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Based on interview and record review the facility failed to actively include the patients in the care planning process (patient's #1, #6 and #7) from March 2018 through June of 2018.


This deficient practice had the likelihood to effect all patients of the hospital.


Findings included:


On 6/12/2018 during the initial tour of the hospital, pt's #6 and #7 were interviewed. Both of these men were alert, oriented and able to leave their rooms. When asked if they had ever participated in their care planning conferences they replied "No". Pt #7 reported he was unaware that there was a care planning conference and that even if he could not attend, his children would without any hesitation.

On 6/12/2018 in the class room, the Chief Nursing Officer was asked if families or patients attended the care planning conferences. He replied "the patients did not attend but the family was invited". No evidence was provided to support patient families were invited to the care planning meetings.

The facility failed to respect the request of the patient and include his request in the discharge planning process. Pt #1 was on Contact isolation precautions but was alert and able to participate in a care planning meeting. Pt #1 was capable of making his desires known and on three separate occasions requested to be discharged. The patient requested discharge 20 days prior to actual discharge.

A review of the documentation representing pt #1's planning meetings were dated;
4/3/2018
4/10/2018
4/17/2018
4/24/2018

Documentation did not indicate the family or the patient attended any care planning meeting. There were no signatures representing the patient or family noted on the documents. There was no evidence a telephone conference call had been attempted with the family. The patients' desire to be discharged was not addressed in the care planning process.

An interview 6/13/2018 with the CNO confirmed the care planning meetings were not held in the rooms with the patient who could not easily leave their beds.

On April 27, 2018 at 1500 PM, pt #1 was transferred to Hot Springs Arkansas LTAC.

Based on document review and interview the facility failed to provide care in a safe setting for 4 of 7 patients (patient's #1, #2 #6 and #7) from March 2018 through June 2018.

This deficient practice had the likelihood to effect all patients of the hospital.

Findings included.

Patient #1
A.
Review of patient (Pt/pt) #1's medical record (MR) indicated he was admitted to room #205. The MR also indicated from the admission history and physical that pt #1 had multiple falls prior to arrival, and was blind in his right eye from injuries sustained in a fall. Pt #1 was placed in a room at the end of the hall with the entrance into the room on his Right side. Pt #1 was unable to easily recognize persons who entered his room due to his vision in the right eye.
On 6/12/2018 during the initial rounding, room #205 was observed to be a private room at the end of the hallway.

Review of the initial assessment of patient #1 revealed the RN failed to document awareness of his blindness in his right eye. Review of the documentation from the initial nursing "Fall Assessment", unsteady gait and sight deficit were not marked as present on admission. This made the score for pt #1's fall assessment in error by 14 points. Unsteady Gait would have been scored as 10 points and sight deficit would have been scored at 4 points. Pt #1's fall risk was scored at 16 points rather than 30. Pt #1, was scored a high risk. "Fall Precautions" was checked off as implemented.


MR review indicated Pt #1 was recorded as frequently not requesting assistance and would get out of bed and ambulate to the bathroom. The nurses note recorded he became very short of breath with very little exertion. On 4/2/2018 at 0440 AM. The RN documented "Bed alarm placed D/T (due to) fall". A thorough review of documentation prior to 4/2/2018 failed to identify a fall or an assessment related to a fall.

Review of the "Fall Prevention policy NSG22", indicated the purpose for the policy was, "To minimize the risk of falling without compromising the mobility and functional independence of patients".

The fall risk policy did not address visual deficit. The policy did not indicate the use of non skid socks as an intervention.

The policy did include moving patients at risk of falls closer to the nurses station and use of a low bed. Nursing documentation recorded the patient, had raised his bed up high or in a high fowlers position. Other than to tell the patient to lower his bed no interventions were recorded as implemented. He was not moved closer to the nurses station.

B.
MR review indicated Pt #1's admission orders indicated Daily weight (wt). On 3/28/2018 Pt #1's initial wt was recorded as 328.9 pounds. Pt #1's admission wt was transferred to the daily flow sheet as 328 pounds. Pt #1's wt was recorded gaining increased wt with only slight decrease in wt recorded. On 4/13/2018 pt #1's wt was recorded as 350.3 lbs. On 4/18/2018 his wt was not recorded as taken. The date of discharge his wt was recorded as 343.7. The RN failed to document the physician was notified of any wt increase. Pt # 1's wt was 328.9 on admission and he had gained 21.4 lbs. with no documentation the physician was notified. Review of the physician progress notes and treatment orders did not reflect awareness of pt #1's daily wt fluctuation.

