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The facility failed to safeguard and uphold the rights of each patient. This failure was resulted in:

A. A geriatric patient was placed in a wheelchair because of over sedation. She was allowed to go to sleep in a slumped position while in the wheelchair. This resulted in multiple bruises to her arms, shoulders, and left breast. Such actions by staff created an environment that was not physically and emotionally safe for the facility's geriatric population.

B. A Nutrition Assessment was ordered on a geriatric patient that had stopped eating. The Registered Dietician documented that she did not complete Nutrition Assessment because she could not find the chart. The patient was transferred to a medical facility with dehydration, pneumonia, and failure to thrive. Such actions by staff created an environment that was not physically safe for the facility's geriatric population.

C. A patient's hearing aid was lost shortly after admission. There was misunderstanding among staff as to the correct procedure for securing hearing aids. In addition, the system for storing personal belongings in the personal property room was not being followed, resulting in patient's items being misplaced or lost by staff. Such actions by staff created emotional stress for patients and patient's families.

Cross reference:
CFR 483.13 A0144 Patient Rights: Care in Safe Setting
CFR 483.13 A0145 Patient Rights: Free from Abuse/Harassment

Based on observation, record review, and interview, the facility failed to ensure that the environment was physically and emotionally safe for their geriatric patients. Failure to do so resulted in 1 of 1 patients (Patient #1) being allowed to sleep in a wheelchair in the dayroom. This resulted in marked bruising to Patient #1's arms, shoulders, and left breast.

Findings:

Record review of Psychiatric Evaluation dictated by Staff O on 2/22/2019 at 11:00 AM for Patient #1 showed: Admission 2/19/2019. 85-year-old female with increased agitation and assaultive behavior. She was very delusional. Abilify 2.5 mg was started at bedtime. Staff O also documented, Patient #1 had disheveled appearance, slowed motor activity, delayed speech, auditory hallucinations, and paranoia.

Record review of a Progress Note by Staff I (NP) on 2/25/2019 at 11:00 AM showed that Patient #1 was calm, cooperative, and groggy. The patient's son was concerned over his mother's LOC [level of consciousness] and requested that the Abilify be discontinued.

Record review of the Physician's Orders on 2/25/19 at 5:00 PM by Staff I (NP) showed that Patient #1's Abilify was discontinued and the Depakote was decreased.

In an interview with Staff L on 5/3/2019 at 11:50 AM, he stated:

1. There was a "change in level of consciousness after admission" in Patient #1 and that he was concerned about this.

2. He saw a picture of Patient #1 smiling and looking at the camera, but "not long after she entered the hospital, she was not responding to care."

3. He wondered why Patient #1 was no longer "bright eyed."


Record review of Skin Assessment & Wound Care Documentation for Patient #1 by Staff Q dated 2/19/2019 at 10:30 PM, showed: "At admission ... No issues / skin intact ..."

Record review of Daily Nurse Notes for Patient #1 by Staff R on 2/25/2019 at 4:50 PM showed no bruises.

Record review of Daily Nurse Notes for Patient #1 by Staff X on 2/27/2019 at 10:00 AM showed no bruises.

Record review of a Progress Note by Staff O on 2/28/2019 at 1:00 PM showed Patient #1 to be disheveled, confused, and in a wheelchair.

Record review of Daily Nurse Notes for Patient #1 by Staff Y on 2/28/2019 at 3:00 PM showed multiple bruises.

Record review of Skin Assessment & Wound Care Documentation for Patient #1 by Staff F (RN) dated 2/28/2019 at 3:00 PM, showed: "Update ... no open wound. Deep purple, brown, and yellow [arrow to right upper arm]. Scattered discoloration [arrow to left upper shoulder]. Bruise dark purple brownish color [arrow to left breast area]. Bruises [arrows to front of upper and lower legs]. Patient has several bruises to lower extremities bilaterally, upper arms bilaterally, and left breast."


