HospitalInspections.org

Based on standard level deficiency citation, observations, staff interviews, patient record reviews, and review of facility documents and policies and procedures, it was determined the facility staff failed to ensure the Condition of Participation for Nursing Services was met and that Care Plans reflected current nursing care needs, Physician orders were followed and/or an appropriate nursing assessment of physiological factors were performed.

These practices affected five (5) of nine (9) patients in the survey sample, Patients #1, #3, $4, #5 and #8. Patient's #1 and #3 experienced significant changes in status which led to a transfer to a higher level of care.

Findings include:

1a, b, c. Patient #4 was admitted to the facility on 1/30/17 and remained at the facility at the time of the survey. The patient's diagnoses included, but were not limited to; respiratory failure, diabetes, and hypertension (high blood pressure).

Review of the clinical record for Patient #4 revealed a physician's order dated 1/31/17 for "Neuro (neurological) checks Q4h (every four hours)". "Flowsheet" documentation for Patient #4 for the dates 1/31/17 through 2/2/17 revealed a "Neurological" assessment which included "motor response, and strength" for both arms and legs. There was no documentation regarding the pupillary checks/responses, nor was there an assessment of the Glasgow coma scale for this patient. Patient #4's 'care plan' did not include the every four hour neuro checks.

Staff Member #3 was interviewed on 2/2/17 at 2:50 PM regarding the nursing assessment of Patient #4's pupillary responses/neuro checks. Staff Member #3 stated, "They may come out of ICU with neuro checks every four hours, but rarely do we do them." When interviewed further about staff training regarding neurological assessments/checks, Staff Member #3 stated, "When you get out of nursing school you should know how to do this. It is a basic nursing assessment, so we do not provide any training to the staff on how to do this if a nurse has not had any experience, they are put with a preceptor and they learn that way, but we do not provide that training...".

2 a,b,c. A review of Patient #1's medical record revealed that he/she was admitted to the facility on 4/20/16 for ventilator weaning s/p (status post) successful elective balloon angioplasty of the right SFA (superficial femoral artery) and popliteal arteries 3/24/16; s/p ruptured aneurysm which required emergent surgery, and change in neuro status with acute left hemiparesis.

Patient #1's care plan listed the problem: Neurosensory, and interventions included in part the following: "1. Assess for and report changes in Neurological Status; 2. Initiate measures to prevent increased intracranial pressure (ICP)...".

The nursing flow sheet documentation in the EMR (electronic medical record) on 5/7/16 at 0900 (9:00 AM) documented pupillary response as "4" and "brisk" for both the right and left pupils, and the LOC (level of consciousness) documented "UTA" (unable to assess).

The Hospitalist Daily Progress Note dated 5/7/16 at 1128 (11:28 AM) under the heading "Assessment and Plan: stated the following, in part:, "...7. Neuropsych/pain management...Acute rupture of L (left) MCA (Middle Cerebral Artery) aneurysm s/p repair. Pt (patient) has left hemiparesis (weakness) and right sided weakness as well, and limited communication abilities beyond occasionally opening and closing eyes at times on request...". "...STAT (immediate) CT (computed tomography) head for any significant change in neuro status...".

On 5/5/16 at 0859 (8:59 AM), the nursing flowsheet did not include documentation of pupillary response or size, and the level of consciousness (LOC) was marked "UTA".
On 5/5/16 at 2121 (9:21 PM), the pupillary reaction and size was recorded as "4" and "brisk" bilaterally, and the LOC was documented "UTA".
On 5/6/16 at 0952 (9:52 AM) the pupillary response was not documented, and the LOC was documented "UTA".
5/6/16 at 1955 (7:55 PM) the pupillary response and size was documented as "4" and "brisk" bilaterally, the LOC was documented as "UTA".
5/7/16 at 0900 (9:00 AM) pupillary response and size was documented "4" and "brisk" bilaterally, with the LOC documented "UTA".
5/7/16 at 2101 (9:01 PM) pupillary response was documented as "4" and "brisk "and LOC was not addressed. Documentation under "strength of RUE (right upper extremity) was "other", and in the comment section, the nurse typed in "decerebrate posture with stimulation-suction/iv stick". Decerebrate posturing had not been documented for Patient #1 before this date/time.

A nursing note dated 5/8/16 at 0239 (2:39 AM) documented the following: "Patient with cool skin and diaphoresis most of shift. Opens eyes but not to command and does not track. When stimulated with suctioning or needle stick there is decerebrate posturing note (sic) to bilateral arms. It is becoming increasingly difficult to obtain needed blood work due to poor options for venous sticks. Midnight cbc (complete blood count) delayed until repeat attempt can be made. Continues with ST (sinus tachycardia) 120s (sic) by telemetry".

There was no documentation available to support that the physician was notified that Patient #1 was having decerebrate posturing on 5/7/16 at 2101 (9:01 PM) when the nursing assessment first indicated that Patient #1 was experiencing decerebrate posturing, or on 5/8/16 at 0239 (2:39 AM) when a nursing note again documented decerebrate posturing in Patient #1.

An interview was conducted with Staff Member #9 on 2/2/17 at 12:00 PM; he/she stated "Nurses do general neuro (neurological) assessments, if there was a change, they would notify the doctor, and a CT scan would probably be ordered". "Neuro assessments are DBE (documentation by exception); we only document exceptions to normal findings".

A Hospitalist Event Note for Patient #1 dated at 0745 (7:45 AM) states in part the following: "CTSP (called to see patient) this AM approximately 0710 (7:10 AM) to assess pt (patient) for change in neurologic condition. Patient has been able to open eyes on verbal stimuli until this morning. (He/She) has rigidity left arm and leg. (He/she) appears diaphoretic. (He/she) remains on vent support having done two pressure support trials yesterday. No active tonic clonic activity appreciated.." "...Neuro: Left hemiparesis with rigidity, withdraws to tactile stimuli BLE (bilateral lower extremities), RUE (right upper extremity) and RLE (right lower extremity) motor appears 4/5 (four of five). No conjugate eye movement, left globe without EOM (extra-ocular movement), right globe wandering. Pupils approx 5 mm (millimeters) and equal although nonreactive. Minimal gag to tongue blade exam. No tremor or tonic clonic activity".

Assessment/Plan: Medically complex patient with neurologic changes. Concerns for intracranial event...". "...Recent intracranial surgery on 4/8 heightens concern for ICH (intracranial hemorrhage)". "...I have reviewed clinical findings, medical history, and recent ongoing treatments with (facility and physician name) who agrees that patient requires urgent workup including CT head, and consultation with appropriate subspecialty services".

A discharge note dated 5/8/16 at 0958 (9:58 AM) documents "change in neurologic status concerning for acute intracranial process" on the list of discharge diagnoses.

There were no nursing notes available for review by the surveyor after the note dated 5/8/16 at 0239 (2:39 AM). The surveyor interviewed Staff Member #3 on 2/2/17 at 3:10 PM regarding the lack of a nursing assessment after 2101 (9:01 PM) on 5/7/16, or a nursing progress note after 0239 (2:39 AM on 5/8/16), and prior to the patient's emergent transfer to (facility name) at 8:45 AM on 5/8/16 due to a change in Patient #1's neurological status. Staff Member #3 stated "Nursing is expected to do an assessment before 11:00 AM, and Patient #1 left the facility at 8:45 AM, but yes, I agree that he/she should have been assessed by the nurse".

