she was previously the wound care nurse, has been the CCO for 6 weeks and had not yet received training for Infection Control.

During an interview in the conference room on 8/8/18 at 10:25 AM, the Quality Manager verified the last Infection Control Committee meeting was in April 2017. The CEO verified there had been no Infection Control Committee meeting in 2018.

During an interview in the conference on 8/13/18 at 2:44 PM, Infectious Disease Physician #1 stated, "I don't know who is over Infection Control. I don't know if there is one [Infection Control Committee]. Infectious Disease Physician #1 was asked if he should be part of the Infection Control Committee. He stated, "I'm the only Infectious Disease Physician here now; I would think so..."

During a telephone interview on 8/13/18 at 3:35 PM, the Medical Director stated, "We lost our Infection Control Nurse when [named corporation] took over. I think that was around this time last year. I'm not aware that we have a designated Infection Control Nurse; I understand it was given to the CCO, but I'm not sure..."

Based on policy review, document review, medical record review, observation, and interview the facility failed to ensure measures to prevent the potential spread of infection were followed during 5 of 5 (Patients #2, 3, 5, 7, and 9) wound care observations and during wound assessment for 1 of 14 (Patient #11) sampled discharged patients with wounds. The facility failed to obtain physician's orders for isolation precautions for 6 of 8 (Patients #1, 2, 3, 4, 5, and 6) sampled patients with isolation precautions, and the facility failed to follow their policy for isolation precautions on 4 of 4 (8/6/18, 8/7/18, 8/9/18, and 8/13/18) days of observations.

The findings included:

1. Review of the facility's "Hand Hygiene" policy revealed, "...A. When hands are visibly dirty or contaminated with proteinaceous material or are visible [visibly] soiled with blood or other body fluids, wash hands with either a non-antimicrobial soap and water or an antimicrobial soap and water. B. If hands are not visibly soiled, alcohol-based hand rub may be used for routinely decontaminating hands. C. Decontaminate hands when...4. after contact with a patients intact skin (e.g. [such as] when taking a pulse or blood pressure, and lifting a patient). 5. after contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressings if hands are not visibly soiled. 6. if moving from a contaminated body site to a clean body site during patient care. 7. after contact with an inanimate object (including medical equipment) in the immediate vicinity of the patient, and 8. after removing gloves. D. Alternatively, wash hands with an antimicrobial soap and water in all clinical situations as described above..."

2. Observations in Patient #2's room on 8/7/18 beginning at 1:50 PM revealed the Wound Care Nurse performed wound care treatment on Patient #2. Patient #2 was in Isolation with Contact Precautions. The Wound Care Nurse donned a gown and gloves and removed a dressing to the left hip, cleaned the wound to the left hip with 4x4 gauze pads saturated with wound cleanser. The Wound Care Nurse changed gloves without performing hand hygiene. The Wound Care Nurse packed the wound with 4x4 gauze pads saturated with 0.125% sodium hypochlorite solution and covered the wound with a partial abdominal pad, secured the pad with tape, and changed gloves without performing hand hygiene. The Wound Care Nurse cleaned a wound to the right hip and a wound to the right buttock without changing gloves between cleaning the two wounds. The Wound Care Nurse changed gloves after cleaning the wounds without performing hand hygiene. The Wound Care Nurse packed the wound to the right hip with 4x4 gauze pads saturated with 0.125% sodium hypochlorite solution and covered the wound with a partial abdominal pad, secured the pad with tape, then applied betadine to the wound on the right buttock without changing gloves. The Wound Care Nurse changed gloves without performing hand hygiene after applying the betadine. The Wound Care Nurse removed the dressing to the lower back and changed gloves without performing hand hygiene. The Wound Care Nurse cleaned the wound to the lower back and changed gloves without performing hand hygiene.

The Wound Care Nurse failed to perform hand hygiene after removing soiled gloves and before donning new gloves repeatedly.

