HospitalInspections.org

Based on interview, record review and policy review, the facility failed to ensure that staff provided the initial Important Message from Medicare (IMM, information about a patient's right to appeal discharge) and ensure it was signed, dated, and placed in the patient's medical record upon admission, but not longer than two calendar days after admission, for five patients (#9, #11, #12, #37 and #49) of 24 Medicare patients' medical records reviewed. This failed practice had the potential to affect all Medicare eligible patients' ability to be informed of their right to appeal discharge. The facility census was 299.

Findings included:

1. Review of the hospital's policy titled, "Case Management, An Important Message from Medicare About Your Rights Notice," dated 12/09/19, showed the following:
- Patient Access Services (PAS) will be responsible for the delivery and signature of the initial IMM, indicating receipt, at the time of registration and forward to Health Information Management (HIM) for scanning into the medical record.
- This will include inpatients admitted from the Emergency Department (ED), Direct Admissions from the Access Line and those patients converted to inpatient from observation status.
- This must be completed within 48 hours of admission or conversion from observation status.
- If the patient is not competent to sign the IMM notice, the information will be delivered to the legal guardian, medical power of attorney, next of kin or primary care giver.
- The notice may be delivered via telephone and documented on the notice with the person notified, date and time. Once this is completed, a copy will be sent via certified mail, faxed or provided to the individual upon arrival to the hospital.

Review of Patient #9's medical record showed that she received Medicare benefits and was admitted to the hospital on 06/13/21. An IMM was never provided to the patient as of eight days after her admission.

Review of Patient #11's medical record showed that he received Medicare benefits and was admitted to the hospital on 06/12/21. An IMM was never provided to the patient as of nine days after his admission.

Review of Patient #12's medical record showed that she received Medicare benefits and was admitted to the hospital on 06/14/21. An IMM was provided to the patient on 06/21/21, seven days after admission.

Review of Patient #37's medical record showed that he received Medicare benefits and was admitted to the hospital 05/29/21. An IMM was provided to the patient on 06/22/21, 24 days after his admission.

Review of Patient #49's medical record showed that she received Medicare benefits and was admitted to the hospital on 06/18/21. An IMM was provided to the patient on 06/21/21, three days after admission.

During an interview on 06/23/21 at 1:30 PM, Staff LLL, Patient Access Manager, stated that his expectation of staff was to obtain signatures for the IMM within 48 hours from inpatient admission. Patient Access Services was staffed seven days a week, and therefore, there should be no delays in obtaining signatures.


41474

Based on observation, interview, record review and policy review, the hospital failed to ensure that:
- Nursing staff followed their policy and procedure for completing a Hester Davis Fall Risk Assessment upon admission, and implement interventions for patients who were at a high risk for falls for five current patients (#78, #79, #80, #81 and #83) of 29 current patient records reviewed, and three discharged patients (#34, #73, and #74) of nine discharged patient records reviewed. (A-395)
- Nursing staff placed patients on continuous pulse oximetry (the percentage of oxygen in the blood stream, a normal reading would be 95 to 100 percent) per physicians' order for seven current patients (#14, #49, #50, #55, #75, #76 and #77) of seven current patients whose records were reviewed, and one discharged patient (#62) of one discharged record reviewed for continuous pulse oximetry orders. (A-395)
- Nursing staff followed their policy and procedure for intravenous (IV, in the vein) tubing maintenance for five patients (#1, #13, #40, #51 and #58) and appropriately dated and initialed peripheral IV dressings (sterile dressings which cover the entrance of a small flexible tube placed into the vein in order to administer medication or fluids) for 11 patients (#1, #4, #7, #8, #10, #15, #19, #40, #46, #52, #58) of 22 patients observed with IVs. (A-395)
-Nursing staff followed their policy and procedure for securing sharps (a term used for devices with sharp points or edges that can puncture or cut skin), when cabinets that contained syringes with needles, lab collection tubes, IV start needles, and butterfly hypodermic needles (a sharp device used to draw blood from a person that is connected to a flexible transparent tubing), were left unsecured in three rooms of three rooms observed in the Emergency Department (ED). (A-395)

These failures had the potential to affect all patients in the hospital. The hospital census was 299.

