HospitalInspections.org

Based on document review and interview, the hospital failed to set forth reasonable visitation privileges in accordance with CMS (Centers for Medicare and Medicaid Services) guidance for 1 facility.

Findings include:

1. A. Review of the policy titled COVID-19, reviewed 3/2021, indicated the following: Hold on visitation starting 3/12/20.

B. Review of the facilities website on 3/22/22, at https://www.brightwellbehavioral.com/ indicated the following was posted: Due to the current uncertainty regarding the COVID-19 virus, we have made the decision to restrict visitation from unnecessary personnel, as well as families, until further notice.

2. Review of CMS Quality, Safety & Oversight Group, Ref: QSO-21-08-NLTC, REVISED 02/04/2022 at https://www.cms.gov/files/document/qso-21-08-nltc-revised.pdf indicated the following: Visitation Restrictions: We recognize that requirements for entering healthcare facilities such as visitation restrictions were used to mitigate the introduction of COVID-19 into facilities. At this time, continued federal guidance regarding visitation restrictions for ACC (acute and continuing care) facilities are no longer necessary. Facilities should continue to adhere to basic COVID-19 infection prevention principles consistent with national standards of practice.

3. On 3/15/22, beginning at approximately 11:00 AM, A1, Administrator, verified the facility does not permit outside visitation and has not changed that policy since 2020 at the start of COVID-19.

Based on document review and interview, the hospital failed to ensure for adequate numbers of nursing staff to provide nursing care to all patients between the dates of 8/1/21 and 8/7/21.

Findings include:

1. Review of the facility's Staffing Matrix recommended the following for shift and census as indicated:
Day shift with Census 17-22: Three (3) nurses [RNs (Registered Nurse) and LPNs (Licensed Practical Nurse)] with at least one (1) RN and 3 Aides should be staffed.
Night shift with Census 17-22: Three (3) nurses with at least one (1) RN and 3 Aides [Nursing Aides (NA)] should be staffed.

2. Review of the Staffing Pattern Worksheet for the week of 8/1/21 through 8/7/21 lacked evidence of appropriate staffing in accordance with the facility matrix as follows:
8/1/21: Day shift, with a census of 20, indicated 2 RNs, 0 LPNs and 2 NAs were staff. Night shift, with a census of 21, indicated 1 RN, 1 LPN and 4 NAs were staffed.
8/2/21: Day shift, with a census of 21, indicated 1 RN, 0 LPNs and 3 NAs were staffed. Night shift, with a census of 21, indicated 2 RNs 0 LPNs and 3.5 NAs were staffed.
8/3/21: Night shift, with a census of 21, indicated 2 RNs, 0 LPNs and 2 NAs were staffed.
8/4/21: Day shift, with a census of 21, indicated 1 RN, 1 LPN and 3.4 NAs were staffed. Night shift, with a census of 20, indicated 2 RNs, 0 LPNs and 3 NAs were staffed.
8/5/21: Day shift, with a census of 20, indicated 2 RNs, 1 LPN and 2.5 NAs were staffed. Night shift, with a census of 21, indicated 2 RNs, 1 LPN and 2 NAs were staffed.
8/6/21: Day shift, with a census of 21, indicated 1 RN, 1 LPN and 1.5 NAs were staffed.
8/7/21: Night shift, with a census of 20, indicated 1 RN, 2 LPNs and 2 NAs were staffed.

3. On 3/15/22, beginning at approximately 7:45 PM, A2, Director of Nursing, verified staffing deficiencies.

Based on document review and interview, the hospital failed to ensure nursing care was provided in accordance with 4 (four) hospital policies/protocol/procedures (hygiene, skin assessments, nutritional screening and feeding assistance) for 4 of 10 patients (P1, P3, P8, and P9).

Findings include:

1. A. Review of the policy titled Patient Grooming and Hygiene Assistance, revised 7/2020, indicated the following:
Purpose: Personal care should be provided with dignity and respect for the individual.
Procedure: Our population may bathe only twice a week, every other day is most preferred. Oral Care: Oral care includes cleaning the teeth, gums, inside of mouth and dentures and must be performed at least daily.

B. Review of the policy titled Skin/Wound Assessments/Reports, issued 4/1/19, indicated the following:
Policy: The skin/wound assessment will be completed for all patients on admission, weekly, post fall, at discharge and on scheduled shower days.
Procedure: The anatomical location of the wound will identify the location of skin breakdown. The wound characteristics are noted. Hospital identification label is applied to photo and placed on skin/wound assessment.

C. Review of the policy titled Nutritional Screening, issued 4/1/19, indicated the following: Patients who score 5 or greater on the Nutritional Screening tool will be consulted and screened by the Registered Dietitian.

