HospitalInspections.org

Based on document review and interview physicain failed to write and/or give a verbal order for orthotic braces and spinal precautions in 2 of 10 MRs (Medical Records) reviewed. (P2, P10); Physician failed to write and/or give a verbal order for Oxygen upon patient admission to facility in 1 of 10 MRs reviewed. (P3)

The cumulative effects of these systemic problems resulted in the facility's inability to provide quality Medical Services.

Based on document review and interview, the facility failed to document follow-up and education to staff involved in complaint/grievance for 1 of 10 MRs (Medical Records) reviewed. (P3)

Findings include:

1. Facility policy titled Patient and Customer Complaint or Grievance, Policy # 8, Last Reviewed Date: 08/15/2024, Page 3 under Patient Grievances-Actions to be taken, The hospital must review, investigate and resolve each patient's grievance within a reasonable timeframe and provide a written response. 5. Hospital Human Resources will follow up with departmental supervisor for action taken regarding employee issues, if indicated.

2. Complaint Raised: 02/28/2025, Concern Involves: General Care, Medication related, Relevant Departments: Nursing, Description of Complaint: FM2 (Spouse) left message on 2/27/25 that he/she does not want N2 (RNT [Rehabilitation Nursing Technician]) to care for P3 again. N2 did not put P3's back brace on him/her until P3 was out of bed and applied it incorrectly. FM2 indicated N2 left P3 in the bathroom without brace on and was pulling on his/her arms to get him/her out of bed. FM2 is afraid for N2 to take care of P3. Action Taken: Education provided in real time by N1 (CRRN [Certified Rehabilitation Registered Nurse]) and OT (Occupational Therapist) with N2 regarding brace, how to put it on and the need for it. Coaching tool also provided to N2. N1 spoke with FM2 about concerns and apologized for the care P3 received on 2/27/25. FM2 was pleasant and appreciated the apology and someone coming to talk with her. N1 explained facility will follow up with N2 and education will be given to him/her about the situation. N2 would not be assigned top P3's care for the remainder of his/her stay. Resolution date and time: 3/05/2025 1016 hours Central. Complaint/Grievance lacked documentation on Coaching tool and follow up education provided to N2.

3. Personnel file for N2, lacked documentation of a coaching tool and reeducation for incident on 2/27/25.

4. In interview on 3/26/25 at 1125 hours with A1 (Director of Quality Risk), he/she confirmed there is no documentation of education/coaching tool for staff regarding use of brace on P3.

5. In interview on 3/26/25 at approximately 1515 hours with N2, he/she confirmed not receiving education or coaching tool regarding any incident involving an orthotic brace.

Based on document review and interview physician failed to write and/or give a verbal order for orthotic braces and spinal precautions in 2 of 10 MRs (Medical Records) reviewed. (P2, P10); Physician failed to write and/or give a verbal order for Oxygen upon patient admission to facility in 1 of 10 MRs reviewed. (P3)

Findings include:

1. Facility policy titled Care Planning, Policy # 230, Last Reviewed Date: 08/15/2024, Page 1, under Purpose: All inpatients will have a plan of care developed by the interdisciplinary team (IDT) responsible for their care which included provider's orders.

2. Facility policy titled Supplemental Oxygen, Policy # 300, Last Reviewed Date: 05/16/2024, Page 1, under Policy: Supplemental oxygen is provided pursuant to a prescriber order and may be initiated by a registered nurse or respiratory therapist. Physician Orders: The use of oxygen requires an order from physician or physician extender authorized to order medications.

3. Facility Medical Staff Bylaws, last approved by the Governing Board 2/20/2025, Page 2, 2.2 Responsibilities of the Medical Staff. It shall be the responsibility of the Medical Staff, acting through the Medical Executive Committee as authorized by these Bylaws, to account to the Governing Board for the quality, safety, and appropriateness of patient care provided by Practitioners, by the way of the following measures: Page 3, 2.2.6 Drugs and Biologicals and Other Services. Orders for drugs, biologicals, and other services (including, but not limited to, rehabilitation and respiratory services shall be made by a Practitioner responsible for the care of the patient, acting within his or her scope of practice under State law, and who is authorized by these Bylaws to order the drugs, biologicals, or other services in accordance with the Medical Staff rules and regulations and/or Hospital policies.

4. Review of P2 MR indicated:
a. P2 was admitted on 3/8/25 with diagnosis of Atrial fibrillation, CAD (Coronary Artery Disease) and L4 (fourth lumbar vertebra) fracture.
b. History and Physical on 3/9/25 at 0920 hours indicated under Impression and Plan: Monitor and manage pain, LSO (Lumbosacral orthosis) when out of bed.
c. MR lacked documentation of an order for LSO brace when out of bed and/or spinal precautions.
d. Physician Progress Note on 3/10/25 at 1824 hours indicated under Rehab Risks/Complications Plan and Recommendations to mitigate the risks: Spinal precautions, neighboring as tolerated bilateral lower extremities. (TSLO [Thoracic-Lumbar-Sacral Orthosis]) when out of bed. Patient has bilateral foot drops he will be advised to wear ankle-foot orthosis to prevent high steppage gait and falls.
e. MR lacked documentation of an order for TSLO orthotic and bilateral ankle-foot orthosis.

