HospitalInspections.org

Based on observation, interview, record review, and policy review, the facility failed to ensure that staff:
- Assessed, re-assessed, and documented assessments for one patient (#8) of one patient reviewed after being seen in the Emergency Department (ED) and returned to the facility with a leg fracture and a knee brace in place;
- Properly performed post fall assessments for nine patients (#1, #8, #9, #11, #12, #13, #14, #15, and #16) of nine patients reviewed;
- Performed proper insulin verification for three patients (#3, #6, and one unknown patient) of three patients observed; and
- Administered medication in a timely manner for two patients (#5 and #6) of six patient observed.
The facility census was 21. These failures increased the risk of injury for all patients admitted to the facility.

After the Centers for Medicare & Medicaid Services (CMS) reviewed the details of the survey, it was determined that the severity of these practices had the potential to place all patients at risk for their safety, also known as Immediate Jeopardy (IJ).

On 11/22/19, the facility was notified of the IJ and the staff created educational tools and began educating all staff and put into place interventions to protect the patients.

On 11/22/19, the facility had provided an immediate action plan sufficient to remove the IJ by implementing the following:
- Education of all clinical staff on the assessment and re-assessment of patients;
- Education of all clinical staff on the fall reduction program;
- Completion of a post fall debriefing form after each patient fall;
- A post fall leadership checklist will be implemented and completed within two hours of a patient fall;
- A re-assessment checklist will be implemented and completed within two hours of a patient returning from a different level of care;
- All clinical staff will be educated prior to the beginning of their next scheduled shift; and
- Clinical leadership will complete audits of all patient falls and all patients returning from a different level of care.

Based on interview, record review and policy review the facility failed to:
- Ensure there were Physician orders for the use of restraints, prior to the application of the restraint for two current patients (#1 and #26), and three discharged patients (#8, #24 and #25), of five restraint patients reviewed.
- Implement the restraint type ordered by the physician for one current patient (#1), and three discharged patients (#8, #24 and #25) of five restraint patient charts reviewed.
- Ensure the physicians order for restraint were written/authorized every 24 hours by a physician prior to the application of a restraint for one current patient (#1), and three discharged patients (#8, #24, and #25) of five restraint patients reviewed.
These failures created an unsafe environment and had the potential to place all patients admitted to the facility at risk for their safety. The facility census was 21.

Findings included:

Review of the facility's policy titled, "Restraints and Seclusion," revised 10/2018 showed the following:
- A physical restraint is any manual method or physical or mechanical device, material or equipment attached or adjacent to the patient's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's own body.
- Devices which serve multiple purposes, for example a geri-chair (a large, padded chair that is designed to help patients with limited mobility), and side rails up times four (the adjustable sides of a hospital bed including two rails on each side of the bed) are considered to be restraints if they restrict a patient's movements and cannot be easily removed by the patient.
- Restraint is used ONLY to meet the patient's individual clinical needs.
- Restraint must be the least restrictive (the restraint that permits the most freedom of movement to meet the needs of the client) intervention that protects the patient's safety when other alternatives have failed.
- Restraint must be ordered by a physician.
- If a physician is not available to issue an order a Registered Nurse (RN), could initiate restraint use based on an appropriate assessment of the patient. In that case, the physician is notified as immediately as clinically possible, for the initiation of restraint, and a telephone order is obtained from the physician and entered into the patient's medical record.
- A written order, for any type of restraint, based on an examination of the patient by the physician is entered into the patient's medical record on a daily basis when restraint use is clinically appropriate.
- Restraint is a high-risk, potentially harmful procedure that is intended to be used only when a patient's behavior interferes with medical treatment and less restrictive methods have not succeeded.
- Physicians and RN's are trained in the assessment of restraint need, the restraint order process, time frames for and processes of reassessments.
- Orders for restraints must be renewed on a daily basis.
- The original order may only be renewed (in accordance with age limits) for up to a total of 24 hours, and, thereafter, a physician must see and assess the patient before issuing a new order.

Review of Patient #1's medical record showed the patient was in soft wrist restraints to both right and left wrists, with no signed or verbal physician orders documented on the following dates:
- 08/05/19 at 7:15 AM;
- 08/07/19 at 10:00 PM;
- 08/17/19 at 10:00 AM, 12:00 PM, 2:00 PM, 4:00 PM and 6:00 PM;
- 08/18/19 at 10:00 AM, 11:00 AM, 12:00 PM, 1:00 PM and 2:00 PM; and
- 08/26/19 at 12:30 AM.

