HospitalInspections.org

Based on observation, record review, and interview the facility failed to ensure patients receive care in a safe environment in 1 of 1 patient units (South unit), in a total sample of 1 patient units observed; and failed to develop and implement a corrective action plan based on a comprehensive root cause analysis and monitor the action plan for compliance in 1 of 1 adverse events reviewed (Patient (Pt) #1), in a total sample of 1 adverse events reviewed.

Facility staff failed to ensure patients receive care in a safe environment. See A-0144.

Facility statff failed to develop and implement a corrective action plan based on a comprehensive root cause analysis and monitor the action plan for compliance. See A-0144.

Based on observation, record review, and interview the facility failed to ensure patients receive care in a safe environment in 1 of 1 patient units (South unit), in a total sample of 1 patient units observed; failed to ensure the safety of 1 of 1 patients (patient #1) who required intensive supervision and failed to develop and implement a corrective action plan based on a comprehensive root cause analysis and monitor the action plan for compliance in 1 of 1 adverse events reviewed (Patient (Pt) #1), in a total sample of 1 adverse events reviewed.

Findings Include:

Review of policy and procedure #21.010 titled, "Incident Report (IR)/Safety Events" last reviewed 01/2023 revealed the following:
-A patient/resident safety event is an event, incident, or condition that could have resulted or did result in harm to a person.
-To provide a comprehensive, responsive system to avoid further unusual occurrences.
-To identify areas of concern where administrative intervention may be indicated.
-Department Directors/Managers are responsible for reviewing reports and determine that listed follow-up actions occurred, and any further actions needed are documented.

Review of policy and procedure #7.870 titled, "Intensive Supervision (IS)" last reviewed 04/23 revealed the following:
- "Intensive Supervision: involves a patient being provided with extra monitoring and/or support to either ensure safety and/or facilitate progress on treatment goals."
- "Sitter: individual responsible for performing the intensive supervision of a patient under the supervision of the assigned nurse."
- "When intensive supervision is necessary, the nurse will initiate the service and then enters an Order for Supervision."
- Nurse is responsible for "Monitoring of the patient in intensive supervision...Providing the sitter with a report of the relevant clinical information regarding the patient's needs and the sitter's expected role, at the beginning of the shift...
Supervising the sitter...Required shift documentation including safety plan of care..."
- "The sitter will not leave the sitter role except to handoff the care of the patient to the care of a treating professional, when relieved for breaks/meals/end of shift by another sitter, as delegated by the nurse or physician responsible for the care of the patient."

Patient #1

Review of Pt #1's medical record revealed Pt #1 was admitted to the sub-acute rehab facility on 09/27/2023 at 1:42 PM status post a Subarachnoid Hemorrhage (brain bleed) on 08/23/2023; Pt #1 was transferred to an acute care hospital on 12/26/2023 at 10:00 PM.

Review of Pt #1's Provider History and Physical dated 09/28/2023 at 12:10 PM revealed, "(Pt #1) is a 36 year old...with a history of left internal carotid artery aneurysm (enlargement of an artery) complicated by intracranial bleed, neurocognitive deficits, here for rehabilitation."

Review of Pt #1 Orders dated 12/26/2023 at 7:00 AM revealed, "Intensive supervision during waking hours...Indication: Impulsive."

Review of Pt #1's Provider Progress Note dated 12/26/2023 at 12:48 PM revealed, "(Pt #1) Continues to need a one to one (sitter) due to impulsivity and attempting to put things in his mouth..." Per progress note Impression, "Patient is ambulatory."

Review of Registered Nurse (RN) D's progress note dated 12/26/2023 at 10:00 PM revealed, "(Pt #1) alert and oriented to self, communicates needs with difficulty due to incomprehensible speech, inconsistently follows commands. (Pt #1) took his medication crushed in pudding. Just before 9:40 PM, (RN D) was called into the patient's room by the CNA (certified nursing assistant) E. One of the nurses found a sealed pill container from a staff member in the hallway. (CNA E) immediately checked her purse in the nurses station and found another pill container containing Amlodipine and body lotion missing. (CNA E) found her body lotion and empty pill container in the patient's room. The pill container was refilled a few days ago and had a 90 day supply of Amlodipine 10 mg (milligrams) tablets which was now empty. (Pt #1's) room and bathroom searched and could not find any medication...Orders received to transfer the patient to the ER (emergency room). (RN D) called (Pt #1's) POA (Power of Attorney)...at 9:46 PM and updated her. (RN D) informed (POA) of the incident, that staff were working and did not observe the patient in the nurses station but it was caught within approximately 10 minutes of the incident. (RN D) also informed (POA) that staff assigned to (Pt #1) were also assigned to other patients..."

