HospitalInspections.org

Based on observation, review of policies and procedures, medical records, patient and family grievance forms, performance improvement forms and staff interview, the hospital failed to have an effective Governing Body. The Governing Body failed to ensure care was provided in a safe setting related to abuse and improper care for four ( #16, #17, 18 and #25) patients, patient rights related to the use of restraints for one patient (Patient #5). This deficiency affected five (Patient #s 5, 16, 17, 18 and 25) of the total of 30 patients whose medical records were reviewed. This has the potential to affect the entire hospital staff and patients. The hospital census was 33.

Findings include:

During this survey conducted on 09/01/10-09/03/10, reviews were conducted of the facility's patient and family grievance report forms and performance improvement forms for staff counseling/corrective action. According to this documentation, the facility permitted staff to continue to work after patients complained of verbal abuse and rough treatment. The facility failed to follow their abuse policy related to documentation of thorough investigations of patient/family/staff complaints of rough treatment and improper care and termination if abuse is verified.

On 09/03/10, a review of the hospital's Policy PC 02-014 titled "Abuse of Patient, Elder, Child byStaff Identification-Response and Reporting" revealed the following:
"Verbal abuse is derogatory, threatening, derisive, or demeaning language, whether in writing, oral, or with gestures. Neglect/mistreatment is the failure or refusal by any person having the care or custody of another (child, elder, adult) to exercise the degree of which a reasonable person in a like position would exercise. Neglect includes, but is not limited to: failure to provide the prescribed medical care and treatment for their physical and mental health needs, and deliberate refusal to implement the individual's treatment program.
This policy stated the following steps should be taken for suspected abuse:first responder/supervisor responsibilities:
1. The employee who first becomes aware of a patient who is said to the abused, neglected, mistreated and/or exploited must take all appropriate steps necessary to protect the patient, including but not limited to, reassignment of staff, removal of staff from patient care, and restriction of visitors.
2. If the report allegation is conveyed by a family member, legal representative, or visitor, assure the individual that the Hospital treats any allegation seriously.
3. Notify the Chief Clinical Officer (CCO) Nursing Supervisor or clinical area Manager immediately in any instance of reported, observed, or suspected patient abuse, neglect, mistreatment and/or exploitation. The CCO, Nursing Supervisor or clinical area manager shall immediately notify the Administrator on call.
4. Notify the patient's attending physician.
5. Document the allegations on a complaint form and enter as an event report. Forward immediately to the DQM or Administrator on call for investigation.

Investigation Guidelines include:
If suspected abuse, neglect, mistreatment and/or exploitation involves an employee, the Hospital Chief Executive Officer will determine the action to be taken based on the investigation performed by the CCO or their designee. The employee may be suspended during the investigation, and if abuse is confirmed, termination of employment will result.
All allegations will be conducted under the guidance of the Administrative staff who will, depending on the circumstance:
Seek information in a thorough, impartial, dignified, and confidential manner.
Interview witnesses, including the charged individual(s), and obtain signed statements when appropriate.
Assure that embarrassment of the patient (s) and/or individual(s) is avoided.
Assess charged employees' work records and note any history of similar incidents or related behaviors.
Investigate all other possible sources of information relating to the incident and/or the personal involved.
Required report to licensing agencies (Board of Nurse Examiners, Board of Respiratory Care Practitioners, Board of Clinical Nursing Assistants, etc.) as mandated by law will be made by the CCO or DQM after consultation with the Hospital Chief Executive Officer.
Reports that are taken from patients and/or families and logged on the Complaint Form will be responded to, in writing, with findings and recommendations resulting from investigation within seven days of receipt of the form by the COO.

On 09/02/10 and 09/03/10, a review of staff counseling/corrective actions for Staff K revealed this employee was verbally counseled on 03/12/10 for being rude to a patient (patient not identified) while assisting the patient. According to an interview on 09/03/10 between 9:15 AM and 10:00 AM, Staff F verified Staff K was verbally rude to this patient and received verbal counseling for violation of behavioral standards set by the facility. A final written warning was give to Staff K on 06/26/10 for behavorial infraction/lack of professionalism. Staff K was discharged on 07/08/10 for unprofessional behavior and poor patient care. This was done after Patient #16 complained Staff K was rude to the patient and had turned the patient roughly. An interview with Staff F on 09/03/10 at 8:58 AM verified this did occur; resulting in dismissal of Staff K on 07/08/10 almost four months after the 03/12/10 incident of verbal abuse of a patient..
The hospital could provide no evidence of a thorough investigation into these allegations. The facility lacked evidence of interviews with staff, the patient, and family regarding these allegations. The facility failed to follow their policy for zero tolerance of staff being rude to patients as Staff K continued to work as a direct care staff after it was verified the employee was rude to a patient in March 2010, until another incident of rudeness to the patient and roughness when turning the patient had occurred.

On 09/03/10, a review of a Patient and Family Grievance Report Form dated 05/19/10, submitted by Patient #17's family member, documented the patient was upset that he/she overheard Staff H making a statement that this patient (referring to Patient #17) needs to be in a padded cell of a psychiatric ward. It was verified by Staff G that Staff H and Staff I were both counseled for making this rude and inappropriate comment about Patient #17. There was no evidence of a thorough investigation for the inappropriate comments made by Staff H and Staff I in May 2010. There was no evidence the facility reported this verbal abuse to the licensing agent as mandated by law. This was verified with Staff F on 09/03/10 at 9:45 AM.