Review of Patient #8's medical record showed the following:
- On 08/05/19 at 8:00 PM, nurse restraint documentation reported the patient was placed in secured/tied mittens (a type of restraint involving closed padded gloves that tie onto the bed) on the right and left hands. There were no physician orders for restraints documented on this day.
- On 08/06/19 at 8:00 PM, nurse restraint documentation showed the patients side rails were up times four, secured/tied mittens to the right and left hands, unsecured/untied mittens (a type of restraint involving closed padded gloves that do not attach to the bed) placed on the right and left hands, and soft wrist restraints (a restraint involving a padded cuff that goes around the wrist and attaches to the bed) to the right and left wrists were in place. The physician orders on 08/06/19 at 6:58 AM, were for tied mittens to both right and left hands.
- On 08/08/19 at 4:00 AM, nurse restraint documentation showed the patient was restrained with the side rails up times four, secured/tied mittens to the right and left hands and unsecured mittens to the right and left hands. There were no physician orders for any restraints documented for this day.
- On 08/08/19 at 8:00 PM, nurse restraint documentation showed the patient was restrained with the side rails up times four, secured/tied mittens on the right and left hands, unsecured/untied mittens to the right and left hands, soft wrist restraints to the right and left wrists and ankles, a lap tray (a type of restraint involving a tray that fits over the lap), a wheelchair belt loop (a type of restraint involving a padded belt that wraps around the waist and the back of the wheelchair) and an enclosure bed (a type of restraint involving a collapsible frame with a net canopy that goes over the patient bed). There were no physician orders for restraints documented on that day.
- On 08/12/19 at 7:00 AM, 8:00 AM, 9:00 AM, 10:00 AM and 11:00 AM, nurse restraint documentation showed the patient was restrained with the side rails up times four, secured/tied mittens on the right and left hands and soft wrist restraints for the right and left wrists in place. The physician orders on 08/12/19 at 7:48 AM, were for tied mittens to the right and left wrists and hands. There were no physician orders for restraints documented on that day.
- On 08/14/19 at 9:52 PM, the nurse restraint documentation showed the patient was restrained with secured/tied mittens to the right and left hands, and soft wrist restraints to the right and left wrists. The physician orders documented on 08/14/19 at 7:00 AM and 7:33 AM, were for untied mittens to the right and left hands.

Review of Patient #24's medical record showed the following:
- On 10/11/19 at 10:00 AM and 12:00 PM, nurse restraint documentation showed the patient was restrained with side rails up times four and soft wrist restraints to the right and left wrists. There were no physician orders documented in the patient record for that day.
- On 10/12/19 at 10:00 PM, nurse restraint documentation showed the patient was restrained with the side rails up times four and unsecured/untied mittens to the right and the left hands. The physician orders on 10/12/19 at 9:46 AM, were for unsecured/untied mittens to the right and left hands.
- On 10/16/19 at 6:00 AM the physician ordered restraints for mittens untied and side rails up times four with no additional documentation to support the use of a double restraint.
- On 10/18/19 at 10:00 PM, nurse restraint documentation showed the patient was restrained with unsecured/untied mittens to the right and left hands. There were no physician orders for restraints documented for that day.

Review of Patient #25's medical record showed the following:
- On 10/17/19 at 8:00 AM, 10:00 AM, 12:00 PM, 2:00 PM, 4:00 PM and 6:00 PM, the nurse restraint documentation showed the patient was restrained with soft wrist restraints to the right and left wrists. There were no physician orders for restraints documented in the medical record on that day.
- On 10/20/19 at 2:00 AM, the nurse restraint documentation showed the patient was restrained with unsecured/untied mittens to the right and left hands. The physician orders on 10/19/19 at 6:22 AM, and on 10/20/19 at 6:26 AM, were for soft wrist restraints to the right and left wrists.
- On 10/21/19 at 6:11 AM, the nurse restraint documentation showed the use of secured/tied mittens to the right and left hands. The physician orders on 10/21/19 at 7:00 AM, were for soft wrist restraints to the right and left wrists.

Review of Patient #26's medical record showed that on 11/03/19 at 1:45 AM, 3:45 AM, 5:45 AM and 7:48 AM, the nurse restraint documentation showed the patient was in soft wrist restraints to the right and left wrists. There were no physician orders for restraints documented in the medical record for 11/03/19.