Record review of six (6) photographs [not dated or timed] of Patient #1 showed the bruises that were documented on the Skin Assessment & Wound Care Documentation by Staff F (RN) dated 2/28/2019 at 3:00 PM.

In an interview with Staff F on 5/3/2019 at 11:35 AM, she stated that she examined Patient #1 on 2/28/2019, took the pictures, and reported her findings to the ADON, Staff L.

In an interview with Staff K on 5/15/2019 at 10:10 AM she stated:

1. The facility conducted an investigation of Patient #1's bruising on 3/5/2019, following a complaint by the Patient #1's son.

2. The investigation was finalized on 3/11/2019.

3. The investigation showed that Patient #1 was "over sedated."

4. Because of the sedation Patient #1 was placed in a wheelchair.

5. Patient #1 fell asleep in the wheelchair and slumped over, pressing against the arm of the wheelchair.

6. This contributed to Patient #1's bruising.

7. The patient should have never been allowed to sleep in the wheelchair. She should have been put to bed if she was that sedated.

Based on observation, record review, and interview, the facility failed to ensure that their geriatric patients were free from all forms of neglect. Failure to do so resulted in necessary services not being provided and an unwarranted loss of the personal property. This failure was evidenced by:

1. The Nutrition Assessment for 1 of 4 patients (Patient #1) was not completed by the Registered Dietician (RD) because the RD "attempted to look for patient's chart but to no avail."

2. The unwarranted loss of property (a hearing aid) and misplaced belongings of 1 of 1 patient's (Patient #1)

3. The personal belongings of 3 of 3 patients (Patient #10, #11, and patient #12) being misplaced in the property room.


Findings:

1. Nutrition Assessment.

Record review of "Diet Review" form for Patient #1 by Staff B dated 2/20/2019 at 8:34 AM showed a regular diet prior to admission. The height of 5'4", weight of 155 lbs., and BMI [body mass index] of 26.6 was documented at the bottom of the page on 2/19/2019 at 10:00 PM.

Record review of Physician's Orders dated 2/25/2019 at 4:35 PM by Staff G (NP) showed an order to increase Patient #1's fluid intake to 1800 cc/day.

Record review of the MAR for by Staff T dated 2/26/2019 [illegible time] showed one can of Ensure was ordered three times a day as a dietary supplement for Patient #1.

Record review of Physician's Orders by Staff G (NP) dated 2/27/2019 at 4:16 PM showed an order to provide a mechanical soft diet, milk - one can three times a day, and staff to assist with meal one on one with Patient #1. There is a note to the side of the order, "Copy to Dietary."

Record review of the Observation Check Sheet / Graphic Flowsheet [various authors] for Patient #1 showed a significant decrease in the patient's nutritional intake. The % [percent] is the documented amount of a meal or snack the patient consumed.

2/20/2019: Breakfast 25%. Lunch 100%. Dinner 75%. Snack 100% X 1.

2/22/2019: Breakfast 25%. Lunch 50%. Dinner 75%. Snack 100% X 3.

2/25/2019: Breakfast, Lunch, Dinner not recorded. Ensure X 2.

2/26/2019: Breakfast 25%. Lunch 25%. Dinner 0%.

2/27/2019: Breakfast 0%. Lunch 25%. Dinner 25%. Snack 50% X 2.

2/28/2019: Breakfast 25%. Lunch 0%. Dinner 0%. Snack 100% X 2.


Record review of Nutrition Assessment for Patient #1 by Staff Z, Registered Dietician Nutritionist, dated 2/27/2019 [not timed], showed an incomplete nutrition assessment. "Patient seen for poor appetite ... attempts to look for patient's chart but to no avail." Much of items on the assessment were marked "unable to obtain" and the Nutritional Risk Assessment is blank. Recommendations: "Maximize oral intake when appetite is good and honor food preferences."


In an interview with Staff AA on 5/15/2019 at 10:50 AM, she stated that she owns Kingsland Dieticians Group and that Staff Z was an employee of the group. Staff AA stated that the Nutrition Assessment performed by Staff Z on Patient #1 was "not acceptable." She went on to say, "If the chart is not there, I come later in the day," adding that returning to perform the assessment is her expectation.