Patient #1 was transferred to a higher level of care on 5/8/16 and expired on 5/9/16.

3. Patient #3 was admitted to the facility on 5/19/16 at approximately 1:39 p.m. He/She had previously been hospitalized at an acute care facility after sustaining a traumatic head injury which required neurosurgical intervention and subsequent placement of a tracheostomy tube for mechanical ventilation, as the patient was not able to breathe on his/her own at that time. Patient #3 had been transferred to the facility in order to receive further care and treatment and potential weaning from mechanical ventilation.

Further review of the clinical record for Patient #3 revealed the following:
The "History and Physical" dated 5/19/16 performed by the attending physician on admission documented, in part, "...(He/She) is essentially noncommunicative, although by report (he/she) has moved (his/her) right foot on request and may visually track with family members...at the time of my interview and exam the patient is noncommunicative and does not respond to my verbal requests...HEENT:...pupils are equal and reactive to light...NEURO- corneal reflexes appear present, no gag, no facial asymmetry, spontaneous withdrawal of BLE (bilateral lower extremities) R>L (right and left) during tracheal suctioning o/w (otherwise) flaccid extremities...pupils equally round and reactive, no tracking... Assessment and Plan: 7. Neuropsych- TBI (traumatic brain injury) scattered SAHs (subarachnoid hemorrhages) and bilateral frontotemporial parietal crainectomies on 5/8- Patient is very neurologically compromised, noncommunicative and appears functionally quadriplegic, (He/She) does spontaneously withdraw BLE with tracheal suctioning...stat CT for significant neurological changes..."

OT (Occupational Therapy) Progress note 5/20/16 at 0930 (9:30 a.m.) documented: "...Vision- unable to track or hold gaze. L (left) eye dilated greater than R (right) eye...Functional Cognition- Pt (patient) was able to blink upon command..."

TCH Pulmonary Concurrent Care Note 5/20/16 at 1047 (10:47 a.m.) "...Interval Events: 5/20/16: rested on vent yesterday; more alert today- occasionally follows commands (wiggle right toe) and attempt to mouth words...Assessment and Plan- ...somewhat more responsive today...reportedly tolerating several hours of TCT prior to this but less in last few days... (TCT- total cycle time- a rate set by the patients respiratory rate- the sum of inspiratory time (breathing in) and expiratory time (breathing out)- used in weaning from mechanical ventilation -www.respiratorytherapy/RT/org)

Hospitalist Daily Progress Note 5/20/16 at 10:11 a.m. "...(family member) in room overnight states that pt seemed more interactive. No purposeful movement on my eval this AM....HEENT...pupils are equal and reactive to light...NEURO: -...no facial asymmetry, spontaneous withdrawal of BLE R>L (bilateral lower extremities right and left) during tracheal suctioning o/w (otherwise) flaccid extremities...pupils equally round and reactive, minimal tracking..."

Physical Therapy Progress Notes 5/20/16 10:44 a.m.- "...Objective Evaluation- Mental Status- Pt was able to blink on command but not tracking. Vision- pupils dilated, but not tracking....Communication- non verbal...Established Goals- Patient will tolerate upright sitting in the chair for 1 (one) hour, while working on vent weaning..."

Hospitalist Daily Progress Note 5/22/16 "...no purposeful movement on my eval. No response to verbal stimuli...HEENT- ...pupils equal are reactive to light...NEURO- no facial asymmetry, no withdrawal to tactile stimuli...pupils equally round and reactive...Assessment and Plan...7. Neuropsych- ...Patient is very neurologically compromised, noncommunicative, appears functionally quadriplegic. (He/she) does spontaneously withdraw BLE with tracheal suctioning...stat head CT for significant neurologic changes..."

Physical Medicine Consult dated 5/23/16 "... (family member) reports that on Tuesday patient kissed (him/her) and mouthed "I love you" when (he/she) visited. Yesterday- no response...Neuro- eyes slightly open but not tracking, slight eye movement noted...pupils, equal round, slightly reactive bilat (bilaterally)...motor strength- no movement noted in any extremity...spoke with patient's (family member) on the phone- concerned (his/her) MS (mental status) has worsened, acknowledged this may be d/t (due to) infection. relayed concerns to primary team..."

Hospitalist Daily Progress Note 5/23/16 at 1356 (1:56 p.m.) performed by Staff Member #11)
"...No overnight problems or events. No change in neurological status. However, (Patient #3's family member) and I spoke and apparently on Thursday of last week (he/she) would recognize (his/her) voice and "pucker up" for a kiss. (He/She) would also squeeze (his/her) hand. (He/She) is asking me to transfer to neuro ICU (intensive Care Unit). I've ordered a CT scan of (his/her) head...General- noncommunicative, nonverbal. HEENT- Aspen collar in place...Pupils equal are reactive to light...Neuro- no facial asymmetry, no withdrawal to tactile stimuli...pupils equally round and reactive...Assessment and Plan- 7. Neuropsych- ...spoke with the (family member) today and it appears that (he/she) has had a decline in (his/her) mental status since (he's/she's) been at TCH (facility). (He/She) tells me that on Thursday of last week (he/she) was responsive and would "pucker up" for a kiss and squeeze (his/her) hand. (He/She) is not responding to verbal stimuli. I've ordered a CT scan of (his/her) brain today..."

The "Discharge Summary" dated 5/23/16 at 1513 (3:13 p.m.) documented the following, "7. Neuropsych: ...-spoke with (family member) today and it appears that (he/she) has had a decline in (his/her) mental status since (he/she's) been at the TCH (transitional care hospital)...I've ordered a CT scan of (his/her) brain urgently today. It revealed a 4.0 cm (centimeter) left cerebral convexity (the aspect of the cerebral hemisphere that lies in contact with the flat bones of the skull; it includes parts of the frontal, parietal, temporal, and occipital lobes.) with 2.0 cm of rightward midline shift (the movement of the brain past the midline due to pressure from fluid, blood, tumor or swelling), evolving contusion injuries, right hydrocephalus (an abnormal accumulation of cerebral spinal fluid in the brain), and collapse of the left ventricle. Spoke with (name of neurologist) as soon as I received the report and he recommended transfer to Neuro ICU and suggested (Patient #3) would need surgery urgently..."

TCH Pulmonary Concurrent Care Note 5/23/16 "...Interval events: 5/20/16- rested on vent yesterday; more alert today- occasionally follows commands (wiggle right toe) and attempt to mouth words...5/21/16 afebrile noncommunicative this a.m....5/22/16 fever last night, non communicative...5/23/16 temperature slightly high last night, but not above 101...MS (mental status) remains unresponsive; not following commands, not opening eyes to commands..."

According to further documentation in the clinical record, on the date of admission 5/19/16 at 2:12 p.m. the Registered Nurse (RN) performed an assessment of Patient #3. Part of the admission included an assessment of the patient's neurological status including the Glasgow Coma Scale. The Glasgow Coma Scale is a scale that is used to assess the severity of a brain injury based on how a patient responds to certain standard stimuli (opening the eyes, verbal response). -Merriam Webster's Medical Dictionary 2014 New Edition.