3. Observations during wound care in Patient #3's room on 8/7/18 beginning at 12:52 PM revealed the Wound Care Nurse donned a gown, washed her hands, and donned gloves. The Wound Care Nurse removed the abdominal dressing and placed it in a biohazard bag, removed her gloves, washed hands, donned a new pair of gloves and continued with wound care. After completing the treatment of the abdominal wound, the wound care nurse removed her gloves, performed hand hygiene and donned a new pair of gloves. The Wound Care Nurse then placed a barrier under Patient #3's feet and lower legs, removed her gloves and donned another set of gloves without performing hand hygiene.

After cleaning Patient #3's right heel with wound cleanser, the Wound Care Nurse removed her gloves and donned another pair of gloves without performing hand hygiene. The Wound Care Nurse then completed the wound treatment to Patient #3's right heel.

The Wound Care Nurse then began the treatment to Patient #3's right calf. The Wound Care Nurse washed her hands, donned gloves, and cleansed the wound with wound cleanser and saline. The Wound Care Nurse then removed her gloves and donned a new pair of gloves without performing hand hygiene.

The Wound Care Nurse failed to perform hand hygiene after removing soiled gloves and before donning new gloves repeatedly.

4. Observations during wound care in Patient #5's room on 8/6/18 beginning at 1:30 PM, revealed the Wound Care Nurse performed hand hygiene, donned gloves, cleaned the patient's left buttock wound with gauze saturated with wound cleanser, placed them into a biohazard container, and removed her gloves. The Wound Care Nurse donned new gloves without performing hand hygiene, obtained an antimicrobial wipe and cleaned her scissors, cut the foam for the wound bed to size and placed it into the wound bed and removed her gloves. Without performing hand hygiene, the Wound Care Nurse donned new gloves and placed a transparent dressing over the peri-wound and unprotected skin extending from the wound bed to the patient's left hip, and applied foam dressing from the wound bed to the left hip on top of the transparent dressing, covered the foam with transparent dressing, attached the wound vacuum device and secured with transparent dressing.

The Wound Care Nurse failed to perform hand hygiene after removing soiled gloves and before donning new gloves repeatedly.

5. Observations during wound care on 8/7/18 beginning at 1:30 PM, revealed Patient #7 was in Isolation with Contact Precautions. Observations revealed the Wound Care Nurse performed hand hygiene, opened packages of 4x4s, moistened one package with saline and the other with wound cleanser and removed the old dressing from the patient's abdomen. The Wound Care Nurse then washed her hands with soap and water, donned gloves, then cleaned and dried the wound and discarded the used 4x4s. The Wound Care Nurse changed her gloves without performing hand hygiene, applied Thera Honey to the patient's wound and covered with a dressing. The Wound Care Nurse changed her gloves without performing hand hygiene, straightened the patient's bed linens, discarded her dressing supplies and performed hand hygiene before leaving the room.

The Wound Care Nurse failed to perform hand hygiene after removing soiled gloves and before donning new gloves repeatedly.

6. Observations revealed Patient #9 was in Isolation with Contact Precautions for Pseudomonas Aerugonosa/Acinetobacter Baumannii. Observations during wound care in Patient #9's room on 8/7/18 beginning at 3:08 PM, revealed the Wound Care Nurse performed hand hygiene, donned gown and gloves, cleaned the wounds on the patient's bilateral lower legs. The Wound Care Nurse removed her gloves and donned new gloves without performing hand hygiene. She then opened the dressings for the wounds onto a clean field on the bed, changed gloves without performing hand hygiene, then applied the dressing to the right lower leg (RLL). The Wound Care Nurse removed her gloves, used a Super-Sani cloth to clean her bandage scissors before cutting a dressing to size. She then donned new gloves without performing hand hygiene and completed the dressing on the RLL. The Wound Care Nurse removed her gloves and gown, left the room to get Thera Honey from the treatment cart, and returned. On return, she washed her hands and donned gown and gloves, then re-cleaned the patient's left lower leg (LLL), applied Thera Honey to the wound and applied the dressing to the wounds on the LLL. Nurse #3 entered Patient #9's room to assist the Wound Care Nurse to reposition Patient #9. On entering the room, Nurse #3 did not wash her hands before donning gloves. Nurse #3 did not don a gown even though Patient #9 was in contact precautions. After assisting to reposition Patient #9, Nurse #3 removed and discarded her gloves, and left the room without performing hand hygiene.