On 09/03/10 a review of Staff Counseling Forms for Staff J (patient care technician) revealed
on 05/21/10, Staff J received verbal counseling regarding Patient #18's complaints of Staff J being rough with the patient during the provision of care, causing the patient's abdominal drainage lines to come apart and spray bile drainage into the patient's face. This resulted in a written warning and Staff J was not allowed to provide care to Patient #18.
The facility provided documentation of a final written warning was given to Staff J on 07/15/10, regarding behavior related concerns which included performing tasks inappropriately, not wearing personal protective equipment, and talking/texting on the phone.
This employee was terminated on 07/26/10, for behavior/failing to follow policies and procedures. This was greater than two months after the 05/21/0 incident involving Patient #18.
The facility failed to follow their policy to remove Staff J from providing patient care after the the verbal counseling regarding providing rough treatment to Patient #18. The facility lacked evidence of a thorough investigation into this incident. There was no evidence the facility reported this abuse to the licensing agent as mandated by law. This was verified with Staff F on 09/03/10 at 9:45 AM.


The medical record for Patient #5 was reviewed on 08/31/10. The patient was admitted to the hospital on 08/13/10, with a diagnosis of Morbid Obesity and status post amputation. The medical record contained evidence the patient's physician ordered the patient to be in bilateral arm restraints on multiple dates during his/her admission, including an order written on 08/25/10 at 8:00 A.M. The reason for the restraints was documented as disturbing medical equipment, risk of injury to self due to inability to understand or remain oriented, frequent attempts to get out of bed/chair and poor judgment/fall risk. The medical record revealed evidence the nurse caring for the patient documented the restraints as " on " at 10:00 A.M., 12:00 P.M., 2:00 P.M. and 4:08 P.M on 08/25/10. The nursing note at 4:08 P.M. described the patient's level of consciousness as " sleeping. " The medical record revealed the patient fell on 08/25/10, as evidenced by a respiratory therapy note at 4:30 P.M.on 08/25/10 which stated the patient was found sitting on floor on buttocks at the side of the bed. The Patient (#5) stated he/she was short of breath and got out of bed. A rapid response was called and two physicians responded. The patient was assessed as having no injuries related to the fall, although the nurse did document on a nurses note an abrasion to the back of the right thigh. The area was cleansed with normal saline, an antibiotic ointment and a bandage was applied. The nurses note further stated the patient's Foley catheter (tube inserted into the urinary bladder) was removed during the fall. The documentation lacked any information regarding the patient's restraint status at the time of the fall. The medical record revealed speech therapy notes indicated the time of a treatment was from 11:45 A.M. to 12:13 P.M.on 08/25/10. The medical record lacked documentation of any care provided to the patient from 12:13 P.M. to 1:28 P.M on 08/25/10. An occupational therapy note revealed therapy was provided at 1:28 P.M. on 08/25/10 for a total of 23 minutes. The patient was transferred to a chair as part of this therapy. At 2:13 P.M.on 08/25/10, the patient care assistant documented the restraints were on and a bath was given. The medical record lacked evidence of a new order to re-apply the restraints or a new assessment by the nurse. At 3:21 P.M.on 08/25/10, rehab notes document the patient was transferred back to bed, for a total treatment time of ten minutes. The nursing documentation at 4:08 P.M.on 08/25/10 by the nurse revealed the restraints were on. The next note in the medical record was at 4:30 P.M on 08/25/10. when the respiratory therapist documented the patient's fall.
These findings were shared with hospital Administrative staff on 09/01/10 at 4:00 P.M. Staff A was interviewed on 09/02/10 at 11:30 A.M. regarding the status of the patient ' s restraints. Staff A indicated interviews were conducted with staff and written documentation regarding the interviews were presented. The documentation revealed the speech therapist indicated the restraints were not reapplied due to Occupational Therapy entering room to work with patient. The documentation stated the nurse was interviewed on 09/01/10 at 5:45 P.M. and indicated no visual assessment was done at the time documented. The nurse verbalized understanding regarding this being false documentation. The nurse was suspended pending further investigation. On 09/02/10 at 10:25 A.M. the patient care technician was interview by phone, but stated she was unable to recall events without reviewing the chart. The patient care technician was also suspended pending completion of the investigation. The documentation, as well as the medical record lacked documentation of when the patient's restraints were removed, or any assessment regarding the patient's safety to have restraints removed. The medical record lacked evidence of any interventions attempted to ensure patient safety when restraints were discontinued.
The medical record for Patient #25 was reviewed on 09/03/10. The medical
record revealed the patient was admitted to the hospital on 07/22/10 with a
primary diagnosis of respiratory failure. The patient was status post recent
fall with multiple trauma. The progress note written by the physician's
assistant and co-signed by the patient's physician dated 07/30/10 at 10:37 A.M.
stated the patient voiced complaints about being left on the bedpan for over an
hour yesterday in the presence of visitors, and that morning he/she awoke and
did not have the phone or call light within reach. The complaint was not noted
to be in the complaint log and no follow up was documented. Staff K stated on 09/03/10 at 12:00 PM the patient was interviewed regarding the bedpan but it was not documented as
this complaint was on a physician's progress note, not on a complaint form.
Staff K further stated on 09/03/10 at 12:00 PM, in regard to the complaint regarding the phone and call light not being in reach, the patient could have "got up and got it".

Based upon medical record review, interview with patients, staff, and administration, review of policies and procedures and grievance and counseling forms, it was determined that the facility failed to provide a safe environment for patients. The hospital failed to implement protective measures to provide a safe environment after staff demonstrated harsh and rough treatment of three ( #16, #17 and #18) patients of a total of 30 patients whose medical records were reviewed.. This all patients of the hospital at risk. The sample size was 30. The hospital census was 33.
Findings include:

During this survey on 09/01/10-09/03/10, reviews were conducted of the facility's patient and family grievance report forms and performance improvement forms for staff counseling/corrective action. According to this documentation, the facility permitted staff to continue to work after patients complained of improper and rough treatment. The facility failed to follow their abuse policy related to documentation of thorough investigations of patient/family/staff complaints of rough treatment and improper care. The facility failed to report substantiated abuse to the proper authority as mandated by law.

