HospitalInspections.org

Based on policy review, medical record review and interview, the hospital failed to ensure nursing staff implemented a patient's care plan for getting out of bed and toileting for 3 of 6 (Patient #1, 2 and 4) sampled patients.

The findings included:

1. Review of the hospital's "NURSING CARE PLAN" policy revealed, "...Purpose...To provide guidelines for a pragmatic approach to the planning of care issue...To recognize the key care issues faced by the Chronic Critically Ill (CCIS) patient population and standardize the approach...Each discipline develops a plan of care...The overall care and progress is reviewed and care plans adjusted based on daily assessments...The key issues that Nursing has primary responsibility for in the CCIS patient include...Mobility plan (outside of Rehab interventions)...Wound prevention and management...Management of discomfort and pain...Procedure...CCIS PROBLEM...Bone Loss...APPROACH...Mobility and Weight Bearing-aggressive restoration of mobility and weight bearing. Up and weight bearing 2x [times] per day if hemodynamically stable...CCIS PROBLEM...Wounds...APPROACH...Mobility including turns, OOB [out of bed]...Prevent and manage moisture associated skin damage (MASD)...CCIS PROBLEM...Delirium, depression...APPROACH...Mobilize..."

2. Medical record review for Patient #1 revealed an admission date of 7/18/18 with diagnoses which included Respiratory Failure with Mechanical Ventilation, Status Post Cardiogenic Shock, Acute Renal Failure and Encephalopathy.

A physician's order dated 7/18/18 revealed, "...Activity...OOB to chair BID [twice daily]..."

The "24 HOUR PATIENT RECORD & PLAN OF CARE" revealed nursing staff got Patient #1 out of bed one time each day on 7/19/18, 7/21/18, 7/22/18, 7/23/18, 7/24/18, 7/25/18, 7/26/18 and 7/27/18. The nursing staff did not get Patient #1 out of bed on 7/18/18, 7/20/18, 7/28/18 or 7/29/18. There was no documentation why nursing staff did not follow the physician's order to get Patient #1 out of bed twice each day.

During a phone interview on 11/15/18 at 9:00 AM, Patient #1's Family Member #1 stated the nursing staff was not getting Patient #1 out of bed. Patient #1's Family Member #1 stated when she or other family members visited, Patient #1 was always lying in the bed. Patient #1's Family Member #1 stated she and other family members often found Patient #1 lying in feces whenever they visited. Patient #1's Family Member #1 stated Patient #1 was having a lot of diarrhea because she received nutrition through tube feeding. Patient #1's Family Member #1 stated she expected Patient #1 to have some redness due to the diarrhea, but she saw Patient #1's bottom when the staff changed her and "it looked like someone took a cheese grater to it ..."

3. Medical record review for Patient #2 revealed an admission date of 10/26/18 for weaning off the ventilator.

Observations in Patient #2's room on 11/15/18 at 10:04 AM revealed Patient #2 was in the bathroom, and Patient #2's spouse was at bedside. Patient #2's spouse stated Patient #2 was incontinent of urine during the first several days of his hospital stay, and she often found him lying in urine when she visited. Patient #2's spouse stated she voiced her concerns to the Charge Nurse, but it continued to be an issue. Patient #2's spouse stated she believed there was not enough staff to provide adequate care for the patients. Patient #2's spouse stated the issues over assistance with toileting have improved, because Patient #2 has become more independent with toileting and other self-care areas.

4. Medical record review for Patient #4 revealed an admission date of 7/13/18 with diagnoses which included Intestinal Obstruction.

Observations in Patient #4's room on 11/15/18 at 10:13 AM revealed Patient #4 lying in bed with his eyes closed and Patient #4's spouse at bedside. When asked about the care the nursing staff provided, Patient #4's spouse stated, "...they don't have many people...they don't have enough staff...I'm here 24 hours a day...they don't always turn him or clean him...sometimes it takes a long time...I wish they had more people..." When asked if the care had gotten better or worse since Patient #4 was admitted back in July, Patient #4's spouse stated, "...it is bad...they (nurses) don't take time to care for him...some do...they are all so busy..." Patient #4's spouse stated Patient #4 has laid in feces for long periods of time before staff would come to the room to clean him up.