Per telephone interview with Family A on 01/08/2024 beginning at 4:00 PM, Family A stated that after taking the pills on 12/26/2023 Pt #1 was transferred to an acute care hospital where Pt #1 had "stomach pumped" and was in the ICU (Intensive Care Unit) for a few days. Per Family A, Pt #1 is out of the ICU but still in the hospital; Per Family A, Pt #1 continues to sleep a lot and does not communicate.

Review of the staffing schedule/patient assignments dated 12/26/2023 revealed Patient Companion L (sitter) was assigned to Pt #1 and Pt #2.

Review of Pt #1's Incident Report revealed on 12/26/2023 at 9:40 PM, Pt #1 ingested personal staff supply (CNA E) of Amlodipine (blood pressure medication) 10 milligrams--approximately 84 pills. Per the description of the incident, "Patient was given his PM medications and was resting in bed. The person assigned to Intensive Supervision role went to use the bathroom as (Pt #1) appeared to be going to sleep...A sealed pill bottle was found on the isolation rack on the door across from (Pt #1's) room. The employee (CNA E) who's name was on the bottle was informed and (CNA E) looked into her bag and discovered a second bottle of pills was empty, missing the cap. They noticed (Pt #1) was no longer lying in bed but was sitting on the side of the bed drooling excessively. (Pt #1's) room is one room away from the nurse station. They looked through (Pt #1's) room and found the pill bottle cap in his bathroom."

Per review of Pt #1's Incident Report, the "Immediate Corrective Action" that was implemented revealed, "Staff required to chart in nursing station. When PC (patient companion) (sitter) needs a break, there must be direct responsibility hand-off. Personal belongings to be stored out of sight or in lockers in lounge."

Review of Pt #1's Incident Report, "Human Factors" contributing to the incident revealed, "Patient was able to enter nursing station, unnoticed, and get into employee bag. An RN was charting in the room next to nursing station-had she been in the nursing station, this would not have occurred. Also, employee assigned to supervise (Pt #1) should have given direct hand-off to someone to assume responsibility.

On 01/10/2024 beginning at 10:20 AM, Observed the nurses station on the South unit (location of Pt #1's incident), while touring with the Director of Quality/Chief Nursing Officer (CNO) B. Per observations, purses and bags were in the cubbies next to the table in the nurses station and there was no locked observed on the door handle.

Per interview with CNA F, RN H, and RN G who were in the nurses station at the time of the observations, staff confirmed that there belongings were being stored in the nurses station. CNA F, RN H and RN G stated that the lockers were too far away so they preferred to keep their belongings in the nurses station.

Per interview with CNO B on 01/10/2024 beginning at 10:20 AM, CNO B stated that there was no lock on the nurses station. Per CNO B, there is a unit secretary in the nurses station during the day shift, but not on the night shift; CNO B stated that on night shift there is not always a staff member present in the nurses station. Per CNO B, an email was sent to all nursing staff in regards to storing personal belongings in locked lockers and conducting Intensive Supervision handoffs when the sitter needs a break; CNO B stated that there was also education given to staff during daily huddles. CNO B stated that she/he was unable to provide evidence of who attended the huddles and a staff email acknowledgements.

Per interview with Nurse Manager K on 01/11/2024 at 9:55 AM, Manager K stated that she/he was involved in investigating Pt #1's incident. Manager K stated that Pt #1 was on Intensive Supervision and required a sitter while awake due to Pt #1 wandering, impulsive, and putting things in his/her mouth. Manager K stated that due to staffing shortage at the time, PC L was assigned to Pt #1 and Pt #2 on 12/26/2023 (date of incident); Manager K stated that a sitter should only be assigned to one patient. Manager K confirmed that Pt #1 was awake prior to the incident. Manager K stated that to address the staffing concerns, the facility is considering agency contract and being more "mindful" of patients being accepted to the facility to ensure staffing can accommodate patient needs. Manager K stated that staffs personal belongings should be locked in the break room and not kept in the nurses station. Manager K stated that staff was educated via email, huddle, and personally spoke with staff; Manager K stated she/he did not have documented evidence of this education.