The severity and cumulative effects of these systemic failures resulted in the hospital being out of compliance with 42 CFR 482.23 Condition of Participation: Nursing Services, and resulted in the hospital's failure to ensure quality healthcare and safety.

Please see the 2567 for additional information.

Based on observation, interview, record review and policy review, the hospital failed to ensure that:
- Nursing staff followed their policy and procedure for completing a Hester Davis Fall Risk Assessment upon admission, and implement interventions for patients who were at a high risk for falls for five current patients (#78, #79, #80, #81 and #83) of 29 current patient records reviewed, and three discharged patients (#34, #73, and #74) of nine discharged patient records reviewed.
- Nursing staff placed patients on continuous pulse oximetry (the percentage of oxygen in the blood stream, a normal reading would be 95 to 100 percent) per physicians' order for seven current patients (#14, #49, #50, #55, #75, #76 and #77) of seven current patients whose records were reviewed, and one discharged patient (#62) of one discharged record reviewed for continuous pulse oximetry orders.
- Nursing staff followed their policy and procedure for intravenous (IV, in the vein) tubing maintenance for five patients (#1, #13, #40, #51 and #58) and appropriately dated and initialed peripheral IV dressings (sterile dressings which cover the entrance of a small flexible tube placed into the vein in order to administer medication or fluids) for 11 patients (#1, #4, #7, #8, #10, #15, #19, #40, #46, #52, #58) of 22 patients observed with IVs.
- Nursing staff followed their policy and procedure for securing sharps (a term used for devices with sharp points or edges that can puncture or cut skin), when cabinets that contained syringes with needles, lab collection tubes, IV start needles, and butterfly hypodermic needles (a sharp device used to draw blood from a person that is connected to a flexible transparent tubing), were left unsecured in three rooms of three rooms observed in the Emergency Department (ED).

These failures had the potential to place all patients admitted to the hospital at risk for their health and safety. The hospital census was 299.

Findings included:

Review of the hospital's policy titled, "Patient Fall Prevention," revised 03/10/21, showed that a fall assessment would be done upon admission, every shift, with a change in level of care, after a fall, and on the day of discharge. The ED would use the Hester Davis Assessment and implement a fall risk intervention bundle for patients at risk for falls.

Review of the hospital's undated document titled, "Emergency Department Nursing Orientation Competency Checklist," showed that fall safety interventions included a fall-risk score, fall precautions and personal alarms.

Review of the hospital's undated document titled, "Hester Davis," showed that fall risk patients would have a bed alarm on (if available).

Review of the hospital's undated document titled, "Integrated Nursing Orientation," showed that patients who were at a high fall risk were to have the following interventions in place:
- A bed/chair alarm;
- Fall mats on one or both sides of the bed or in front of the chair; and
- Always place a fall mat at the bedside when leaving the patient unattended.

Review of the hospital's document titled, "Algorithm for Requesting Patient Safety Assistant/Sitter (person assigned to continuously observe a patient within close proximity, to ensure their safety)," revised 01/06/21, showed the following:
- Patients who had restlessness, wandering, and climbing out of bed were considered to have harmful or potentially harmful behaviors.
- Interventions for patients who had harmful or potentially harmful behaviors should include fall precautions, a bed alarm, and an enclosure bed (a bed with either metal bars or netting designed to restrain a person of any given age within the boundaries of the bed) if appropriate.
- General interventions to promote patient safety included the use of Hester Davis fall reduction strategies per the Hester Davis score.
- If the above interventions were not successful in redirecting patients with harmful or potentially harmful behaviors then staff were to contact their supervisor to request a patient safety assistant/sitter.

