HospitalInspections.org

Based on staff interviews, policy review and observation it was determined the facility failed to provide patients the right to be free from restraint, of any form, imposed as a means of coercion, discipline, convenience or retaliation by staff. This failure has the potential for all patients treated at the facility to be at risk for injuries by use of a restraint in an unsafe setting.

Findings include:

1. A phone interview was conducted on 11/27/18 at 2:50 p.m. with Registered Nurse (RN #1). When asked if she observed use of a reminder belt turned around backwards to be used as a restraint, RN #1 stated: "Yes, I have seen the reminder belt used as a restraint. It was at the end of September or the beginning of October."

2. A phone interview was conducted on 11/27/18 at 3:20 p.m. with Licensed Practical Nurse (LPN #2). When asked if she observed use of a reminder belt turned around backwards used as a restraint, LPN #2 stated: "Yes, I have seen a patient with the velcro belt more than one (1) time, usually on dayshift and nightshift turned around. I turned the belt the right way. It has not been frequent but seen it three (3) times since June."

3. An observation was conducted on 11/27/18 at approximately 5:30 p.m. with the Nurse Supervisor and Director of Quality. The Nurse Supervisor demonstrated placement of the reminder belt around a wheelchair, velcroed the ends together in the front where the patient would be seated and then demonstrated that patients can pull the ends apart to self-release from the reminder belt. The Nurse Supervisor explained that when a patient is in the wheelchair, the reminder belt is placed and connected to an alarm placed behind the wheelchair. The Director of Quality verbalized patients could potentially turn the belt around causing the velcroed ends to unintentionally be in the back while the patient is in the wheelchair, creating a potential restraint. Surveyors, Nurse Supervisor and Director of Quality attempted to turn the reminder belt around to place the velcroed connection in the back of the wheelchair. It was very difficult to turn. The reminder belt, if plugged into the alarm, would also hinder turning the reminder belt around causing the alarm to sound. The Nurse Supervisor verbalized anytime a patient is placed in the wheelchair with the reminder belt on, the reminder belt should be connected to the alarm at all times. Sometimes nurses forget to connect the reminder belt to the alarms.

4. An interview was conducted on 11/28/18 at approximately 9:45 a.m. with a Registered Nurse (RN #2). When asked if she observed use of a reminder belt turned around backward used as a restraint, RN #2 stated: "Have not seen a belt backwards as a restraint, but had a nurse tell me she did it." RN #2 continued: "It was a patient that had multiple falls when that nurse used it. So, the nurse turned it around. The nurse joked about it."

5. Review of employee notification titled Posey Reminder Belt, on 11/28/18, states in part: "All patients, upon admission, be provided with a Posey Reminder Belt, regardless of their fall risk." Written in the section titled Admission, further states in part: "A patient who is NOT ABLE to self release the belt independently is not appropriate for this fall prevention measure. This is considered a restraint and requires a physician order. The patient's nurse should alert the physician for an order as it is now considered a restraint."

6. On 11/28/18 a review of HealthSouth Mountainview Regional Rehabilitation Hospital policy #10, Use of Restraints, in section I. Determination if a device is a restraint, states in part: "It is the device's intended use (such as physical restriction), its involuntary application, and/or the identified patient need that determines whether the device used is a restraint. If the effect of using an object fits the definition of restraint for that patient at that time, then for that patient at that time, the device is a restraint." and in section II. Devices NOT Approved for use, further states, "1. Restraint belts: non-removable fabric belt placed around the torso or waist with straps to restrain individuals in bed or chair."

Based on staff interviews, policy review and observation it was determined the facility staff failed to implement use of restraint in accordance with safe and appropriate restraint techniques as determined by hospital policy in accordance with State law. This failure has the potential for all patients treated at the facility to be at risk for injuries by use of a restraint.

Findings include:

1. A phone interview was conducted on 11/27/18 at 2:50 p.m. with a Registered Nurse (RN #1). When asked if she observed use of a reminder belt turned around backwards to be used as a restraint, RN #1 stated: "Yes, I have seen the reminder belt used as a restraint. It was at the end of September or the beginning of October."