Per interview with CNA E on 01/10/2024 at 2:15 PM, CNA E confirmed that PC L was "sitting" with Pt #1 and Pt #2 on the night of Pt #1's incident (12/26/2023). Per CNA E Pt #1 walked around all the time and would come into the nurses station, but when the incident occurred no staff were present in the hallway or in the nurses station to witness Pt #1 taking CNA E's medications. When asked if CNA E received any emails containing follow up education to the incident, CNA E responded "No" and stated that she/he has not checked her work email.

Per interview with RN D (Pt #1's RN at the time of incident) on 01/10/2024 at 5:03 PM, RN D stated that PC L was assigned as the sitter for Pt #1 and Pt #2, Per RN D this is "not ideal." Per interview, RN D was not aware that an order for Intensive Supervision meant the patient needed to have a sitter, RN D thought it was a "step down" from having a sitter. Per RN D, if there was "enough staff" then Intensive Supervision could be a one-to one.

Per interview with Quality Coordinator C on 01/10/2024 at 2:00 PM, Coordinator C confirmed that the documented investigation did not include comprehensive root cause analysis which included analyzing the cause and implementing a plan to address Patient Companion (L) being assigned as a sitter for Pt #1 and Pt #2 on 12/26/2023. Coordinator C confirmed that there was no documented evidence that all staff were educated on the corrective action plan addressed in the incident report to ensure that all staff were aware of the expectations. Coordinator C stated that staff are not currently monitoring (auditing) compliance with the corrective action plan.

Environmental Observations

Review of policy and procedure #11.080 titled, "Crash Cart Checks" last reviewed 10/21 revealed, "The carts are to be locked at all times with breakaway locks or keyed lock if appropriate to assure the integrity of the contents."

Review of the Crash Cart medication list revealed the following medications: Amiodarone (heart rhythm), Narcan (narcotic overdose), Magnesium sulfate, Dopamine (increase blood pressure), Atropine (increase heart rate), Dextrose (increase blood sugar), Epinephrine (severe allergic reactions).

Observations off the South unit (location of incident) while touring with Director of Quality/Chief Nursing Officer (CNO) B on 01/10/2024 beginning at 10:45 AM to 10:55 AM (10 minutes) revealed the following:
-Observed a supply room (in the patient hallway) housing an emergency Crash Cart secured with a break away lock (pull off to gain access); the Crash Cart contained multiple medications (see list). Per observations, there was no lock on the supply door. Observations revealed there was no staff present in the hallway to ensure that patients did not have access to the supply room and crash cart.
-Observed a housekeeping cart left unattended in the patient hallway; the cart contained bottles of bleach, isopropyl alcohol, toilet cleaner, and bathroom cleaner.
-Observed a patient walking back and forth down the hallways during the observations, no staff were present in the hallway during the observations lasting approximately 10 minutes.

Per interview with Housekeeper I on 01/10/2024 beginning at 10:56 AM, Housekeeper I stated that he/she normally will leave the housekeeping cart in the hallway (unattended), while Housekeeper I cleans the medication room and other rooms secured with a key lock. Housekeeper stated that he/she did not feel comfortable bringing the housekeeping cart in the medication room.

Per interview with CNO B on 01/10/2024 beginning at 10:40 AM, CNO B confirmed there was no lock on the supply room door. CNO B stated that the facility provides care to a large number of patients with neurobehavioral issues and traumatic brain injuries who may suffer from confusion and/or disorientation. CNO B confirmed that medications in the crash cart were not secured from unauthorized access. CNO B confirmed that the housekeeping cart should not be left unattended in the hallway as confused patients could gain access to unsafe chemicals.

Based on record review and interview staff failed to ensure a Registered Nurse (RN) supervises and evaluates the care of all patients assigned to a Licensed Practical Nurse (LPN) in 8 of 10 medical records reviewed (Patient (Pt) #3, 4, 5, 6, 7, 8, 9, 10), and failed to ensure a RN performs a nursing shift assessment and progress note on all patients as per policy in 10 of 10 medical records reviewed (Pt #1, 2, 3, 4, 5, 6, 7, 8, 9, 10), in a total sample of 10 records reviewed.