5. Medical record review for Patient #5 revealed an admission date of 7/7/18 with diagnoses which included Respiratory Failure with Hypoxia, Interstitial Pulmonary Fibrosis, Coronary Artery Disease with History of Coronary Artery Bypass, Ischemic Cardiomyopathy, Hypertension and Peripheral Vascular Disease. Patient #5 became more unstable, developed bradycardia with subsequent cardiac arrest and passed away on 7/13/18.

A physician's order dated 7/7/18 revealed, "...Activity...OOB to chair BID..."

The "24 HOUR PATIENT RECORD & PLAN OF CARE" revealed nursing staff did not get Patient #5 out of bed during his hospital stay from 7/7/18 to 7/13/18.

Based on policy review, medical record review and interview, the hospital failed to ensure the confidentiality of protected health information for 1 of 6 (Patient #1) sampled patients.

The findings included:

1. Review of the hospital's "Safeguarding Protected Health Information (PHI)" policy revealed, "...It is the policy of [named Hospital's Corporation] that reasonable safeguards will be put in place to protect individuals' protected health information (PHI) and personally identifiable information (PII) from any intentional or unintentional use or disclosures in violation of HIPPA [Health Insurance Portability and Accountability Act]...Medical records or billing records should be kept in a secure place...Patient information should never be left unattended. This includes leaving patient information, whether stored on any media type, including, but not limited to paper or on a laptop in a vehicle overnight or leaving patient information lying around in plain sight for others to see..."

2. Medical record review for Patient #1 revealed an admission date of 7/18/18 with diagnoses which included Respiratory Failure with Mechanical Ventilation, Status Post Cardiogenic Shock, Acute Renal Failure and Encephalopathy.

The Case Management Progress Note dated 7/27/18 revealed, "...Medicaid paperwork left at patients [patient's] bedside, spoke with daughter [Patient #1's named daughter] to pick up [,] sign and return to me to scan back to [named provider of revenue cycle management solutions]..."

3. During an interview in the Nurse Manager's Office on 11/15/18 at 8:49 AM, the Senior Director for Case Management stated Case Managers sometimes leave a Medicaid application in a patient's room if requested to do so by the family. The Senior Director for Case Management confirmed there would have been personal information on the application and stated the application should have been in an envelope.

During a phone interview on 11/15/18 at 9:00 AM, Patient #1's Family Member #1 stated the hospital violated HIPPA law by leaving paperwork with Patient #1's personal information on it out in the patient's room for the family to sign.

During an interview in the Nurse Manager's Office on 11/15/18 at 12:05 PM, Case Manager #1 stated she would take the application for Medicaid to the family. Case Manager #1 confirmed a patient's personal information would be on the form. Case Manager #1 stated she would leave the application in the room for the family to complete if the family requested her to do so.

Based on policy review, medical record review and interview, the hospital failed to assess and document a patient's skin condition at discharge for 1 of 3 (Patient #1) sampled discharged patients.

The findings included:

1. Review of the hospital's "Wound Assessment" policy revealed, "...Purpose...To provide guidelines for wound and ostomy assessment...Procedure...Photographs of the wound will be taken on admission, within every 7 days and at discharge (within 1 day before discharge) as part of the wound assessment. Additionally, at admission and discharge, all abnormal, non-intact, non-healthy skin will be photographed..."

2. Medical record review for Patient #1 revealed an admission date of 7/18/18 with diagnoses which included Respiratory Failure with Mechanical Ventilation, Status Post Cardiogenic Shock, Acute Renal Failure and Encephalopathy. Patient #1 was discharge home on 7/29/18 with home hospice for end of life care.