The RN assessed Patient #3 on admission as having a Glasgow score of 11 at 2:12 p.m. (Eye opening -4, Best Verbal- 1, Best Motor- 6) At 10:22 p.m. the score was assessed as "10" (Eye opening - 3, Best Verbal- 1, Best Motor- 6). On 5/20/16 at 10:00 a.m. the score was "10", however at 9:58 p.m. the score had dropped to "7" (Eye opening 3, Best verbal- OT [other], Best motor-4). Patient #3 remained at a Glasgow score of "7" until 5/22/16 at 9:09 p.m. when there was no further documentation of the scale being assessed.

The "Flowsheet Data" documentation revealed on 5/19/16 upon admission, the RN also documented an assessment of the "Pupillary Size/Reaction - Size R (right) pupil (mm - millimeter) 4, Reaction R Pupil- Brisk, Size L (left) pupil (mm) 4- Reaction L pupil- Brisk". Further review of the flowsheet documentation revealed the pupils were assessed as follows: 5/20/16 at 10:00 a.m. - Size R pupil 4, Reaction R Pupil- brisk, Size L pupil 4, Reaction L pupil- brisk, 5/20/16 2158 (9:58 p.m.) Size R pupil- 5, Reaction R pupil -sluggish, Size L pupil -5, Reaction L pupil -sluggish. 5/21/16 7:31 a.m. - Size R pupil- 5, Reaction R pupil- brisk, Size L pupil- 5, Reaction L pupil- brisk. There was no further documentation of any other assessments of Patient #3's pupillary responses other than the documented OT assessment that the pupils were unequal, and the PT assessment that the pupils were sluggish (documented 5/20/16 at 9:30 a.m. and 10:44 a.m. respectively).

According to "The Lippincott Manual of Nursing Practice 11th Edition" Pupillary changes can be caused by increasing pressure or an expanding clot displacing the brain against the oculomotor or optic nerve...this is an emergency situation that can lead rapidly to death or result in a vegetative state for the patient."

In an interview with Staff Member #3 on 2/2/17 at 2:50 p.m., in regards to the nurse assessment of patients pupillary responses/neuro checks, Staff Member #3 stated, "They may come out of ICU with neuro checks every four hours, but rarely do we do them." When interviewed further about the training the staff receives regarding performing a neurological assessment on a patient since so many of the patients at the facility has neurological injury or compromise, Staff Member #3 stated, "When you get out of nursing school you should know how to do this. It is a basic nursing assessment, so we do not provide any training to the staff on how to do this. If a nurse has not had any experience, they are put with a preceptor and they learn that way, but we do not provide that training..."

The facility documented the scoring of the scale as follows:
Eye Opening- 4= spontaneous, 3= to speech, 2= to pain, 1= none, C=swollen shut
Best Verbal- 5= Oriented, 4=Confused, 3=Inappropriate words, 2= Incomprehensible speech, 1=none/not intubated, OT=None/intubated
Best Motor- 6=Obeys Commands, 5=Localizes pain, 4= withdraws from pain, 3=Flexion to pain, 2=Extension to pain, 1=None

On 2/1/17 at 4:20 p.m., as the surveyor was reviewing the Glasgow coma scale documentation, Staff Member #1 was interviewed. The surveyor asked if the drop in the Glasgow coma scale, as assessed, from an 11 on admission to a 7 would be of a concern to the staff. Staff Member #1 stated, "That would be a big problem". The surveyor then inquired as to why this was not addressed by the nursing staff, as no documentation was found in the nursing notes or in the clinical record that the physician had been made aware of this change. Staff Member #1 stated, "I don't know. I will have to get someone with more expertise on this matter to look at it..."

The surveyor reviewed a document "InterQual Review Summary" which was dated as being completed on 5/19/16 and was identified by Staff #1 on 2/2/16 at 4:00 p.m. as "referral information for admission review". According to this document Patient #3 was assessed at the previous facility (before transfer) as having a Glasgow coma scale of "9 - with some tracking and squeezing of (spouses) hand on request". A document "Trauma Surgery Discharge/Transfer Summary" from the transferring facility dated 5/19/16 documented, in part: "...ICU Course...MS (mental Status) improving-loathe (sic) to follow commands during exam, but will kiss (his/her) (family member) on command and says "I love you" to (him/her) after (he/she) says it to (Patient #3)...Discharge Exam: ...Neuro- eyes tracking, not following commands...GCS...=9..."

The "Care Plan" for Patient #3 did not include any interventions related to the monitoring of the patient's neurological status interventions, other than "At Risk for Delirium- Patient will be free from delirium". This was on the plan of care for the RN who was assigned to care for that patient on the first shift. The subsequent nursing "Plan(s) of Care" documented each shift by the RN assigned to the care for Patient #3 from 5/20/16 (day shift) through discharge on 5/23/16 which did not evidence the inclusion of monitoring the patient's neurological status. When interviewed regarding the nursing "plan of care" on 2/2/17 at 2:50 p.m., Staff Member #3 stated, "Each nurse puts on their daily care plan what they are monitoring from the things they think are most important..."

On 2/2/17 at 9:35 a.m., the surveyor interviewed Staff Member #11 (Medical Director). Staff Member #11 stated he was not the admitting physician for Patient #3 and only saw the patient on 5/23/16. Staff Member #11 stated the admitting physician no longer at the facility as he/she had resigned. During the interview, the surveyor inquired as to the assessment of Staff Member #11 for Patient #3 on the date (he/she) examined the patient. Staff Member #11 stated, "I had not seen the patient prior to the 23rd, but I did receive a sign-off from the other physician and was told that neurologically there was not much there. I observed that when I rounded on the Patient. The patients (family member) had a concern that something had changed so I ordered an emergency CT and it showed (he/she) had a hygroma which is a late complication of this type of head injury..." The surveyor inquired as to whether Staff Member #11 was aware of the changes in the Glasgow coma scale documented by the staff and what would be the action if he/she had been informed of this change. Staff Member #11 stated he/she was not made aware of the change and that "with (his/her- Patient #3) history and it was on a Friday night and there was no imaging here- the night doctor may have seen (him/her) but I would have reassessed the patient and tried to reproduce the higher response (10) and if I could not, then I would have ordered a stat CT. The patient's (family member) told me that (he/she) felt there was a decline in responsiveness, so I ordered the CT... the patient was then transferred for necessary intervention...back to neuro ICU (intensive care unit) and they had to put a drain in [his/her] head and do some revisions to the craniotomy..."

On 2/2/17 at 12:15 p.m., the surveyor interviewed Staff Member #12, a Registered Nurse (RN) who had documented the Glasgow coma scale (GCS) change from 10 to 7 on 5/20/16 at 9:58 p.m. The surveyor inquired as to whether the RN had observed the change in the GCS scoring and what interventions had been done, or if the physician had been notified. Staff Member #12 stated, "Maybe there was a difference in the way I looked at the question under verbal. He (physician) made a habit of coming to talk with us about patient progress and changes. We communicated that way a lot. He would touch base more than once a day; he was always at the nurses station. I didn't write down every time we talked but we stayed in communication." The surveyor was unable to locate any documentation in the medical record that there had been notification of the physician of the change in the GCS.

