HospitalInspections.org

Based on observation, record review and interview, the facility failed to track and trend patient grievances, failed to ensure patient safety interventions are implemented for 3 of 5 patients (Patient #1, Patient #2, Patient #5) and failed to protect the patient's right to privacy for 10 of 10 inpatients on the Traumatic Brain Unit (Patient #1, Patient #2, Patient #3, Patient #4, Patient #5, Patient #9, Patient #10, Patient #11, Patient #12, Patient #13), out of a total census of 38 patients. The cumulative effect of these deficiencies has the potential to affect all 38 patients at this facility at the time of the survey.

Findings include:

Patient complaints and grievances are not tracked, trended and resolved per policy. See tag A119.

Video monitoring is not used as authorized by the physician and in conjunction with privacy policies for 10 of 10 patients. See tag A143.

Interventions are not implemented to protect patient safety. See tag A144.

Based on record review and interview, facility staff failed to track, trend and respond to patient grievances per policy in 1 of 1 grievance procedure reviewed (Complaint/Grievance Process).

Findings include:

Review of facility policy "Patient Complaint/Grievance Process" dated 9/17/2015 revealed "If the complaint cannot be resolved at the time of the complaint by staff present, is postponed for later resolution, is referred to other staff for later resolution, requires investigation, and/or requires further actions for resolution, then the complaint is a grievance..." The policy goes on to describe the process for responding to and resolving grievances, including "Initiate the Complaint and Grievance form. 9. Once action has been taken: ...b. Ascertain whether or not THEY consider the matter resolved. 10. If resolution has been expressed by the complainant: a. Complete the complaint log with the resolution."

During an interview on 2/14/2018 at 3:00 PM, Plant Operations Area Manager D stated complaints of cold water were brought to Plant Operations Manager L's attention beginning on 1/13/2018 via email from staff. Review of the email logs in which complaints of water temperatures were sent to Plant Operations Manager L include: room 218 on 1/15/2018; room 218 on 1/18/2018; rooms 116, 126, 121, 212, 220, 222, 118, 103 and 113 on 1/24/2018; rooms 111, 116, 214, 113, 222, 121, 220 and the suite tub on 1/25/2018. During an interview on 2/14/2018 at 9:10 AM, Chief Clinical Officer A stated " It was a big project, parts needed to be replaced on 160 faucets. Everything was resolved sometime early February."

In an email dated 1/25/2018, Staff P wrote "We waited approximately 10 minutes in the shower for the water to warm up, but it remained cold. The patient is very upset about this." Additional emails show that there were at least 5 other patients that were unable or refused to shower due to cold water temperatures from 1/18/2018 to 1/26/2018.

An all staff email was sent by Quality Director C on Friday, 1/26/2017 stating "If you have any patients that you feel are very upset by this over the weekend, please provide a list to [sic] the Charge nurse and we will go meet with those patients."

Review of the facility's complaint and grievance log revealed the facility had only one grievance on file, dated 7/10/2017. There is no evidence that any of the complaints received related to water temperatures were tracked and responded to per the facility's grievance policy. During an interview on 2/14/2018 at 12:00 PM, Quality Director C stated "we only track grievances, not complaints. Most complaints we receive can be resolved right away."

Based on observation, record review and interview, the facility failed to ensure video surveillance can only be viewed by authorized personnel; failed to obtain orders for video surveillance in 3 of 3 patients that had received video surveillance monitoring (Patient #1, Patient #2, Patient #5); and failed to ensure video monitoring is limited based on clinical need per policy in 12 of 12 patient rooms with video monitoring capabilities (Rooms 201-212).

Findings include:

Review of facility policy "Patient Surveillance Monitoring" dated 9/17/2015 revealed "Surveillance monitoring through the use of video monitoring is utilized to help maintain patient and others safety while maintaining the patient's privacy, and will only be seen by authorized hospital personnel. The physician may authorize use of camera surveillance with input from the interdisciplinary team working with the patient. ...A sign will be placed in the patient room to remind the patient and visitors when the camera is on to protect their privacy as much as possible. Procedure: B. Nurse will enter an order every 24 hours into Health Link listing rationale for video monitoring. C. Place a sign in the patient's room to remind the patient and visitors when the camera is on to protect their privacy as much as possible. ...H. Assessment for ongoing need will occur daily."

