HospitalInspections.org

Based on review of the Life Safety Code survey report of the Life Safety survey conducted May 02, 2013, it was determined the hospital was not in compliance with 42 CFR Part 482: Conditions of Participation for Hospitals (Rev. October 11/2008) for Physical Environment.

Findings:

Please refer to the Life Safety Code report of May 02, 2013.

Based on document review and interview, the facility staff failed to ensure patients and/or representatives were informed of the complaint process and failed to adequately document complaint investigations.

Findings:

The facility's complaint policy and admission documents to be presented to patients upon admission were reviewed on 4/15/13 and 4/16/13. The admission information and documents presented to patients did not include the address of the State Agency or the Quality Improvement Organization (QIO). The policy stated the patient's would be given the address of the State Agency. The policy did not state the QIO agency's number and address would be provided-only that "...a mechanism for timely referral of patient concerns regarding quality of care or premature discharge..." The QIO number was provided-but not an address.

Random complaint/grievances were reviewed on 4/16/13. The complaint documentation did not include evidence of an investigation of the allegations. The documentation did not include evidence of an investigation of patient or family member's concerns, record review, observations, or interviews. The Administrator was interviewed on 4/16/13 at 10:10 a.m. and additional evidence of each investigation was requested. The Administrator stated the interviews with employees or other investigative details were not documented.

On 4/16/13 at 11:25 a.m. one patient and family member (Patient # 5) were interviewed and stated they were unaware of the process or address of the state agency, or the process to file a complaint/grievance.

Based on document review and interview, the Governing Body failed to review and resolve grievances, or to delegate the responsibility in writing to a Grievance Committee.

Findings:

The Governing Body meeting minutes and bylaws, the facility policy and procedures and grievance processes were reviewed 4/16/13/ and 4/17/13. The complaint log and randomly selected complaints were also reviewed. The documentation did not evidence that the Governing Body delegated in writing the process of complaint/grievance review and resolution, to a Grievance Committee. The Administrator was interviewed on 4/16/13 at 10:10 a.m. and evidence of the delegation of this responsibility was requested. On 4/17/13 at 10:50 a.m. the Administrator stated that the facility did not have a Grievance Committee until January 2013, and the Governing Body was responsible prior to that date. No evidence of the Governing Body's delegation of complaint/grievance investigation and resolution to a Grievance Committee was presented during the survey.

Based on interviews and review of clinical records, it was determined that the facility staff failed to ensure three of twenty patients (#5, #4 and #15) were adequately assessed by skilled nurses.

1. Patient # 5 developed an Un-stageable Pressure Ulcer of the left ankle which resulted in a hospital acquired infection. 2. Patient # 4's clinical record did not evidence documentation of meal intake. 3. Patient # 15 was not assessed when vital signs were outside the parameters determined by facility protocol.

The findings included:

1. Patient #5 was admitted to the rehabilitation hospital on 3/22/13 with disuse myopathy (A muscular disease in which the muscle fibers do not function for any one of many reasons, resulting in muscle weakness) , Fracture of L 1(Lumbar), L 3 and L 4 resulting in a kyphoplasty Surgery conducted on 4/12/13, to stop the pain caused by a spinal fracture, to stabilize the bone and to restore some or all of thee lost vertebral body height due to the compression fracture. Comorbidities (Multiple diseases.) included Hypertension, Diabetes Type II, Bipolar Disease, Sleep Apnea and Atrial Fibrillation.

On 4/15/13, a 0. 9 cm x 3 cm (One centimeter equals 0.393 inches) pressure ulcer was found on the left ankle. The nurse documented the wound was an Un-stageable Pressure Ulcer due to slough (Un-stageable or Unclassified )and/or eschar (A dry scab formed on the skin). The Wound Nurse Consultant #14 verified that the Pressure Ulcer to the left ankle was discovered on 4/15/13, at 10:40 a.m. The current measurements of the pressure ulcer was 0.9 cm x 1.2 cm and remained Un-stageable due to determine the depth of the wound due to the slough, stated Wound Consultant #14, during interview on 4/17/13, at 09:15 A.M. During interview, Wound Consultant #14 verified that this Pressure Ulcer was reported to Medicare as a Hospital Acquired Wound.