The surveyor discussed with the facility Staff Members #1, #3 and #5 on 2/2/17 at 3:00 p.m. the concerns regarding the conflicting documentation regarding Patient #3's mental status, the change in the assessment of the GCS that was not reported to the physician, and the documentation of the pupillary responses in the neuro assessment. The OT (Occupational Therapy) documentation of unequal pupils that was not reported or followed up on and the subsequent findings on the CT scan of increased fluid presence in Patient #3's brain along with a midline shift resulting in the need to emergently transfer Patient #3 to a higher level of care for further neurological treatment was also discussed as well as the lack of evidence of care planning regarding continued monitoring of interventions related to the patient's neurological status. Staff Member #1 stated that the chart contained all the documentation to evidence the patient received good care and that the staff had assessed the patient.

On 2/2/17 at approximately 6:30 p.m., the surveyor discussed the concerns regarding the changes in the patient's neurological status and associated documentation concerns with the administrative staff (Staff Members #1, #2, #3, #4, and# 5) and that there was no inclusion on the care plan for Patient #3 regarding the neurological status of a patient with a traumatic brain injury with a craniotomy.

4a. A review of Patient #8's medical record revealed physician orders for daily weights, calorie counts, and a discharge summary from the vascular surgeon transferring Patient #8 dated 1/21/17, which stated in part the following "...It is important to note the abdominal fascia is not closed, only the skin over top; so (patient) must wear an abdominal binder to prevent dehiscence(a separation of the layers of a surgical wound; it may be partial or only superficial, or complete with separation of all layers and total disruption)".

Documentation sent from the transferring hospital included information that Patient #8 had abdominal wound dehiscence with evisceration (extrusion of viscera outside the body, especially through a surgical incision; https:// medical-dictionary) on 12/28/16; the abdomen was closed at that time with retention sutures. Patient #8 experienced another wound dehiscence and evisceration on 1/10/17 when "bedside abdominal tissue expander placed; fascia in poor health". On 1/13/17 there is documentation that "...skin closure over abdominal wound was without closure of fascia". Patient #8 was admitted to the the long term acute care hospital on 1/21/17 due to the abdominal wound, optimization of nutritional status, and post-op sepsis, and remained a patient at the time of the survey.

During an interview with Staff Member #15 on 2/1/17 between 1:10 PM and 1:40 PM while navigating the record, he/she stated "There is no physician order for an abdominal binder, and the care plan does not include the abdominal binder; there is no nursing documentation that the abdominal binder was on before 1/29/17 ". "It was a nursing judgement to place the abdominal binder". The abdominal binder was not on Patient #8's careplan at the time of the initial record review. Staff Member #15 added the abdominal binder to the care plan on 2/1/17 at 1:15 PM.

The surveyor asked Staff Member #15 how the admitting physician gets report from the transferring hospital when accepting a new patient for admission, he/she stated "the doctor gets a verbal hand off from the physician at the transferring facility".

At 1:00 PM on 2/1/17 Staff Member #15 accompanied the surveyor to Patient #8's room where his/her nurse, Staff Member 16, was preparing to administer medications. After donning PPE (personal protective equipment), the surveyor asked Staff Member #16 to check for placement of an abdominal binder. The abdominal binder was on; however, it was not covering the abdominal dressing/wound; it was positioned above the dressing and colostomy bag, and therefore, not providing support to the abdomen in order to decrease the risk for wound dehiscence. Staff Member #16 pulled at the bottom of the binder and the attempt to re-position was unsuccessful. Staff Member #16 stated "It was over the dressing when [he/she] got up in the chair this morning".

4 b. A review of the medical record revealed that Patient #8 had physician orders for calorie counts and daily weights. The calorie count forms available for review had incomplete documentation of daily calorie counts on six (6) out of nine (9) days between 1/21/17 and 1/29/17.

Documentation of daily weights between 1/22/17 and 2/1/17 was incomplete. On five (5) days there were no weights documented (1/22/17, 1/25/17, 1/27/17, 1/30/17, and 1/31/17).

On 2/1/17 at 2:00 PM, Staff Member #15 stated "We record percent eaten on the I&O (intake and output) sheets, but it's not the same as a calorie count. The nurse should be watching that weight loss and let the dietitian know, or have the PCT (patient care technician) re-weigh the patient. If weights are fluctuating, they should weigh the patient with a regular scale, not the bed scale".

There was no documentation in Patient #8's record that his/her weight loss had been recognized or addressed by the dietitian, nursing staff, or physician before being brought to the attention of Staff Member #15 by the surveyor during the medical record review on 2/1/17.
Patient #8's weight was documented as 59.4 kg (kilograms) (130.68 pounds) on 1/22/17. Patient #8's weight showed a downward trend each time the weight was obtained, down to 55.3 kg (121.6 pounds) on 2/1/17, for a total documented weight loss of 9.08 pounds over a period of eleven days.

At 4:30 PM on 2/1/17, Staff Member #6 told the surveyors "Starting today the dietitian will be entering all dietary orders. Prior to this, either the doctor or dietitian could order".

5 a. The medical record for Patient #5 was reviewed. The patient remained in the facility at the time of the survey. The surveyor noted the following documentation by the Wound Care nurse dated 1/9/17 at 0923 (9:23 AM): "Deep tissue injury. Cover with Mepilex on heel, change every 3 days". There was no documentation that Mepilex had been changed on 1/12/17, 1/15/17, 1/21/17, or 1/24/17. There was documentation dated 1/25/17 that "DTI (deep tissue injury) to left heel has healed". Mepilex dressing changes to the left heel were not included as part of Patient #5's care plan.

At 11:15 AM on 2/1/17 while Staff Member #15 assisted the surveyor in navigating Patient #5's medical record, he/she stated "Mepilex is not on the care plan, it is in the orders. There's no good place to put it".

On 2/2/17 at 11:30 AM, Staff Member #4 looked for documentation of the Mepilex dressing changes, but stated, "there are no dressing changes documented".

Please refer to A0396 for additional information.

21229


Based on observations, staff interviews, patient record reviews, and review of facility documents and policies and procedures, it was determined the facility staff failed to ensure:
a. Care plans reflected current nursing care needs for five (5) patients (Patients #4, #1, #3, #8, and #5),
b. Physician orders were followed for five (5) patients (Patients #4, #1 # 5, #8 , and #3), and
c. An appropriate nursing assessment of physiological factors was performed for three (3) patients (Patients #4, #1 and #3).

These practices affected five (5) of nine (9) patients in the survey sample, Patients #1, #3, $4, #5 and #8. Patients #1 and #3 required transfer to a higher level of care.

Findings include:

1a, b, c. Patient #4 was admitted to the facility on 1/30/17 and remained at the facility at the time of the survey. The patient's diagnoses included, but were not limited to; respiratory failure, diabetes, and hypertension (high blood pressure).