The Wound Care Nurse failed to perform hand hygiene after removing soiled gloves and before donning new gloves repeatedly. On entering the room of the patient with Contact Precautions, Nurse #3 failed to don Personal Protective Equipment (PPE) and failed to perform hand hygiene before and after donning gloves in the room.

7. During an interview in the conference room on 8/8/18 at 10:37 PM, the Quality Manager was asked when she expected staff to perform hand hygiene. The Quality Manager stated, "...after removing gloves..."

8. Closed medical record review for Patient #11 revealed an admission date of 4/25/18 with diagnoses which included Stage IV Sacral Pressure Ulcer With Wound Infection, Severe Sepsis with Septic Shock, End Stage Renal Disease, Bacteremia Secondary to Proteus, Anemia, Diabetes Mellitus, Atrial Fibrillation and Encephalopathy With Myoclonic Jerks.

The History and Physical dated 4/26/18 revealed, "...Patient was noted to have a large sacral pressure ulcer. He had been having drainage from his sacral ulcer. He was admitted with a presumptive diagnosis of severe sepsis with septic shock secondary to infected sacral pressure ulcer versus healthcare-associated pneumonia...Patient's wound cultures grew proteus and Bacillus fragilis. Proteus was CRE [Carbapenem-resistant Enterobacteriaceae]. He also had Proteus bacteremia..."

The "WOUND PHOTOGRAPHIC DOCUMENTATION" dated 4/26/18 revealed a picture of Patient #11's sacral wound with an illegible measuring guide. The measuring guide was held by a gloved hand, and Patient #11's skin (left buttock) was held by an ungloved right hand. The first finger of the ungloved hand was approximately 1 centimeter from the opening of the infected sacral wound.

9. Medical record review for Patient #1 revealed an admission date of 6/8/18 with diagnoses which included Acute Respiratory Failure with Hypoxemia, Acute on Chronic Diastolic Congestive Heart Failure, Acute Spontaneous Intraparenchymal Intracranial Hemorrhage and Basal Ganglia/Acute Ischemic Stroke, Severe Generalized Muscle Weakness and Debility/Left-sided Hemiplegia With All Flaccid Extremities and Oropharyngeal Dysphagia.

The "DAILY NURSING ASSESSMENT" dated 8/12/18 documented Patient #1 was in Contact Isolation/Precautions.

There were no orders for contact isolation precautions noted in Patient's #1's medical record.

Observations in the hallway outside Patient #1's room on 8/13/18 at 11:35 AM revealed a posted sign, "...For all staff...Contact Precautions...in addition to Standard Precautions..."

10. Medical record review for Patient #2 revealed an admission date of 7/16/18 with diagnoses which included Stage IV Sacral Decubitus, Right Hip Stage IV Decubitus, Left Stump Unstageable Wound, Left Buttock Deep Tissue Injury, Diabetes Mellitus, Hypertension, Neurogenic Bowel and Bladder, T [thoracic] 9 Paraplegia and History of Left Above the Knee Amputation.

A facility roster dated 8/6/18 revealed Patient #2 was in isolation for Methicillin-resistant Staphylococcus aureus and Escherichia coli.

Observations in the hallway outside Patient #2's door on 8/6/18 at 1:17 PM revealed a sign posted at the door for Contact Precautions.

There were no orders for contact isolation precautions noted in Patient's #2's medical record.

