HospitalInspections.org

Based on policy review, record review, and interview, the facility failed to:
- Ensure there was one on-site Chief Nursing Officer (CNO)/Director of Nursing (DON) who had oversight of and responsibility for all nursing services. (A-386)
- Ensure ongoing nursing assessment, supervision, and oversight to meet the patient's care/services and/or prevention of complications on three restrained patients (#3, #8, and #14) of three restrained patients reviewed. (A-395)
- Ensure ongoing nursing assessment, oversight, and/or procedures that followed internal policy for maintaining the proper position to prevent complications on four patients (#2, #6, #8, and #11) of four patients receiving internal continuous tube feedings. (A-395)
- Provide patient hygiene timely according to facility's guidelines on six patients (#1, #9, #13, #15, #16, and #18) of nine patients reviewed. (A-395)

Refer to 2567 A-386, and A-395

These deficient practices resulted in the facility's non-compliance with specific requirements found under the Condition of Participation: Nursing Services.

The severity and cumulative effect of these practices had the potential to place all patients at risk for their health and safety, also known as Immediate Jeopardy (IJ).

On 11/01/17, after the survey team informed the facility of the IJ, the staff created educational tools and began educating all staff and put into place interventions to protect the patients.

As of 11/02/17, at the time of the survey exit, the facility had provided an immediate action plan sufficient to remove the IJ by implementing the following:
- An interim CNO of record was appointed on 11/01/17, using the interim CNO duties checklist. Staffs were notified officially of this appointment on 11/01/17.
- Education was to begin on 11/1/17 on Restraints and Seclusion for all current staff and prior to start of staff's next scheduled shift. Education focused on performance and documentation of restraint monitoring of patients in real time without being back charted. Bed side observations/monitoring started on 11/01/17 for compliance. The staffs identified as noncompliant during the survey were given final written warnings.
- A policy was modified for patient safety with tube feedings, which included head of bed (HOB) elevation and how long tube feeding will be held prior to laying a patient flat when necessary. A shower gurney had been ordered that fostered head of the bed elevation that will arrive on 11/7/17. The use of impervious wedges will be used as interim safety measure until shower gurney arrived. Education was to begin on 11/01/17 on HOB elevation and tube feeding holds for all current staff and prior to start of staff's next scheduled shift. Bed side observations/monitoring started on 11/01/17 for compliance.

Based on interview and record review, the facility failed to ensure there was one on-site Chief Nursing Officer (CNO)/Director of Nursing (DON) who had oversight of and responsibility for all nursing services. This had the potential for nursing services to be provided in a manner that was inconsistent and without uniform supervision, which could lead to substandard nursing practice and poor patient outcomes. The facility census was 29.

Findings included:

1. Although requested, the facility failed to provide a policy related to Nursing Services oversight by a CNO/DON.

2. Record review of the facility's undated form titled, "Select Specialty Hospital of Springfield," showed an organizational chart of the facility, with the CNO position vacant. The vacant CNO was responsible for all Registered Nurses (RNs), License Practical Nurses (LPNs), Certified Nurse Aids (CNAs), Wound Care, and Radiology.

3. During an interview on 10/30/17 at 1:30 PM, Staff A, Director of Quality Management, identified who had overall responsibility for Nursing Services, and stated that Staff BB, RN, was the CNO.

Review of the personnel record for Staff BB, RN, showed no job description, an appointment, and/or no record of any evaluation, education, related to the job performance of CNO.

4. During an interview on 10/31/17 at 3:30 PM, Staff A, Director of Quality Management, stated as of this date, the facility had no documentation that showed the appointment of Staff BB, RN, as the CNO. Staff A also stated that the facility had left the CNO position open and unfilled because the corporate office planned to send a CNO from another corporate facility to function as CNO in August 2016.

Based on policy review, record review, and interview, the facility failed to:
- Ensure ongoing nursing assessment, supervision, and oversight to meet the patient's care/services and/or prevention of complications on three restrained patients (#3, #8, and #14) of three restrained patients reviewed.
- Ensure ongoing nursing assessment, oversight, and/or procedures that followed internal policy for maintaining the proper position to prevent complications, specifically aspiration, on four patients (#2, #6, #8, and #11) of four patients receiving internal continuous tube feedings.
- Provide patient hygiene timely according to facility's guidelines on six patients (#1, #9, #13, #15, #16, and #18) of nine patients reviewed.

The severity and cumulative effects of these systemic practices had the potential to cause injury and/or death, and had the potential to affect all patients admitted to this facility. The facility's census was 29.