Review of the clinical record for Patient #4 revealed a physician's order dated 1/31/17 for "Neuro (neurological) checks Q4h (every four hours)". "Flowsheet" documentation for Patient #4 for the dates 1/31/17 through 2/2/17 revealed a "Neurological" assessment which included "motor response, and strength" for both arms and legs. There was no documentation regarding the pupillary checks/responses, nor was there an assessment of the Glasgow coma scale for this patient. Patient #4's 'care plan' did not include the every four hour neuro checks.

Staff Member #3 was interviewed on 2/2/17 at 2:50 PM regarding the nursing assessment of Patient #4's pupillary responses/neuro checks. Staff Member #3 stated, "They may come out of ICU with neuro checks every four hours, but rarely do we do them." When interviewed further about staff training regarding neurological assessments/checks, Staff Member #3 stated, "When you get out of nursing school you should know how to do this. It is a basic nursing assessment, so we do not provide any training to the staff on how to do this if a nurse has not had any experience, they are put with a preceptor and they learn that way, but we do not provide that training...".

2 a,b,c. A review of Patient #1's medical record revealed that he/she was admitted to the facility on 4/20/16 for ventilator weaning s/p (status post) successful elective balloon angioplasty of the right SFA (superficial femoral artery) and popliteal arteries 3/24/16; s/p ruptured aneurysm which required emergent surgery, and change in neuro status with acute left hemiparesis.

Patient #1's care plan listed the problem: Neurosensory, and interventions included in part the following: "1. Assess for and report changes in Neurological Status; 2. Initiate measures to prevent increased intracranial pressure (ICP)...".

Increased ICP is a rise in the pressure inside the skull that can result from or cause brain injury). An increase in intracranial pressure is a serious medical problem. The pressure can damage the brain or spinal cord by pressing on important structures and by restricting blood flow into the brain. Common causes include brain hemorrhage, increased fluid around the brain, stroke, and aneurysm. (https://umm.edu/health/medical/ency//articles/increased-intracranial-pressure).

The nursing flow sheet documentation in the EMR (electronic medical record) on 5/7/16 at 0900 (9:00 AM) documented pupillary response as "4" and "brisk" for both the right and left pupils, and the LOC (level of consciousness) documented "UTA" (unable to assess).

The Hospitalist Daily Progress Note dated 5/7/16 at 1128 (11:28 AM) under the heading "Assessment and Plan: stated the following, in part:, "...7. Neuropsych/pain management...Acute rupture of L (left) MCA (Middle Cerebral Artery) aneurysm s/p repair. Pt (patient) has left hemiparesis (weakness) and right sided weakness as well, and limited communication abilities beyond occasionally opening and closing eyes at times on request...". "...STAT (immediate) CT (computed tomography) head for any significant change in neuro status...".

On 5/5/16 at 0859 (8:59 AM), the nursing flowsheet did not include documentation of pupillary response or size, and the level of consciousness (LOC) was marked "UTA".
On 5/5/16 at 2121 (9:21 PM), the pupillary reaction and size was recorded as "4" and "brisk" bilaterally, and the LOC was documented "UTA".
On 5/6/16 at 0952 (9:52 AM) the pupillary response was not documented, and the LOC was documented "UTA".
5/6/16 at 1955 (7:55 PM) the pupillary response and size was documented as "4" and "brisk" bilaterally, the LOC was documented as "UTA".
5/7/16 at 0900 (9:00 AM) pupillary response and size was documented "4" and "brisk" bilaterally, with the LOC documented "UTA".
5/7/16 at 2101 (9:01 PM) pupillary response was documented as "4" and "brisk "and LOC was not addressed. Documentation under "strength of RUE (right upper extremity) was "other", and in the comment section, the nurse typed in "decerebrate posture with stimulation-suction/iv stick". Decerebrate posturing had not been documented for Patient #1 before this date/time.

Decerebrate posture is defined as "an abnormal posturing of the body in which the arms and legs are held out straight and the toes are pointed downward. The neck and head are arched in a backward position. The muscles are tightened and rigid. This type of posturing is seen when there has been severe damage to the brain". (Merriam-Webster's Medical Dictionary 2014 New Edition). "Causes of decerebrate posture include: Bleeding in the brain from any cause, brain stem tumor, stroke, brain problem due to drugs, poisoning, or infection, head injury, brain problem due to liver failure, increased pressure in the brain from any cause, primary brain tumor, secondary brain tumor". (https://medlineplus.gov).

A nursing note dated 5/8/16 at 0239 (2:39 AM) documented the following: "Patient with cool skin and diaphoresis most of shift. Opens eyes but not to command and does not track. When stimulated with suctioning or needle stick there is decerebrate posturing note (sic) to bilateral arms. It is becoming increasingly difficult to obtain needed blood work due to poor options for venous sticks. Midnight cbc (complete blood count) delayed until repeat attempt can be made. Continues with ST (sinus tachycardia) 120s (sic) by telemetry".

There was no documentation available to support that the physician was notified that Patient #1 was having decerebrate posturing on 5/7/16 at 2101 (9:01 PM) when the nursing assessment first indicated that Patient #1 was experiencing decerebrate posturing, or on 5/8/16 at 0239 (2:39 AM) when a nursing note again documented decerebrate posturing in Patient #1.

An interview was conducted with Staff Member #9 on 2/2/17 at 12:00 PM; he/she stated "Nurses do general neuro (neurological) assessments, if there was a change, they would notify the doctor, and a CT scan would probably be ordered". "Neuro assessments are DBE (documentation by exception); we only document exceptions to normal findings".

On 2/2/17 at 3:00 PM, Staff Member #3, when asked what training the nursing staff received related to neuro assessments, he/she stated "If a nurse comes from a hospital setting, the nurse should know how to perform a basic neuro assessment; nurses learn how to do a basic neuro assessment in school. We don't give any training in nursing assessment. New nurses are precepted".

A Hospitalist Event Note for Patient #1 dated at 0745 (7:45 AM) states in part the following: "CTSP (called to see patient) this AM approximately 0710 (7:10 AM) to assess pt (patient) for change in neurologic condition. Patient has been able to open eyes on verbal stimuli until this morning. (He/She) has rigidity left arm and leg. (He/she) appears diaphoretic. (He/she) remains on vent support having done two pressure support trials yesterday. No active tonic clonic activity appreciated.." "...Neuro: Left hemiparesis with rigidity, withdraws to tactile stimuli BLE (bilateral lower extremities), RUE (right upper extremity) and RLE (right lower extremity) motor appears 4/5 (four of five). No conjugate eye movement, left globe without EOM (extra-ocular movement), right globe wandering. Pupils approx 5 mm (millimeters) and equal although nonreactive. Minimal gag to tongue blade exam. No tremor or tonic clonic activity".

Assessment/Plan: Medically complex patient with neurologic changes. Concerns for intracranial event...". "...Recent intracranial surgery on 4/8 heightens concern for ICH (intracranial hemorrhage)". "...I have reviewed clinical findings, medical history, and recent ongoing treatments with (facility and physician name) who agrees that patient requires urgent workup including CT head, and consultation with appropriate subspecialty services".

A discharge note dated 5/8/16 at 0958 (9:58 AM) documents "change in neurologic status concerning for acute intracranial process" on the list of discharge diagnoses.