During an interview on 11/05/19 at 2:20 PM, Staff C, RN, stated that staff were required to obtain a physician's order for all restraints, and even if more than one restraint was ordered, staff were not allowed to apply multiple devices.

During an interview on 11/05/19 at 8:35 AM, Staff B, Director of Quality Management, stated that:
- Staff were required to obtain a physician's order for any type of restraint.
- The use of four side rails in an up position on the bed would be considered a restraint.
- The use of four side rails and wrist restraints at the same time would be considered double restraints.

During an interview on 11/05/19 at 2:00 PM, Staff A, Chief Nursing Officer (CNO), stated that:
- All restraints required a physician's order.
- There were several gaps and holes in the nursing documentation.
- Per their policy the facility required a new physician order for each restraint.

The facility failed to follow their policy on restraint and seclusion which placed all patients in the facility at risk for serious harm.

Based on observation, interview, record review, and policy review, the facility failed to ensure that staff assessed, re-assessed, and documented assessments for one patient (#8) of one patient reviewed after returning from an Emergency Department (ED) and returned to the facility with a leg fracture and a knee brace in place; and properly performed post fall assessments for nine patients (#1, #8, #9, #11, #12, #13, #14, #15, and #16) of nine patients reviewed.
The facility census was 21. These failures increased the risk of injury for all patients admitted to the facility.

Findings included:

1. Review of the facility's policy, titled "Fall Reduction Program," dated October 2017, showed the directives for staff to:
- Perform a post fall assessment that must include vital signs, location and quality of any pain, complete neurological and vascular assessment, observation for fractures, especially hip fracture with leg shortening, abduction (the movement of a limb inward from the center of the body), external rotation (the movement of a limb outward from the center of the body); bruising; and lacerations (a cut or tear in the skin);
- Revise the plan of care immediately regardless of injury to the patient;
- Notify the physician, with complete assessment information, the administrator on call, and the family;
- Perform and document neurovascular checks and vital signs every 15 minutes times four, every hour times four, every two hours times four, and every four hours times three;
- Complete an incident/event report; and
- Complete a post fall debriefing form and forward to the Chief Nursing Officer (CNO)/Director Quality Management (DQM).

Review of the facility's Fall Log showed that Patient #8 experienced a fall on 08/02/19 and 08/24/19.

Review of the facility's Event Occurrence Executive Summary dated 08/02/19 showed that the patient was in right and left wrist restraints, threw her legs over the bed rails and slid between the rails to the floor.

Review of the facility's Event Occurrence Executive Summary dated 08/24/19 showed that the patient was found sitting on a mat on the side of the bed.

Review of the patient's medical record showed that staff did not document a post fall assessment for either fall experienced by the patient on 08/02/19 or 08/24/19. The record did not contain documentation of vital signs (blood pressure, heart rate and respirations), neuro checks (level of consciousness) or assessment for signs and symptoms of injury. The patient's plan of care was not updated after either fall.

Review of Progress Notes dated 09/04/19 showed that Staff P, Registered Nurse (RN), documented that the patient was transferred to a local ED, Hospital A, because of results of the x-ray of the left knee completed at the facility.

Review of the ED record from Hospital A dated 09/04/19 showed that patient had fallen about one week ago but hospital staff was unsure of the circumstances. Staff reported that the patient had left knee swelling for a week, with slight increased warmth and bruising noted. The patient had x-rays done today that showed a distal femur fracture (above the knee break). Orthopedics (medical specialty in bones) consulted and recommended an immobilizer. An ace wrap and immobilizer was applied to the left knee. The patient was discharged back to the facility with knee/leg immobilizer in place.

Review of the Radiology Report dated 09/04/19 showed that the patient likely had an acute (abrupt onset), comminuted (fracture producing multiple bone splinters) of the left distal femur.

Review of the patient's medical record showed that facility staff failed to document assessment of the patient when she returned from the ED on 09/04/19 that included her left knee fracture, left knee/leg immobilizer and the condition of the skin under the left knee/immobilizer. Staff failed to document re-assessments of the patient's left knee fracture, left knee/leg immobilizer and the condition of the skin under the left knee/leg immobilizer from the time she returned from the ED on 09/04/19 through her discharge from the facility on 09/18/19 for a total of 14 days.

