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Based on record review and interview, the facility failed to review and resolve a grievance. The deficient practice is evidenced by failure to document an investigation for 1(#2) of 1 reviewed patient records with an associated grievance.
Findings:

Review of Policy #14231748,"Patient /Family Grievance," last approved 07/2021, revealed in part, "G. In cases of a grievance the Director of Social Services/ case manager or the Director of Nursing will investigate the substance of the grievance, if resolution of the grievance cannot be achieved within 5 business days , the Director of Social Services or case manager will alert the Director of Nursing or Hospital Administrator to assist with resolution. H. If by the 7th day the grievance still cannot be resolved, the patient and /or their representative will be sent a written letter informing them that the investigation is still underway and that a letter of resolution will be sent to them within 21 days by the Director of Social Services."

Review of the requested grievances revealed a "Patient Complaint Form" filled out by the case manager dated 12/19/2023 at 2:59 p.m. The complaint was initiated by the son of Patient #2. The document revealed the son had called the police because he found another patient's medication in his father's medication and he believed it was causing the patient to act abnormally. The bottle of medication was requested back by the case manager and she was informed by the son that emergency medical services had taken the bottle. Nursing staff, the administrator and the physician had been notified. There was no investigation associated with the grievance and no attempt at resolution documented.

In interview on 04/23/2024 at 3:11 p.m., S4RN verified there was no additional documentation to indicate the facility attempted to investigate and/or resolve the grievance.

Based on record review and interview, the facility failed to resolve a grievance with written notice of the hospital decision that contained the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. The deficient practice is evidenced by failure to send the requisite letter to 1 (#2) of 1 reviewed patient records with an associated grievance.
Findings:

Review of Policy #14231748,"Patient /Family Grievance," last approved 07/2021, revealed in part, "G. In cases of a grievance the Director of Social Services/ case manager or the Director of Nursing will investigate the substance of the grievance, if resolution of the grievance cannot be achieved within 5 business days , the Director of Social Services or case manager will alert the Director of Nursing or Hospital Administrator to assist with resolution. H. If by the 7th day the grievance still cannot be resolved, the patient and /or their representative will be sent a written letter informing them that the investigation is still underway and that a letter of resolution will be sent to them within 21 days by the Director of Social Services."

Review of the requested grievances revealed a "Patient Complaint Form" filled out by the case manager dated 12/19/2023 at 2:59 p.m. The complaint was initiated by the son of Patient #2. The document revealed the son had called the police because he found another patient's medication in his father's medication and he believed it was causing his father to act abnormally. The bottle of medication was requested back by the case manager and she was informed by the son that emergency medical services had taken the bottle. Nursing staff, the administrator and the physician had been notified. There was no investigation associated with the grievance and no attempt at resolution documented.

In interview on 04/23/2024 at 3:11 p.m., S4RN verified a letter was not sent to the patient of his family.

Based on record review and interview, the hospital failed to ensure proper documentation of informed consent. The deficient practice is evidenced by failure of the person obtaining the consent to sign the document in 2 (#1, #5) of 5 (#1-#5) reviewed patient records.
Findings:

Review of Policy#14224978, "Consent/Legal Documents, Witnessing of," last approved 06/2017, revealed in part, "It is the policy of this facility that the witnessing of legal documents while a patient is in the care of the facility be approved by the registered nurse or social worker."

Review of the admission consents for Patient #1 revealed a six page document which included the consent to medical procedures, nursing care, the legal relationship between the hospital and the physician, release of information, consent to photograph, assignment of benefits, notification of emergency services when a physician is not present at the facility, visitation, and financial responsibility. The sixth page was signed by the patient's representative. The form was not dated, did not indicate the relationship of the person who signed to the patient, and did not have the signature of the person obtaining the consent.

In interview on 04/23/2024 at 5:30 p.m., S4RN verified the person obtaining the consent did not sign the document and the document was not dated.

Review of the admission consents for Patient #5 revealed the Consent to Photograph/Videotape was signed and dated by the patient but there was no signature by hospital staff to indicate who was responsible for obtaining the consent and the form was not witnessed.

In interview on 04/23/2024 at 3:46 p.m., S4RN verified the consents were not witness and were not signed by the person who obtained the consent from the patient. S4RN also verified that Patient #5 had wounds and pictures were taken.

The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient.
Findings:

Based on record review and interview the hospital failed to employ adequate numbers of nurses. The deficient practice is evidenced by documentation of two nurses working 2 consecutive 12-hour shifts. Findings:
Review of Policy #14224630, "Staffing Plan," last approved 08/2020, revealed in part, "Procedure: A. Work Schedule: 1. It is the facility's prerogative to specify any employee's work hours according to operational requirements. 2. Patient care staff should not work more than 16 consecutive hours or 60 hours per week without approval of the Administrator. . . .3. Master schedules comprising a minimum of 4 weeks, should be prepared for the facility by the DON or designee. A definite work schedule for full-time and part-time employees will be established and be prepared at least fourteen (14) days in advance. . . . B. Schedules: 1. Unit schedules will be saved for a period of five (5) years, two (2) years of nursing unit staffing will be filed in the DON's office. 2. Daily staffing schedules should include documentation of: a Date; b. Shift hours; c. Employee's name, skill level; d. Illness or absence reason."