Findings included:

1. Record review of the facility's policy titled, "Restraints and Seclusion," revised 07/2017, showed the directives for staff to provide safety, and minimize the use of restraints:
- Restraint: Any method of applying involuntary restriction on a patient's bodily movement or access to his or her body areas;
- Medical record, at a minimum, documentation will show evidence of monitoring of the patient's condition during restraints;
- Medical record must show observations/interventions/findings from periodic observations to include: safety, comfort, mobility, skin integrity, food/hydration and toileting; and
- Removal of restraints at least 10 minutes every two hours or more, and observations every two hours for medical restraints.

2. Record review of Patient #3's History and Physical (H&P) dated 10/27/17, showed that she was a 56 year old female who was involved in a bike accident and suffered a major head injury. She had multiple bibasilar skull fractures and facial fractures requiring postoperatively a tracheotomy tube (tube placed surgically in the neck to facilitate breathing) and a percutaneous endoscopic gastronomy tube (PEG - tube placed in stomach through abdominal wall to provide means of feeding.)

Observation on 10/30/17 at 3:00 PM showed Patient #3 with a restraint on the right arm.

Record review of Patient #3's 24 hour patient record dated 10/30/17, (reviewed on 10/30/17 at 3:03 PM), showed no documentation from 7:00 AM through 3:00 PM that the staff had performed a skin assessment, periodic observation, or removal of restraints for 10 minutes every two hours.

During an interview on 10/30/17 at 3:05 PM, Staff D, Registered Nurse (RN), stated that:
- He had not documented or performed the required tasks for restraints on Patient #3;
- He did not have time; and
- He could just "back log the documentation."

Observation on 10/31/17 at 9:00 AM showed Patient #3 with a restraint on the right arm.

Record review of Patient #3's 24 hour patient record dated 10/30/17, (reviewed on 10/31/17 at 8:45 AM), showed documentation that Staff D, RN and Staff K, Certified Nurse Aid (CNA) had performed a skin assessment, periodic observation, and removal of restraints for 10 minutes every two hours from 7:00 AM through 3:00 PM on 10/30/17.

Record review of Patient #3's 24 hour patient record dated 10/31/17, (reviewed on 10/31/17 at 9:05 AM), showed no documentation from 7:00 AM through 9:00 AM that the staff had performed a skin assessment, periodic observation, or removal of restraints for 10 minutes every two hours on 10/31/17.

Record review of Patient #3's 24 hour patient record dated 10/31/17, (reviewed on 10/31/17 at 1:35 PM) showed documentation that Staff L, RN, and Staff K, CNA had performed a skin assessment, periodic observation, and removal of restraints for 10 minutes every two hours from 7:00 AM through 9:00 AM.

During an interview on 10/31/17 at 1:40 PM, Staff L, RN, stated that she did "back log" the restraint documentation and that she had not assessed the patients she was assigned to, because she had not completed report until 8:30 AM.

3. Record review of Patient #8's H & P dated 10/26/17, showed that he was a 57 year old male who was involved in a bike accident and suffered a major head injury. He had a stroke with right side weakness. He required a tracheotomy tube and a PEG tube.

Observation on 10/31/17 at 9:25 AM showed Patient #8 with restraints on both the right and left arm.

Record review of Patient #8's 24 hour patient record dated 10/31/17, (reviewed on 10/31/17 at 9:30 AM), showed no documentation from 7:00 AM through 9:00 AM that the staff had performed a skin assessment, periodic observation, or removal of restraints for 10 minutes every two hours.

During an interview on 10/31/17 at 9:38 AM, Staff S, RN, stated that:
- She had not documented or performed the required tasks for restraints on Patient #8;
- She did not have time; and
- She could just "back log the documentation, it would make her look bad if she left it undocumented."

Record review of Patient #8's 24 hour patient record dated 10/31/17, (reviewed on 10/31/17 at 11:30 AM,) showed documentation that the staff had "missed" to perform a skin assessment, periodic observation, and removal of restraints for 10 minutes every two hours from 7:00 AM through 9:00 AM on 10/31/17.

4. Record review of Patient #14's H & P dated 10/21/17, showed that he was a 61 year old male who had fallen from a ladder and suffered a major head injury. He required a tracheotomy tube and a PEG tube.

Observation on 10/31/17 at 9:45 AM showed Patient #14 with restraints on both the right and left arm.

Record review of Patient #14's 24 hour patient record dated 10/31/17, (reviewed on 10/31/17 at 9:50 AM), showed no documentation from 7:00 AM through 9:00 AM that the staff had performed a skin assessment, periodic observation, or removal of restraints for 10 minutes every two hours.