11. Medical record review for Patient #3 revealed an admission date of 8/4/18 with diagnoses which included Surgical Wound Dehiscence and Wound Infection with Proteus Mirabilis, Aspiration Pneumonia, Paroxysmal Atrial Fibrillation, Seizure Disorder, and Acute Respiratory Failure Status Post Tracheostomy with Ventilator Support.

There were no orders for contact isolation precautions noted in Patient's #3's medical record.

Observations in the hallway outside Patient #3's room on 8/6/18 at 1:14 PM and on 8/7/18 at 8:14 AM revealed no posted isolation sign.

Observations in the hallway outside Patient #3's room beginning on 8/7/18 at 2:30 PM revealed a sign labeled, "Contact Precautions."

During an interview on 8/7/18 at 12:52 PM, in the hallway, the Wound Care Nurse revealed that Patient #3 was in contact isolation for a wound infection.

During an interview at the nurses station on 8/7/18 at 2:40 PM, Nurse #8 revealed that she did not believe a physician's order was needed to place a patient in isolation. Nurse #8 verified that Patient #3 should have been in contact isolation on 8/6/18 and "...someone must have taken the sign down..."

12. Medical record review for Patient #4 revealed an admission date of 8/3/18 with diagnoses which included Pneumonia, Status Post Tracheotomy, Atrial Fibrillation and Hypertension.

A physician order dated 8/12/18 revealed that Patient #4 had Candida in his trach aspirate.

Observations outside Patient #4's room on 8/13/15 and 8/14/18 revealed a sign labeled, "Contact Precautions."

During an interview at the nurses station on 8/13/18 at 12:23 PM, Nurse #8 verified there was not a physician order for Patient #4 to be in contact precaution. Nurse #8 revealed that the decision is sometimes a nursing judgement.

There were no orders for contact isolation precautions noted in Patient's #4's medical record.

13. Medical record review for Patient #5 revealed an admission date of 7/14/18 with diagnoses which included Stage IV Left Hip/sacral Pressure Ulcer, Sever Protein-calorie Malnutrition, Chronic Atrial Fibrillation, Osteoarthritis, Hypertension, Dehydration, Chronic Pain Syndrome, Anxiety and Insomnia.

Observations outside Patient #5's room on 8/13/18 and 8/14/18 revealed a sign labeled, "Contact Precautions."

There were no orders for contact isolation precautions noted in Patient #5's medical record.

During an interview at the nurse's station on 8/13/18 the Chief Clinical Officer (CCO) confirmed there were no physician's orders for contact isolation precautions in Patient #5's medical record and stated, "I don't see any isolation orders other than the first one that said standard precautions."

14. Medical record review for Patient #6 revealed an admission date of 7/19/18 with diagnoses which included Neuromyelitis Optica with Paraplegia and Decubitus Ulcer of the Coccyx.

A physician's progress note dated 8/6/18 revealed Patient #6 had a Stage II coccygeal pressure ulcer with wound infection, secondary to Methicillin-resistant Staphylococcus aureus and Enterococcus.

Observations outside Patient #6's door on 4 of 4 (8/6/18, 8/7/18, 8/8/18, 8/13/18) observation days of the survey revealed a sign labeled, "Contact Precautions."

There were no orders for contact isolation precautions noted in Patient #6's medical record.

During an interview at the nurse's station on 8/8/18 at 9:55 PM, the Health Information Manager verified there were no physician's orders for the isolation precautions.

15. During an interview in the conference room on 8/8/18 at 10:37 AM, the Quality Manager verified that a physician's order should be obtained prior to putting a patient in isolation precautions.

During a telephone interview with the Medical Director on 8/13/18 at 3:35 PM, the Medical Director was asked if he expected a patient in isolation to have a physician's order. The Medical Director stated, "Yes, I thought that was a requirement."

During an interview on 8/14/18 at 9:25 AM, the Interim Nurse Manager stated she was informed in June when (named accreditations agency) was there (for an Accreditation survey) that a physician's order was required to put someone in isolation.