5. Review of P3 MR indicated:
a. P3 admitted on 2/25/25 with diagnosis of Cervical neck fracture, T10 fracture and Acute hypoxic respiratory failure secondary to pneumonia.
b. Adult Admission Assessment on 2/25/25 at 1830 hours indicated under Vital signs: Oxygen flow rate 3 Liters per Nasal Cannula Continuous.
c. MR lacked documentation of an order for Oxygen 3 Liters per Nasal Cannula Continuous.

6. Review of P10 MR indicated:
a. P10 admitted on 12/30/24 with diagnosis of Status post T11-L3 fusion, and major multiple trauma.
b. Physical Therapy Initial Evaluation on 12/31/25 at 1100 hours indicated patient required spinal precautions and Jewett brace prior to transition.
c. History and Physical on 12/31/25 at 1931 hours indicated a cervical collar and Jewett brace was recommended.
d. MR lacked documentation of an order written for cervical collar, Jewett brace and spinal precautions.

7. In interview on 3/26/25 at 1230 hours with A8 (CNO [Chief Nursing Officer]), he/she confirmed an order should be written if a patient is to wear an orthotic brace with instructions on type of brace, when to apply brace and duration the patient must wear brace. A8 confirmed P2's MR lacked order for back brace, spinal precautions, bilateral extremity braces when out of bed and P10's MR lacked documentation of order for cervical collar, Jewett brace and spinal precautions.

8. In interview on 3/26/25 at approximately 1300 hours with A4 (RRT [ Registered Respiratory Therapist]), he/she confirmed documentation indicated P3 was wearing oxygen on 2/25/25, and an order was not placed for oxygen until 2/27/25.

Based on document review and interview, nursing services failed to maintain documentation of the application of an orthotic brace when patient out of bed in 3 of 10 MRs reviewed. (P2, P3, P10)

Findings include:

1. Facility policy titled Assessment, Re-Assessment, Policy #3, Last Reviewed Date: 08/15/2024, under Policy IV. Reassessment across all disciplines is ongoing and occurs at designated intervals during the patient's stay/treatment to determine the response to and effectiveness of certain care, treatment and services received.

2. Review of P2 MR indicated:
a. P2 was admitted on 3/8/25 with diagnosis of Atrial fibrillation, CAD (Coronary Artery Disease) and L4 (fourth lumbar vertebra) fracture.
b. History and Physical on 3/9/25 at 0920 hours indicated under Impression and Plan: Monitor and manage pain, LSO (Lumbosacral orthosis) when out of bed.
c. Physician Progress Note on 3/10/25 at 1824 hours indicated under Rehab Risks/Complications Plan and Recommendations to mitigate the risks: Spinal precautions, weight bearing as tolerated bilateral lower extremities. (TSLO [Thoracic-Lumbar-Sacral Orthosis]) when out of bed. Patient has bilateral foot drops he will be advised to wear ankle-foot orthosis to prevent high steppage gait and falls.
d. Foresheets lacked documentation of RNT (Rehabilitation Nursing Technicians) applying orthotic braces when P2 out of bed, including, but not limited to dates from 3/19/25 at 1500 hours through 3/20/25 at 1100 hours.

3. Review of P3 MR indicated:
a. P3 admitted on 2/25/25 with diagnosis of Cervical neck fracture, T10 fracture and Acute hypoxic respiratory failure secondary to pneumonia.
b. Adult Admission Assessment on 2/25/25 at 1830 hours indicated under Vital signs: Oxygen flow rate 3 Liters per Nasal Cannula Continuous.
c. MR lacked documentation of an order for Oxygen 3 Liters per Nasal Cannula Continuous.
d. Order sheet on 2/25/25 at 1833 hours indicated Brace must remain on while patient is up out of bed. Order comments: may remove at night for comfort, brace must be put on before all out of bed activities. Spinal Precautions No twist/bend with bed mobility/transfer.
e. Physical Therapy note on 2/27/25 at 1530 hours indicated upon arrival to P3's room, P3 sitting on commode without Jewett brace on, educated patient and spouse that the nursing staff should have donned the brace prior to the patient leaving the bed. PT (Physical Therapist) immediately donned brace while Patient was on commode. Patient reported 9/10 pain in back.
f. Flowsheets lacked documentation of RNT applying orthotic brace to patient when out of bed including, but not limited to on 2/27/25 from 0800 hours through 2000 hours, and 3/2/25 at 1900 hours through 3/3/25 at 1108 hours.
g. Physician Discharge Summary indicated P3 Condition at time of Discharge: Stable. Prognosis: guarded.

4. Review of P10 MR indicated:
a. P10 admitted on 12/30/24 with diagnosis of Status post T11-L3 fusion, and major multiple trauma.
b. Physical Therapy Initial Evaluation on 12/31/25 at 1100 hours indicated patient required spinal precautions and Jewett brace prior to transition.
c. Flowsheets lacked documentation of RNT applying orthotic braces to P10 when out of bed including, but not limited to from 12/30/25 at 2000 hours through 1/1/25 at 0800 hours.

5. In interview on 3/26/25 at 1230 hours with A8 (CNO [Chief Nursing Officer]), he/she confirmed if the patient must wear brace, it should be documented in medical record if staff placed brace on patient for activities of ambulation, up to bathroom or up in chair. A8 confirmed P2 MR lacked documentation of application of braces by technicians with patient transfers and ambulation; P3 MR lacked documentation of technicians applying brace to patient prior to ambulation and transfers; P10 MR lacked documentation of application of brace by technicians with patient transfers and ambulation.