On 09/03/10, a review of Policy PC 02-014 titled Abuse of Patient, Elder, Child by Staff Identification-Response and Reporting revealed the following:
Verbal abuse is derogatory, threatening, derisive, or demeaning language, whether in writing, oral, or with gestures. Neglect/mistreatment is the failure or refusal by any person having the care or custody of another (child, elder, adult) to exercise the degree of which a reasonable person in a like position would exercise. Neglect includes, but is not limited to: failure to provide the prescribed medical care and treatment for their physical and mental health needs, and deliberate refusal to implement the individual's treatment program.
This policy stated the following steps should be taken for suspected abuse:first responder/supervisor responsibilities:
1. The employee who first becomes aware of a patient who is said to the abused, neglected, mistreated and/or exploited must take all appropriate steps necessary to protect the patient, including but not limited to, reassignment of staff, removal of staff from patient care, and restriction of visitors.
2. If the report allegation is conveyed by a family member, legal representative, or visitor, assure the individual that the Hospital treats any allegation seriously.
3. Notify the Chief Clinical Officer (CCO) Nursing Supervisor or clinical area Manager immediately in any instance of reported, observed, or suspected patient abuse, neglect, mistreatment and/or exploitation. The CCO, Nursing Supervisor or clinical area manager shall immediately notify the Administrator on call.
4. Notify the patient's attending physician.
5. Document the allegations on a complaint form and enter as an event report. Forward immediately to the DQM or Administrator on call for investigation.

Investigation Guidelines include:
If suspected abuse, neglect, mistreatment and/or exploitation involves an employee, the Hospital Chief Executive Officer will determine the action to be taken based on the investigation performed by the CCO or their designee. The employee may be suspended during the investigation, and if abuse is confirmed, termination of employment will result.
All allegations will be conducted under the guidance of the Administrative staff who will, depending on the circumstance:
Seek information in a thorough, impartial, dignified, and confidential manner.
Interview witnesses, including the charged individual(s), and obtain signed statements when appropriate.
Assure that embarrassment of the patient (s) and/or individual(s) is avoided.
Assess charged employees' work records and note any history of similar incidents or related behaviors.
Investigate all other possible sources of information relating to the incident and/or the personal involved.
Required report to licensing agencies (Board of Nurse Examiners, Board of Respiratory Care Practitioners, Board of Clinical Nursing Assistants, etc.) as mandated by law will be made by the CCO or DQM after consultation with the Hospital Chief Executive Officer.
Reports that are taken from patients and/or families and logged on the Complaint Form will be responded to, in writing, with findings and recommendations resulting from investigation within seven days of receipt of the form by the COO.

On 09/02/10 and 09/03/10, a review of Staff Counseling/Corrective Actions Forms for Staff K revealed this employee was verbally counseled on 03/12/10 for being rude to a patient (patient not identified) while assisting the patient. According to an interview on 09/03/10 between 9:15 AM and 10:00 AM, Staff F verified Staff K was verbally rude to this patient and received verbal counseling for violation of behavioral standards set by the facility. A final written warning was give to Staff K on 06/26/10 for behavorial infraction/lack of professionalism. Staff K was discharged on 07/08/10 for unprofessional behavior and poor patient care. This was done after Patient #16 complained Staff K was rude to the patient and had turned the patient roughly. An interview with Staff F on 09/03/10 at 8:58 AM verified this did occur; resulting in dismissal of Staff K on 07/08/10 almost four months after the 03/12/10 incident of verbal abuse of a patient.
The hospital could provide no evidence of a thorough investigation into these allegations. The facility lacked evidence of interviews with staff, the patient, and family regarding these allegations. The facility failed to follow their policy for zero tolerance of staff being rude to patients as Staff K continued to work as a direct care staff after it was verified the employee was rude to a patient in March 2010, until another incident of rudeness to the patient and roughness when turning the patient had occurred.

On 09/03/10, a review of a Patient and Family Grievance Report Form dated 05/19/10, submitted by Patient #17's family member, documented the patient was upset that he/she overheard Staff H making a statement that this patient (referring to Patient #17) needs to be in a padded cell of a psychiatric ward. It was verified by Staff G that Staff H and Staff I were both counseled for making this rude and inappropriate comment about Patient #17. There was no evidence of a thorough investigation for the inappropriate comments made by Staff H and Staff I in May 2010. There was no evidence the facility reported this verbal abuse to the licensing agent as mandated by law. This was verified with Staff F on 09/03/10 at 9:45 AM.

On 09/03/10 a review of Staff Counseling Forms for Staff J (patient care technician) revealed
on 05/21/10, Staff J received verbal counseling regarding Patient #18's complaints of Staff J being rough with the patient during the provision of care, causing the patient's abdominal drainage lines to come apart and spray bile drainage into the patient's face. This resulted in a written warning and Staff J was not allowed to provide care to Patient #18.
The facility provided documentation of a final written warning was given to Staff J on 07/15/10 regarding behavior related concerns which included performing tasks inappropriately, not wearing personal protective equipment, and talking/texting on the phone.
This employee was terminated on 07/26/10 for behavior/failing to follow policies and procedures. This was greater than two months after the incident involving Patient #18.
The facility failed to follow their policy to remove Staff J from providing patient care after the the verbal counseling regarding providing rough treatment to Patient #18. The facility lacked evidence of a thorough investigation into this incident. There was no evidence the facility reported this abuse to the licensing agent as mandated by law. This was verified with Staff F on 09/03/10 at 9:45 AM.