During interview on 10/29/19 at 10:34 AM, Staff A, RN, CNO, stated to date the facility had not performed any Root Cause Analysis (RCA, a systematic process for identifying causes of problems or events and finding ways to prevent them) post patient falls because no falls had resulted in significant patient injury/injuries that required a RCA to be conducted by the facility.

During interviews on 10/30/19 Staff A, RN, CNO, stated that:
- At 9:50 AM, Staff A stated that she expected staff to perform a head-to-toe assessment after a patient fall and for that assessment to be documented in the patient's medical record;
- At 3:22 PM, Staff A stated that the patient's medical record did not have any documentation related to the patient's left knee fracture upon return from the ED on 09/04/19 until her discharge on 09/18/19;
- Staff did not document the patient had a left knee/immobilizer in place upon return from the ED on 09/04/19 through her discharge on 09/18/19; and
- Staff did not document the condition of the patient's skin under the left knee/leg immobilizer upon return from the ED through her discharge on 09/18/19.

During an interview on 10/30/19 at 2:00 PM, Staff B, RN, DQM, stated that the patient did not have post fall assessments that included vital signs, neuro checks or assessment for signs and symptoms of injury documented in the medical record for either un-witnessed fall on 08/02/19 or 08/24/19. Staff B stated that the patient's plan of care was not updated after the falls.

During an interview on 11/04/19 at 3:48 PM, Staff N, Physician, stated that:
- He expected staff to document in the medical record a post fall assessment after a patient had experienced a fall.
- The patient could become very agitated and would hit her legs against the bed rails.
- When he assessed the patient, her left knee did not have any bruising or blood collection to indicate an acute fracture.
- He did not feel like the patient's fracture was acute because it did not have signs or symptoms that it occurred within 24 to 48 hours.
- Normally you would see blueness of deep tissue from blood from a fractured bone.
- The patient was sent to the ED for new onset of left knee swelling and agitation (possible sign of pain) to obtain x-rays and have an orthopedic consult (09/04/19).
- In elderly patients, because of slow healing and non-healing of fractures it is hard to determine the age of a fracture.
- With a clinical exam that shows hematoma (collection of blood) or blue coloration of the deep tissues would be a sign of acute fracture and not a fracture of undetermined age.

During a telephone interview on 11/07/19 at 14:58 PM, Staff H, RN, stated that:
- She did not recall if she was the patient's primary care nurse when the patient fell on 08/24/19 and she did not recall the specific events of the patient's fall. (Review of the Event Occurrence Executive Summary, Fall Debriefing and Interview Worksheet, Nursing Progress Notes and Flowsheets dated 08/24/19, Staff H was assigned and involved in the post fall activities).
- When a patient experienced either a witnessed or non-witnessed fall staff are responsible to ensure the patient was safe by performing a head-to-toe assessment to check for injuries, check the patient's vital signs and do neuro checks.
- She did not recall if she documented the post fall assessment that included a head-to-toe assessment, vital signs or neuro checks into the patient's medical record.
- She was not sure if the electronic medical health record had a post fall form for staff to utilize to document post fall assessments.
- The facility did not have a paper form that staff utilized to document post fall assessments on.
- The facility provided training/education related to falls during orientation and during yearly competencies, however, she did not recall elements on the fall modules and the last date of the competencies was sometime in 2018.

Review of documents from the facility, Hospital A, Hospital B, Hospital C and the Nursing Home showed the following time line of events:
- The patient experienced an un-witnessed fall on 08/02/19 and 08/24/19.
- The patient was sent to Hospital A's ED on 09/04/19 for x-rays of the left knee/leg that showed she had a fractured knee.
- The patient was discharged from the facility on 09/18/19 and transported by ambulance to a Nursing Home.
- The patient was transferred from the Nursing Home to Hospital B's ED per ambulance on 09/19/19 at 12:06 AM and at 5:05 AM was transported by ambulance from Hospital B back to the Nursing Home.
- The patient was transported by ambulance from the Nursing Home to Hospital C's ED on 09/19/19 at 2:00 PM.
- When Hospital C's ED staff removed the patient's left knee/leg immobilizer, it was noted that the fractured bone protruded through the skin.
- The patient was admitted to Hospital C's PCU.
- Per consultation provided by Hospital C's orthopedic group, the patient may require surgical repair of her fractured left knee.
Facility staff failed to document post fall assessments after she experienced two un-witnessed falls that included vital signs, neuro checks or signs/symptoms of injury. Facility staff failed to document assessment of the patient's left fractured knee, left knee/leg immobilizer or the condition of the skin under the immobilizer upon return from Hospital A's ED on 09/04/19 through her discharge from the facility on 09/18/19, for a total of 14 days.