2. A phone interview was conducted on 11/27/18 at 3:20 p.m. with a Licensed Practical Nurse (LPN #2). When asked if she observed use of a reminder belt turned around backwards used as a restraint, LPN #2 stated: "Yes, I have seen a patient with the velcro belt more than one (1) time, usually on dayshift and nightshift turned around. I turned the belt the right way. It has not been frequent but seen it three (3) times since June."

3. An observation was conducted on 11/27/18 at approximately 5:30 p.m. with the Nurse Supervisor and Director of Quality. The Nurse Supervisor demonstrated placement of the reminder belt around a wheelchair, velcroed the ends together in the front where the patient would be seated and then demonstrated that patients can pull the ends apart to self-release from the reminder belt. The Nurse Supervisor explained that when a patient is in the wheelchair, the reminder belt is placed and connected to an alarm placed behind the wheelchair. The Director of Quality verbalized patients could potentially turn the belt around causing the velcroed ends to unintentionally be in the back while the patient is in the wheelchair, creating a potential restraint. Surveyors, Nurse Supervisor and Director of Quality attempted to turn the reminder belt around to place the velcroed connection in the back of the wheelchair. It was very difficult to turn. The reminder belt, if plugged into the alarm, would also hinder turning the reminder belt around causing the alarm to sound. The Nurse Supervisor verbalized anytime a patient is placed in the wheelchair with the reminder belt on, the reminder belt should be connected to the alarm at all times. Sometimes nurses forget to connect the reminder belt to the alarms.

4. An interview was conducted on 11/28/18 at approximately 9:45 a.m. with a Registered Nurse (RN #2). When asked if she observed use of a reminder belt turned around backward used as a restraint, RN #2 stated: "Have not seen a belt backwards as a restraint, but had a nurse tell me she did it." RN #2 continued: "It was a patient that had multiple falls when that nurse used it. So, the nurse turned it around. The nurse joked about it."

5. Review of employee notification titled Posey Reminder Belt, on 11/28/18, states in part: "All patients, upon admission, be provided with a Posey Reminder Belt, regardless of their fall risk." Written in the section titled Admission, further states in part: "A patient who is NOT ABLE to self release the belt independently is not appropriate for this fall prevention measure. This is considered a restraint and requires a physician order. The patient's nurse should alert the physician for an order as it is now considered a restraint."

6. On 11/28/18 a review of HealthSouth Mountainview Regional Rehabilitation Hospital policy #10, Use of Restraints, in section I. Determination if a device is a restraint, states in part: "It is the device's intended use (such as physical restriction), its involuntary application, and/or the identified patient need that determines whether the device used is a restraint. If the effect of using an object fits the definition of restraint for that patient at that time, then for that patient at that time, the device is a restraint." and in section II. Devices NOT Approved for use, further states, "1. Restraint belts: non-removable fabric belt placed around the torso or waist with straps to restrain individuals in bed or chair."

Based on staff interviews, it was revealed the facility failed to provide adequate staffing to provide patient care. This failure was identified in eleven (11)) of eleven (11) nursing staff interviews conducted. This failure has the potential to adversely affect all patients.

Findings include:

1. An interview was conducted with Licensed Practical Nurse (LPN) #1 on 11/27/18 at 1:35 p.m. When asked if she feels the facility is understaffed she stated: "Yes." She stated she feels patients have to wait on call lights due to staffing. She stated the Pediatric Pulmonary Unit (PPU) will have one (1) LPN and one (1) Rehabilitation Nurse Technician (RNT) caring for the patients. She stated the supervisor, who is a Registered Nurse (RN), will take some shifts to cover. She stated afternoon shift has more nurses.

2. An interview was conducted with RNT #1 on 11/27/18 at 1:55 p.m. When asked about staffing, RNT #1 stated: "Some days it is pretty hectic." RNT #1 stated: "I have had twenty-seven (27) patients at one (1) time. I have been the only tech in the whole building before." RNT #1 stated not all nurses help the RNT's when someone needs the bedpan. She stated she has been the only RNT working and a nurse will tell her a patient on the other end of the hall needs a bedpan.

3. An interview was conducted with RNT #2 on 11/27/18 at 2:20 p.m. When asked about staffing, RNT #2 stated: "I feel we are understaffed unless the state is here." RNT #2 stated: "I had eighteen (18) patients by myself yesterday and it depends on the nurse if you get any help, even if you need help." RNT #2 stated: "I have seen a supervisor and nurse stand under a call light and not answer it and when I went in the patient's room, they just needed a blanket." RNT #2 stated PPU and Speciality Care Unit (SCU) are slammed with patients.