The Wound Care Assessment dated 7/24/18 (5 days before discharge) revealed Patient #1 had a deep tissue injury to the right heel measuring 2 centimeters (cm) in length by 3 cm in width and a deep tissue injury to the left heel measuring 3 cm in length by 3 cm in width. There were no further assessments documented of the wounds and no documented skin assessment for Patient #1 at discharge.

3. During an interview in the Nurse Manager's Office on 11/19/18 at 8:07 AM, Wound Care Nurse #1 stated the Wound Care Team should perform and document a full skin assessment within 24 hours of discharge. Wound Care Nurse #1 stated the Charge Nurse should perform and document the assessment if the Wound Care Team was not available at discharge. Wound Care Nurse #1 confirmed there was no skin assessment documented for Patient #1 within 24 hours of discharge.

Based on protocol review, medical record review and interview, the hospital failed to ensure speech-language services were provided for 1 of 6 (Patient #1) sampled patients.

The findings included:

1. Review of the "Speech-Language Pathology Medical Intervention Protocol" revealed, "...The Speech Pathologist will evaluate swallowing, speech, language, voice, and/or cognitive-communication intervention upon receiving a physician (or other qualified medical provider) order for SLP [Speech-Language Pathologist] to 'evaluate and treat'. At that time the SLP may order for the above noted areas within his/her scope of practice per the following protocol...Write order for an NPO status related to oropharyngeal dysphagia and aspiration precaution in collaboration with the Medical Provider and Registered Dietitian...Write orders for food and liquid consistency changes, upgrade and/or downgrade, to facilitate safe oropharyngeal and/or esophageal swallowing problems in collaboration with the Medical Provider and Registered Dietitian..."

2. Medical record review for Patient #1 revealed an admission date of 7/18/18 with diagnoses which included Respiratory Failure with Mechanical Ventilation, Status Post Cardiogenic Shock, Acute Renal Failure and Encephalopathy.

A physician's order dated 7/18/18 revealed, "...SLP to eval [evaluate] & [and] treat..."

The "Speech-Language Pathology Medical Intervention Protocol" was signed by the physician on 7/18/18.

The "SPEECH-LANGUAGE INITIAL/DISCHARGE EVALUATION" dated 7/18/18 revealed, "...Current diet: NPO [nothing by mouth]-NG [nasogastric] tube..."

The "SPEECH PATHOLOGY CLINICAL DYSPHAGIA EVALUATION" dated 7/19/18 revealed, "...RECOMMENDATIONS/TREATMENT PLAN...Diet Level...NPO...Liquid Level...Sips c [with] chips [ice] for pleasure..."

There was no order by the SLP for NPO status or for sips with ice chips documented in Patient #1's medical record.

During an interview in the Nurse Manager's Office on 11/15/18 at 12:17 PM, Speech Therapist #1 stated the Speech Pathologist should write an order for NPO status and for sips with ice chips. When asked about Patient #1's NPO status and the recommendation for sips with ice chips, Speech Therapist #1 stated, "...I don't see an order...there should be an order..."

2. Medical record review for Patient #5 revealed an admission date of 7/7/18 with diagnoses which included Respiratory Failure with Hypoxia, Interstitial Pulmonary Fibrosis, Coronary Artery Disease with History of Coronary Artery Bypass, Ischemic Cardiomyopathy, Hypertension and Peripheral Vascular Disease.

A physician's order dated 7/7/18 revealed, "...Nutrition...Previously cardiac diet, Have Speech evaluate..."

The "Speech-Language Pathology Medical Intervention Protocol" was signed by the physician on 7/7/18.

The "SPEECH THERAPY DAILY PROGRESS NOTES" dated 7/9/18 revealed, "eval held and NPO sign posted..."

The "24 HOUR PATIENT RECORD & [and] PLAN OF CARE dated 7/7/18 revealed, "...Diet...NPO..."

There was no order by the SLP for diet or NPO status documented in Patient #5's medical record.

3. During an interview in the Nurse Manager's Office on 11/19/18 at 9:30 AM, the Director of Quality Management confirmed the Speech-Language Pathologist should write an order for NPO status and for sips with ice chips according to the hospital's protocol.