Concerns were voiced by Patient #5's spouse during observation of the wound care provided by Wound Consultant #14, on 4/16/13, at 11:25 AM. The process for pressure ulcer prevention was started too late stated Patient #5's Spouse during interview, because he had been admitted since 3/22/13.



21229

2. The clinical record for Patient # 4 (four) was reviewed on 4/16/13. Patient # 4 was admitted to the facility on 4/3/13 with the diagnoses of, but not limited to: debility secondary to respiratory failure and pneumonia and recent pelvic fracture. The surveyor was unable to locate the documentation for meal intake on the following days: 4/9/13 - no dinner meal intake was documented, 4/10/13 - no lunch nor dinner intake was documented, 4/11/13 - no lunch nor dinner intake was documented, 4/12/13 - no dinner meal intake was documented, 4/13/13- no lunch nor dinner meal intake was documented. Patient # 4 had a dietician consult on 4/6/13 which evidenced a concern for poor appetite and food intake. There was no weight documented on admission 4/3/13, however, on 4/6/13, Patient #4's weight was recorded as 177 pounds. Other weights documented in the clinical record revealed" 4/8 - 159.9 lbs (pounds), 4/9 - 165.4 lbs., 4/10 - 169.2 lbs., 4/13- 134.5 lbs., and 4/14/13 - 161.1. There was no evidence of re-weight, or assessment/investigation as to the weight discrepancies. There was a dietician progress note dated 4/11/13 which did not address the weight inconsistencies and there was no evidence the dietician was aware of the weights obtained after 4/11/13.

3. The facility staff failed to ensure Patient # 15 was evaluated when the blood pressure fell below the parameters specified by the physician.

Review of the clinical record for Patient #15 revealed the patient was admitted on 4/4/13 with the diagnoses of, but not limited to : chronic demyelinating polyneuropathy (progressive muscle distraction and weakness) and hypertension. A document "vital signs" was contained in the clinical record which evidenced parameters for blood pressure monitoring. If the patient's blood pressures fell below or exceeded the parameters listed, the MD (physician) was to be notified. The parameters for the blood pressure were as follows: A systolic blood pressure below 90 or above 160. A diastolic blood pressure below 60 or above 100.
On 4/13/13, Patient #15's blood pressure was documented as 98/57. On 4/14 - 96/58, 4/15 - 99/58, and on 4/16/13 - 80/58. Patient # 15 was also receiving 80 milligrams of an antihypertensive medication Propranolol for which there was no documentation the medication had been held, or the physician had been notified of the low blood pressures.

On 4/16/13 at 4:00 p.m., the surveyor discussed the findings with Staff # 3 and #7. Further information was requested. On 4/17/13 at 11:30 a.m., Staff #3 acknowledged the finding.

Based on staff interview and clinical record review, the facility staff failed to develop and update care plans for 6 (six) of 20 (twenty) patients of the survey sample. Patient #'s 8, 14, 15, 17, 18, and #19.

The findings included:

1. Review of the clinical record for Patient #8 revealed on 4/11/13 a change in the diet consistency to "pureed with honey thickened liquids". On 4/16/13, the diet consistency was again changed to "Nectar thick liquids- no straws, pureed solids and medications crushed in applesauce". Review of the care plan for Patient #8 evidenced no changes in the care plan. Patient #8 was documented as being "NPO" (nothing by mouth) on the current care plan. Patient #8 also was admitted to the facility with a pressure ulcer which had deteriorated . There was no revision to the care plan regarding the pressure ulcer.

2. Patient #14 was receiving an anticoagulant medication Lovenox, for the prevention of blood clots, and also receiving an antibiotic for the treatment of a urinary tract infection (4/12/13). There was no revision to the care plan to include the Lovenox, nor the addition of the urinary tract infection. Patient # 14 was admitted to the facility on 4/11/13 with diagnoses that included, but were not limited to: multiple sclerosis left total hip arthroplasty, and hypertension.