The facility's TBI (Traumatic Brain Injury) unit consists of 12 patient rooms with 10 inpatients on 2/14/2018. On 2/14/2018 at 9:05 AM, Nursing Assistant G was sitting at the nursing station in front of the video monitoring screen. The screen had 2 patient rooms on it at the time of observation and was facing the entrance of the unit, making it viewable to all staff, visitors and patients entering the unit. During an interview with Nursing Assistant G on 2/14/2018 at 9:05 AM, G stated all the rooms on the unit have cameras and the cameras are "on all the time, I can peek [in any room] at any time." When asked who G was currently monitoring, G stated "room 202 [Patient #1] and room 203 [Patient #2]." When asked when other patients might be viewed, G stated "when we are doing frequent checks or accounting for patients."

During an interview on 2/14/2018 at 10:30 AM, Nursing Assistant I stated "when I am scheduled for monitoring I basically just sit there, sometimes I get up and help with [patients]." I stated that "all the patients are pulled up on the screen" if there are no patients ordered for video monitoring and staff can watch everyone from the nurses station.

During an interview on 2/14/2018 at 12:00 PM, when asked about signage in rooms to notify patients when they are being observed via video monitoring, Nursing Assistant G stated "the signs are posted in all the rooms all the time." During observation of the TBI unit on 2/14/2018 at 12:15 PM, patient rooms were observed to have the following permanent sign attached to the wall "Please Note: This room is monitored by video feed to the nurse station. This provides an extra measure of safety as we are able to remotely monitor the room when a staff member is not present. This video is not recorded."

Per medical record review, Patient #1 was admitted to the TBI unit on 2/4/2018. Patient #1's orders include an order for "Evaluate for Constant Observation" dated 2/7/2018 and 2/12/2018. The order does not include type of constant observation. Patient #1's constant observation flowsheet documents the use of video monitoring on 2/6/2018 and 2/7/2018 and the type of constant observation is documented as "Patient Safety Attendant" on 2/8/2018 through 2/13/2018. Review of the TBI unit staffing logs reveal Patient #1 was on video monitoring and not assigned a Patient Safety Attendant on 2/10/2018, 2/11/2018, 2/12/2018, 2/13/2018 and 2/14/2018.

Per medical record review, Patient #2 was admitted to the TBI unit on 2/2/2018. Patient #2's constant observation flowsheet documents the type of constant observation as "video monitoring" daily on 2/9/2018 through 2/14/2018. There is no order for video monitoring in Patient #2's medical record.

Per medical record review, Patient #5 fell at the facility on 2/10/2018. After the fall, staff documented "New intervention to monitor patient closely on the monitor at the nurses station..." There are no orders in Patient #5's chart for video surveillance monitoring. Patient #5's constant observation flowsheet includes documentation that video surveillance was used to monitor Patient #5.

During an interview at the time of the review on 2/14/2018 at 12:50 PM, Nurse Manager B stated "I'm not sure about the constant observation orders." When asked about the policy for orders every 24 hours, Nurse Manager B stated "they aren't there [in the records]."

Based on record review and interview, the facility failed to perform patient safety rounds as indicated for 2 of 2 patients requiring constant observation (Patient #1, Patient #2) and failed to ensure high fall risk interventions are implemented per policy for 2 of 5 high fall risk patients reviewed (Patient #1, Patient #5).

Findings include:

Per medical record review, Patient #1 was admitted to the facility on 2/4/2018 with an intervention of "Constant Observation" since admission. On 2/13/2018 at 11:00 PM, nursing documentation noted "yes" under constant observation for behaviors of "Attempts to get out of bed/chair without assistance." Review of Patient #1's Constant Observation Log includes a section for documentation titled "Patient Safety Observer -- RN or NA [Registered Nurse or Nursing Assistant] to document every 4 hours." There was no documentation on the log for 2/14/2018 at the time of the review on 2/14/2018 at 12:50 PM. The last documentation was on 2/13/2018 at 11:00 PM. The last documented safety round under "Patient Safety Attendant - document every 1 hour" was on 2/13/2018 at 11:00 PM.