These failures by the facility placed all patients at increased risk for serious injury/harm for their safety and health related to assessments, re-assessments and falls.

Record review of Patient #11 showed the patient fell on 05/13/19 at 5:30 AM with:
- No revisions were made to the care plan.
- Neurovascular checks performed at 7:30 AM, 8:00 AM, 9:25 AM, 12:30 PM, and 1:30 PM.
- No vital signs were documented.

Record review of Patient #12 showed the patient fell on 06/06/19 with:
- No revisions were made to the care plan.
- No nurses' notes were documented regarding the fall.
- No vital signs were documented.
- No neurovascular checks were documented.
- No post fall debriefing form was completed.

Record review of Patient #13 showed the patient fell on 07/01/19 with:
- No revisions were made to the care plan.
- No nurses' notes were documented regarding the fall.
- No vital signs were documented.
- No neurovascular checks were documented.

Record review of Patient #14 showed the patient fell on 07/31/19 with:
- No revisions were made to the care plan.
- No nurses' notes were documented regarding the fall.
- No vital signs were documented.
- No neurovascular checks were documented.
- No post fall debriefing form was completed.

Record review of Patient #16 showed the patient fell on 09/01/19 at 6:30 AM with:
- No revisions were made to the care plan.
- No neurovascular checks were documented.
- Vital sign documentation only at 7:02 AM, 7:23 AM, 10:25 AM, and 1:41 PM.

Record review of Patient #15 showed the patient fell on 09/12/19 with:
- No revisions were made to the care plan.
- No nurses' notes were documented regarding the fall.
- No vital signs were documented.
- No neurovascular checks were documented.

Record review of Patient #9 showed the patient fell on 09/08/19 with:
- No revisions were made to the care plan.
- No nurses' notes were documented regarding the fall.
- No vital signs were documented.
- No neurovascular checks were documented.

During an interview on 10/29/19 at 9:15 AM, Staff B, DQM stated that she did not have debriefing forms for all of the patients listed on the fall log.

During an interview on 10/30/19 at 10:56 AM, Staff D, RN stated that when a patient fell she would assess the patient, follow the fall reduction policy, enter a nurses' note, and complete an event report.

During an interview on 10/30/19 at 1:55 PM, Staff B, DQM stated that she expected the post fall policy would be followed for all patients after a fall.

During an interview on 11/05/19 at 1:50 PM, Staff A, CNO stated that:
- A post fall debriefing form should be completed and turned in to Staff B, DQM, who then checked for opportunities for fall prevention.
- She did not know if anyone did a chart audit for falls.
- She was aware of gaps in the documentation.

During an interview on 11/04/19 at 3:45 PM, Staff N, Physician stated that nurses should document an exam after a patient falls and should call the physician to report any injuries to the patient.

These failures had the potential to cause serious injury to all patients receiving care in the facility.





18018

Based on observation, interview and policy review, the facility failed to perform proper insulin verification for three patients (#3, #6, and #28) of three patients observed, and failed to administer medication in a timely manner to two patients (#5 and #6) of six patients observed. The facility census was 21. These failures increased the risk of injury to all patients admitted to the facility.

Findings included:

1. Review of the facility's policy titled, "Diabetes, Glycemic, and Insulin Management," dated 08/01/18 showed the directives for staff to:
- Obtain the insulin from the designated storage area.
- Draw up the insulin according to the order.
- Obtain a witness.
- Label the insulin syringe if appropriate.

Review of the facility's policy titled, "Medication Administration," dated 07/01/18 showed the directive for staff to have two licensed nurses or a licensed nurse and pharmacist verify insulin vial and dose prior to administration and document on the electronic medical record.

Observation on 10/29/19 at approximately 9:15 AM showed Staff F, Registered Nurse (RN):
- Walked down the hallway with a labeled syringe in her hand for Patient #28;
- Staff F asked Staff G, RN, if he could verify the medication in the syringe:
- Staff G looked at the label on the syringe and verified the medication: and
- Staff G verified the medication in the syringe without seeing the medication vial.

