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Based on document review and interview, the facility failed to ensure patient was free from all forms of abuse or harassment in 1 (patient 11) of two grievances reviewed.

Findings include:

1. Review of Elder Spousal/Partner, Or Child Abuse, Issued 5/2015, Policy No. I-A.20, indicated, page 2, General Information/Scope: 1. All staff at the hospital has a responsibility to immediately report any incidents of suspected abuse involving patients by contacting the appropriate chain of command who will assist in contacting Adult Protective Services or appropriate law enforcement.

2. Review of patient Grievance Form indicated, on 8/4/2017, facility received information patient 11 had verbalized accusation that some guy at facility had raped patient 11 during admission. Investigation results, corrective actions, 8/7/2017, included information received also included patient 11 had several fractured ribs and bruises. Facility MR revealed pt (patient) admitted to facility with bruising to hips and abdomen.

3. Interview on 9/29/2017, at approximately 3:28 pm, per phone with N5 (Chief Executive Officer) confirmed no incident report was made for grievance on 8/29/2017, pertaining to allegation of rape by patient 11. Staff N5 had no proof that Protective Services or appropriate law enforcement had been contacted. Staff N5 confirmed that N5 did not contact Adult Protective Services or law enforcement.

Based on document review, observation and interview, the registered nurse failed to ensure that policies and procedures were followed and patients were evaluated for 3 of 11 medical records (MR) reviewed (patients 1, 2 and 3) - (see tag A 385) and the facility failed to ensure medications were prepared and administered in accordance with the orders of the practitioner responsible for the patient's care and accepted standard of practice for 3 of 11 Medical Records (MR) reviewed (patient 1, 5 and 8) - (see tag A 405).

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure that Nursing Services provided quality health care in a safe environment.

Based on document review, observation and interview, the registered nurse failed to ensure that policies and procedures were followed and patients were evaluated for 3 of 11 medical records (MR) reviewed (patients 1, 2 and 3).

Findings include:

1. Review of policy, Pressure Ulcer Prevention/Pressure Ulcer Risk Assessment, Policy No. II-D.2 indicated, 1. Standard and individualized interventions to prevent skin breakdown will be developed and implemented.

2. Review of patient 1's Medical Record (MR), nursing admission database indicated on 8/18/17, old bruise on bilateral shoulders, left back upper arm, tracheostomy and G-tube NPHI Nursing Daily Assessment, on 8/18/2017, pink, on 8/19/2017, skin, intact, turgor appropriate for age, warm, G-Tube, on 8/23/17, at 19:00 hours, integumentary, normal, g-tube site, feet small areas, healing bruise left eye/forehead, no time indicated, skin intact, at 19:00 hours, skin, normal, on 8/27/17 at 0700 hours, Reassessment, indicated skin normal, Physician's Orders, on 8/21/17, at 13:00 hours, wrap exposed toes with scabbed areas in gauze daily, apply bacitracin and non-stick pad to cover open areas. PRN MEDs (as needed medication) sheet, indicated, treatments only, start date 8/21/17, wrap exposed toes with scabbed areas in gauze daily, apply bacitracin and non-stick pad to any open areas, indicated done on 8/24, 8/25, 8/26 and 8/27 of 2017. Skin/wound report indicated, on 8/18/17, old bruise on bilateral shoulders, left back upper arm, tracheostomy and G-tube, on 8/25/17, wound on both toes and heels of both feet. MR lacked documentation of heel wounds present on admission.

3. Review of Grievance dated 8/29/17, indicated, Patient 1's spouse came in and asked to speak with N2 (Director of Social Services). Was upset (patient) had been sent to emergency room and had wounds to (patient) feet. Medical staff M.D. N9 (medical doctor) informed (spouse) those wounds were present on admission and are old wounds, that could not have developed in the 6 days (patient) was at facility.

4. Interview on 9/29/2017, at approximately, at 10:48 am, in the conference room with N3 (Associate Chief Executive Officer) confirmed patient 1's MR lacked indication of heel wounds on arrival.

5. Review of patient 1's MR lacked documentation of individualized interventions for patient 1's bilateral heel wounds from 08/18/17 to 08/21/17.

6. Review of policy, Fall Risk Identification and Precaution, Policy No. II-A.9 indicated, 3. A yellow arm band will be placed for all patients identified to be a moderate or high risk for falls immediately after the risk is identified.

7. Review of patient 2's medical record (MR) indicated, admitted on 9/27/2017, bipolar disorder with behavior disturbances and suicidal ideation's, diabetic. Nursing Admission Database, Morse Fall Scale, 70 high risk.

8. Review of patient 3's medical record (MR) indicated, admitted on 9/24/2017, major neurocognitive disorder related to Alzheimer's dementia with behavioral disturbances. Nursing Admission Database, Morse Fall Scale from 9/24/17, 30 Moderate risk.