Findings Include:

Review of policy and procedure #7.660 titled, "Nursing Daily Documentation" last reviewed 04/23 revealed the following:
-"For each shift, nursing will generate a progress note that reflects medical status to communicate ongoing individualized treatment goals, levels of care, and the patient's clinical condition."
-"All nursing personnel are required to complete daily documentation within Wellsky Electronic Medical Record (EMR) during each shift."
-"Nurses will be responsible for the accuracy of the information documented."
-"Nurses co-signing documentation for LPN, students, and persons in orientation must identify whom they are co-signing for..."

Review of policy and procedure #07.020 titled, "Nursing Care Plan" last reviewed on 04/23 revealed the following:
-"The Registered Nurse (RN) is responsible for all components of the nursing process, including assessment, care planning, education , and evaluation of care, including patient progress toward goals. Data collection and the implementation and documentation of specific medical and nursing interventions may be delegated to assistive staff, including LPN and Certified Nursing Assistants (CNA)."
-"The RN will assess the patient's physical, psychosocial, cultural, spiritual, nutritional, functional, educational., daily activity level, and medical and discharge expectations/needs."
-"Data collected and related to care and treatment will be documented in the electronic medical record."
-"The nurse is accountable for documenting all relevant patient information gathered independently or by delegation."

Review of Pt #1's medical record revealed there was no documented evidence of a nursing assessment completed on 12/26/2023 for first shift (7:00 AM to 7:00 PM).

Review of Pt #2's medical record revealed there was no documented evidence of a nursing assessment completed on 12/26/2023 for first shift (7:00 AM to 7:00 PM) and on 12/25/2023 for night shift (7:00 PM to 7:00 AM).

Review of Pt #3's medical record revealed a LPN documented performing Pt #3's nursing shift assessment on 12/29/2023 4:18 AM and 12/30/2023 at 2:10 AM, there was no documented evidence of a RN supervising and evaluating Pt #3's care during this time.

Review of Pt #4's medical record revealed a LPN documented performing Pt #4's nursing shift assessment on 12/26/2023 4:49 PM, 12/27/2023 at 3:48 AM, and 12/28/2023 at 6:18 PM, there was no documented evidence of a RN supervising and evaluating Pt #4's care during this time.

Review of Pt #5's medical record revealed a LPN documented performing Pt #5's nursing shift assessment on 1/04/2024 8:00 PM and 1/06/2024 at 4:41 AM, there was no documented evidence of a RN supervising and evaluating Pt #5's care during this time. Review of Pt #5's medical record revealed there was no RN day shift progress note completed on 1/04/2024, 1/05/2024, and 1/08/2024 as per policy.

Review of Pt #6's medical record revealed a LPN documented performing Pt #6's nursing shift assessment on 12/26/2023 11:23 AM, 12/28/2023 at 3:01 PM, and 12/29/2023 at 12:28 AM, there was no documented evidence of a RN supervising and evaluating Pt #6's care during this time. Review of Pt #6's medical record revealed there was no RN night shift progress note completed on 12/26/2023 and no RN day shift progress note completed on 12/28/2023 and 12/31/2023 as per policy.

Review of Pt #7's medical record revealed a LPN documented performing Pt #7's nursing shift assessment on 1/05/2024 2:08 AM and 1/09/2024 at 2:00 AM, there was no documented evidence of a RN supervising and evaluating Pt #7's care during this time.

Review of Pt #8's medical record revealed a LPN documented performing Pt #8's nursing shift assessment on 1/06/2024 4:27 PM, 1/07/2024 at 5:20 PM, 1/08/2024 at 4:08 PM , there was no documented evidence of a RN supervising and evaluating Pt #8's care during this time. Review of Pt #8's medical record revealed there was no RN day shift progress note completed on 1/08/2024 as per policy.

Review of Pt #9's medical record revealed a LPN documented performing Pt #9's nursing shift assessment on 12/27/2023 11:59 PM and 1/01/2024 at 8:54 PM, there was no documented evidence of a RN supervising and evaluating Pt #9's care during this time. Review of Pt #9's medical record revealed there was no RN day shift progress note completed on 12/27/2023 and 12/31/2023 as per policy.

