HospitalInspections.org

Based on record review and interview, the facility failed to ensure the quality processes (incident report/complaints) were followed to identify/report/track/trend 3 of 3 issues (1/23/19, 1/24/19, and 1/27/19) surrounding Patient #6 during his admission.

Findings included

There were no incident report or patient/family complaints for the:

~ 1/23/19 nurse notes that reflected, "Son said we were the worst caregivers ever...I found crown royal whiskey bottles in the trash, 50 ml (milliliters) bottles, three of them..."

~ 1/24/19 met with daughter. She was preventing the staff from caring for the patient. Daughter smelled of alcohol, looked as if she wet herself, and looked like urine on the floor.

~ 1/27/19 Nurse note reflected, "Family expressed feeling unsafe due to a situation where they happen to know (name) RN, working as Tele Tech. Supervisor spoke with family but still scared for their patient being here. They expressed taking their patient out..."

During an interview on 2/12/19 at 11:26 Personnel #2 described an issue on 1/24/19 where she met with daughter. Daughter was preventing the staff from caring for the patient. Daughter smelled of alcohol, looked as if she wet herself, and looked like urine on the floor. Daughter was holding the patient and shaking/rocking him. Patient had an ET tube. Personnel #2 discussed she couldn't hurt the staff or father. Personnel #2 stated daughter was told we would have to call security/Police, if she didn't allow care.

During an interview on 2/12/19 ending at 4:45 PM, Personnel #1 and #2 were informed of the above findings. Personnel #1 and #2 agreed, no incident or complaint were put in for these items.

The facility's last revised 1/01/18 "Risk Management Incident Reporting" policy required, "incident report will be completed promptly and accurately by any employee involved in or discovering an incident or having an incident reported to him/her by a patient or visitor...completed electronically prior to the end of the shift..."

The facility's last revised 10/01/17 "Complaint and Grievance Process" policy required, "The hospital staff member receiving the complaint or grievance will initiate the complaint/grievance form..."

Based on record review and interview, the facility failed to ensure a RN (Registered Nurse) supervised and evaluated the nursing care for each patient in accordance with the patient's needs for 3 of 3 post-fall patients (Patient #5, #6, and #7), in that, Patient #5's, #6's, and #7's nursing care did not document the post fall vital signs and neuro check assessments per policy.

Findings Included

Patient #5's, #6's, and #7's nursing care did not document the post fall vital signs and neuro check assessments per policy.

Patient #5's care plan was not updated post fall.

During an interview on 2/13/19 ending at 2:05 PM, Personnel #1 reviewed the records and confirmed the post fall vital signs and neuro check assessments were not documented per policy.

The facility's October 2017, last revised "Fall Reduction Program" required, "Post fall assessment and revision to Plan of Care...post fall assessment must include...neurovascular checks and vital signs: every 15 minutes x 4, every hour x 4, every 2 hours x 4, every 4 hours x 3...Patient will be placed on telemetry for a minimum of 24 hours following an unsafe fall...unwitnessed..."

Based on record review and interview, the facility failed to ensure nursing staff keep current a nursing plan of care for each patient which addresses the patient's needs for 3 of 5 patients (Patient #5, #6, and #8), in that, Patient #5's, #6's, and #8's nursing care plan were not updated after a change in status.

Findings Included

Patient #5's nursing care plan was not updated post fall.

Patient #6's, and #8's nursing care plan was not updated post intubation and respiratory distress.

During an interview on 2/13/19 ending at 2:05 PM, Personnel #1 reviewed the records and confirmed the nursing care plan was not updated after the event.

During an interview on 2/13/19 at 12:17 PM, Personnel #11 explained the plan to change to electronic charting is third or fourth quarter this year. At that point, the nurse would have all system care plans to draw from for each patient."

The facility's October 2017, last revised "Fall Reduction Program" required, "Post fall assessment and revision to Plan of Care..."

The facility's April 2017, last revised "Nursing Care Plan" policy required, "updating and revising the patient's nursing care plan in response to assessments...The interdisciplinary plan of care does not minimize or eliminate the need for a nursing care plan..."

Based on record review and interview, the facility failed to ensure complete documentation - dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided for 1 of 1 patient (Patient #6), in that,

Patient #6's record did not document a physician's order to transfer the patient to ICU (Intensive Care Unit) on 1/24/19 after a change of status and intubation; and

Patient #6's record did not document a physician's progress note for the 2/04/19 code.

Findings included

Patient #6's record did not a physician's order to transfer the patient to ICU on 1/24/19 after a change of status and intubation; and
did not document a physician's progress note for the 2/04/19 code.

During an interview on 2/13/19 at 1:30 PM, Personnel #2 was informed of the findings and reviewed the record. Personnel #2 stated there was no physician order to transfer Patient #6 to ICU after the intubation and there was no physician's progress note by Personnel #26 pertaining to Patient #6's care during the code.

The facility's 1/01/19, last revised "Assessment and Reassessment" policy required, "collaboratively performed...all patients receiving care or treatment...reassessed when a significant change occurs in patient condition, when a significant change occurs in the patient's diagnosis...will be documented in the patient's medical record...The documentation of the ongoing reassessments performed daily by a physician...for the care of the patient can be found in: progress notes...Physician orders..."

Based on observation and interview, the facility infection control officer failed to ensure safe environment due to infection control issues found during the 2/13/19 tour of the facility.

Findings included

During a tour of the 26 bed hospital's ICU (Intensive Care Unit) and Med-surg (Medical/Surgical) units on 2/13/19 ending at 11:40 AM, the dirty utility in the ICU area was found in disarray and unclean conditions including the hopper had black, organic material, scum circumferential around the bowl with clean, clear water. There were yellowish, brown, dried, drips around the top of the hopper, on the floor around the hopper and in one dirty bedpan on the floor below the hopper. There were 5 basin tubs scattered on the Formica cabinet around the sink. The basin that could be looked into/visualized had the same yellowish, brown dried drips. There was a bed headboard on the floor under the sink cabinet (no doors on the cabinet). The right side of the sink cabinet was covered in Formica, and the Formica was buckled away from the wood.

The second dirty utility contained the laboratory specimen refrigerator. When opened, the bottom 2 areas of the refrigerator had dried, greenish liquid. The room had a hopper and a sink in the right hand corner. Three (3) large blue plastic sacks (LAL Mattress-low air loss) were stored on the floor which prevented staff use of the sink. There was another blue plastic bag that was small with an unknown item in it. There was an un-bagged patient gown on the floor below the dirty linen container.

The small trash room at the end of the hallway contained an opened trash bin on the left and a plastic sink in the left hand corner. At the meeting (base) of the 2 walls and floor, there was old, brown-black organic material all along both sides of the sink area. The floor of the room contained a yellow dried pooled liquid approximately 3 inches by 8 inches and a dried liquid with varying red colors under the trash bin, size could not be fully seen. The room was quite odiferous.

The biohazard room had unused folded boxes stored on the floor.

During an interview and tour on 2/13/19 ending at 11:40 AM, Personnel #2 witnessed the 2 dirty utility rooms and the trash room in disarray and indicated the rooms should be clean and not left in the state they were found. Personnel #2 witnessed the biohazard room with the clean boxes on the floor and indicated they should be placed on something.