4. A telephone interview was conducted with RN #1 on 11/27/18 at 2:50 p.m. When asked about staffing, she stated: "Yes, we are constantly understaffed." She stated: "Short on the side units, two (2) nurses and one (1) RNT." She stated one (1) RNT is not able to take care of all the patients. She stated she has see call lights with lengthy wait times, ten (10) minutes max.

5. A telephone interview was conducted with LPN #2 on 11/27/18 at 3:20 p.m. When asked about staffing, she stated: "Absolutely understaffed." She stated they had two (2) nurses for eighteen (18) patients a week ago. She stated it is very hard to give medications on time due to doing primary care. She stated the side units, PPU and SCU, are understaffed. General Rehab Unit (GRU) is the easiest unit with the most staff.

6. An interview was conducted with RNT #3 on 11/27/18 at 4:10 p.m. RNT #3 stated: "I have had a total of eighteen (18) patients with two (2) nurses. RNT #3 stated nurses don't always answer call lights. She stated a couple of weeks ago she was working and another staff member asked if they needed to go to Administration about all the call lights on. She stated she informed the staff member that there is a no pass zone and everyone is responsible to answer a call light. She stated you never know about staffing when coming to work.

7. An interview was conducted with RN #2 on 11/28/18 at 9:45 a.m. When asked about staffing, RN #2 stated: "You have good and bad wherever you work." She stated: "Staffing is an issue sometimes, the weekends are the worst." She stated she has worked on the SCU with just another RN and it makes it difficult to care for the patients. She stated the supervisor is to float and help but it doesn't happen. She stated they are unable to care for the patients properly and getting charting done is difficult. She stated this does not happen every day or every weekend. She stated she has taken staffing issues to her supervisor and she feels it wasn't addressed. She noted some nurses won't answer call lights as they think it is the RNT's job and she had to answer the call light. She stated there is better staffing on GRU than the PPU and SCU. She stated nurses will ignore patients when medications are due. She stated she has been really late giving afternoon medications due to her not being able to be in that many places at once. She stated they are more understaffed here than anywhere else she has worked.

8. An interview was conducted with LPN #3 on 11/28/18 at 10:25 a.m. When asked about staffing, she stated: "At times we are understaffed." She stated she tries to work together but some staff have no work ethic. She stated GRU is better staffed. She stated: "Two (2) weeks ago SCU had two (2) nurses and one (1) RNT. They had nine (9) patients each, it was rough there." She stated medications suffer and are late due to staffing.

9. An interview was conducted with RN #3 on 11/28/18 at 11:20 a.m. When asked about staffing, she stated: "There is always times when understaffed and I have worked at worse."

10. An interview was conducted with RN #4 on 11/28/18 at 12:35 p.m. When asked about staffing, she stated: "Sometimes they are short staffed." She stated SCU and PPU are short staffed more than GRU. She stated she feels sometimes she doesn't give 100% due to staffing and not enough time. She stated call lights are not being answered routinely when short staffed.

11. An interview was conducted with the Nursing Supervisor on 11/27/18 at 5:45 p.m. When asked about staffing, she stated: "I float to all units and try to help, if needed, when the units are short." She stated staffing is getting better. She stated she gets frustrated with admissions when they don't have enough staff and they keep getting admissions. She stated she is mainly on the GRU.

Based on document review and staff interviews, it revealed the nursing staff failed to follow the abuse/neglect policy. This failure has the potential affect all patients.

Findings include:

1. A review of the policy titled Allegations of Abuse/Neglect, effective date 7/16/18, stated in part: "Un-witnessed Report of Abuse 1. Take immediate action to protect the patient from harm. 2. Unit staff must contact their supervisor and/or a supervisor on duty immediately upon notification of allegation/findings of any form of abuse/neglect. 3. The patient must be: A. examined immediately for injury. B. treated, if necessary. C. secured from harm by taking any additional necessary actions to ensure the patient's safety and welfare, including, but not limited to I. moving the patient to another unit. II. reassigning staff ."