Record review of Patient #14's 24 hour patient record dated 10/31/17, (reviewed on 10/31/17 at 11:30 AM), showed documentation that the staff had "missed" to perform a skin assessment, periodic observation, and removal of restraints for 10 minutes from 7:00 AM through 9:00 AM on 10/31/17.

5. During an interview on 10/31/17 at 10:45 AM, Staff H, Charge Nurse, stated that:
- The staff should perform and document a skin assessment, periodic observation view for safety, and removal of restraints for 10 minutes every two hours;
- The nurse and the CNA rotate the restraint tasks so that the patients were checked every hour;
- The 24 hour patients record was in the room and should have been documented in "real time"; and
- If the nurse or the CNA did not document during restraint rounding to include: the skin assessment, periodic observation, and removal of restraints for 10 minutes every two hours, it was not performed.

This failed nursing oversight of patients in restraints had the potential to cause injury and/or death, and had the potential to affect all patients in the facility that required restraints.

6. Record review of the facility's policy titled, "Gastric/Duodenal tube guideline: PEG, Gastronomy Tube, Small-Bore Nasal Tube, Nasogastric Tube, Orogastric," revised 04/01/17, showed the directives for staff to position the patients and minimize risk for aspiration, for patients receiving a tube feeding by maintaining the head of the bed (HOB) elevated at 30 degrees or greater at all times.

7. Even though requested, the facility failed to provide a policy that showed directives for staff on the duration to hold tube feedings prior to lowering the HOB less than 30 degrees on patients that received continuous tube feedings.

8. Record review of Patient #2's H & P dated 10/17/17, showed that he was a 52 year old male who was recently discharge from this facility and then readmitted. He had returned from another facility's Emergency Department with complaints of having food that came through his tracheotomy tube. He had a history of brainstem stroke and chronic respiratory failure. He required a tracheotomy tube and a PEG tube.

Observation and concurrent interview on 10/30/17 at 3:45 PM, showed Staff C, RN, held the continuous tube feeding and immediately lowered the bed flat (0 degrees) to assist Patient #2 up in bed, and then returned the HOB to 30 degrees. Patient #2 had a brown color liquid that presented into the tracheotomy tube that required Staff C to perform suction to remove the liquid from Patient #2's tracheotomy tube. Staff C stated that she was aware that the patient required the HOB greater than 30 degrees, and she could have called for assistance to pull the patient up, while maintaining HOB greater than 30 degrees, however, "this was how we do it here."

Record review of Patient #2's physician's orders dated 10/25/17 showed a physician order to maintain the HOB elevated at least 30 degrees at all times due to aspiration risk. Tube feeding (brown liquid color) was to be administered through the PEG tube at 55 milliliters per hour continuously.

9. Record review of Patient #6's H & P dated 10/17/17, showed that she was a 67 year old female who had acute respiratory failure, and was difficult to extubate. She had no improvement and required a tracheotomy tube and a PEG tube.

Observation on 10/31/17 at 9:30 AM, showed Staff O, CNA, held the continuous tube feeding and immediately lowered the bed flat (0 degrees) to assist Patient #6 onto a flat cart (unable to raise the patients head), where Staff O had taken Patient #6 to a shower where the patient was flat for more than 25 minutes.

During an interview on 10/31/17 at 9:55 AM, Staff O, CNA, stated all patients that were unable to stand or sit were placed on the cart to be given a shower. The cart had no ability to be raised to keep the patient's head elevated to 30 degrees.

10. Record review of Patient #8's H & P dated 10/26/17, showed that he was a 57 year old male who was involved in a bike accident and suffered a major head injury. He had a stroke with right side weakness. He required a tracheotomy tube and PEG tube.

Observation on 11/01/17 at 9:45 AM, showed Patient #8 scrunched down on his side with HOB less than 30 degrees and the tube feeding running at 80 milliliters per hour.

During an interview on 10/31/17 at 10:45 AM, Staff W, RN, stated that it was impossible to make sure Patient #8's HOB was elevated at 30 degrees at all times.

Observation on 11/01/17 at 9:45 AM, showed Staff S, RN, held the continuous tube feeding and immediately lowered the bed flat (0 degrees) to assist Patient #8 up in bed, and then returned the HOB to 30 degrees.

During an interview on 11/01/17 at 11:07 AM, Staff S, RN, stated that it was okay to lay the patient flat if you hold the tube feeding. She also stated that she was not aware of the duration of wait time between the tube feeding being put on hold and when the HOB could be decreased below 30 degrees.