Record review of Physician's Orders by Staff G (NP) dated 3/1/2019 at 9:51 AM - 10:05 AM for Patient #1 showed: Transfer to a medical hospital for pneumonia, failure to thrive, and dehydration. Start IV [intravenous] line on, give NS [normal saline] 500 cc over one hour then 500 cc if tolerated.


2. Patient #1's lost hearing aid and misplaced belongings.

In an interview with Staff B at 8:55 AM, she stated that:

1. The patient's hearing aid is placed "in a case at the bedside" at night.

2. "Staff may put glasses behind the nurse's station."


In an interview with Staff K on 5/3/2019 at 9:00 AM, she stated:

1. The Licensed Vocational Nurse (LVN) is to ask for the patient's hearing aid at night and lock it in the med cart.

2. The process is currently "revamping" because "nurses don't know to put the hearing aid in the med cart."


In an interview with Staff L on 5/3/2019 at 11:50 AM, he stated Patient #1 was discharged without her left hearing aid. He also stated that a staff member, along with the patient or a family member, are to sign off on the "Inventory of Patient Possessions" form when the belongings are returned to the patient at the time of discharge.

Record review of the Admit Nursing Assessment by Staff Q dated 2/19/2019 at 9:40 PM showed that the right and left hearing aid was "with patient."

Record review nursing note by Staff L on 3/1/2019 at 2048 showed that the patient's daughter-in-law came to the hospital to collect the patient's belongings. Some of the clothes were missing. After she left the facility, staff found a bog of items "which weren't noted on the belongings list. A message was left with the patient's son.

Record review of the "Inventory of Patient Possessions" form [not dated or timed] for Patient #1 stated: "Discharge: All of the above items have been return to me." Neither the patient/legal representative nor staff signed, dated, or timed the form.


3. Misplaced belongings of multiple patients.

Record review of the policy RTS-14, "Personal Belongings," effective date 1/11/2016, showed:

" ... The facility has established a process for safeguarding patient's belongings, and providing accountability to ensure patient's personal effects ae available for patients while in the facilities care and returned upon discharge ...

Admissions Staff / Receptionist / Nursing Staff / Senior Leadership / Other Staff: ... Searches and inventories all belongings brought to unit on Belongings Form and files in chart. Indicates all medical equipment brought in on Belongings Form ...

Return of Items: Nursing Staff: Upon discharge notifies business office staff or admission's staff of valuable items stored in Medication Room. Upon escorting patient out of building, retrieves items stored in luggage room and obtains signature of patient acknowledging receipt of items ..."


Observation of the patient personal property room with Staff C on 5/3/2019 at 9:05 AM, showed shelving units with the following categories for patient's belongings: A-G, H-M, N-S, and T-Z.

1. Belongings for Patient 10 [last name begins with an "M"] were in the A-G section.

2. Belongings for Patient #11 [last name begins with an "S"] and Patient #12 [last name begins with a "B"] were in the T-Z section.


In an interview with Staff C on 5/3/2019 at 9:05 AM, he stated:

1. There have been problems with patient's belongings in the past.

2. The personal property room is much better than it has been.

3. The patient's belongings are placed on shelves in the patient personal property room alphabetically by last name to remedy the problem of losing belongings.

4. Some of the patient's belongings were being stored in the wrong section.

5. "A hearing aid might get misplaced."

Based on record review and interview, the facility failed to ensure that the registered nurse provided supervision and evaluation of the nursing care provided to 1 of 1 patients (Patient #1). Failure to do so resulted in Patient #1 being placed in a wheelchair where she fell asleep in the dayroom. This resulted in marked bruising to Patient #1's arms, shoulders, and left breast.