Review of Patient #34's medical record dated 04/10/21 through 04/17/21, showed the following:
- She was an 89 year old female who presented to the ED on 04/10/21 at 6:16 PM, after having two falls at the nursing home, which resulted in a hematoma (collection of blood below the skin) to her forehead, and reported left-sided facial droop and left-sided weakness (symptoms of a stroke, increases fall risk) .
- Her medical history included dementia (a loss of thinking abilities and memory), atrial fibrillation (a fib, an irregular, often rapid heart rate that commonly causes poor blood flow) and high blood pressure (all increase fall risk).
- A computerized tomography (series of X-ray images) scan of her head upon arrival resulted negative for bleeding in her brain.
- Staff were made aware to watch the patient (for safety).
- At 9:07 PM, the ED physician received notification that Patient #34 fell onto her head. She received a cut to her left eyebrow which required six stitches to repair. He ordered a (second) CT scan. The scan showed a small subarachnoid hemorrhage (SAH, a medical emergency where there is bleeding in the space between the brain and the tissue covering the brain) and a small subdural hemorrhage (SDH, a pool of blood between the brain and its outermost covering).
- At 9:42 PM, the patient continued attempts to get off the stretcher, while she was left alone.
- There was no Hester Davis Fall Risk Assessment completed until 04/11/21 at 10:32 AM (15 hours after she presented to the ED). Her score of 29 indicated she was a high fall risk.
- On 4/17/21, the patient was discharged to the nursing home with end of life/comfort care orders.

During an interview on 06/24/21 at 10:52 AM, Staff MMM, RN Team Plus (a traveling as needed nursing pool that works in the ED only), stated Patient #34 presented for a stroke evaluation, after she fell at a nursing home. The CT scan was negative, so the patient was placed close to the nurse's station, with her bed down low and in Trendelenburg position (when an individual is lying on their back with their head declined below the feet), to make climbing out of bed more difficult. The side rails were up, and the ED room curtain was open. For unknown reasons, the patient's curtain was closed, and the patient fell to the floor while the curtain was closed. Staff MMM stated, that they did not use bed alarms in the ED even though she had requested them twice, and that sitters (staff assigned to sit in close proximity of a patient who is at risk for injury) were primarily used for behavioral health patients. She thought they should use safety sitters for high fall risk patients, but they were short staffed. She reported that she should have completed a fall risk assessment when she got the patient to the ED room and then implement and document interventions put in place to prevent falls. Staff MMM added that curtains in patient rooms should always be left open for patients who were a high fall risk and alone.

Review of the hospital's undated document titled, "Quality/Patient Safety Action Plan," showed the following opportunities for improvement were identified related to Patient #34's fall:
- There were no bed alarms available for use in the ED for high risk patients.
- The Hester Davis Fall Risk Assessment scores were not completed for Patient #34 at triage.
- The ED RN did not escalate safety concerns about the patient because she felt there were no additional resources (staff) to stay with the patient.

During an interview on 06/24/21 at 8:35 AM, Staff N, ED Director, stated that safety sitters were primarily used in the ED for psychiatric patients but could and should be used for patients who were confused or at a high risk for falls. Patients who were at a high risk for falls should not have their curtain closed, should be near the nurse's station, their bed in a low position and the side rails up.

During an interview on 06/22/21 at 9:58 AM with Staff SS, Patient Safety and Clinical Outcomes Regional Director, stated that when Patient #34 presented to the ED they did not have any bed alarms. The Hester Davis Fall Risk Assessment was not completed and the staff nurse did not relay her concerns for Patient #34 to her charge nurse because she felt there were no additional resources available. She would expect the staff nurse to escalate her concerns for patient fall risk to the charge nurse to problem solve together. She would expect the Hester Davis Assessment to be completed by the triage nurse on all patients.

Review of Patient #74's medical record, showed that he was an 88 year old male who presented to the ED on 04/15/21 at 7:19 PM, with right leg weakness after a fall. A Hester Davis Fall Risk Assessment completed on 04/16/21 at 7:35 PM (24 hours after he presented to the ED) and indicated he was at a high risk for falls. There were no interventions to prevent falls documented in the electronic health record.