Review of the "Daily Staffing Assignment Sheet" for 03/08/2024 revealed S5RN and S7LPN worked the day shift. Further review revealed S5RN, S7LPN along with S6LPN and S8LPN worked the night shift. There was no documentation on the assignment sheet that any of the nurses worked a partial shift.

In interview on 04/23/2024 at 11:46 a.m., S7LPN verified there was no documentation that either worked only part of the night shift.

Based on record review and interview, the hospital failed to ensure a registered nurse supervised the care of each patient. The deficient practice is evidenced by: 1) one daily staffing assignment sheet with no documented registered nurse at the facility; 2) failure of nursing staff to document vital signs twice a day as ordered in 1 (#5) of 5 (#1- #5) reviewed medical records; and 3) failure of nursing staff to document rounds every 2 hours in 1 (#5) of 5 (#1- #5) reviewed medical records.
Findings:

1) One daily staffing assignment sheet with no documented registered nurse at the facility.

Review of the "Daily Staffing Assignment Sheet" for the night shift on 03/10/2024 revealed only 2 licensed practical nurses were providing care with 9 patients in the facility.

In interview on 04/23/2024 at 11:40 a.m., S4RN verified the assignment sheet did not document a registered nurse was on site to supervise the care of the patients.

2)Failure of nursing staff to document vital signs twice a day as ordered.

Review of the medical record for Patient #5 revealed admission on 04/10/2024 with a diagnosis of cardiac disorder and heart failure.

Review of the admission orders for Patient #5 revealed vital signs were to be performed two times a day.

Review of the vital signs revealed they were performed only once on 04/11/2024 and 04/12/2024.

In interview on 04/23/2024 at 4:17 p.m., S4RN verified the vital signs were not documented twice a day as ordered.

3) Failure of nursing staff to document rounds every 2 hours.

Review of the medical record for Patient #5 revealed admission on 04/10/2024 with a diagnosis of cardiac disorder and heart failure.

Review of the "Daily Nursing Flowsheet" for Patient #5 for 04/20/2024 revealed no rounds were documented between 7:00 p.m. on 04/20/2024 and 5:00 a.m. on 04/21/2024.

In interview on 04/23/2024 at 4:15 p.m., S6LPN verified the rounds were not documented. S6LPN verified the rounds should have been documented every 2 hours.

Based on record review and interview, the hospital failed to ensure the Nursing Care Plan was completed per hospital policy. The deficient practice is evidenced by 1) failure to complete the Nursing Care Plan within the first 24 hours of admission for 1 (#4) of 5 (#1-#5) reviewed patient records; and 2) failure to modify the care plan after a significant event for 1 (#3) of 5 (#1-#5) reviewed patient records.
Findings:

1)Failure to complete the Nursing Care Plan within the first 24 hours of admission.

Review of Policy #14224971, "Patient Care Standards," last approved 02/2125, revealed in part, "II. PLANNING: A. An individual care plan will be developed within eight hours of admission."

Review of the medical record for Patient #4 revealed admission on 12/08/2023 at 3:04 p.m. Further review revealed the Nursing Care Plan was not completed until 12/11/2023.

In interview on 04/23/2024 at 2:11 p.m., S6LPN verified the Nursing Care Plan was not completed in the timeframe required by the facility's policy.

2) Failure to modify the care plan after a significant event.

Review of the medical record for Patient # revealed admission on 11/29/2023.

Review of the Wound Care Sheet and photographs for Patient #4 on admit revealed the patient had a 5 -6 centimeter intact pressure sore on the left hip and preventive measures were initiated.

Review of the Wound Care Sheet for Patient #4 on 12/06/2024 revealed the skin was no longer intact. Further review of the orders, nursing notes, and care plan failed to reveal the nurse initiated any additional care and there was no documentation that the physician was notified. Photographs were not taken.

Further review of the record revealed on 12/11/2023 a photograph of the lesion on the left hip was taken. The photograph revealed an 8 centimeter crusted open lesion. Additional measures for treatment were initiated at that time.

In interview on 04/23/2024 at 4:53 p.m., S4RN and S6LPN verified the above findings. The Policy #14231906,"Wound Care: Pressure Ulcer Prevention & Management of Pressure Ulcers," last approved 06/2020, was reviewed. The policy did not address when photographs should be taken or notification of the physician. S6LPN verified the hospital policy is to take photographs when a change in the pressure ulcer is noted. S6LPN verified the care plan should have been modified, pictures should have been taken and the physician should have been notified on 12/06/2024 when it was first discovered to have non-intact skin.