Findings:

Record review of a Progress Note by Staff I (NP) on 2/25/2019 at 11:00 AM showed that Patient #1 was calm, cooperative, and groggy. The patient's son was concerned over his mother's LOC [level of consciousness] and requested that the Abilify be discontinued.

In an interview with Staff L on 5/3/2019 at 11:50 AM, he stated:

1. There was a "change in level of consciousness after admission" in Patient #1 and that he was concerned about this.

2. He saw a picture of Patient #1 smiling and looking at the camera, but "not long after she entered the hospital, she was not responding to care."

3. He wondered why Patient #1 was no longer "bright eyed."


Record review of Daily Nurse Notes for Patient #1 by Staff X on 2/27/2019 at 10:00 AM showed no bruises.

Record review of a Progress Note by Staff O on 2/28/2019 at 1:00 PM showed Patient #1 to be disheveled, confused, and in a wheelchair.

Record review of Daily Nurse Notes for Patient #1 by Staff Y on 2/28/2019 at 3:00 PM showed multiple bruises.

Record review of Skin Assessment & Wound Care Documentation for Patient #1 by Staff F (RN) dated 2/28/2019 at 3:00 PM, showed: "Update ... no open wound. Deep purple, brown, and yellow [arrow to right upper arm]. Scattered discoloration [arrow to left upper shoulder]. Bruise dark purple brownish color [arrow to left breast area]. Bruises [arrows to front of upper and lower legs]. Patient has several bruises to lower extremities bilaterally, upper arms bilaterally, and left breast."

Record review of six (6) photographs [not dated or timed] of Patient #1 showed the bruises that were documented on the Skin Assessment & Wound Care Documentation by Staff F (RN) dated 2/28/2019 at 3:00 PM.


In an interview with Staff F on 5/3/2019 at 11:35 AM, she stated that she examined Patient #1 on 2/28/2019, took the pictures, and reported her findings to the ADON, Staff L.


In an interview with Staff K on 5/15/2019 at 10:10 AM she stated:

1. The facility conducted an investigation of Patient #1's bruising on 3/5/2019, following a complaint by the Patient #1's son.

2. The investigation was finalized on 3/11/2019.

3. The investigation showed that Patient #1 was "over sedated."

4. Because of the sedation Patient #1 was placed in a wheelchair.

5. Patient #1 fell asleep in the wheelchair and slumped over, pressing against the arm of the wheelchair.

6. This contributed to Patient #1's bruising.

7. Patient #1 should not have been put in the wheelchair and allowed to fall asleep. If she was that sedated, she should have been put in bed.

Based on record review and interview, the facility failed to ensure that the Discharge Summary for 1 of 3 patients (Patient #1) ncluded a recapitulation of the patient's hospitalization that contained treatment achieved during hospitalization; a baseline of the psychiatric, physical, and social functioning of the patient at the time of discharge, and evidence of the patient/family response to the treatment interventions.


Findings:

Record review of policy HIM-01.12, "Patient's Discharge Summary," stated: B. The discharge summary will contain the following information:

...4. Course and progress in the hospital - include mental status at admission, target symptoms, address treatment modalities utilized, response to treatment, adverse or unexpected results of treatment, special treatment procedures used, and patient's role in he treatment process.

5. Conditions at Discharge ...

6. Prognosis /level of risk at discharge ..."


Record review of the "Discharge Summary" for Patient #1 dictated by Staff I, a Nurse Practitioner, dated 3/31/2019 at 10:00 AM showed insufficient documentation:

1. "The patient was sent to the ER [Emergency Room] for medical reasons, March 1, 2019."

2. NA [not applicable] for the following sections:

a. Condition upon Discharge;

b. Mental Status Exam on Discharge;

c. Patient behavior at the Time of Discharge;

d. Aftercare Plan; Prognosis;

e. Discharge Medications; and

f. Discharge Diagnosis.


In an interview with Staff E, HIM [Health Information Management] Director, on 5/3/2019 at 12:30 PM, she stated that the Discharge Summary for Patient #1 was incomplete and did not follow the hospital policy.