16. Review of the facility's "Guidelines for Isolation Precautions" policy revealed, "...B. Transmission-based Precautions- are designed for patients documented or suspected to be infected or colonized with highly transmissible or epidemiologically important pathogens for which additional precautions beyond Standard Precautions are needed to interrupt transmission in hospitals...they are to be used in addition to Standard precautions..."

17. Review of the facility's "Personal protective equipment (PPE), putting on" document revealed, "...Standard and transmission-based precautions help to prevent the spread of infection from patient to patient, from patients to health care workers, and from health care workers to patients...Central to the success of these precautions is the selection of the proper personal protective equipment...such as gowns, gloves, masks, and eye protection, as well as adequate training of those who use it...Materials required for standard and transmission-based precautions typically include PPE...and a door card or sign to alert staff members and others entering the room that transmission-based precautions are in effect...Perform hand hygiene...Put on the gown and wrap it around the back of your uniform, making sure it overlaps and completely covers your uniform to prevent contact with the patient and the patient's environment...Place the mask snugly over your nose and mouth and below your chin...Choose eye protection according to your risk of exposure...Put on gloves and pull them over the cuffs of your gown to cover the edges of the gown's sleeves..."

18. Review of the facility's signs placed outside the doors of Patient #1, 2, 3, 4, 5, 6, 7, 8, and 9's rooms revealed, "...For all staff Contact Precautions in addition to Standard Precautions Before entering room 1 Perform hand hygiene 2 Put on gown or apron 3 Put on gloves On leaving room 1 Dispose of gloves 2 Perform hand hygiene 3 Dispose of gown or apron 4 Perform hand hygiene..."

19. Random observations outside Patient #6's room on 8/6/18 at 1:20 PM, revealed a sign labeled "Contact Precautions." Nurse #1 and another staff member were observed repositioning Patient #6 in her room. The staff members were wearing gloves but no additionl PPE.

During an interview at the nurse's station on 8/6/18 at 1:22 PM, Nurse #1 confirmed that Patient #6 was in Contact Isolation for Methicillin-resistant Staphylococcus aureus (MRSA) in her wound.

20. Random observations in Patient #2's room on 8/7/18 at 2:15 PM revealed a sign labeled "Contact Precautions." Infectious Disease Physician #1 entered the room without donning any PPE, walked around the bed and examined Patient #2's exposed wound to the lower back. Infectious Disease Physician #1 discussed the wound with the Wound Care Nurse and left the room.

Infectious Disease Physician #1 failed to don any PPE while in Patient #2's room.

Random observations in Patient #2's room on 8/7/18 at 2:34 PM revealed Certified Nurse Technician (CNT) #1 entered the room with a vital signs machine after donning a gown and gloves. CNT #1 emptied the urinary catheter drainage bag into a urinal and emptied the urinal in the toilet. CNT #1 changed gloves without performing hand hygiene and took Patient #2's vital signs (temperature, blood pressure and pulse). CNT #1 used the blood pressure cuff designated for Patient #2 kept in the room but did not clean the tubing connected to the vital signs machine before taking the machine out of the room.

21. Random observations outside of Patient #6's room on 8/8/18 at 3:26 PM, revealed a sign labeled "Contact Precautions." Nurse #2 and Infectious Disease Physician #1 were observed entering the room without donning any PPE. Nurse #2 proceeded to rearrange patient equipment while the physician began his assessment of the patient. Infectious Disease Physician #1 then left the patient, walked to the door and donned gloves, then returned to the patient.

During an interview in the hallway, 8/8/18 at 3:28 PM, Nurse #2 confirmed Patient #6 was in contact isolation and that he was not wearing PPE when he was in her room rendering care.

22. During an interview in the conference room on 8/8/18 at 10:37 AM, the Quality Manager was asked what staff should do prior to entering the room of a patient in isolation. The Quality Manager stated, "They are expected to don gown and gloves...all staff including physicians..."