"The average pupil size is 2-5mm (Bersten et al, 2003). The pupils should be equal in size. Pupil reaction to light should be brisk and after removal of the light source, the pupil should return to its original size.

Pupil reaction should be documented as per local policy, for example B (brisk), S (sluggish) or N (no reaction)". (nursingtimes.net; accessed on 2/15/2017 at 11:15 AM). Any changes in the patient ' s pupil reaction, size or shape, together with other neurological signs, are an indication of raised intracranial pressure (ICP) and compression of the optic nerve. (nursingtimes.net).

There were no nursing notes available for review by the surveyor after the note dated 5/8/16 at 0239 (2:39 AM). The surveyor interviewed Staff Member #3 on 2/2/17 at 3:10 PM regarding the lack of a nursing assessment after 2101 (9:01 PM) on 5/7/16, or a nursing progress note after 0239 (2:39 AM on 5/8/16), and prior to the patient's emergent transfer to (facility name) at 8:45 AM on 5/8/16 due to a change in Patient #1's neurological status. Staff Member #3 stated "Nursing is expected to do an assessment before 11:00 AM, and Patient #1 left the facility at 8:45 AM, but yes, I agree that he/she should have been assessed by the nurse".

Patient #1 was transferred to a higher level of care on 5/8/16 and expired on 5/9/16.

3a. Patient #3 was admitted to the facility on 5/19/16 at approximately 1:39 p.m. He/She had previously been hospitalized at an acute care facility after sustaining a traumatic head injury which required neurosurgical intervention and subsequent placement of a tracheostomy tube for mechanical ventilation, as the patient was not able to breathe on his/her own at that time. Patient #3 had been transferred to the facility in order to receive further care and treatment and potential weaning from mechanical ventilation.

The first documented "hygiene" was on 5/20/16 at 5:15 a.m. as "peri-care". Patient #3 was not documented as "bathed" until 5/21/16 at 2:00 p.m. and again on 5/22/16 at 4:17 p.m. Bathing was again documented on 5/23/16 at 11:52 a.m. There was no other documentation on the nursing "flowsheets" regarding peri-care. Another document "Vital signs complex" documented "comfort rounds- completed" which occurred at frequent intervals, however some were documented as occurring within two (2) minutes of a previously documented round.

When interviewed on 2/2/17 at 10:00 a.m., Staff Member #1 stated, "That means they were checking on (the patient) and during that time they could have provided for hygiene needs. I am not sure why the documentation looks like that with the time, but it says it was completed." When interviewed as to why, if hygiene was performed at that time it was not documented under the hygiene section, Staff Member #1 stated, "... They also documented the chlorhexidine bag baths (an antimicrobial skin cleanser) on the MAR because they have to sign out for them when they are given and they documented it daily and that is evidence of the daily bath..."

Based on information provided by the complainant, he/she stated when he/she visited on 5/22/16 at 9:30 a.m., Patient #3 did not appear to have been cared for, had a foul odor and the gown was dirty. The clinical record documented a bath on 5/21/16 (the previous day) at 2:00 p.m. The complainant stated he/she asked the staff about a bath for Patient #3. Upon review of the MAR for the chlorhexidine bath bag, the surveyor was not able to find any documentation that the bath had been given per the physicians orders on 5/22/16 on the day the complainant visited.

Further documentation in the clinical record revealed Patient #3 was on a mechanical ventilator with a tracheostomy. According to a "progress note" made by the wound nurse on 5/20/16, "Noted that (Patient #3) has copious secretions from (his/her) trach (tracheostomy) that are saturating (his/her) c-collar & (and) gown and requiring frequent suctioning, trach care and c-collar pad changes...Skin under trach is intact, but becoming macerated and slightly reddened. Suggest frequent trach care and sponge changes. To wipe down skin under and around trach with skin protective wipes to help guard against further maceration from the copious secretions."

Review of the documentation contained in the clinical record revealed the following regarding tracheostomy care and the changing of the dressing:

On 5/19/16 (date of admission) 4 episodes of tracheostomy suctioning - 1 documented dressing change - no documentation of c-collar pad changes.
5/20/16 - 5 episodes of tracheostomy suctioning - 3 documented dressing changes - no documentation of c-collar pad changes.
5/21/16 - 10 episodes of tracheostomy suctioning (Patient #3 was undergoing weaning trials at this time) - 2 documented dressing changes - no documentation that the c-collar pads were changed.
5/22/16 - 8 episodes of tracheostomy suctioning - 1 documented dressing change - no documentation of c-collar pads being changed.
5/23/16 (date of discharge) 3- episodes of tracheostomy suctioning - no dressing change- no c-collar pad changes.

In an interview with Staff Member #1 on 2/2/17 at 10:15 a.m., the surveyor discussed the trach care and c-collar concerns. Staff Member #1 stated, "The staff would have changed the c-collar pads when they needed to be changed....it may not have been documented though but respiratory therapy would have changed the trach dressing when they suctioned (him/her) if it needed to be changed...Physical Therapy would have helped with the c-collar pad changes because there would need to be someone to keep the neck (spine) in line..." The surveyor was unable to locate any documentation in the clinical record regarding the changing of the c-collar pads. (Patient #3 had a physician's order dated 5/19/16 "Aspen cervical collar to remain in place.")

On 2/2/17 at approximately 6:30 p.m., the surveyor discussed the concerns regarding the staff's failure to follow the physician's order regarding the daily "bag baths" and the lack of evidence concerning the changing of the c-collar pads with the administrative staff (Staff Members #1, 2, 3, 4, and 5) and that there was no inclusion on the care plan for Patient #3 regarding the use of the ASPEN collar and the interventions/care needs that would be done by staff.

5b. Further review of the clinical record for Patient #3 revealed the following:

The "History and Physical" dated 5/19/16 performed by the attending physician on admission documented, in part, "...(He/She) is essentially noncommunicative, although by report (he/she) has moved (his/her) right foot on request and may visually track with family members...at the time of my interview and exam the patient is noncommunicative and does not respond to my verbal requests...HEENT:...pupils are equal and reactive to light...NEURO- corneal reflexes appear present, no gag, no facial asymmetry, spontaneous withdrawal of BLE (bilateral lower extremities) R>L (right and left) during tracheal suctioning o/w (otherwise) flaccid extremities...pupils equally round and reactive, no tracking... Assessment and Plan: 7. Neuropsych- TBI (traumatic brain injury) scattered SAHs (subarachnoid hemorrhages) and bilateral frontotemporial parietal crainectomies on 5/8- Patient is very neurologically compromised, noncommunicative and appears functionally quadriplegic, (He/She) does spontaneously withdraw BLE with tracheal suctioning...stat CT for significant neurological changes..."

OT (Occupational Therapy) Progress note 5/20/16 at 0930 (9:30 a.m.) documented: "...Vision- unable to track or hold gaze. L (left) eye dilated greater than R (right) eye...Functional Cognition- Pt (patient) was able to blink upon command..."