Observation on 10/29/19 at 9:47 AM, showed Staff D, RN:
- Had a labeled syringe in her hand for Patient #6;
- Staff D asked Staff F, RN, if she could verify the medication in the syringe;
- Staff F looked at the label on the syringe and verified the medications; and
- Staff F verified the medication in the syringe without seeing the medication vial.

Observation on 10/29/19 at 9:47 AM, showed Staff D, RN:
- Had a labeled syringe in her hand for Patient #3;
- Staff D asked Staff E, RN if she could verify the medication in the syringe;
- Staff E looked at the label on the syringe and verified the medication; and
- Staff E verified the medication in the syringe without seeing the medication vial.

During an interview on 10/29/19 at approximately 9:25 AM, Staff G, RN, stated that:
- He trusted his co-worker to have in the syringe what the label had written on it;
- Staff F, RN, verbally told him what was in it; and
- He acknowledged that he did not see Staff F draw up the medication.

During an interview on 10/29/19 at 2:35 PM, Staff F, RN stated that:
- When she gave insulin she checked the medication administration record for the number of units.
- The drawer opened in the medication dispensing system and she cleaned off the top of the vial, drew up the insulin, placed a sticker on the syringe and then took the syringe to the nurse who was going to verify it and documented the verification.
- She then scanned the patient and scanned the insulin and documented the administration.
- That was the safest way to give insulin since the only drawer that opened in the medication dispensing system was the correct insulin.

During an interview on 10/29/19 at 2:42 PM, Staff E, RN stated that:
- She would check the patients' blood sugar.
- She asked a second nurse to go to the medication room, sign in the medication dispensing system, put in the correct number of units of insulin, then the drawer would open and she would draw up the insulin.
- She would have the second nurse verify the sticker that she placed on the syringe then take the medication to the patient and scan the patient and scan the insulin.

During an interview on 10/30/19 at 10:56 AM, Staff D, RN stated that she should draw up the insulin and verify with another nurse before she labeled the syringe.

During an interview on 11/05/19 at 9:24 AM, Staff O, Director of Pharmacy stated that:
- Two nurses should go to the medication dispensing machine when obtaining insulin.
- The insulin should be drawn up, verified by two nurses, and a sticker placed on the syringe.
- The nurse should then go to the bedside and verify the insulin prior to administration.

During an interview on 11/05/19 at 1:50 PM, Staff A, Chief Nursing Officer (CNO) stated that:
- Two nurses should be at the medication dispensing machine when insulin was drawn up.
- Two nurses should be at the bedside for medication verification.
- Nurses should not verify medications when they have not seen them come out of the medication dispensing system.

2. Review of the facility's policy titled, "Medication: Standard Administration Times," dated 07/2017 showed the directive for staff to administer scheduled medications within one hour before or after the scheduled time.

Observation on 10/29/19 at 11:17 AM, showed Staff D, RN, administered 10:00 AM scheduled medications to Patient #5.

Observation on 10/29/19 at 11:43 AM, showed Staff D, RN administered 10:00 AM scheduled medications to Patient #6.

During an interview on 10/30/19 at 10:56 AM, Staff D, RN stated that:
- She documented late medication administration on the electronic medication administration record with a comment.
- She would not complete an event report.
- She would not notify the physician.

During an interview on 11/05/19 at 9:24 AM, Staff O, Director of Pharmacy stated that the nurse should call the physician when a medication was administered late and the only documentation of late administration was in the computerized charting.

During an interview on 11/05/19 at 1:50 PM, Staff A, CNO stated that:
- Late medication administration reasons were documented on the electronic medication administration record.
- Pharmacy ran reports on late medication administration.
- She was aware of late medication administrations.

These failures had the potential to affect all patients from receiving correctly timed and appropriate medications.



18018

Based on observation, interview, and policy review, the facility failed to ensure that staff followed the hand hygiene policy while administering medications to six patients (#2, #3, #4, #5, #6, and #7) of six patients observed; and while performing dressing changes for three patients (#2, #7, and #9) of three patient observed.
The facility census was 21. These failures increased the risk of infection and injury for all patients admitted to the facility.

Findings included:

1. Review of the facility's policy titled, "Hand Hygiene", dated October 2018, showed the directives for staff to perform hand hygiene:
- Before going into a patient room and before leaving a patient room;
- Before putting on either sterile or non-sterile gloves;
- Between glove changes, after removing gloves after any contact with body fluids, dressings, or patient linen;
- Between patient care activities within the same episode of care; and
- When moving from high contamination patient care activities to cleaner activities.