The condition of Nursing Services remains as cited on the 04/15/2010 complaint survey.

Based on observation, staff interview and medical record review, the facility failed to ensure the prevention and control of infections related to the use of personal protective equipment. This affected 2 patients ( #6, #1) of the total of 30 medical records reviewed. The total census was 33.

Findings include:

On 08/31/10 at 3:25 PM, observations were conducted of Staff E providing care to Patient #6 room in Room 610. An additional contracted staff nurse was observed providing hemodialysis care to this patient. A yellow contact precaution sign was observed on the door. Review of the medical record on 09/02/10 in the morning hours, revealed the patient was in isolation due to an infectious organism in a wound. This sign stated the staff should wear gloves and a protective gown when in the room with the patient and take the gown off inside the room before leaving. Staff E was observed lifting a large bedside commode (BSC) out of the patient's bathroom, over a soiled linen hamper and into the outer doorway. This employee was observed wearing gloves as personal protective equipment but not a gown. The employee did not have on a protective gown when lifting the bedside commode out of the bathroom. After relocating the BSC to the hallway outside the Patient's room, Staff E was observed using disinfectant wipes to clean the commode. Staff E did not have on a protective gown to clean this equipment.

An interview was conducted with Staff E at 3:37 PM regarding whether a gown should have been worn during this procedure. Staff E stated he/she did not know if the BSC had been used by the patient. This employee also stated there are certain times a gown should be worn and was unsure if he/she should have one on when cleaning the equipment. This employee was then observed questioning Staff F about whether a gown should be worn. Staff F said Staff should have worn a gown when cleaning the patient's equipment.

During the tour of the 5th floor of the hospital between 10:30 AM and 11:35 AM on 08/30/2010, an isolation patient (#1) was being repositioned in bed by a female without Personal Protective Equipment (PPE). The surveyor asked the Chief Clinical Officer (CCO) if the female was a family member. The CCO stated that the female was the registered nurse (Staff D) responsible for this patient's (#1) care. The CCO told Staff D she/he needed to have PPEs on. Staff D stated that the patient had just returned from an ultrasound test. Staff D stated that he/she felt so hot that she/he did not want to put on the gown since she was "so wet" as if she had just taken a shower. The CCO stated that Staff D was so hot from wearing the PPEs. The patient was in contact isolation for Methicillin Resistant Staphylococcus Aureus (MRSA) in the blood and sputum which required PPEs. Staff D washed her hands and left the patient's room. Staff D proceeded to brush against other surfaces and care for other patients without a change of clothing. There was a potential of contamination of other surfaces and patients. The patient census was 25 on the fifth floor

The hospital's policy and procedure for contact isolation (Policy #H-IC 02-002) dated 05/2010, indicated; if staff has direct contact with the patient or potentially contaminated environment surfaces, the staff should wear a gown and/or gloves. The staff are to wash or sanitize hands and wear gown and gloves.


The surveyor observed at 10:00 AM on 8/30/10 four unoccupied patient rooms on the 5th floor which was reported by the charge nurse as being ready for an admission. However, these rooms were in need of cleaning. The computer keys in rooms 501, 503, and 506 contained a build up of dust and debris. There was visible dust and dyed substances on the window sill. The closet in room 506 contained two floor mattresses in need of cleaning. The nursing staff on the unit stated the room was ready for a patient and that the discharge cleaning staff had cleaned the room that the morning.

The above findings were confirmed with Staff A on 08/30/2010 at 11:35 P.M.





03245

Based on review of patient and family grievance forms and performance improvement forms, staff interview, medical record review and review of facility policy related to abuse, the facility failed to ensure all care was provided in a safe setting. This affected five patients (#5, #16, #17, #18, #25) from the total of 30 patients medical records reviewed.

Findings include:

During this survey on 09/01/10-09/03/10, reviews were conducted of the facility's patient and family grievance report forms and performance improvement forms for staff counseling/corrective action. According to this documentation, the facility permitted staff to continue to work after patients complained of improper and rough treatment. The facility failed to follow their abuse policy related to documentation of thorough investigations of patient/family/staff complaints of rough treatment and improper care.

On 09/03/10, a review of Policy PC 02-014 titled Abuse of Patient, Elder, Child by Staff Identification-Response and Reporting revealed the following:
Verbal abuse is derogatory, threatening, derisive, or demeaning language, whether in writing, oral, or with gestures. Neglect/mistreatment is the failure or refusal by any person having the care or custody of another (child, elder, adult) to exercise the degree of which a reasonable person in a like position would exercise. Neglect includes, but is not limited to: failure to provide the prescribed medical care and treatment for their physical and mental health needs, and deliberate refusal to implement the individual's treatment program.
This policy stated the following steps should be taken for suspected abuse:first responder/supervisor responsibilities:
1. The employee who first becomes aware of a patient who is said to the abused, neglected, mistreated and/or exploited must take all appropriate steps necessary to protect the patient, including but not limited to, reassignment of staff, removal of staff from patient care, and restriction of visitors.
2. If the report allegation is conveyed by a family member, legal representative, or visitor, assure the individual that the Hospital treats any allegation seriously.
3. Notify the Chief Clinical Officer (CCO) Nursing Supervisor or clinical area Manager immediately in any instance of reported, observed, or suspected patient abuse, neglect, mistreatment and/or exploitation. The CCO, Nursing Supervisor or clinical area manager shall immediately notify the Administrator on call.
4. Notify the patient's attending physician.
5. Document the allegations on a complaint form and enter as an event report. Forward immediately to the DQM or Administrator on call for investigation.