TCH Pulmonary Concurrent Care Note 5/20/16 at 1047 (10:47 a.m.) "...Interval Events: 5/20/16: rested on vent yesterday; more alert today- occasionally follows commands (wiggle right toe) and attempt to mouth words...Assessment and Plan- ...somewhat more responsive today...reportedly tolerating several hours of TCT prior to this but less in last few days... (TCT- total cycle time- a rate set by the patients respiratory rate- the sum of inspiratory time (breathing in) and expiratory time (breathing out)- used in weaning from mechanical ventilation -www.respiratorytherapy/RT/org)

Hospitalist Daily Progress Note 5/20/16 at 10:11 a.m. "...(family member) in room overnight states that pt seemed more interactive. No purposeful movement on my eval this AM....HEENT...pupils are equal and reactive to light...NEURO: -...no facial asymmetry, spontaneous withdrawal of BLE R>L (bilateral lower extremities right and left) during tracheal suctioning o/w (otherwise) flaccid extremities...pupils equally round and reactive, minimal tracking..."

Physical Therapy Progress Notes 5/20/16 10:44 a.m.- "...Objective Evaluation- Mental Status- Pt was able to blink on command but not tracking. Vision- pupils dilated, but not tracking....Communication- non verbal...Established Goals- Patient will tolerate upright sitting in the chair for 1 (one) hour, while working on vent weaning..."

Hospitalist Daily Progress Note 5/22/16 "...no purposeful movement on my eval. No response to verbal stimuli...HEENT- ...pupils equal are reactive to light...NEURO- no facial asymmetry, no withdrawal to tactile stimuli...pupils equally round and reactive...Assessment and Plan...7. Neuropsych- ...Patient is very neurologically compromised, noncommunicative, appears functionally quadriplegic. (He/she) does spontaneously withdraw BLE with tracheal suctioning...stat head CT for significant neurologic changes..."

Physical Medicine Consult dated 5/23/16 "... (family member) reports that on Tuesday patient kissed (him/her) and mouthed "I love you" when (he/she) visited. Yesterday- no response...Neuro- eyes slightly open but not tracking, slight eye movement noted...pupils, equal round, slightly reactive bilat (bilaterally)...motor strength- no movement noted in any extremity...spoke with patient's (family member) on the phone- concerned (his/her) MS (mental status) has worsened, acknowledged this may be d/t (due to) infection. relayed concerns to primary team..."

Hospitalist Daily Progress Note 5/23/16 at 1356 (1:56 p.m.) performed by Staff Member #11)
"...No overnight problems or events. No change in neurological status. However, (Patient #3's family member) and I spoke and apparently on Thursday of last week (he/she) would recognize (his/her) voice and "pucker up" for a kiss. (He/She) would also squeeze (his/her) hand. (He/She) is asking me to transfer to neuro ICU (intensive Care Unit). I've ordered a CT scan of (his/her) head...General- noncommunicative, nonverbal. HEENT- Aspen collar in place...Pupils equal are reactive to light...Neuro- no facial asymmetry, no withdrawal to tactile stimuli...pupils equally round and reactive...Assessment and Plan- 7. Neuropsych- ...spoke with the (family member) today and it appears that (he/she) has had a decline in (his/her) mental status since (he's/she's) been at TCH (facility). (He/She) tells me that on Thursday of last week (he/she) was responsive and would "pucker up" for a kiss and squeeze (his/her) hand. (He/She) is not responding to verbal stimuli. I've ordered a CT scan of (his/her) brain today..."

The "Discharge Summary" dated 5/23/16 at 1513 (3:13 p.m.) documented the following, "7. Neuropsych: ...-spoke with (family member) today and it appears that (he/she) has had a decline in (his/her) mental status since (he/she's) been at the TCH (transitional care hospital)...I've ordered a CT scan of (his/her) brain urgently today. It revealed a 4.0 cm (centimeter) left cerebral convexity (the aspect of the cerebral hemisphere that lies in contact with the flat bones of the skull; it includes parts of the frontal, parietal, temporal, and occipital lobes.) with 2.0 cm of rightward midline shift (the movement of the brain past the midline due to pressure from fluid, blood, tumor or swelling), evolving contusion injuries, right hydrocephalus (an abnormal accumulation of cerebral spinal fluid in the brain), and collapse of the left ventricle. Spoke with (name of neurologist) as soon as I received the report and he recommended transfer to Neuro ICU and suggested (Patient #3) would need surgery urgently..."

TCH Pulmonary Concurrent Care Note 5/23/16 "...Interval events: 5/20/16- rested on vent yesterday; more alert today- occasionally follows commands (wiggle right toe) and attempt to mouth words...5/21/16 afebrile noncommunicative this a.m....5/22/16 fever last night, non communicative...5/23/16 temperature slightly high last night, but not above 101...MS (mental status) remains unresponsive; not following commands, not opening eyes to commands..."

According to further documentation in the clinical record, on the date of admission 5/19/16 at 2:12 p.m. the Registered Nurse (RN) performed an assessment of Patient #3. Part of the admission included an assessment of the patient's neurological status including the Glasgow Coma Scale. The Glasgow Coma Scale is a scale that is used to assess the severity of a brain injury based on how a patient responds to certain standard stimuli (opening the eyes, verbal response). -Merriam Webster's Medical Dictionary 2014 New Edition.

The RN assessed Patient #3 on admission as having a Glasgow score of 11 at 2:12 p.m. (Eye opening -4, Best Verbal- 1, Best Motor- 6) At 10:22 p.m. the score was assessed as "10" (Eye opening - 3, Best Verbal- 1, Best Motor- 6). On 5/20/16 at 10:00 a.m. the score was "10", however at 9:58 p.m. the score had dropped to "7" (Eye opening 3, Best verbal- OT [other], Best motor-4). Patient #3 remained at a Glasgow score of "7" until 5/22/16 at 9:09 p.m. when there was no further documentation of the scale being assessed.

The "Flowsheet Data" documentation revealed on 5/19/16 upon admission, the RN also documented an assessment of the "Pupillary Size/Reaction - Size R (right) pupil (mm - millimeter) 4, Reaction R Pupil- Brisk, Size L (left) pupil (mm) 4- Reaction L pupil- Brisk". Further review of the flowsheet documentation revealed the pupils were assessed as follows: 5/20/16 at 10:00 a.m. - Size R pupil 4, Reaction R Pupil- brisk, Size L pupil 4, Reaction L pupil- brisk, 5/20/16 2158 (9:58 p.m.) Size R pupil- 5, Reaction R pupil -sluggish, Size L pupil -5, Reaction L pupil -sluggish. 5/21/16 7:31 a.m. - Size R pupil- 5, Reaction R pupil- brisk, Size L pupil- 5, Reaction L pupil- brisk. There was no further documentation of any other assessments of Patient #3's pupillary responses other than the documented OT assessment that the pupils were unequal, and the PT assessment that the pupils were sluggish (documented 5/20/16 at 9:30 a.m. and 10:44 a.m. respectively).

According to "The Lippincott Manual of Nursing Practice 11th Edition" Pupillary changes can be caused by increasing pressure or an expanding clot displacing the brain against the oculomotor or optic nerve...this is an emergency situation that can lead rapidly to death or result in a vegetative state for the patient."