2. A review of the complaint/grievance filed on 11/12/18 revealed on 11/10/18 patient #1 reported to RNT #2 that a nurse came up behind her and yanked her pants up hard, causing her pain for some time that required ice. On 11/11/18 at 5:01 p.m. RNT #2 sent an email to the Nurse Manager about the complaint. On 11/12/18 at approximately 8:30 a.m. Senior Management received the email from RNT #2 about the complaint. Shortly after 9:30 a.m. on 11/12/18 the Nurse Manager interviewed the patient.

3. An interview was conducted with RNT #2 on 11/27/18 at 2:20 p.m. When asked why he waited to report the complaint, he stated he was waiting on RN #1 to help him write the email to Administration. He stated he did not know what to do on 11/10/18.

4. A telephone interview was conducted with RN #1 on 11/27/18 at 2:50 p.m. She stated when RNT #2 told her about the complaint she helped him write the email to the Nurse Manager. RN #1 stated she was filling in as charge nurse.

5. A review of the medical record for patient #1 revealed patient #1 was assessed by the RN on 11/10/18 at 9:31 p.m., on 11/11/18 at 7:30 a.m. and 8:00 p.m. and by the physician at 4:02 p.m. on 11/12/18.

6. An interview was conducted with the Nurse Manager on 11/27/18 at approximately 12:30 p.m. She stated she did not examine patient #1 after receiving the email about the complaint. She concurred the nursing staff failed to report the complaint immediately to their supervisor or a supervisor on duty and the charge nurse failed to immediately examine the patient after being notified of the complaint.


40222


Based on staff interviews and document reviews, it was determined the facility failed to have an adequate number of Licensed Registered Nurses (LPN's), Licensed Practical Vocational Nurses (LPVN's) and other personnel to provide nursing care to all patients as needed. This failure has the potential for all patients to be at risk for inability of staff to meet and respond appropriately to individual patient needs.

Finding include:

1. An interview was conducted on 11/27/18 at approximately 1:35 p.m. with LPN #1. When LPN #1 was asked about staffing, she stated: "Yes, feels works understaffed, with a twelve (12) hour shift working understaffed today. I have worked over forty (40) hours each pay period as a PRN, as needed, and was only called off two (2) times since April." When discussing patient wait times, LPN #1 stated: "Yes, patients have waited for their call bells to be answered but the Visilert tracking has helped to decrease patient's waiting with call lights."

2. An interview was conducted on 11/27/18 at 1:55 p.m. with Rehab Nursing Technician (RNT) #1. RNT #1 was asked about staffing and stated: "We do great work, hard work. I have had twenty-seven (27) patients in one day but it happens. I never leave here feeling bad. We are short staffed a lot. We have had agency staff to help but they don't show up or they call off." RNT #1 further states: "The worst thing was putting chairs in the hallway for Registered Nurses (RN's). They get comfortable. I was asked to get a bedpan down the hallway while in the middle of caring for another patient."

3. An interview was conducted on 11/27/18 at 2:20 p.m. with RNT #2. RNT #2 was asked about staffing and stated: "Yes, we are understaffed. Anytime the state comes management makes it look good. I had 18 patients by myself yesterday. It consistently happens. Sometimes I don't get help from nurses, but it depends on the nurse." RNT #2 stated" "There was a call bell was going off and I was coming out of the water room, getting patients water, and a nurse and supervisor were right outside of the door but didn't go in to answer. I stopped in to answer and the patient only needed a blanket. The Pediatric Pulmonary Unit (PPU) and Specialty Care Unit (SCU) usually have 1 tech with 12-13 patients. The General Rehab Unit (GRU) is usually staffed."

4. A phone interview was conducted on 11/27/18 at 2:50 p.m. with RN #1. RN #1 was asked about staffing and stated: "Yes, we are constantly working understaffed, mostly with RNT's but with nurses also. There are days there will be only two (2) nurses or one (1) tech working for four (4) hours. Seventeen (17) patients is too much for one (1) tech. There have been call lights ringing and not answered timely, about 10 minutes wait time. Occasionally some staff spend more time than others on their phones." RN #1 was asked about late medication administration and stated: "Meds have been late. Nurses have had nine (9) patients and have to act as techs (RNTs)."