Per medical record review, Patient #2 was admitted to the facility on 2/2/2018. An intervention of "Constant Observation" was initiated on 2/4/2018 for "Confused and pulling at lines/drains/airway." On 2/13/2018 at 11:00 PM, the RN documented "yes" under constant observation and under Status "Continue." Review of Patient #2's Constant Observation Log includes a section for documentation titled "Patient Safety Observer -- RN or NA to document every 4 hours." There was no documentation on the log for 2/14/2018 at the time of the review on 2/14/2018 at 1:50 PM. The last documentation was on 2/13/2018 at 11:00 PM. The last documented safety round under "Patient Safety Attendant - document every 1 hour" was on 2/13/2018 at 11:00 PM.

These findings were confirmed at the time of the review on 2/14/2018 at 1:50 PM with Nurse Manager B. Nurse Manager B stated "all patients are rounded on hourly." When asked if the rounds are expected to be documented, B stated staff "can go in and document the hourly rounds and enter the time they were performed." When asked if there was a time frame within rounds are expected to be documented after they occur, Nurse Manager B stated "I can see how that [not documenting in real time] would be a problem."

Review of facility policy "Fall Prevention and Risk Assessment" dated 11/14/2016 revealed "High Risk Fall Prevention Interventions. These interventions should be in place for any patient who may require a higher level of fall risk awareness and interventions... d. Remain in arms reach of the patient while in the bathroom. e. Perform frequent safety checks."

During an interview on 2/14/2018 at 12:25 PM, Patient #1's spouse pointed to a sign posted on Patient #1's bathroom door. The sign read: "High Fall Risk Guidelines--High Fall Risk Interventions: Stay with patient while toileting." Patient #1's spouse stated "They are supposed to be staying with [Patient #1] in the bathroom, they don't do that all the time." There is no documentation in Patient #1's chart that staying with Patient #1 in the bathroom is being used as a fall prevention intervention.

Per medical record review, Patient #5 fell at the facility on 2/6/2018 and 2/10/2018. The Fall Occurrence Note documented on 2/6/2018 at 11:13 PM revealed: "Where did the fall occur: Bathroom. ...Patient pulled bathroom call light. Found on right side with head next to toilet and feet near door." Per RN notes, Patient #5 was found to be incontinent of both bowel and bladder at the time of discovery in the bathroom. The post-fall interventions include a toileting regimen. There is no documentation that a toileting regimen was implemented as part of Patient #5's safety and fall prevention plan. Review of the second Fall Occurrence Note for Patient #5, documented on 2/10/2018 at 10:35 AM, revealed: "Where did the fall occur: Bathroom. ......Patient was found on the bathroom floor on [right] side next to the toilet."

Based on record review and interview, the facility failed to use daily monitoring logs for early identification and mitigation of potential problems affecting quality of care in 1 of 3 physical environment indicators reviewed (Water Temperature).

Findings include:

During an interview on 2/14/2018 at 9:15 AM, Chief Clinical Officer A stated "we had a water temperature problem for a few weeks, it's resolved now."

During an interview on 2/14/2018 at 3:00 PM, Plant Operations Area Manager D stated the first complaint of hot water was brought to Plant Operations Manager L on 1/13/2018 via email from staff. Review of the email dated 1/13/2018 stated "The shower in room 126 didn't get warm enough when we tried to shower in OT today." Plant Operations Manager L stated on 2/14/2018 at 3:00 PM "I adjusted the stops on the mixing valve on the shower" in room 126 in response. Per L, the problem was only identified in one individual room at the time. Review of the email logs in which complaints of water temperatures were sent to Plant Operations Manager L include: room 218 on 1/15/2018; room 218 on 1/18/2018; rooms 116, 126, 121, 220, 222, 118, 103 and 113 on 1/24/2018.

In an email dated 1/18/2018, Staff N wrote "We have to do our OT [Occupational Therapy] shower eval for performance day tomorrow morning and the patient is unwilling to come down to the [OT] suite to take a shower if [patient's shower] isn't warming up."