Review of Pt #10 medical record revealed a LPN documented performing Pt #10's nursing shift assessment on 12/26/2023 11:19 AM, there was no documented evidence of a RN supervising and evaluating Pt #9's care during this time. Review of Pt #10's medical record revealed there was no nursing day shift assessment completed on 12/22/2023 and 12/26/2023 and no night shift assessment completed on 12/23/2023, 12/24/2023, and 12/25/2023. Review of Pt 10's medical record revealed there was no RN day shift progress note completed on 12/20/2023 and 12/26/2023, and no night shift progress note completed on 12/23/2023 and 12/24/2023 as per policy.

Per interview with Quality Coordinator C while conducting medical records reviews on 01/10/2024 beginning at 2:45 PM, Coordinator C confirmed the above findings and stated that nursing assessments should be documented as completed on each shift and there should be a nursing progress note completed each shift.

Per interview with Nurse Manager K on 01/11/2024 beginning at 9:55 AM, Manager K stated that the facility currently does not have a process in place reflecting RN supervision of LPNs and showing oversight of all patient care. Per Manager K this is an "area that needs improvement." Per Manager K, LPNs will go to charge RN with question and concerns, but RNs do not sign off on LPNs documentation as evidence of supervising and evaluating patient care.

Based on record review and interview the facility failed to ensure an appropriate safety care plan was implemented for patients requiring Intensive Supervision/sitter as per policy in 3 of 10 medical records reviewed (Patient (Pt) #1, 2, 10), in a total sample of 10 medical records reviewed.

Findings Include:

Review of policy and procedure #07.020 titled, "Nursing Care Plan" last reviewed 04/23 revealed the following:
-"An individualized Nursing Care Plan, which utilizes best practices and includes patient education, is developed for each patient within 24 hours of admission. The Nursing Care Plan is reviewed every shift and revised as appropriate based on changes in the patient's condition and abilities. Any needs or goals identified by the patient should be reviewed and explored by the RN for incorporation into the plan of care."
-"The Nursing Care Plan includes individualized interventions, with realistic, measurable actions and goals directly relating to the nursing diagnosis."

Review of policy and procedure #7.870 titled, "Intensive Supervision (IS)" last reviewed 04/23 revealed that nursing responsibilities include: "Required shift documentation including safety plan of care."

Pt #1:

Review of Pt #1 Orders dated 12/26/2023 at 7:00 AM revealed, "Intensive supervision during waking hours...Indication: Impulsive."

Review of Pt #1's Provider Progress Note dated 12/26/2023 at 12:48 PM revealed, "(Pt #1) Continues to need a one to one (sitter) due to impulsivity and attempting to put things in his mouth..."

Review of Pt #1's Nursing Care Plans revealed there was no documented evidence of nursing staff implementing a "Safety" Nursing Care Plan as per policy.

Pt #2:

Review of Pt #2's Provider Progress Note dated 12/26/2023 at 12:44 PM revealed Pt #2 "Remains on 1:1 (sitter) for impulsivity..."

Review of Pt #2's Orders dated 12/26/2023 at 7:00 AM revealed, "Intensive Supervision...Indication: Impulsive."

Review of Pt #2's Nursing Care Plans revealed there was no documented evidence of nursing staff implementing a "Safety" Nursing Care Plan as per policy.

Pt #10:

Review of Pt #10's Provider Progress Note dated 12/06/2023 at 08:23 AM revealed "TBI (traumatic brain injury) encephalopathy due to motorcycle accident...Patient is on one-to-one supervision due to impulsivity."

Review of Pt #10's Orders dated 12/25/2023 at 7:00 AM revealed, "Intensive Supervision...Indication: Impulsive."

Review of Pt #10's Nursing Care Plans revealed there was no documented evidence of nursing staff implementing a "Safety" Nursing Care Plan as per policy.

Per interview with Nurse Manager K on 01/11/2024 beginning at 9:55 AM, Manager K stated that nursing staff should be implementing a Safety Nursing Care Plan to address each patient's individual safety concerns related to needing Intensive Supervision/sitter.