Investigation Guidelines include:
If suspected abuse, neglect, mistreatment and/or exploitation involves an employee, the Hospital Chief Executive Officer will determine the action to be taken based on the investigation performed by the CCO or their designee. The employee may be suspended during the investigation, and if abuse is confirmed, termination of employment will result.
All allegations will be conducted under the guidance of the Administrative staff who will, depending on the circumstance:
Seek information in a thorough, impartial, dignified, and confidential manner.
Interview witnesses, including the charged individual(s), and obtain signed statements when appropriate.
Assure that embarrassment of the patient (s) and/or individual(s) is avoided.
Assess charged employees' work records and note any history of similar incidents or related behaviors.
Investigate all other possible sources of information relating to the incident and/or the personal involved.
Required report to licensing agencies (Board of Nurse Examiners, Board of Respiratory Care Practitioners, Board of Clinical Nursing Assistants, etc.) as mandated by law will be made by the CCO or DQM after consultation with the Hospital Chief Executive Officer.
Reports that are taken from patients and/or families and logged on the Complaint Form will be responded to, in writing, with findings and recommendations resulting from investigation within seven days of receipt of the form by the COO.

On 09/02/10 and 09/03/10, a review of staff counseling/corrective actions for Staff K revealed this employee was verbally counseled on 03/12/10 for being rude to a patient (patient not identified) while assisting the patient. According to an interview on 09/03/10 between 9:15 AM and 10:00 AM, Staff F verified Staff K was verbally rude to this patient and received verbal counseling for violation of behavioral standards set by the facility. A final written warning was give to Staff K on 06/26/10 for behavorial infraction/lack of professionalism. Staff K was discharged on 07/08/10 for unprofessional behavior and poor patient care. This was done after Patient #16 complained Staff K was rude to the patient and had turned the patient roughly. An interview with Staff F on 09/03/10 at 8:58 AM verified this did occur; resulting in dismissal of Staff K on 07/08/10 almost four months after the 03/12/10 incident of verbal abuse of a patient.

The hospital could provide no evidence of a thorough investigation into these allegations. The facility lacked evidence of interviews with staff, the patient and family regarding these allegations. The facility failed to follow their policy for zero tolerance of staff being rude to patients as Staff K continued to work as a direct care staff after it was verified the employee was rude to a patient in March 2010, until another incident of rudeness to the patient and roughness when turning the patient had occurred.

On 09/03/10, a review of a Patient and Family Grievance Report Form dated 05/19/10, submitted by Patient #17's family member, documented the patient was upset that he/she overheard Staff H making a statement that this patient (referring to Patient #17) needs to be in a padded cell of a psychiatric ward. It was verified by Staff G that Staff H and Staff I were both counseled for making this rude and inappropriate comment about Patient #17. There was no evidence of a thorough investigation for the inappropriate comments made by Staff H and Staff I in May 2010. There was no evidence the facility reported this verbal abuse to the licensing agent as mandated by law. This was verified with Staff F on 09/03/10 at 9:45 AM.

On 09/03/10 a review of Staff Counseling Forms for Staff J (patient care technician) revealed
on 05/21/10, Staff J received verbal counseling regarding Patient #18's complaints of Staff J being rough with the patient during the provision of care, causing the patient's abdominal drainage lines to come apart and spray bile drainage into the patient's face. This resulted in a written warning and Staff J was not allowed to provide care to Patient #18.
The facility provided documentation of a final written warning was given to Staff J on 07/15/10 regarding behavior related concerns which included performing tasks inappropriately, not wearing personal protective equipment, and talking/texting on the phone.
This employee was terminated on 07/26/10 for behavior/failing to follow policies and procedures. This was greater than two months after the incident involving Patient #18.
The facility failed to follow their policy to remove Staff J from providing patient care after the the verbal counseling regarding providing rough treatment to Patient #18. The facility lacked evidence of a thorough investigation into this incident. There was no evidence the facility reported this abuse to the licensing agent as mandated by law. This was verified with Staff F on 09/03/10 at 9:45 AM.