23. Random observations in the hallway outside of Patient #6's room on 8/13/18 at 11:05 AM, revealed a sign labeled "Contact Precautions." Speech Language Pathologist (SLP) #1 was sitting on a stool at Patient #6's bedside talking with her and her family. SLP #1 was not wearing a gown or gloves.

During an interview in the hallway on 8/13/18 at 11:10 AM, SLP #1 was asked if she was wearing PPE when she was in Patient #6's room. SLP #1 stated, "Not in this case; most of the time I will..."

24. Random observations in the hallway outside Patient #3's room on 8/13/18 at 11:18 AM revealed a sign labeled "Contact Precautions." Nurse #9 was in the room performing care for Patient #3 without wearing a gown.

25. Random observations in the hallway outside of Patient #5's room on 8/13/18 at 11:07 AM, revealed a sign labeled "Contact Precautions." CNT #2 knocked on the door, entered the room, donned gloves only, and began rendering care to Patient #5. CNT #2 failed to don a gown.

26. During an interview in the conference room on 8/13/18 at 2:44 PM, Infectious Disease Physician #1 was asked to explain the process used to determine which patients required isolation precautions. Infectious Disease Physician #1 stated, "You generally identify the source...have a routine evaluation done on admission...results come back; if MRSA screen positive contact isolation initiated...the Infection Control Nurse will make sure signs are put up and make sure nursing staff are informed about isolation..." Infectious Disease Physician #1 was asked who determined the type of isolation required. He stated, "the Infection Control Nurse." Infectious Disease Physician #1 was asked if a physician's order was needed for isolation precautions; he stated, "No, they don't have to write one, I don't think that's part of the policy." Infectious Disease Physician #1 was asked how staff would know if a patient was in isolation. He stated, "A sign on the door." He was then asked if there was no sign, would that mean the patient was not in isolation. He stated, "No sign would imply they are not in isolation...many things have changed here..." Infectious Disease Physician #1 was asked what he expected staff to do before entering the room of a patient with contact precautions in place. He stated, "The normal thing is gown, gloves, and some wear masks." Infectious Disease Physician #1 was asked if reusable equipment should be cleaned before going to another room. He stated, "Yes, if they are not doing it; horrible!" Infectious Disease Physician #1 was asked if PPE was required for all staff including physicians for contact precautions. He stated, "No, if they come into contact with the patient, then yes. Like me, I go in the room but don't come into contact with the patient so I don't need to wear it..."

During a telephone interview on 8/13/18 at 3:35 PM, the Medical Director stated feedback for infection control was delegated to Infectious Disease Physician #1. When asked if a patient needed a physician's order for isolation, the Medical Director stated, "Yes, I thought that was a requirement..." The Medical Director stated the hospital had lost the Infection Control Nurse when the present company took over the hospital. The Medical Director stated he was not aware of anyone designated full time as the Infection Control Nurse but the responsibility was delegated to the Chief Clinical Officer.

During an interview in the conference room on 8/14/18 at 9:25 AM, the Interim Nurse Manager confirmed all staff members including physicians should wear both a gown and gloves when entering the room of a patient with contact precautions in place.

Based on policy review, facility document review, medical record review, observation and interview, the facility failed to ensure the Chief Executive Officer (CEO), Medical Staff, and Director of Nursing Services/Chief Clinical Officer (CCO) addressed identified problems with infection control and implemented successful corrective action plans.