Review of the hospital's document titled, "Safe Force," dated 04/16/21, showed that at 2:00 AM, Patient #74 was found on the floor in front of his bed. He had a history of previous falls and sensory impairments (vision, hearing and balance difficulty). The fall was contributed to the patient's confusion. The fall details were not completed.

Review of Patient #73's medical record, showed that he was a 55 year old male who presented to the ED on 06/13/21 at 7:08 PM, with substance abuse (misuse of alcohol and or other drugs) and altered mental status. He smelled like alcohol and appeared to be intoxicated. There was no Hester Davis Fall Assessment or interventions to prevent falls documented in the patient's electronic health record.

Review of the hospital's document titled, "Safe Force," dated 06/14/21, showed that at 7:45 AM, Patient #73 got out of bed and walked towards the hallway. He lost his balance, fell into the door, and landed on the floor outside of his room. Fall risk assessment documentation indicated he was at increased risk for falls. On the question "did this fall happen in a hospital" the answer was "no." The Hester Davis pre-fall score was not completed and the fall details were not completed.

Review of Patient #79's medical record, showed that he was a 75 year old male who presented to the ED on 06/24/21 at 7:06 AM, with chest pain. At 9:34 AM, no Hester Davis Fall Risk Assessment or interventions to prevent falls had been documented.

Review of Patient #78's medical record, showed that he was a 68 year old male who presented to the ED on 06/24/21 at 8:24 AM, with no diagnosis or chief complaint. A Hester Davis Fall Risk Assessment was completed at 8:50 AM, which indicated he was at high fall risk. No interventions to prevent falls were documented in the electronic health record.

Review of Patient #80's medical record, showed that he was a 73 year old male who presented to the ED on 06/23/21 at 11:28 PM, following a fall with weakness and hip pain. A Hester Davis Fall Risk Assessment was completed at 11:40 PM, and indicated that he was at high risk for falls. No interventions to prevent falls were documented in the electronic health record.

Review of Patient #81's medical record, showed that he was a 46 year old male who walked into the ED on 06/23/21 at 10:32 PM, with suicidal ideation (SI, thought of causing one's own death) and homicidal ideation (HI, thoughts or attempts to cause another's death). A Hester Davis Fall Risk Assessment was completed at 10:30 PM, and indicated that he was at high risk for falls. No interventions to prevent falls were documented in the electronic health record.

Review of Patient #83's medical record, showed that he was a 62 year old male who presented to the ED on 06/23/21 at 5:05 PM, with chest pain. A Hester Davis Fall Risk Assessment was completed at 5:12 PM, and indicated that he was at high risk for falls. There were no interventions to prevent falls documented in his electronic health record.

2. Review of the hospital's policy titled, "Pulse Oximetry," dated 03/19/18, showed that all patients needing pulse oximetry will receive this monitoring.

Review of the hospital's policy titled, "Orders for Diagnostic and Therapeutic Care," revised 10/02/20, showed that all orders for diagnostic and therapeutic care, including but not limited to orders for medication, diet, special equipment, consultations and procedures, will be pursuant to the order of a member of the Medical and Allied Health Professional Staff privileged within the scope of his/her practice to write orders for patient care. All orders for diagnostic and therapeutic care shall be documented in the patient's electronic health record (EHR), and include the date and time of entry.

Review of the hospital's incident report, dated 10/07/20, showed that discharged Patient #62 had an order for continuous pulse oximetry and was never placed on it.

Review of Patient #62's medical record showed the following:
- He was an 85 year old male admitted to Six North Medical Telemetry (remote observation of a person's heart rhythm, using signals that are transmitted from the patient to a computer screen) Unit on 09/28/20, with sepsis (life threatening condition when the body's response to infection injures its own tissues and organs) from COVID-19 and acute respiratory failure (condition in which not enough oxygen passes from the lungs into the blood) with hypoxia (not enough oxygen reaching the cells and tissues in the body).
- A physician order for continuous pulse oximetry was entered on 09/28/20 and discontinued when the patient was discharged on 10/10/20.
- Patient #62 was not on continuous pulse oximetry, his oxygen saturation was monitored by spot check (intermittently) every three to five hours.