The medical record for Patient #5 was reviewed on 08/31/10. The patient was admitted to the hospital on 08/13/10, with a diagnosis of Morbid Obesity and status post amputation. The medical record contained evidence the patient's physician ordered the patient to be in bilateral arm restraints on multiple dates during his/her admission, including an order written on 08/25/10 at 8:00 A.M. The reason for the restraints was documented as disturbing medical equipment, risk of injury to self due to inability to understand or remain oriented, frequent attempts to get out of bed/chair and poor judgment/fall risk. The medical record revealed evidence the nurse caring for the patient documented the restraints as " on " at 10:00 A.M., 12:00 P.M., 2:00 P.M. and 4:08 P.M on 08/25/10. The nursing note at 4:08 P.M. described the patient's level of consciousness as " sleeping. " The medical record revealed the patient fell on 08/25/10, as evidenced by a respiratory therapy progress note note dated 08/25/10 at 4:30 P.M., which stated the patient was found sitting on floor on buttocks at the side of the bed. The Patient (#5) stated he/she was short of breath and got out of bed. A rapid response was called and two physicians responded. The patient was assessed as having no injuries related to the fall, although the nurse did document on a nurses progress note an abrasion to the back of the right thigh. The area was cleansed with normal saline, an antibiotic ointment and a bandage was applied. The nurses note further stated the patient's Foley catheter (tube inserted into the urinary bladder) was removed during the fall. The documentation lacked any information regarding the patient's restraint status at the time of the fall. The medical record revealed speech therapy notes indicated the time of a treatment was from 11:45 A.M. to 12:13 P.M.on 08/25/10. The medical record lacked documentation of any care provided to the patient from 12:13 P.M. to 1:28 P.M on 08/25/10. An occupational therapy note revealed therapy was provided at 1:28 P.M. on 08/25/10 for a total of 23 minutes. The patient was transferred to a chair as part of this therapy. At 2:13 P.M.on 08/25/10, the patient care assistant documented the restraints were on and a bath was given. The medical record lacked evidence of a new order to re-apply the restraints or a new assessment by the nurse. At 3:21 P.M.on 08/25/10, rehab notes document the patient was transferred back to bed, for a total treatment time of ten minutes. The nursing documentation at 4:08 P.M.on 08/25/10 by the nurse revealed the restraints were on. The next note in the medical record was at 4:30 P.M on 08/25/10. when the respiratory therapist documented the patient's fall.
These findings were shared with hospital Administrative staff on 09/01/10 at 4:00 P.M. Staff A was interviewed on 09/02/10 at 11:30 A.M. regarding the status of the patient ' s restraints. Staff A indicated interviews were conducted with staff and written documentation regarding the interviews were presented. The documentation revealed the speech therapist indicated the restraints were not reapplied due to Occupational Therapy entering room to work with patient. The documentation stated the nurse was interviewed on 09/01/10 at 5:45 P.M. and indicated no visual assessment was done at the time documented. The nurse verbalized understanding regarding this being false documentation. The nurse was suspended pending further investigation. On 09/02/10 at 10:25 A.M. the patient care technician was interview by phone, but stated she was unable to recall events without reviewing the chart. The patient care technician was also suspended pending completion of the investigation. The documentation, as well as the medical record lacked documentation of when the patient's restraints were removed, or any assessment regarding the patient's safety to have restraints removed. The medical record lacked evidence of any interventions attempted to ensure patient safety when restraints were discontinued.
The medical record for Patient #25 was reviewed on 09/03/10. The medical
record revealed the patient was admitted to the hospital on 07/22/10 with a
primary diagnosis of respiratory failure. The patient was status post recent
fall with multiple trauma. The progress note written by the physician's
assistant and co-signed by the patient's physician dated 07/30/10 at 10:37 A.M.
stated the patient voiced complaints about being left on the bedpan for over an
hour yesterday in the presence of visitors, and that morning he/she awoke and
did not have the phone or call light within reach. The complaint was not noted
to be in the complaint log and no follow up was documented. Staff K stated on 09/03/10 at 12:00 PM the patient was interviewed regarding the bedpan but it was not documented as
this complaint was on a physician's progress note, not on a complaint form.
Staff K further stated on 09/03/10 at 12:00 PM, in regard to the complaint regarding the phone and call light not being in reach, the patient could have "got up and got it".

Based on review of hospital policy related to abuse, staff interview, review of medical records, review of staff counseling/corrective action reports and grievenance reports, the facility failed to follow their abuse policy related to documentation of thorough investigations of patient/family/staff complaints of rough treatment and improper care. This affected 2 patients (#17, #18) from the total of 30 patient medical records reviewed. The hospital census was 33.

Findings include:

On 09/03/10, a review of Policy PC 02-014 titled Abuse of Patient, Elder, Child by staff identification-response and reporting revealed the following:
Verbal abuse is derogatory, threatening, derisive, or demeaning language, whether in writing, oral, or with gestures. Neglect/mistreatment is the failure or refusal by any person having the care or custody of another (child, elder, adult) to exercise the degree of which a reasonable person in a like position would exercise. Neglect includes, but is not limited to: failure to provide the prescribed medical care and treatment for their physical and mental health needs, and deliberate refusal to implement the individual's treatment program.
This policy stated the following steps should be taken for suspected abuse:first responder/supervisor responsibilities:
1. The employee who first becomes aware of a patient who is said to the abused, neglected, mistreated and/or exploited must take all appropriate steps necessary to protect the patient, including but not limited to, reassignment of staff, removal of staff from patient care, and restriction of visitors.
2. If the report allegation is conveyed by a family member, legal representative, or visitor, assure the individual that the Hospital treats any allegation seriously.
3. Notify the Chief Clinical Officer (CC)), Nursing Supervisor or clinical area Manager immediately in any instance of reported, observed, or suspected patient abuse, neglect, mistreatment and/or exploitation. The CCO, Nursing Supervisor or clinical area manager shall immediately notify the Administrator on call.
4. Notify the patient's attending physician.
5. Document the allegations on a complaint form and enter as an event report. Forward immediately to the DQM or Administrator on call for investigation.

Investigation Guidelines include:
If suspected abuse, neglect, mistreatment and/or exploitation involves an employee, the Hospital Chief Executive Officer will determine the action to be taken based on the investigation performed by the CCO or their designee. The employee may be suspended during the investigation, and if abuse is confirmed, termination of employment will result.
All allegations will be conducted under the guidance of the Administrative staff who will, depending on the circumstance:
Seek information in a thorough, impartial, dignified, and confidential manner.
Interview witnesses, including the charged individual(s), and obtain signed statements when appropriate.
Assure that embarrassment of the patient (s) and/or individual(s) is avoided.
Assess charged employees' work records and note any history of similar incidents or related behaviors.
Investigate all other possible sources of information relating to the incident and/or the personal involved.
Required report to licensing agencies (Board of Nurse Examiners, Board of Respiratory Care Practitioners, Board of Clinical Nursing Assistants, etc.) as mandated by law will be made by the CCO or DQM after consultation with the Hospital Chief Executive Officer.
Reports that are taken from patients and/or families and logged on the Complaint Form will be responded to, in writing, with findings and recommendations resulting from investigation within seven days of receipt of the form by the COO.