C.

MR review indicated Pt #1 was admitted with an order for "daily intake and output" (I&O). The H&P recorded a plan for strict I&O's, and a total fluid intake of 1000 ml's per 24 hours. Pt #1's fluid intake was held at or below 1000 ML 3 of 31 days. Review of the nurses notes failed to identify any evidence the physician was notified. Review of the physician progress notes and treatment orders did not reflect awareness of pt #1's inability to adhere to the 1000 ml restriction.

D.
MR record review indicated Pt #1 was admitted with orders for Bipap. On 4/12/2018 at 1925 PM, the RN documented in the Auxiliary Notes, "Wife with call to floor re: (Related to) Pt stating that his Bipap machine was taken away and given to someone else". "Explained to wife he refused to wear it et (and) the doctor d/c'd (discontinued) it." No evidence a physician's order was written and no evidence a verbal order was transcribed to discontinue pt #1's Bipap machine.


Patient #2

On 6/12/2018 during the initial tour of the building, Pt #2, a female patient, recently had a change in room assignment. The new room was at the end of a hallway. Upon entering the room to interview the pt, the call light was observed placed on a table against the wall near a box fan. The patient could not reach the table from her supine position in the bed. The CNO (Chief Nursing Officer) was notified the patient's hospital arm band had the incorrect physician's name on it.

On 6/13/2018 pt #2 was visited again. This patient's hospital arm band was checked and indicated physician #1. Physician #1 resigned his position at the hospital on 3/16/2018. His last day to work was mid April. This was verified in his credentialing file. The CNO was notified pt #2 still did not have the correct physician information on her hospital arm band.

Review of the hospital policy "ID Bracelet" (Identification Bracelet), NSG26 was reviewed. The purpose for the ID bracelet was, "To provide a safe environment by ensuring each patient receives the appropriate care."
Procedure
"1. The unit clerk will provide the completed identification band to the nurse responsible for the admission assessment.
2. The nurse will validate spelling of patient's name and to her identification information is correct."


Patient #6 and #7
On 6/12/2018 both male patients were observed in their respective room with socks on their feet. The socks did not have a non skid surface. Both pt #6 and Pt #7 were identified as requiring "Fall prevention" intervention. Both pt's confirmed they were not bed confined and could get up and ambulate if desired. Both patient were near the end of the hallway.

On 6/12/2018 interview with the CNO revealed patient's who were on fall risk precautions should wear non skid socks. Review of the hospital's policy for falls risk did not include the use of non skid socks. No fall risk interventions were evident for patient #6 and #7.

Based on document review and interview the facility failed to evaluate the need for requested discharge for one of one patients (Patient #1).

This deficient practice had the likelihood to effect all patients of the hospital.

Findings included:


On 6/14/2018 the entire medical record for patient (Pt/pt) #1 was reviewed. The medical record indicated pt #1 voiced his desire to leave the hospital on 4/7/2018. The pt was not discharged and the pt's behavior began to deteriorate until the date of discharge finally occurred on 4/27/2018.

During the 20 days between the pt's first request to leave and the actual date of discharge the patient demonstrated behavior that inhibited his care. He refused physical therapy, he refused to use his Bipap for breathing at night, he refused his restricted fluid order for Cardiac, Respiratory and Renal function, he refused his oral medication, refused to call for assistance when needing to be out of bed for bathroom use, and on 4/21/2018 the nurses notes recorded at 1800 PM "HOB (head of bed) elevated. Alert. Respirations even and unlabored. No distress noted. No needs at this time." At 1930 PM the assessment included "Pt has no IV (intravenous) access and refuses to placement, physician and RN's aware". Pt later the same day refused lab work to be performed.

Pt #1 remained in the hospital until April 26 without an IV access.

On April 27,2018 pt #1 was discharged to Hot Spring Arkansas LTAC (long term acute care)hospital.

During the exit conference the Chief Executive Officer (CEO) was told pt #1 should have been discharge sooner. She replied, " Is there a regulation that requires a hospital to discharge a patient"? It was explained to the CEO, once hospital services are not being provided there is every expectation the patient will be discharge. Pt #1 refused all hospital services including not having IV access. Why did he need hospital care? She did not respond.

The facility demonstrated disregard for discharge related to the need of the patient. No system was offered for evaluating patient need for discharge when services were no longer being provided by the hospital.

The was no policy identified that addressed need for discharge related to inability to provide acute care services.