In an email dated 1/24/2018, Staff O wrote "My patient is refusing Pday [performance day] shower because of cold water temp."

In an email dated 1/25/2018, Staff P wrote "We waited approximately 10 minutes in the shower for the water to warm up, but it remained cold. The patient is very upset about this."

In an email dated 1/25/2018, Staff Q wrote "...same goes for 111, 113, 222. I also have a patient declining a pday shower."

In an email dated 1/25/2018, Staff R wrote, "The shower in 121 and 220 is still not getting warm enough. The pt. declined a pday shower."

In an email dated 1/26/2018, Staff S wrote, "Unable to give shower for OT evaluation today due to water temperature too cold."

Per review of the facility's Daily Mechanical Room/Equipment Checks sheet, water temperatures of water heaters and domestic water is monitored daily. Return temperature of "Domestic H2O" includes a comment for a desired temperature "above 124 deg. F." Review of the daily temperatures logged on the sheet reveal temperatures below 124 degrees from 1/15/2018 through 2/8/2018. Temperatures on the dates of complaints regarding water temperatures include: 1/15/2018: 114 degrees; 1/18/2018: 108 degrees; 1/24/2018: 106 degrees; 1/25/2018: 98 degrees; 1/26/2018: 104 degrees.

During an interview on 2/14/2018 at 3:00 PM, Plant Operations Manager L stated L performs the temperature checks daily. When asked about actions taken when the temperature is below the desired range of 124 degrees, L stated "I wasn't sure of the significance of the temperature. Now I know."

Based on record review and interview, facility staff failed to document progress toward goals on patient care plans in 2 of 2 patient care plans reviewed (Patient #4, Patient #5).

Findings include:

Review of facility policy "Plan of Care -- Individualized and Interdisciplinary" dated 9/17/2015 revealed "3. The plan is continuously evaluated and monitored for effectiveness in meeting its intended goals at team conferences, with updates or modifications a minimum of weekly or as necessary to monitor: A. Effectiveness in meeting the goals of the plan of care... B. Modifications are made to the plan of care and resource allocations are made based on reassessment of the patient at specific intervals and related to the following elements: 1. Progress toward goals 2. Failure to make progress..."

Review of facility policy "Fall Prevention and Risk Assessment" dated 11/14/2016 revealed "3. The FRS [Fall Risk Screen] obtained through the designated fall risk screening tool is discussed as part of the Interdisciplinary Team conference to determine and implement appropriate interventions for fall risk reduction. 4. Patients are subsequently re-screened for fall risk with a change of condition... 5. The current re-screen fall risk score is discussed at the IMOC [Interdisciplinary Model of Care] conference to address any individual patient care needs as related to fall risk. ...The fall risk score and current fall risk status is discussed as part of the IMOC rounds." The procedure to follow after a patient has fallen includes: "12. Nursing leadership responsibilities: ...c. i. Confirm plan of care is complete and updated."

Per medical record review, Patient #4 was admitted to the facility on 2/8/2018. A focus/problem area of Safety: At high risk for falls/injury was established on Patient #4's care plan on 2/8/2018. The plan includes a goal of "Patient will remain free from falls" with an estimated completion date of 2/22/2018. Patient #4 fell at the facility on 2/10/2018. Review of Patient #4's weekly IMOC conference notes, dated 2/13/2018, do not address current fall risk or Patient #4's fall. There is no update to the care plan regarding goal status or progress toward goal of remaining free from falls.

Per medical record review, Patient #5 was admitted to the facility on 2/1/2018. A focus/problem area of Safety: At high risk for falls/injury was established on Patient #5's care plan on 2/1/2018. The plan includes a goal of "Patient will remain free from falls" with an estimated completion date of 2/8/2018. Patient #5 fell at the facility on 2/6/2018 and 2/10/2018. Review of Patient #5's weekly IMOC conference notes, dated 2/12/2018, do not address Patient #5's falls. There is no update to the care plan regarding goal status or progress toward goal of remaining free from falls.

During an interview on 2/14/2018 at 4:00 PM, when asked about documenting progress toward goals on the patient care plans, Quality Director C stated "we're not documenting on the care plans like we should."