On 09/02/10 and 09/03/10, a review of staff counseling/corrective actions for Staff K revealed this employee was verbally counseled on 03/12/10 for being rude to Patient (unknown -no name provided) regarding assisting the patient. According to an interview on 09/03/10 between 9:15 AM and 10:00 AM, Staff F verified Staff K was verbally rude to this patient and received verbal counseling for violation of behavioral standards set by the facility. On 03/17/10, another staff reported Staff K for giving a patient the incorrect consistency of liquids, which was validated by Staff F. On 06/26/10, Staff K received a written warning regarding answering a personal cell phone in a patient's room. A final written warning was give to Staff K on 06/26/10 for behavorial infraction lack of professionalism. Staff K was discharged on 07/08/10 for unprofessional behavior and poor patient care. This was done after Patient #16 complained Staff K was rude to the patient and turned the patient roughly. An interview with Staff F on 09/03/10 at 8:58 AM verified this did occur; resulting in dismissal of Staff K at that time.

The facility failed to follow their policy for zero tolerance of staff being rude to patients as Staff K continued to work as a direct care staff after it was verified the employee was rude to a patient in March 2010.

On 09/03/10, a review of patient and family grievance report form dated 05/19/10 submitted by Patient #17's family member documented the patient was upset that he/she overheard Staff H making a statement that this patient needs to be in a padded cell of a psychiatric ward. It was verified by Staff G that this employee and Staff I were both counseled for making this rude and inappropriate comment about Patient #17.
This was verified with Staff F on 09/03/10 at 9:45 AM.

On 09/03/10 a review of staff counseling forms for Staff J (patient care technician) revealed the employee provided inappropriate care to patients as follows:
on 05/21/10, received verbal counseling regarding behavior regarding Patient #18's complaints of being rough with the patient during care, causing the patient's abdominal drainage lines to come apart and spray bile drainage into the patient's face. This resulted in a written warning and not allowing this employee to provide further care to Patient #18. This employee was terminated on 07/26/10 for behavior/failing to follow policies and procedures. The facility failed to follow their policy to remove Staff J from providing patient care after the the verbal counseling regarding providing rough treatment to Patient #18. This was verified with Staff F on 09/03/10 at 9:45 AM.

Based on review of the medical record and interview and confirmation with staff it was determined that the facility failed to ensure that a written physician's order was obtained fora patient who was in restraints. This involved 3 patients (#12, #19, #25) from the total of 30 medical records reviewed. The hospital census was 33.
Findings include:
The medical record for Patient #12 was reviewed on 09/02/10. Patient #12 was admitted on 08/10/10, with respiratory failure and pneumonia. On 08/11/10, an order was written for Patient #12 to be placed in restraints. On 08/19/10, an order was written to extend the use of restraints for 24 hours.The medical record lacked evidence of the time this order was written. There was no further written order regarding the use of restraints until 08/21/10, when the physician wrote an order to discontinue the use of restraints. However, Patient #12 remained in restraints throughout this period of time according to the nursing progress notes. There was no order to for the use of restraints from 08/20/10 to 08/21/10 at 3:36 PM. This was confirmed with Staff F on 09/02/10 at 3:00 PM.
The medical record for Patient #19 was reviewed on 09/03/10. Patient #19 was admitted on 07/26/10, with diagnoses of chronic respiratory failure, recent stroke and diabetes. On 08/07, 08/12, 08/13 it was noted that the physician signed the restraint orders but did not complete the order regarding the emergent need for the restraint, location, site, reason and duration of the order. This was confirmed with Staff O on 09/03/10 at 9:00 AM.

Based on review of the medical record, review of the hospital policy and interview and confirmation with staff it was determined that the staff failed to ensure that a patient who was in restraints was monitored every 2 hours. This affected 1 patient (#19) from the total of 30 patient medical records reviewed. The hospital census was 33.

Findings include:

The medical record for Patient #19 was reviewed on 09/03/10. Patient #19 was admitted on 07/26/10 with diagnoses of respiratory failure, diabetes and a recent stroke. Patient #19 was in restraints. A review of the hospital policy completed on 09/03/10 and revealed that every 2 hours restrained patients should be assessed for their mental status, need for toileting assistance, fluids should be offered and every 4 hours their nutritional needs must be assessed. On 09/01/10 from 3:00 AM to 8:07 AM, the medical record lacked evidence the patient was observed and assessed while in restraints. This was confirmed with Staff O on 09/03/10 at 9:00 AM.

Based on medical record review and staff interview, the facility failed to ensure the registered nurse evaluated the nursing care for each patient related to reporting of a patient's rash and assessment for fall risk. This affected 2 patients (#1, #15) from the total of 30 patient medical records reviewed. The total census was 33.

Findings include:

Review of Patient #1's medical record on 8/30/2010 and 8/31/2010, revealed a nursing assessment on 8/18/2010 at 1:48 PM, that reported the patient had a rash (scattered, flattened and red blanchable) on the entire torso, abdomen and the right and left anterior thighs. The rash was next noted in a nurses note dated 8/21/2010 at 1:53 AM, that the patient had a rash on the entire torso, abdomen, right and left anterior thighs. The rash was scattered, raised, smooth and red non-blanchable. The nurses note on 8/23/10 noted the rash was on the entire torso, abdomen, right and left anterior thighs scattered. On 8/24/2010 at 9:47 AM the nurses notes noted that the rash was still present. The nurses' notes on 8/27/2010 addressed the rash. There was no documentation of notification of the physician regarding the rash. The history and physical performed by the physician on admission (8/18/2010 at 3:50 PM) and the infectious disease consult physician on 8/19/2010, reported there was no rash on admission.
The next mention of a rash in the nurses' notes was dated 8/31/2010. The nurses' note indicated Patient #1's skin was scarlet red from head to toe with fluid filled blisters ranging from 1 cm (centimeter ) to 6 cm and the skin was sloughing off at the left thoracic area, abdomen, hips and legs as well as the chest. The Physician Assistant and the Physician were notified. The Physician assessed the patient. The Physician's progress note on 8/31/2010 at 10:00 PM stated the rash was new. The patient was sent out to the hospital on 9/1/2010 in the AM.
Interview of Staff B on 8/31/2010 at 2:00 PM, regarding when the rash was first identified, revealed there was discrepancy between the physicians and the nurses documentation. The physicians stated that there was no rash on admission or during the patient's stay until the nurse notified them of a rash on 8/31/2010.