5. A phone interview was conducted on 11/27/18 at 3:20 p.m. with LPN #2. LPN #2 was asked about staffing and stated: "Yes, work short staffed. Me and an RN had eighteen (18) patients. Has happened several times. The last time was last week. Evening shift is worse then at 10:00 p.m. we will get extra staff from 10:00 p.m. to 6 a.m." When asked about answering call bells, LPN #2 stated: "Yes, patients have to wait for call lights being answered. A tech put a patient in the bathroom and forgot them in the bathroom on the toilet. It's hard to get meds to patients on time due to providing primary care. GRU is easier than SCU and PPU. Side units are understaffed frequently."

6. An interview was conducted on 11/27/18 at 4:10 p.m. with RNT #3. RNT #3 was asked about staffing and stated: "A pharmacy tech said, do I need to get a Nurse Supervisor? I told her that she can acknowledge the patient's light. We have a no pass zone, anyone can acknowledge a light. No, I don't feel understaffed. I have seen nurses staying at their work station on wheels (WOW) and not answer call bells. I have had 18 patients. Supervisors don't help out."

7. An interview was conducted on 11/27/18 at 5:45 p.m. with a Nursing Supervisor. When asked about staffing, the Nursing Supervisor stated: "Staffing is getting better. It is frustrating with admits and not enough staff. It's frustrating with staffing but we are working on it and trying. I'm mostly General and round on the side units (PPU and SCU)."

8. An interview was conducted on 11/28/18 at 8:40 a.m. with Physical Therapist (PT) #1. When asked about staffing, PT #1 stated: "We have plenty of physical therapy staff. The barriers are call offs with staff. Nursing staff are struggling on the weekends. Most times is staffed appropriately but have a lot of call outs. I would staff extra to cover. There are some staff that are not one hundred (100) percent in it but there are some very good staff that are tremendous."

9. An interview was conducted on 11/28/18 at 9:45 a.m. with RN #2. RN #2 was asked about staffing and stated: "It's the first place here I don't dread coming to work. Sometimes staffing is OK and other times uncomfortable with the patient load. I have primary care with twelve (12) patients multiple times, mostly on the weekends. I have been on a locked unit with only 2 people to care for the floor patients. It's happened more frequently the past couple of months on the weekends. The Supervisor is to float but doesn't happen. I notified the Supervisor when short, can't leave for lunch or give food to patients. When I talked to the Supervisor, they said I know, we are doing the best we can. There are times when the Supervisor or the Charge has patient loads. Evenings are better staffed. Call bells are not answered in a timely manner. I have had nine (9) patients as primary and can't get to call lights. There are techs and nurses not answering call lights. You know which nurses won't answer lights." RN #2 verbalized: "Some nurses change the times on the Visilert to put in ridiculous times to not have alarms not go off. It happens every shift. I have worked in other places that were understaffed but not to this extent."

10. An interview was conducted on 11/28/18 at 10:25 a.m. with LPN #3. LPN #3 was asked about staffing and stated: "I feel at times we can be understaffed and need more help. We always manage together. Yes, I feel staff answer call bells, sometimes bell may not be answered timely, but we get there as soon as we can. Days short of staff, we are not able to get there sooner. The GRU is better staffed than SCU. The SCU has had seventeen (17) patients with two (2) nurses and one (1) tech is tough. I have eight (8) patients today with a tech."

11. An interview was conducted on 11/28/18 at 11:20 a.m. with RN #3. When asked about staffing, RN #3 stated: "With any hospital it can happen. It doesn't happen a lot, but I've seen worse."

12. An interview was conducted on 11/28/18 at 12:35 p.m. with RN #4. RN #4 was asked about staffing and stated: "Sometimes it feels short staffed in all the units. I've had primary care on the side units (PPU and SCU) with about 5 patients. I'm unable to give one hundred ten (110) percent to patients."