9. Observation of facility's 200 unit white board indicated patients 2 and 3, special treatment YB (yellow band).

10. On tour on 9/28/2017 at approximately 10:20 am, on the 200 unit, with N3 (Associate Chief Executive Officer) the following was observed, patient 2 and 3 had no yellow fall risk arm band.

11. Interview on 9/28/2017, at approximately 10:55 am, in the facility, with N3 confirmed lack of arm bands for fall risk patients on the 300, 200 and 100 units.

12. Review of patient 1's Medical Record (MR), dated 8/27/2017, Medical Progress, Lethargy/Decrease Responsive: Send to (facility 2) for non emergency evaluation (per N13 (Medical Doctor). Narrative Behavior Intervention Response Plan, on 8/27/2017, indicated, at 15:30 hours, patient lethargic and difficult to arouse BMP, CBC (with) diff and UA, C&S (labs), ordered and obtained. At 18:50 hours, patient being sent to (facility 2) for lethargy & (and) unresponsive. At 20:30 hours, report received, pt (patient) care assumed, pt (patient) in room at this time waiting for transport. At 21:50 hours, pt (patient) transferred to (facility 2) for lethargy & (and) unresponsive. MR lacked documentation of Registered Nurse notifying medical doctor of patient 1's, at 18:50 hours, change of condition of unresponsiveness.

Based on document review and interview, the facility failed to ensure medications were prepared and administered in accordance with the orders of the practitioner responsible for the patient's care and accepted standard of practice for 3 of 11 Medical Records (MR) reviewed (patient 1, 5 and 8).

Findings include:

1. Review of policy, High Risk Medications, policy no. : II-F.61, revised, 7/2017 indicates the following, 2. to reduce the overall risk of errors of high-risk medication: c. Double check processes shall be implemented, used and maintained, 5. High Alert Medications will require a double nurse verification prior to administration, 7. High Alert Drug Categories, e. Insulin, subcutaneous and IV.

2. Review of patient 1's Medical record indicated the following, Medications included Lantus 22 units at bedtime subq (subcutaneous) for diabetes. Humalog per sliding scale protocol. Accu-Cheks before meals and at bedtime for diabetes and Humalog solution insulin lispro was initiated. Chemistry, collected date, on 8/19/2017, at 0137 hours, Glucose random 497. Physician's Orders include, on 8/19/2017, at 17:30 hours, give 20 units insulin lispro now and recheck in 2 hours. For blood sugar 475. PRN MEDS (as needed medications) sheet indicated, on 8/19/2017, Accu-cheks done at 6:30 hours blood sugar 65, at 11:30 hours, blood sugar 356 and at 16:30 hours, blood sugar 475. No blood sugar checks indicated after 16:30 hours. Scheduled: 7 units Humalog given on 8/21/2017 at 16:30 hours, on 8/22/2017 at 6:30 hours, 11:30 hours and 16:30 hours, on 8/23/2017 at 6:30 hours, 11:30 hours and 1630 hours, lacked indication of double nurse verification. On 8/21/2017, 2 units given no indication of double nurse verification, no indication of time given, sliding scale did not indicate to give 2 units, at 0700 hours blood sugar 454, at 1200 hours blood sugar 504, at 2100 hours blood sugar 287 only indication of insulin given was 2 units one time, sliding scale indicates to treat blood sugars of 251-300 with 4 units, 301-350 with 6 units, 351-400 with 8 units, 401-450 with 10 units, 451-500 with 12 units >500 with 14 units, >450 call M.D. <60 call M.D. On 8/23/2017, at 0700 hours, and at 1200 hours lacked indication of double nurse verification. PRN MEDs (as needed medication) indicated, on 8/19/17 at 17:30 hours, give 20 units insulin and recheck in two hours, one time only for hyperglycemia, lacked indication of double nurse verification.

3. Interview on 9/29/2017, at 9:22 hours with N3 (Associate Chief Executive Officer) in the conference room, indicated, patient 1's chart lacked indication of ordered blood sugar 2 hour reassessment on 8/19/2017, for insulin given at 17:30 hours.

4 . Review of patient 5's medical record (MR) indicated, diabetic. MR scheduled medication sheet indicated Sliding scale for 9/23/17, at 0630 hours blood sugar 164, 4 units given, at 11:30 hours lacked documentation of blood sugar completed, at 1630 hours blood sugar 263, 12 units given, at 2100 hours blood sugar 242, 8 units given.

5. Review of patient 8's medical record (MR) indicated, admitted on 8/23/2017, and discharged 9/13/2017, diagnosis, major vascular neurocognitive disorder with behaviors. Patient MR indicated diabetic mellitus type 2. MR lacked documentation of double nurse verification for insulin given on dates 8/24, 8/25, 8/26, 8/27 and 8/30 of 2017. MR lacked documentation of signature to go with initials of double nurse verification. Insulin given on dates 8/28/17 and 8/29/17.

6. Interview on 9/29/2017, at 9:11 hours, in the conference room with N3 indicated patient 8's MR lacked double nurse verification and signatures. Patient 5's MR lacked 9/23/2017, at 11:30 hours, blood sugar assessment.