3. Patient #15 was admitted on 4/4/13 with the diagnoses of, but not limited to : chronic demyelinating polyneuropathy (progressive muscle destruction and weakness) and hypertension. Patient # 15 was receiving 80 milligrams of an antihypertensive medication (Propranolol) and blood pressure monitoring (parameters) for which there was no care plan developed for hypertension or monitoring of the blood pressures.

4. Patient #17 had no care plan developed to address pain. Patient #17 was admitted to the facility on 4/8/13 with the diagnoses of, but not limited to: left bimalleolar fracture status post open reduction internal fixation, and bipolar disorder. Patient # 17 on 4/9, 4/11, and 4/13 had complaints of pain documented on the nursing daily assessment and had received as needed pain medications on two occasions. Patient #17 was receiving therapy/treatment for a foot fracture and was status-post surgery for the fractured foot.

5. Patient #18 had no care plan developed to address pain. Patient # 18 was admitted to the facility on 4/11/13 with the diagnoses of, but not limited to: deconditioning, and esophageal cancer. Patient #18 was being administered a Fentanyl patch (pain medication) for pain control and had received as needed pain medication to control break-through pain.

6. Patient #19 had a diet consistency change on 4/12/13 and the care plan was not updated to reflect this change. Patient #19 was transitioning from being tube fed to oral intake. Patient #19 was admitted to the facility on 3/23/13 with diagnoses of, but not limited to: stroke, and dysphagia status post feeding tube placement.

On 4/16/13 at 11:40 a.m., Staff #11 was interviewed as to who could update care plans. Staff #11 stated "Anyone can update the care plans. Usually, though it is the RN (Registered Nurse) who cares for the patient because he/she knows them better..."

On 4/16/13 at 4:00 p.m., Staff #3 and #7 were informed of the findings. Staff #3 stated that any staff could update the care plans and the admitting RN (Registered Nurse) was the one who began the care plan process. On 4/17/13 at 11:30 a.m., Staff #3 stated "we will be working on documenting and care plans".

The facility policy and procedure for "Interdisciplinary Care Plans" was reviewed. The policy and procedure documented, in part: "...Each patient will have a care plan based on the admitting diagnosis...Each problem identified on the Interdisciplinary Assessment (IDA) should be carried over to the POC (Plan of Care)...The POC should be updated whenever new problems are identified, goals are met or problems are resolved, or when there is a significant change in patient condition..."

Based on clinical record review and staff interview, the facility staff failed to properly file patient documents for 1 (one) of 20 (twenty) patients of the survey sample, Patient # 4.

The findings included:

During the clinical record review for Patient #4, another patients information ( lab results and physician's progress notes) was found within the record. Patient # 4 was admitted to the facility on 4/3/13 with the diagnoses of, but not limited to: debility secondary to respiratory failure and pneumonia and recent pelvic fracture.

On 4/16/13 at 11:45 a.m. the surveyor interviewed staff #3 as to who files the documents in the clinical records. Staff #3 stated the unit secretary usually does, but other staff can put documents into the charts as well. Staff #3 stated the documents would be removed from Patient #4's record and placed into the correct chart.

Based on staff interview and clinical record review, the facility staff failed to ensure a complete and accurate clinical record for 7 (seven) of 20 (twenty) clinical records reviewed, Patient #'s 4, 14, 15, 16, 17, 3 and 5.

The findings included:

1. The clinical record for Patient # 4 (four) was reviewed on 4/16/13. Patient #4 was admitted to the facility on 4/3/13 with diagnoses of, but not limited to: debility secondary to respiratory failure and pneumonia and hypertension. The surveyor was unable to locate the documentation for meal intake on the following days: 4/9/13 - no dinner meal intake was documented, 4/10/13 - no lunch nor dinner intake was documented, 4/11/13 - no lunch nor dinner intake was documented, 4/12/13 - no dinner meal intake was documented, 4/13/13- no lunch nor dinner meal intake was documented. Patient # 4 had a dietician consult on 4/6/13 which evidenced a concern for poor appetite and food intake. There was no weight documented on admission 4/3/13, however, on 4/6/13, Patient #4's weight was recorded as 177 pounds. Other weights documented in the clinical record revealed" 4/8 - 159.9 lbs (pounds), 4/9 - 165.4 lbs., 4/10 - 169.2 lbs., 4/13- 134.5 lbs., and 4/14/13 - 161.1. There was no evidence of re-weight, or assessment/investigation as to the weight discrepancies. There was a dietician progress note dated 4/11/13 which did not address the weight inconsistencies and there was no evidence the dietician was aware of the weights obtained after 4/11/13.