The findings included:

1. Review of the facility's "Infection Control Plan" policy revealed, "...The infection control (IC) plan defines the structure and activities for surveillance, prevention, and control of infections among patients, employees, and all others who may come into contact with patients and establishes responsibility for oversight of these activities...Authority: A qualified individual will be appointed as the Infection Control Preventionist (ICP). The ICP has clinical authority over the infection control program. The ICP is responsible for the daily management of infection control activities and developing/implementing policies governing control of infection and communicable diseases. The ICP is responsible for the system of identifying, reporting, investigating and controlling infections and communicable diseases. The ICP will have access to all medical records needed for infection control and prevention activities...Infection Control Committee Authority Statement...This committee and will, through its chairperson, the ICP, and all members, have the authority under the medical staff bylaws to institute appropriate control measures when and if an infectious hazard is identified or anticipated that may affect any patient, visitor, or employee...Goals...Limiting unprotected exposure to pathogens...Limiting the transmission of infections associated with procedures...Limiting the transmission of infections associated with the use of medical equipment, devices, and supplies...improving compliance with hand hygiene guidelines..."

Review of the facility's "Guidelines for Isolation Precautions" policy revealed, "...PURPOSE...To establish guidelines for Isolation precautions to meet the following objectives...to recognize the importance of all body fluids, secretions and excretions in the transmission of nosocomial pathogens...to contain adequate precautions for infections transmitted by the airborne and contact routes of transmission...The [named corporation] will have two sets of isolation precautions...In the second tier are precautions designed only for the care of specified patients. These additional 'Transmission-based Precautions' are used for patients known or suspected to be infected or colonized with epidemically important pathogens which can be transmitted by airborne or droplet transmission or by contact with dry skin or contaminated surfaces...Handwashing and Gloving...Washing hands as promptly and thoroughly as possible between patient contacts and after contact with blood, body fluids, secretions, excretions and equipment of articles contaminated by them is an important component of infection prevention control and isolation precautions...gloves must be changed between patient contacts and hands are washed after gloves are removed...Wearing gloves does not replace the need for handwashing because...gloves may have small inapparent defects or be torn during use, and...hands can become contaminated during removal of gloves...Noncritical equipment contaminated with blood, body fluids, secretions or excretions and disinfected after use..."

2. The CEO failed to designate an Infection Control Officer who was qualified through education, training, experience or certification to develop and implement policies governing control of infections and communicable diseases. Refer to A 748.

3. The CCO failed to ensure measures to prevent the potential spread of infection during wound assessment and treatment and the policy for isolation precaution were followed by staff. Refer to A 749.

4. During an interview in the conference room on 8/13/18 at 2:42 PM, Infectious Disease Physician #1 stated he used to be the Chairman of the Infection Control Committee, but now the committee was "defunct." Infectious Disease Physician #1 stated he could not remember the last time the Infection Control Committee met and was unsure if the committee was presently in existence. Infectious Disease Physician #1 stated he was the only infectious disease physician at the hospital. Infectious Disease Physician #1 stated he was on the Medical Executive Committee (MEC), but he was unable to remember the last time the committee met. Infectious Disease Physician #1 stated the Infection Control Nurse was responsible for putting patients in isolation, putting up the isolation precaution signs and informing staff, patients and family about isolation precautions. When asked if the hospital had a current Infection Control Nurse, Infectious Disease Physician #1 stated, "...I don't know if one exists..."

During a telephone interview on 8/13/18 at 3:35 PM, the Medical Director stated the MEC has had one meeting since (named corporation) had taken over the hospital. The Medical Director stated Infection Control was delegated to Infectious Disease Physician #1. The Medical Director stated the hospital lost the Infection Control Nurse when (named corporation) took over. The Medical Director stated he was not aware of anyone designated as the Infection Control Nurse, but the responsibility was delegated to the CCO.

During an interview in the conference room on 8/14/18 at 9:23 AM, the Interim Nurse Manager stated patients were put in isolation after their lab sheets came back. When asked if patients needed a physician's order to be put in isolation, the Interim Nurse Manager stated, "...they're supposed to...we were told that by [Named Accreditation Agency][Accreditation survey was completed 6/14/18]..." The Interim Nurse Manager stated staff were expected to put on gown and gloves before entering the room and perform hand hygiene upon entering and leaving the room. When asked if the expectations for donning personal protective equipment included physicians, the Interim Nurse Manager stated, "Yes."