Review of Patient #14's medical record showed the following:
- He was a 77 year old male admitted to the hospital's Intensive Care Unit (ICU, a unit where critically ill patients are cared for) on 06/14/21, for shortness of breath.
- He had a past medical history of irregular heart rhythm and congestive heart failure (CHF, a weakness of the heart that causes it to not pump blood like it should leading to a buildup of fluid in the lungs and surrounding body tissues).
- He required a breathing tube while in the ICU.
- He was transferred to Six North Medical Telemetry Unit on 06/21/21, with orders for continuous oxygen monitoring while on 3 liters of oxygen per nasal cannula (NC, a lightweight tube that splits into two prongs for insertion into the nostrils and delivery of oxygen).
- Patient #14 was not on continuous pulse oximetry, his oxygen saturation was monitored by spot check every three to five hours.

Review of Patient #75's medical record showed the following:
- He was a 56-year-old male admitted to Six North Medical Telemetry Unit on 06/21/21, with shortness of breath and pulmonary edema (an abnormal buildup of fluid in the lungs).
- There was an active physician order for continuous pulse oximetry.
- Patient #75 was not on continuous pulse oximetry, his oxygen saturation was monitored by spot check every three to five hours.

Review of Patient #76's medical record showed the following:
- He was an 83-year-old male admitted to Six North Medical Telemetry Unit on 06/22/21, with shortness of breath, CHF, pneumonia (infection in the lungs) and abnormal heart rhythm.
- There was an active physician order for continuous pulse oximetry and oxygen per nasal cannula to maintain saturations greater than 92%.
- Patient #76 was not on continuous pulse oximetry, his oxygen saturation was monitored by spot check every three to five hours.

Review of Patient #77's medical record showed the following:
- She was an 85-year-old female admitted to Six North Medical Telemetry Unit on 06/17/21, with shortness of breath and possible pneumonia.
- There was an active physician order for continuous pulse oximetry.
- Patient #77 was not on continuous pulse oximetry, her oxygen saturation was monitored by spot check every three to five hours.

Review of Patient #49's medical record showed the following:
- She was a 75-year-old female admitted to Five North Medical Pulmonology (related to the lungs) Unit on 06/18/21, with shortness of breath, cough and fever.
- There was an active physician order for continuous pulse oximetry.
- Patient #49 was not on continuous pulse oximetry, her oxygen saturation was monitored by spot check every three to five hours.

Review of Patient #50's medical record showed the following:
- She was an 85-year-old female admitted to the hospital's ICU on 05/30/21, with respiratory failure (condition in which not enough oxygen passes from the lungs into the blood), low heart rate, and heart failure.
- There was an active physician order for continuous pulse oximetry from 05/30/21 through 06/24/21.
- Patient #50 was not on continuous pulse oximetry while on Five North Medical Pulmonology Unit; her oxygen saturation was monitored by spot check every three to five hours.

Review of Patient #55's medical record showed the following:
- He was a 43-year-old male admitted to Six South Medical Unit on 06/16/21 with COVID-19 (highly contagious and sometimes fatal virus) pneumonia.
- There was an active physician order for continuous pulse oximetry.
- Patient #55 was not on continuous pulse oximetry, his oxygen saturation was monitored by spot check every three to five hours.

During an interview on 06/22/21 at 3:30 PM, Staff CCC, RN, stated that she was the nurse caring for Patient #55 and she was not aware that he had an order for continuous pulse oximetry.

During an interview on 06/22/21 at 2:45 PM, Staff AAA, Unit Five South RN Manager, stated that her expectation of staff was to follow physician orders and to notify the physician to discontinue an order if it was not needed.