Observation on 10/29/19 at 10:05 AM, showed Staff D, Registered Nurse (RN), failed to perform hand hygiene before putting on her gloves during medication administration for Patient #2.

Observation on 10/29/19 at 10:35 AM, showed Staff D, RN, failed to perform hand hygiene after removing her gloves during medication administration for Patient #3.

Observation on 10/29/19 at 11:35 AM, showed Staff D, RN, failed to perform hand hygiene before putting on her gloves during medication administration for Patient #6.

Observation on 10/30/19 at 9:40 AM, showed Staff K, RN, failed to perform hand hygiene after removing her gloves during a medication administration for Patient #7.

Observation on 10/29/19 at 10:47 AM, showed Staff D, RN, failed to perform hand hygiene before putting on her gown and gloves during medication administration for Patient #4.

Observation on 10/29/19 at 11:08 AM, showed Staff D, RN, failed to perform hand hygiene before putting on gloves and between glove changes during medication administration for Patient #5.

During an interview on 10/30/19 at 10:56 AM, Staff D, RN stated that hand hygiene should be performed:
- Before you entered the patients' room;
- When your hands were dirty; and
- Before you leave the patients' room.

2. Observation on 10/30/19 at 8:55 AM, showed Staff I, RN, Wound Care Certified, failed to perform hand hygiene between glove changes during a dressing change for Patient #7.

Observation on 10/30/19 at 8:55 AM, showed Staff J, Certified Nurse Assistant (CNA), failed to perform hand hygiene before putting on her gloves during a dressing change for Patient #7.

During an interview on 10/31/19 at 3:05 PM, Staff J, CNA, stated that hand hygiene should be performed:
- Before you entered a patients' room;
- Between glove changes;
- When moving from dirty to clean; and
- Before leaving a patients' room.

During an interview on 10/31/19 at 3:10 PM, Staff I, RN stated that hand hygiene should be performed:
- Before going into the patients' room;
- Before you put on gloves;
- When you change gloves;
- When moving from dirty to clean; and
- When you leave the patients' room.

Observation on 10/29/19 at 11:46 AM showed Staff H, RN, failed to perform hand hygiene after she removed non-sterile gloves and before she put on sterile gloves to perform a sterile dressing change for Patient #2.

Observation on 10/29/19 at 2:51 PM showed Staff H, RN, failed to perform hand hygiene after she removed non-sterile gloves and before she put on sterile gloves to perform a sterile dressing change for Patient #9.

During an interview on 10/29/19 at 3:00 PM, Staff H stated that hand hygiene should be performed:
- Before entry into a patient's room and when exiting;
- Before putting on gloves and when removal of gloves; and
- When moving between clean and dirty.
Staff H stated that she received hand hygiene training and education upon hire and then yearly.

During an interview on 11/05/19 at 1:50 PM, Staff A, Chief Nursing Officer (CNO) stated that hand hygiene should be performed:
- Before going into the patients' room;
- When moving from dirty to clean processes; and
- Before leaving the patient's room.

These failures had the potential to increase the risk of infection for all patients in the facility.

Based on interview, record review and policy review, the facility failed to re-assess one discharged patient (#8) of five discharged and three current patients' discharged records reviewed for discharge planning. The facility census was 21.

Findings included:

Review of the facility's policy titled, "Discharge Planning," dated 07/06/17 showed that re-assessment and planning for discharge takes place throughout the patient's stay. The discharge plan is coordinated between the involved physicians, interdisciplinary team, primary caregivers/family and the case manager. Any changes in the patient's condition that may require a change to the discharge plan is discussed through the interdisciplinary process.

Review of Patient #8's medical record showed that the patient was sent to a local ED, Hospital A, on 09/04/19 for complaints of left knee swelling. The ED record from Hospital A showed that the patient's left knee was swollen, slightly warm to the touch, had bruising and was tender upon palpation. The radiology report dated 09/04/19 showed that the patient had a fractured left knee. An orthopedic (medical specialty dealing with bones) consult was requested and recommendation was made for the patient to have an ace wrap and a knee immobilizer applied. ED staff applied an ace wrap and knee/leg immobilizer on the patient and she was sent back to the facility with the immobilizer in place.

Review of the patient's medical record showed that facility staff failed to document assessment of the patient when she returned from the ED on 09/04/19 that included her left knee fracture, left knee/leg immobilizer and the condition of the skin under the left knee/leg immobilizer. Staff failed to document re-assessments of the patient's left knee through discharge from the facility on 09/18/19 for a total of 14 days.

