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Based on record review and interview, the hospital failed to provide the contact information for the Oklahoma State Department of Health, The Joint Commission and their Quality Improvement Organization (QIO) as entities for patients to contact to register complaints/grievances and list the current QIO on the admission Important Message from Medicare.

Findings:

A document titled "Conditions of Admission/Consent for Treatment Form" contained a section "Patient Rights". The section did not contain contact information for the Oklahoma State Department of Health, The Joint Commission or Kepro (the Quality Improvement Organization) to allow patients to file a complaint/grievance outside the facility.

A document titled "An Important Message From Medicare About Your Rights" presented at the time of admission, listed the name of the QIO to report quality of care concerns as the previous QIO.

On 06/05/18 at 10:00 am, Staff K stated the contact information was not listed on the notice given to patients, and the listed QIO on the Important Message from Medicare given at admission was the name given to her/him.

Based on observation and interview, the hospital failed to provide a safe setting by having expired supplies, equipment requiring maintenance and unidentified supplies in a room identified as "respiratory room".

Finding:

06/05/18 during a tour of the facility, surveyors observed stored equipment with expired annual maintenance dates, equipment on shelves with cords hanging in front of and behind the shelves, and covered and uncovered equipment in a room identified as "respiratory room". Staff were unable to determine if equipment was in working order, if the equipment was clean or if the equipment was awaiting maintenance.

06/05/18 at 10:06 am, Staff B stated "I don't know" regarding the status of the equipment in the room.

Based on observation and interview, the hospital failed to maintain confidentiality of Patient #1's medical record.

Finding:

On 06/05/18 at 10:20 am, during a tour of the emergency treatment room, identification labels for Patient #1 were found on the top of the PICC (peripherially inserted central catheter) cart. The emergency treatment room was not locked, and was accessible to the public.

Staff B stated the PICC insertion procedure scheduled for Patient #1 was cancelled and the identification labels were not returned to the patient's chart.

Based on record review and interview, the hospital failed to ensure the registered nurse assessed and monitored the consistency in charting wound location and treatment for one of 20 (Patient # 12) records reviewed.

The failed practice had the potential for patient # 12's wound to not be monitored for healing or deterioration.

Findings:

See Tag A - 0467

Based on record review and interview, the hospital failed to ensure the physician completed the history and physical within 24 hours according to Appendix A for four of 20 (Patient # 7, 10, 12 &14) records reviewed.

This failed practice had the potential to cause harm or improper treatment for patient # 7, 10, 12 & 14 who were admitted to the hospital.

Findings:

A review of "Appendix A" says the History and Physical documentation must be placed in the medical record within 24 hours of admission or registration.

Patient # 7

A review of record titled "History and Physical" shows patient was admitted on 05/25/18 and the date dictated was 05/29/18.

Patient # 10

A review of record titled "Initial Assessment" completed by Staff P shows date of admission as 04/05/18.

A review of record titled "History and Physical" completed by Staff O shows date dictated was 04/07/18.

Patient # 12

A review of record titled "History and Physical" completed by Staff O shows date of admission as 04/03/18 and the date dictated was 04/05/18.

Patient # 14

A review of record titled "Initial Assessment" completed by Staff Q shows date of admission as 05/02/18.

A review of record titled "History and Physical" completed by Staff O shows date of service as 05/03/18 and the date dictated was 05/04/18.

On 06/05/18 at 10:30, Staff R stated the history and physical should be completed within 24 hours of admission.

Based on record review and interview, the hospital failed to ensure the registered nurse was consistent in charting wound location and treatment for one of 20 (Patient # 12) records reviewed.

The failed practice had the potential for patient # 12's wound to not be monitored for healing or deterioration.

Findings:

A review of policy titled "Integumentary System Assessment" says an assessment of the integumentary system is performed on all patients at the beginning of every shift, every 12 hours and as needed...document all pertinent data...perform appropriate wound care per physicians order.

Patient # 12

Documentation of wound location:

Patient was admitted on 04/02/18 and discharged on 04/26/18.

A review of record titled "Initial Assessment" Staff S documented on 04/02/18 a pressure wound to coccyx with tissue type that was pink and pressure to left heel with tissue type that was black.

A review of record titled "Progress Notes Details" Staff T documented on 04/03/18 and 04/24/18 a Stage 4 pressure ulcer of sacral region and an unstageable pressure ulcer of left heel.

04/03/18 - 04/08/18: Nursing documentation on document titled "Patient Care Record" showed wounds to coccyx/sacrum and left heel

04/09/18 - 04/10/18: Nursing documentation on document titled "Patient Care Record" showed wounds to right foot only

04/11/18 - 04/12/18: Nursing documentation on document titled "Patient Care Record" showed wounds to coccyx and right foot/heel

04/13/18 - 04/26/18: Nursing documentation on document titled "Patient Care Record" showed wounds to coccyx only.

This review of record showed that nursing staff did not document the left heel wound for 18 days.

Documentation of Treatment:

The review of document titled "Treatment Sheet" showed no documentation on sacrum and left heel wounds for the following days: 04/07/18, 04/09/18, 04/10/18, 04/13/18, 04/14/18, 04/15/18, 04/16/18, 04/17/18, 04/19/18 & 04/22/18.

A review of record titled "Progress Notes Details" Staff T documented on 04/03/18 to cover sacral wound with bordered gauze daily and apply betadine to left heel every shift.

On 06/07/18 at 2:30 pm, Staff B stated the nurses are terrible at charting wounds; he/she can't speak for why the nurses didn't chart wounds and treatment.

On 06/08/18 at 12:30 pm, Staff H stated there was no explanation why wounds were not charted; wound care orders is listed on treatment sheet.