11. Record review of Patient #11's H & P dated 10/11/17, showed that he was a 58 year old male who was quadriplegic (person affected by paralysis of all four limbs). He required a tracheotomy tube and PEG tube.

Observation on 10/31/17 at 11:00 AM showed that staff held Patient #11's continuous tube feeding and immediately lowered the bed flat (0 degrees), turned him to his side, changed a wound dressing and then returned the HOB to 30 degrees. Immediately, Patient #11 required to be suctioned from his tracheotomy tube.

This failed nursing oversight to follow directives of internal policies and physician's orders had the potential to cause injury and/or death to all patients that were in the facility that required tube feedings.

12. Record reviews of the facility's policy titled, "Guidelines and Protocols Clinical," revised 10/01/17 showed the directive to ensure quality patient care, and certain standards of care to follow. Hygiene that will be performed with minimum frequency:
- Patients will be bathed, or showered, daily;
- Hair will be combed and shaved, daily; and
- Oral care will be performed every morning and night, daily.

13. During an interview on 10/31/17 at 9:05 AM, Patient #1 stated that he had not received a bed bath or shower every day. Patient #1's spouse stated that he was admitted on 10/25/17 and had not received a bed bath or shower for two days, and she had to demand that he received a bath. Patient #1's spouse also stated that he did not receive a bed bath or shower on 10/30/17.

Record review of Patient #1's 24 hour patient record dated 10/25/17, 10/26/17, and 10/30/17 showed that the staff had not performed a bath/shower, oral/denture care, and/or hair washed and shaved.

During an interview on 10/31/17 at 1:30 PM, Staff K, CNA, stated that:
- She was the aid for Patient #1 on 10/30/17;
- The patient should have received a bath every day; and
- She did not perform hygiene on Patient #1 on 10/30/17 due to lack of time.

14. During an interview on 10/31/17 at 9:30 AM, Patient #9 stated that he had not received a bed bath or shower every day.

Record review of Patient #9's 24 hour patient record dated from 10/19/17 through 10/30/17 showed that the staff had not performed a bath/shower, oral/denture care, and/or hair washed and shaved, on 10/19/17, 10/20/17, 10/22/17, 10/25/17, and 10/28/17. Patient #9 had not received any hygiene for five of 11 days of admission.

15. During an interview on 10/31/17 at 9:00 AM, Patient #13 stated that she had not received a bed bath or shower every day.

Record review of Patient #13's 24 hour patient record dated 10/27/17 showed that the staff had not performed a bath/shower, oral/denture care, and/or hair washed.

16. During an interview on 10/31/17 at 9:15 AM, Patient #15 stated that she had not received a bed bath or shower every day. There were so many patients, we have to take turns.

Observation and concurrent interview on 11/01/17 at 10:30 AM showed Staff T, RN, had performed an assessment. Patient #15 had an unpleasant odor, and Staff T had wiped the perineum (between the legs). Staff T stated that Patient #15 was not soiled, she used the wipes because of the unpleasant odor. Patient #15 stated she had not received a bath in two days.

Record review of Patient #15's 24 hour patient record showed that the staff had not performed a bath/shower, oral/denture care, and/or hair washed, on 10/15/17, 10/16/17, 10/22/17, 10/29/17, and 10/31/17.

17. During an interview on 10/31/17 at 9:30 AM, Patient #16 stated that the care here was 'terrible" and she had not received a bed bath or shower every day.

Record review of Patient #16's 24 hour patient record showed that the staff had not performed a bath/shower, oral/denture care, and/or hair washed, on 10/25/17, 10/26/17, and 10/29/17.

18. Observation and concurrent interview on 11/01/17 at 10:25 AM showed Staff G, RN, had performed an assessment. Patient #18's linens were disheveled, as well as the patient's hair. Patient #18 stated that she had not received a bed bath or shower every day.

Record review of Patient #18's 24 hour patient record showed that the staff had not performed a bath/shower, oral/denture care, and/or hair washed, on 10/19/17, 10/20/17, 10/22/17, 10/24/17, 10/26/17 and 10/27/17.

During an interview on 10/31/17 at 10:45 AM, Staff H, Charge Nurse, stated the staff should have performed and documented a bath/shower, oral/denture care, and/or hair washed and shaved every day. If documentation was not filled out, it was not performed.

This failed nursing oversight to provide patients personal care to promote personal, social, health and wellness had the potential to affect all patients in the facility. This failed practice had the potential to affect the psychological aspect of all patients admitted to this facility.