During interviews on 10/30/19 at 3:22 PM, Staff A, CNO, stated that:
- Staff did not document assessment in the patient's medical record that she had a left knee fracture, that she had a left knee/leg immobilizer on, or the condition of the skin under the left knee/leg immobilizer when she returned to the facility on 09/04/19 from Hospital A.
- Staff did not document re-assessments of the patient's left knee/immobilizer or the condition of the skin under the left knee/leg immobilizer from 09/04/19 through discharge on 09/18/19.

Review of the patient's After Visit Summary (discharge instructions sent with the patient at the time of discharge from the facility) dated 09/18/19 showed that staff failed to mention the patient's left knee fracture, the knee/leg immobilizer or what her weight bearing status was for the left leg.

During an interview on 10/31/19 at 8:41 AM, Staff L, Director of Case Management, acknowledged that the patient's discharge instructions did not include her fractured left knee, the left knee/leg immobilizer or weight bearing status. Staff L stated that the overall responsibility for over-sight of discharge planning was hers. Staff L stated that she was not sure why these elements were missed on the patient's discharge instructions.

During an interview on 11/04/19 at 2:48 PM, Staff Q, RN, Certified Registered Nurse Practitioner (CRNP), stated that she expected staff to include the patient's fractured knee, immobilizer and weight bearing status on the discharge instructions sent with the patient when she was discharged from the facility.

During an interview on 11/04/19 at 3:48 PM, Staff N, Physician, stated that the patient's discharge instructions should have included:
- Safety needs of the patient;
- Frequency of suctioning;
- Oxygen demands;
- Ensure staff at the nursing facility was able to provide suctioning for the patient; and
- Various therapy needed.
Staff N stated that the patient's immobilizer, weight bearing status and left knee fracture needed to be included in the patient's discharge instructions, however, they were not addressed in the discharge instructions given to the patient at discharge.

Even though requested, the facility failed to provide the State Agency with Respiratory Therapy assessments of the patient's respiratory status and oxygen demands at the time of discharge from the facility on 09/18/19.

During interview on 11/13/19 at 11:15 AM, Staff R, CNO, RN (Nursing Home) stated that the facility knew the patient had a trach because she had it before she was transferred to the hospital, however; the facility was not informed of the extent of the patient's current oxygen demands.

During an interview on 11/15/19 at 10:30 AM, Charge Nurse, RN, (Nursing Home) stated that:
- She received report from facility staff the day the patient was transported to the nursing home.
- She was informed that the patient had an immobilizer to her left knee/leg but was not informed the patient had a fractured knee/leg.
- The report she received did not include the patient's need for continuous oxygen to the trach or frequency of needed suctioning.
- The report did not include that the patient required 28% FiO2 continuously per aerosol trach collar, because the facility did not have equipment available to provide that kind of demand.
- If the facility had received information that the patient required continuous oxygen to her trach, they would not have accepted the patient for admission to the facility.
- The report given by the facility did not contain specific information related to the patient's current medical status and needs and the report received was a "generic" report.

Review of the ED record from Hospital C's ED on 09/19/19, one day after the patient was discharged from the facility showed that:
- The patient presented to the facility with complaints of hypoxia (not enough oxygen reaching the cells and tissues in the body) per EMS transportation.
- The patient required six liters (L) of oxygen, which was an increase from her baseline of three L.
- When the patient's left lower leg brace was removed it was noted that the femur protruded through the skin.
- Orthopedics was consulted, they thoroughly irrigated the opened fracture, applied a dry dressing and recommended irrigation and debridement of the fracture as well as possible surgical repair.
- The patient was admitted to the facility's Progressive Care Unit (PCU, a hospital unit that provides a higher level of care than a regular hospital floor).

Staff failed to assess the patient's needs prior to discharge. Staff failed to address the patient's fractured left knee, the left knee/leg immobilizer, condition of the skin under the left knee/leg immobilizer, her weight bearing status, the patient's changed oxygen needs, or the suctioning of the trach needs prior to her discharge. The discharge information did not include the patient's new medical needs. The staff failed to include all those elements in the discharge instructions that was sent with the patient when she was discharged to the nursing home.

These failed practices by the facility staff placed all patients ready for discharge at increased risk for their safety and health.