In an interview with Staff Member #3 on 2/2/17 at 2:50 p.m., in regards to the nurse assessment of patients pupillary responses/neuro checks, Staff Member #3 stated, "They may come out of ICU with neuro checks every four hours, but rarely do we do them." When interviewed further about the training the staff receives regarding performing a neurological assessment on a patient since so many of the patients at the facility has neurological injury or compromise, Staff Member #3 stated, "When you get out of nursing school you should know how to do this. It is a basic nursing assessment, so we do not provide any training to the staff on how to do this. If a nurse has not had any experience, they are put with a preceptor and they learn that way, but we do not provide that training..."

The facility documented the scoring of the scale as follows:
Eye Opening- 4= spontaneous, 3= to speech, 2= to pain, 1= none, C=swollen shut
Best Verbal- 5= Oriented, 4=Confused, 3=Inappropriate words, 2= Incomprehensible speech, 1=none/not intubated, OT=None/intubated
Best Motor- 6=Obeys Commands, 5=Localizes pain, 4= withdraws from pain, 3=Flexion to pain, 2=Extension to pain, 1=None

On 2/1/17 at 4:20 p.m., as the surveyor was reviewing the Glasgow coma scale documentation, Staff Member #1 was interviewed. The surveyor asked if the drop in the Glasgow coma scale, as assessed, from an 11 on admission to a 7 would be of a concern to the staff. Staff Member #1 stated, "That would be a big problem". The surveyor then inquired as to why this was not addressed by the nursing staff, as no documentation was found in the nursing notes or in the clinical record that the physician had been made aware of this change. Staff Member #1 stated, "I don't know. I will have to get someone with more expertise on this matter to look at it..."

The surveyor reviewed a document "InterQual Review Summary" which was dated as being completed on 5/19/16 and was identified by Staff #1 on 2/2/16 at 4:00 p.m. as "referral information for admission review". According to this document Patient #3 was assessed at the previous facility (before transfer) as having a Glasgow coma scale of "9 - with some tracking and squeezing of (spouses) hand on request". A document "Trauma Surgery Discharge/Transfer Summary" from the transferring facility dated 5/19/16 documented, in part: "...ICU Course...MS (mental Status) improving-loathe (sic) to follow commands during exam, but will kiss (his/her) (family member) on command and says "I love you" to (him/her) after (he/she) says it to (Patient #3)...Discharge Exam: ...Neuro- eyes tracking, not following commands...GCS...=9..."

The "Care Plan" for Patient #3 did not include any interventions related to the monitoring of the patient's neurological status interventions, other than "At Risk for Delirium- Patient will be free from delirium". This was on the plan of care for the RN who was assigned to care for that patient on the first shift. The subsequent nursing "Plan(s) of Care" documented each shift by the RN assigned to the care for Patient #3 from 5/20/16 (day shift) through discharge on 5/23/16 which did not evidence the inclusion of monitoring the patient's neurological status. When interviewed regarding the nursing "plan of care" on 2/2/17 at 2:50 p.m., Staff Member #3 stated, "Each nurse puts on their daily care plan what they are monitoring from the things they think are most important..."

On 2/2/17 at 9:35 a.m., the surveyor interviewed Staff Member #11 (Medical Director). Staff Member #11 stated he was not the admitting physician for Patient #3 and only saw the patient on 5/23/16. Staff Member #11 stated the admitting physician no longer at the facility as he/she had resigned. During the interview, the surveyor inquired as to the assessment of Staff Member #11 for Patient #3 on the date (he/she) examined the patient. Staff Member #11 stated, "I had not seen the patient prior to the 23rd, but I did receive a sign-off from the other physician and was told that neurologically there was not much there. I observed that when I rounded on the Patient. The patients (family member) had a concern that something had changed so I ordered an emergency CT and it showed (he/she) had a hygroma which is a late complication of this type of head injury..." The surveyor inquired as to whether Staff Member #11 was aware of the changes in the Glasgow coma scale documented by the staff and what would be the action if he/she had been informed of this change. Staff Member #11 stated he/she was not made aware of the change and that "with (his/her- Patient #3) history and it was on a Friday night and there was no imaging here- the night doctor may have seen (him/her) but I would have reassessed the patient and tried to reproduce the higher response (10) and if I could not, then I would have ordered a stat CT. The patient's (family member) told me that (he/she) felt there was a decline in responsiveness, so I ordered the CT... the patient was then transferred for necessary intervention...back to neuro ICU (intensive care unit) and they had to put a drain in [his/her] head and do some revisions to the craniotomy..."

On 2/2/17 at 12:15 p.m., the surveyor interviewed Staff Member #12, a Registered Nurse (RN) who had documented the Glasgow coma scale (GCS) change from 10 to 7 on 5/20/16 at 9:58 p.m. The surveyor inquired as to whether the RN had observed the change in the GCS scoring and what interventions had been done, or if the physician had been notified. Staff Member #12 stated, "Maybe there was a difference in the way I looked at the question under verbal. He (physician) made a habit of coming to talk with us about patient progress and changes. We communicated that way a lot. He would touch base more than once a day; he was always at the nurses station. I didn't write down every time we talked but we stayed in communication." The surveyor was unable to locate any documentation in the medical record that there had been notification of the physician of the change in the GCS.

The surveyor discussed with the facility Staff Members #1, #3 and #5 on 2/2/17 at 3:00 p.m. the concerns regarding the conflicting documentation regarding Patient #3's mental status, the change in the assessment of the GCS that was not reported to the physician, and the documentation of the pupillary responses in the neuro assessment. The OT (Occupational Therapy) documentation of unequal pupils that was not reported or followed up on and the subsequent findings on the CT scan of increased fluid presence in Patient #3's brain along with a midline shift resulting in the need to emergently transfer Patient #3 to a higher level of care for further neurological treatment was also discussed as well as the lack of evidence of care planning regarding continued monitoring of interventions related to the patient's neurological status. Staff Member #1 stated that the chart contained all the documentation to evidence the patient received good care and that the staff had assessed the patient.

On 2/2/17 at approximately 6:30 p.m., the surveyor discussed the concerns regarding the changes in the patient's neurological status and associated documentation concerns with the administrative staff (Staff Members #1, #2, #3, #4, and# 5) and that there was no inclusion on the care plan for Patient #3 regarding the neurological status of a patient with a traumatic brain injury with a craniotomy.

5c. Patient #3's clinical record revealed a physician's order for "Multipodus boots" on 5/22/16 at 10:25 a.m. There was no documentation in the clinical record that the Patient was wearing the physician ordered boots after 5/22/16 at 11:30 a.m., and there was no inclusion on the "care plan" that the multipodus boots were ordered or in use. (Multipodus boots are a protective orthosis that corrects foot misalignments and minimizes the chance of skin breakdown. www.multipodus.com)

In an interview with Staff Member #3 on 2/2/17 at 2:50 p.m., Staff Member #3 stated, "(Patient #3) came with them. We do not need an order for them, but since there is one, there should be documentation. They would document the use and put it on the care plan whether there was an order or not, but we don't need an order to use them..."

The "Care Plan" dated 5/19/16 documented "consider heel suspension boots to wear while in bed" however; this care plan was discontinued on 5/20/16. There had been no update to the care plan after the order was received on 5/22/16 evidencing the us