During an interview on 06/23/21 at 9:00 AM, Staff XX, Unit Six North Medical Telemetry RN Manager, stated that if there was a physician order for continuous pulse oximetry, her expectation of staff was to make sure the patient continued on continuous pulse oximetry and if it was not needed, have the physician discontinue the order.

During an interview on 06/23/21 at 9:30 AM, Staff M, Telemetry Services Director, stated that most of the telemetry boxes had the capability to monitor the patient's oxygen saturation and be viewed by the central telemetry staff at all times. If a telemetry box with oxygen saturation capability was not available, her expectation of staff was to obtain a bedside oxygen saturation machine to monitor the patient's oxygen saturation continuously, as ordered.

3. Review of the hospital's policy titled, "Intravenous Medications, Fluids, and Tubing," dated 02/10/21, showed the directive for nursing staff to label IV tubing upon initiation, with the date and time initiated, and the initials of the individual initiating the infusion.

Review of the hospital's policy titled, "Peripheral Intravenous Catheter Insertion, Management, and Removal," dated 02/10/2021 showed the directive for nursing staff to apply a clear occlusive dressing over the insertion site of the IV catheter, and to label with the individual's initials and the date applied.

Observation on 06/22/21 at 11:15 AM on Unit One West, showed that Patient #46's IV dressing was not dated or initialed.

Observations on Unit Two South showed the following:
- On 06/21/21 at 2:50 PM, Patient #1's IV dressing was not dated or initialed, and the IV tubing was not dated, timed or initialed.
- On 06/22/21 at 8:25 AM, Patient #58's IV dressing was not dated or initialed, and the IV tubing was not dated, timed or initialed.

Observation on 06/21/21 at 3:00 PM on Three North, showed patient #4's IV dressing was not dated, timed or initialed.

During an interview on 06/21/21 at 3:15 PM, Staff D, Registered Nurse (RN), stated that all dressing were to be dated, timed and initialed and this dressing had been applied in surgery.

Observation on 06/22/21 at 8:45 AM on Three South, showed patient #15's IV dressing was not dated, timed or initialed.

During an interview on 06/22/21 at 8:55 AM, Staff U, RN, stated that all dressings were to be dated, timed and initialed when they were applied.

Observation on Unit Five North, showed the following:
- On 06/22/21 at 2:00 PM, Patient #51's IV tubing was not dated, timed or initialed.
- On 06/22/21 at 2:50 PM, Patient #40's IV dressing was not dated or initialed, and the IV tubing was not dated, timed or initialed.
- On 06/22/21 at 2:30 PM, Patient #52's IV dressing was not dated or initialed.

Observation on 06/21/21 at 3:30 PM on Unit Six North, showed that Patient #13's IV and tube feeding tubing was not dated, timed or initialed.

Observation on 06/21/21 at 4:00 PM, on Unit Seven North, showed that Patient #10's IV dressing was not dated or initialed.

Observation in the ED showed that on 06/21/21 at 3:10 PM, Patient #7's IV dressing was not dated or initialed, and at 3:25 PM, Patient #8's IV dressing was not dated or initialed.

Observation on 06/22/21 at 9:00 AM, on the Labor and Delivery Unit, showed that Patient #19's IV dressing was not dated or initialed.

During an interview on 06/26/21 at 8:15 AM, Staff DDD, Interim Chief Nursing Officer (CNO), stated that he was unsure of the expectations related to dating IV insertion sites dressings, or labeling of IV tubing.

4. Review of the hospitals policy titled, "Needle and Sharps Safety," dated 03/19/20, showed that sharps must not be left unattended in unsecured or patient care areas.

Observation on 06/21/21 at 3:10 PM, in the ED, showed unsecured cabinets in three patient rooms which contained various types of needles (sharps) that were accessible to patients and visitors.

During an interview on 06/21/21 at 3:20 PM, Staff M, Director, stated that cabinets containing sharps in patient rooms should be locked when staff were not present.


39562




41474








27727