The medication administration records (MAR) for Patient #4 were also reviewed and revealed on 4/12/12 Lovenox (an anticoagulant medication) was not documented as being administered at 6:00 a.m. On 4/13/13, Neurontin (an anti-seizure medication often used for pain control) and Lactobacillus (a pro-biotic) were not documented as being administered (8:00 p.m., and 10:00 p.m.). On 4/14/13, The lactobacillus was not documented as being administered at 8:00 p.m. (2000) .

2. Patient # 14's clinical record was reviewed 4/16/13. No dinner meal intakes were documented on 4/13 or 4/15/13. Patient #14 was admitted to the facility on 4/11/13 with diagnoses that included: multiple sclerosis and total left hip arthroplasty.

3. Patient # 15 was admitted on 4/4/13 with the diagnoses of, but not limited to : chronic demyelinating polyneuropathy (progressive muscle destruction and weakness) and hypertension. The clinical record was reviewed on 4/16/13. On 4/6 and 4/8/13, no lunch and no dinner meal intake was documented. On 4/9 and 4/14/13, no intake was documented for any meal. On 4/12 and 4/13/13, no dinner intake was documented. Patient # 15 had no pain assessment documented on the admission assessment dated 4/4/13.

4. Patient # 16 was admitted to the facility on 4/5/13 with diagnoses that included: left tibia/fibula fracture status-post open reduction internal fixation . Patient #16 had no dinner meal intake documented on 4/6, 4/9, and 4/11/13. There was no intake documented for any meal on 4/12/13. On 4/13/12, there was no intake documented for lunch or dinner.

5. Patient #17 was admitted to the facility on 4/8/13 with diagnoses that included: left bimalleolar fracture status-post open reduction internal fixation and bipolar disorder. The clinical record for Patient #17 revealed no pain assessment documented on the admission assessment dated 4/8/13. On 4/13/13, the following medications were not documented as being administered: Celexa ( an antidepressant) at 9:00 a.m., Dicyclomine (an antispasmodic) at 1630 (4:30 p.m.), Claritin (antihistamine) and Potassium Chloride (an electrolyte) at 1400 ( 2:00 p.m.).

On 4/16/13 at 4:00 p.m., the surveyor discussed the findings with Staff # 3 and 7, and further information was requested.

On 4/17/13 at 11:30 a.m., Staff # 3 stated,, he/she had reviewed the records and acknowledged the documentation "is not there".




09881

6. Patient #3 was admitted on 4/1/13, with diagnoses of Respiratory Failure with Heart Block, Generalized Weakness and Stage III Back Pressure Ulcer. Skilled nursing notes on 4/11/13, at 22:30 p.m. (10:30 p.m.), assessed the wound as Stage II on the medial back and measured 0.9 x 0.4 x 0, Stage III was assessed by Wound Consultant #14, on 04/12.13, due to slough ((Un-stageable or Unclassified) , with the depth immeasurable.

Wound Consultant #14 stated that education was needed for the staff to document wound consistently. The interview was conducted on 4/17/13, at 09:22 AM.

7. Patient #5 was admitted to the rehabilitation hospital on 3/22/13 with disuse myopathy (A muscular disease in which the muscle fibers do not function for any one of many reasons, resulting in muscle weakness.) , Fracture of DL 1(Lumbar), L 3 and L 4 resulting in a kyphoplasty Surgery conducted on 4/12/13, to stop the pain caused by a spinal fracture, to stabilize the bone and to restore some or all of thee lost vertebral body height due to the compression fracture. Comorbidities (Multiple diseases.) included Hypertension, Diabetes Type II, Bipolar Disease, Sleep Apnea and Atrial Fibrillation.