Based on record review and interview, the hospital failed to ensure patient care assignments were performed according to hospital policy and use of the Patient Acuity Tool. The deficient practice is evidenced by failure to assign patient acuities for 10 of 14 shifts in the week prior to the survey.
Findings:

Review of the provided document, "Patient Acuity Scoring Process," which was provided as the current policy for patient assignments which was not dated and not associated with an approved policy, revealed in part, "1. Educate all nursing staff on the use of patient acuity tool Monday 8/21. 2. Nurses will complete a patient acuity tool on each of their assigned patients."

Review of the document, "United Medical Rehabilitation Hospital Patient Acuity Tool," which was provided as current but did not have a date of review or approval, revealed in part, "Each shift the RN will review the acuity tables and will make assignments according to acuity and competency of the licensed nurse up to 20 points per nurse."

Review of the assignment sheets from 04/15/2024 through 04/21/2024 revealed patient acuity was not documented on the day shift or night shift for each patient on the assignment sheet for 04/15/2024, 04/16/2024, 04/17/2024, 04/18/2024, and 04/19/2024.

In interview on 04/23/2024 at 11:26 p.m., S4RN verified the patients were not assigned by acuity.

Based on record review and interview, the facility failed to ensure contract staff were properly supervised. The deficient practice is evidenced by the use of contracted registered nurses as a charge nurse on 5 shifts between 03/16/2024 and 04/10/2024.
Findings:

Review of the provided list of recently used agency nurses included S8ARN, S9ARN, and S11ALPN.

Review of the "Daily Staffing Assignment Sheet" from 03/16/2024 through 04/10/2024 revealed the following:

-On 03/16/2024 on the day shift, S8ARN was the only registered nurse on the schedule.

-On 03/31/2024 on the day shift, S8ARN was the only registered nurse on the schedule. S8ARN was identified as a contracted nurse by the placement of "RN-A" on the schedule.

-On 03/31/2024 on the night shift, S10ARN was the only registered nurse on the schedule. S10ARN was identified as a contracted nurse by the placement of "RN-A" on the schedule.

-On 04/21/2024 on the night shift, S8ARN was the only registered nurse on the schedule. Further review revealed there was only one licensed practical nurse working that shift, S11ALPN, who was also a contracted nurse.

-On 04/10/2024 on the night shift, S8ARN was the only registered nurse on the schedule. S8ARN was identified as a contracted nurse by the placement of "RN-A" on the schedule.

In interview on 04/23/2024 at 11:50 a.m., S6LPN verified the use of agency nurses as the nurse in charge of the shifts.

Based on record review and interview, the hospital failed to ensure each admitted patient had a history and physical performed no more than 30 days before or 24 hours after admission. The deficient practice is evidenced by a history and physical documented more than 24 hours after admission in1 (#4) of 5(#1- #5) reviewed medical records.
Findings:

Review of Policy #14224590, "Time Frames," last approved 02/2015, revealed in part, "Document- History and Physical-Completion time: 24 hours."

Review of the medical record for Patient #4 revealed admission on 12/08/2023 at 3:04 p.m. Review of the documented history and physical revealed it was performed on 12/10/1013 at 9:20 a.m.

In interview on 04/23/2024 at 2:10 p.m., S6LPN verified the history and physical was not completed within 24 hours of admission.

Based on observation, record review, and interview, the hospital failed to ensure the infection prevention program included surveillance of the facility to identify and mitigate identified sources with potential for transmission of infection. The deficient practice is evidenced by: 1) expired items in the emergency cart; 2) tape covering a hole in the therapy mat; 3) failure to ensure food was kept free of spoilage.
Findings:

1) Presence of expired items in the emergency cart.

Direct observation during tour of the facility on 04/23/2024 at 8:40 a.m. revealed 2 boxes of nitrile gloves with an expiration date of 09/2022 and 3 non-rebreather masks with an expiration of 02/2016.

At the time of discovery, S4RN verified the items were expired.

2) Presence of tape covering a hole in the therapy mat.

Direct observation during tour of the facility on 04/23/2024 at 8:55 a.m. revealed the therapy mat had two pieces of tape covering palpable holes in the covering.

In interview at the time of discovery, S4RN verified the tape was an infection control issue.

3) Failure of the hospital to ensure food was kept free for spoilage.

Review of the temperature logs for the patient refrigerator and the patient freezer for March of 2024 revealed the temperatures were not checked on 03/30/2024 and 03/31/2024.

In interview on 04/23/2024 at 8:35 a.m., S4RN verified the refrigerator and freezer temperatures were not checked.