This same patient,according to the nurses' progress notes, fell on 8/19/2010 at 7:40 AM. The nurses note indicated that the patient was seen sitting on floor next to the bed with knees bent. The patient was assessed to be oriented to person only. The patient's PICC line was stretched and only partly inserted in the patient's arm. The patient had a history of falls according to the nurses' note. The same nurses note stated no follow up was anticipated. There was no further mention of the fall and no evidence of monitoring of the patient. The admission nursing assessment and the physician history and physical indicated that the patient was alert and oriented to time, place and person. The plan of care, initiated after the fall, indicated the patient had a history of falls; however the nursing initial assessment and the physician's history and physical did not indicate the patient was at risk for falls.


The medical record for Patient #5 was reviewed on 08/31/10. The patient was
admitted to the hospital on 08/13/10 with a diagnosis of Morbid Obesity. The
patient is status post an amputation. The patient is currently admitted to the
facility. The medical record contained evidence the patient's physician
ordered the patient to be in bilateral arm restraints on multiple dates during
his/her admission, including an order written on 08/25/10 at 8:00 A.M. The medical
record revealed evidence the nurse caring for the patient had documented the
restraints as " on " at 10:00 A.M., 12:00 P.M., 2:00 P.M. and 4:08 P.M. on 08/25/10. The note at 4:08 P.M. described the patient's level of consciousness as " sleeping. "
The documentation lacked any information regarding the patient's restraint status at
the time of the fall. These findings were shared with hospital Administrative
staff on 09/01/10 at 4:00 P.M. Staff A was interviewed on 09/02/10 at 11:30 A.M.
regarding the status of the patient's restraints. Staff A indicated interviews
were conducted with staff and written documentation regarding the interviews
was presented to the surveyor for review. The documentation revealed the speech therapist progress notes indicated the restraints were removed for treatment and not reapplied due to Occupational Therapy entering room to work with patient. The documentation stated the
nurse (Staff L) was interviewed on 09/01/10 at 5:45 P.M. and indicated no visual
assessment was done at the time she had documented the restraints were "on". The nurse verbalized understanding regarding this being false documentation. The nurse was suspended pending further investigation. On 09/02/10 at 10:25 A.M., the patient care technician was
interviewed by phone, but she stated she was unable to recall events without reviewing
the chart. The patient care technician was also suspended pending completion of
the investigation.

Based on medical record review and staff interview, the facility failed to ensure all patients identified as at risk for falls had care plans that identified this risk. This affected 2 patients (#14, #15) from the total of 30 patients medical records reviewed. The total census was 33.


Findings include:


On 09/02/10, review of Patient #14's electronic medical record was conducted with Staff G. The record revealed the patient was admitted on 08/28/10, for acute renal failure. The patient was identified at risk for falls on 09/01/10. According to an interview with Staff G on 09/02/10 at 2:52 PM, the patient was in a low bed and was receiving hourly checks (all eyes on me program) for the first 24 hours after admission. There was no care plan in place for the low bed or for the hourly checks. This was verified with Staff G on 09/02/10 at 2:53 PM.


An electronic record review of Patient #15's medical record, conducted with Staff G on 09/02/10, revealed the patient had fall precautions in place prior to a fall on 07/11/10 at 1:45 AM. The record documented the respiratory department found the patient on the floor on his/her hands and knees with his/her head resting on the bed. The patient stated he/she was standing to use the bathroom, his/her knees buckled and gave out, resulting in a fall to his/her knees. The fall precaution measures in place at the time of the fall were as follows: falling leaf on the door frame of the room to alert staff to fall risk, educate the patient to ambulate with assistance, assist with transferring, bed in low position, side rails in up position, call light within reach, hazardous objects removed from patient's reach, check for safety every two hours. After the fall on 07/11/10, staff implemented hourly checks for 24 hours.
There was no care plan in place for the hourly checks, the low bed, or for moving the patient closer to the nursing station. Staff G verified the lack of a care plan for these fall precautions for Patient #15.

Based on review of the medical record, review of the hospitals policies and procedures and interview and confirmation with staff it was determined that the staff failed to administer blood as ordered by the physician in a timely manner. This involved one (Patient #9) patient from the total of 30 patient medical records reviewed. The hospital census is 33.

Findings include:

On 09/03/10, a medical record review was performed for Patient #17'. This patient had a physician's order on 07/13/10 at 6:30 AM, to receive one unit of blood for a low hemoglobin level of 7.9. The record documented the blood was not given to the patient until 7:30 PM on that same date (13 hours later) because the nurse on duty at the time the physician's order was received did not call a courier service to pick up the blood product that resulted in a delay of 13 hours. According to an interview conducted with Staff F on 09/03/10 at 9:45 AM, Staff H forgot to call the courier to pick up the unit of blood at the off-site facility after receiving notification the type and crossmatch was done. Staff F stated another nurse coming in on the evening shift on 07/13/10, recognized the unit of blood had not been given, called the courier, and then administered the blood at 7:30 PM, to Patient #17, after it arrived at this facility.




27700