13. A documentation review was conducted of HealthSouth Mountainview Rehab Hospital Staffing Grids and Nursing Shift Assignments, for the date of 10/27/18, showed 5 out of 6 shifts were short a staff member. The SCU Staffing Grid with seventeen (17) patients expected two (2) RN's and two (2) RNT's to be scheduled for dayshift, evening shift and night shift. The actual staff scheduled on dayshift were two (2) RN's with an additional RN to assist with medication administration, completing vital signs and performing patient assessments, with no RNT. The actual staff scheduled on evening shift were two (2) RN's and one (1) LPN with the expectation that the RNT assigned to the PPU, which had sixteen (16) patients, was also expected to come and assist patients on the SCU. The actual staff scheduled on night shift was one (1) RN, one (1) LPN and one (1) RNT. On 10/27/18 the PPU Staffing Grid with sixteen (16) patients expected one (1) RN, one (1) LPN and two (2) RNT's to be schedule for dayshift and evening shift and two (2) RN's and one (1) RNT for night shift. The actual staff scheduled on dayshift were two (2) RN's with one (1) orientee. The actual staff scheduled on evening shift were two (2) RN's with an orientee and one (1) RNT, who was expected to help assist patients on the SCU which had seventeen (17) patients. The actual staff scheduled to work 10/27/18 on night shift were three (3) RN's and one (1) RNT.

14. A documentation review was conducted of the HealthSouth Mountainview Rehab Hospital Staffing Grids and Nursing Shift Assignments, for the date of 11/1/18, showed 1 out of 6 shifts were short a staff member. The SCU Staffing Grid with eighteen (18) patients expected two (2) RN's and two (2) RNT's to be schedule for dayshift, evening shift and night shift. The actual staff scheduled on dayshift were three (3) RN's and one (1) RNT. The actual staff scheduled on evening shift were (2) RN's, one (1) LPN and two (2) RNT's. The actual staff scheduled to work night shift was one (1) RN, one (1) LPN and one (1) RNT. On 11/1/18 the PPU Staffing Grid with fifteen (15) patients expected one (1) RN, one (1) LPN and two (2) RNT's to be schedule for dayshift and evening shift and one (1) RN, one (1) LPN and one (1) RNT for night shift. The actual staff scheduled on dayshift were two (2) RN's with one (1) orientee and one (1) LPN. The actual staff scheduled on evening shift were two (2) RN's, one (1) LPN and one (1) RNT. The actual staff scheduled on night shift were two (2) RN's and one (1) RNT.

Based on staff interviews and a tour of the patient units, it was revealed the hospital failed to maintain a sanitary environment to avoid sources and transmission of infection and communicable diseases. This failure was identified in three (3) of three (3) patient units toured. This failure has the potential to adversely affect all patients.

Findings include:

1. A tour of the General Rehab Unit (GRU), Speciality Care Unit (SCU) and the Peds/Pulmonary Unit (PPU) was conducted on 11/26/18 at 11:13 a.m. The Chief Nursing Officer (CNO) and the Director of Quality/Risk accompanied the surveyors on the tour. The Plant Operations Director joined the tour. A tour of the clean supply room on the SCU revealed the linen supply cart had one (1) sheet, one (1) container of deodorant and one (1) bottle of lotion lying on the floor under the cart. A water only cart located in the clean supply room, with a sign stating For Water Only, had a wash basin, personal hygiene supplies and an abdominal binder located in the water only cart. Large dust balls and black spots were noted on the floors of the SCU. Room #320 had a trash can completely full of blue pads and a pair of non-slip footies located on the bathroom floor. A tour of the clean supply room on the GRU revealed multiple linens were lying on the floor under the linen supply cart. A tour of the storage room for clean equipment on the GRU revealed three (3) Intravenous (IV) pumps were not bagged as clean, two (2) hoyer lifts were not tagged as clean, one (1) baby crib was not tagged as clean, four (4) pillows were not bagged as clean and two (2) dirty carts were stored in the storage room. A tour of the clean supply room on the PPU revealed multiple linens lying on the floor under the linen supply cart and one (1) dirty bladder scanner located in the clean supply room. Large dust balls were located on the floors of the PPU.

2. During the tour an interview was conducted with the Plant Operation Director. He concurred the facility failed to maintain a sanitary environment.

Based on staff interview and a tour of the Respiratory Therapy Room, it was revealed the facility failed to ensure all supplies for patient use had not expired. This failure has the potential to adversely affect all patients.

Findings Include:

1. A tour of the Respiratory Therapy room was conducted on 11/26/18 at 12:20 p.m. It revealed twenty six (26) expired arterial blood gas kits located in the supply drawer for patient use.

2. During the tour an interview was conducted with the Licensed Respiratory Therapist. He stated he just stocked the arterial blood gas kits in the supply drawer. He concurred twenty-six (26) kits had expired.