D. Review of the form titled Admission Nutrition Risk Data Collection and Assessment indicated, in the Physical and Mental Functioning section, that patients with a score of 1 point in that section were to receive feeding assistance.

2. A. The MR of patient P1, admission 7/30/21 to 8/6/21 indicated the following: The initial nursing assessment on 7/30/21 indicated the patient required assistance with ADLs (activities of daily living) for bathing, oral care, grooming, shaving, dressing and shampooing. The Admission Nutrition Risk Data Collection and Assessment (Admission Nutrition RA) indicated the patient was a high risk (score of 5 or more points) and needed feeding assistance. The MR lacked documentation of daily oral care on 8/3. The MR lacked documentation of feeding assistance provided.

B. The MR of patient P3, admission 8/4/21 to 8/12/21 indicated the following: Per the 8/4/21 Admission Nutrition RA, the patient was a high nutritional risk with a score of 5 and needed feeding assistance. The form lacked documentation of the dietician (RD) having been contacted as per instructions for HIGH risk. The Admission Assessment indicated hygiene assistance was to be provided for all ADLs.
Nursing Daily Assessments indicated the following: 8/11/21 7P-7A NNs: Shift Daily assessment indicated the patient had a "Rash", location and characteristics were not documented.
Nutrition Assessment note dated 8/13/21 at 4:00 PM indicated the following: RD consulted for resident who had steady decline in po (oral) intake and was refusing medication. SLP (Speech Language Pathologist) was contacted a 2nd time, completed evaluation 8/12/21. Resident passed evaluation. RD arrived to facility and resident had discharged 8/12/21. The MR lacked documentation of the RD having evaluated the patient prior to discharge. The MR lacked documentation of feeding assistance provided for meals.
The MR lacked evidence of patient hygiene having been provided and/or patient assistance given for hygiene as follows: The MR lacked documentation of oral care on 8/5/21. The MR lacked documentation of the patient having received a bath/shower or shampoo at admission on 8/4/21 and none were documented until 8/11/21.
MR photographs dated 8/8/21 indicated the following: Photograph 1: appeared to show redness around patient's waist and lower trunk without open sores. Photograph 2: appeared to show redness in patient gluteal cleft without open areas. The MR lacked narrative documentation pertaining to the photographs and/or skin characteristics. The MR lacked documentation of wound assessments weekly and at discharge.

C. The MR of patient P8, admission 8/12/21 to 8/27/21 indicated the following: The initial nursing assessment on 8/12/21 indicated the patient required assistance with ADLs. The MR lacked documentation of daily oral care on 8/12/21, 8/13/21 and 8/14/21. The MR lacked documentation of daily denture care on 8/12/21, 8/13/21 and 8/16/21.

D. The MR of patient P9, admission 8/12/21 to 8/27/21 indicated the following: The initial nursing assessment on 8/12/21 indicated the patient required assistance with ADLs. The MR lacked documentation of daily denture care on 8/12/21, 8/13/21, 8/14/21 and 8/15/21.

3. On 3/15/22, beginning at approximately 5:30 PM, A2, Director of Nursing (DON) verified MR findings and acknowledged the MRs lacked documentation of staff assistance for patient feeding. A2 also confirmed the RD did not provide consult for patient P3 within 72 hours.

Based on document review and interview, the hospital failed to ensure the consultant dietician performed services in accordance with hospital policy for 1 of 2 patients (P3) who were ordered a dietitian consult.

Findings include:

1. Review of the policy titled Nutritional Screening, issued 4/1/19, indicated the following: When the need to consult the contracted Registered Dietitian (RD) arises... The contracted dietitian will perform an assessment within 72 hours.

2. The medical record (MR) of patient P3 indicated the following: Per the 8/4/21 Admission Nutrition RA, the patient was a high nutritional risk (5 or more points). The form indicated the following; If HIGH Dietitian contact. On 8/8/21, 7A-7P nursing notes indicated the patient refused to eat or drink and would not take medications. Dietitian ordered by MD (physician). The MR indicated the physician ordered a dietitian consult on 8/8/21 (time not obtained). Nutrition Assessment note dated 8/13/21 at 4:00 PM indicated the following: RD consulted for resident who had steady decline in po (oral) intake and was refusing medication. RD arrived to facility and resident had discharged 8/12/21. The MR lacked documentation of the RD having evaluated the patient.

3. Review of the Nutrition Consult Log indicated the following for P3: Nutrition Consult Requested: Date: 8/8/21. Time: 1800 (hours). Nutrition Consult Completed: Date: 8/13//21. Time: 4:00 pm.

4. On 3/15/22, beginning at approximately 5:30 PM, A2, Director of Nursing, verified MR findings. A2 verified the RD did not provide an assessment for patient P3 within 72 hours.