Physician's orders included assessing for pain and documenting twice daily, with weight measured weekly. The days that pain was not documented on the vital sign documentation were 04/07/13, 04/07/13 for Patient #5. During the evening, the skilled nurse failed to document the amount of pain that Patient #5 was having on 04/10/13 and 04/16/13. Weights for Patient #5 was on 4/7/13 only.

Chief Nursing Officer #3 verified that documentation remained a challenge for the nursing staff. This interview occurred on 04/16/13, at 4:00 PM.

Based on clinical record review and staff interview, the facility staff failed to ensure the nutritional needs of patients were being met by documenting the meal intake for 1 (one) of 20 (twenty) Patients of the survey sample. Patient #'s 4.

The findings included:

The clinical record for Patient # 4 (four) was reviewed on 4/16/13. Patient #4 was admitted to the facility on 4/3/13 with diagnoses of, but not limited to: debility secondary to respiratory failure and pneumonia and hypertension. The surveyor was unable to locate the documentation for meal intake on the following days: 4/9/13 - no dinner meal intake was documented, 4/10/13 - no lunch nor dinner intake was documented, 4/11/13 - no lunch nor dinner intake was documented, 4/12/13 - no dinner meal intake was documented, 4/13/13- no lunch nor dinner meal intake was documented. Patient # 4 had a dietician consult on 4/6/13 which evidenced a concern for poor appetite and food intake. There was no weight documented on admission 4/3/13, however, on 4/6/13, Patient #4's weight was recorded as 177 pounds. Other weights documented in the clinical record revealed" 4/8 - 159.9 lbs (pounds), 4/9 - 165.4 lbs., 4/10 - 169.2 lbs., 4/13- 134.5 lbs., and 4/14/13 - 161.1. There was no evidence of re-weight, or assessment/investigation as to the weight discrepancies. There was a dietician progress note dated 4/11/13 which did not address the weight inconsistencies and there was no evidence the dietician was aware of the weights obtained after 4/11/13.

On 4/16/13 at 4:00 p.m., the surveyor discussed the findings with Staff # 3 and 7, and further information was requested.

On 4/17/13 at 11:30 a.m., Staff # 3 stated, he/she had reviewed the records and acknowledged the documentation "is not there".

Based on observation, policy review and interview, the facility staff failed to ensure oxygen cylinders were stored in a safe manner.

Findings:

On 4/15/13 at 2:00 p.m. an oxygen storage room was observed with the Chief Nurse Executive. Small "E" tank oxygen cylinders were observed. Seven tanks were stacked on top of additional "E" tanks. The full tanks on top were not secured or in a maintained in a manner to prevent them from falling. The CNE stated this was not an acceptable oxygen storage method. A policy regarding the storage of oxygen was requested at 4:15 p.m. On 4/16/13 at 10:00 a.m. the Director of Plant Operations was interviewed and he stated it was not acceptable to stack the oxygen cylinders. The policy directing the storage of oxygen was requested. A policy was not presented to evidence a procedure to ensure the safe storage of oxygen. The contract and the schedule for the delivery and pick up of oxygen cylinders was reviewed, it did not include the method in which the agency would ensure the appropriate storage, use and delivery of the small "E" oxygen cylinders.

OXYGEN STORAGE REQUIREMENTS NFPA 99 1999 EDITION LESS THAN 3000 CUBIC FEET Division of Quality Assurance Bureau of Regulatory Compliance (Revised March 2004) requires the following for oxygen storage:
"8-3.1.11.2 Storage for nonflammable gases less than 3000 cubic feet... (h) Cylinder or container restraint shall meet 4-3.5.2.1(b)27.
4-3.5.2.1(b)27 Freestanding cylinders shall be properly chained or
supported in a proper cylinder stand or cart...."

The Administrator was informed of the above concern on 4/17/13 at 12:10 p.m.