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Based on observation, record review and interview, the hospital failed to protect and promote patient's rights to be free from harm and neglect as evidenced by:

1. Failing to provide appropriate nursing interventions for patient #2 which resulted in a tibia plateau fracture, and patient #1 which resulted in the patient with a new above the knee amputation falling out of bed. (Refer to A-144, A-395)

Based on record review and interview, the hospital failed to ensure:

A. An RN supervised each unit in the facility and was immediately available for bedside care of a patient at all times.

This failed practice had the potential for hospital-acquired infections, delayed wound healing, and poor pain management due to the lack of patient assessments by an RN and supervision of nursing care provided by inexperienced nurses. (Refer to A-392)


B. An RN evaluated care for 3 (Patients #1, 2, and 11) of 21 records reviewed.

This failed practice resulted in:

1. Patient #1 not being treated as a high fall risk and subsequently sustained a fall;
2. Patient #2's repeated removal of invasive lines and repeated acts of self-harm, including ingestion (and/or suspected ingestion) of multiple objects and substances; and
3. The potential for deterioration of multiple medical conditions for Patient #11 due to the lack of supervision of nursing staff without current training or demonstrated competencies providing care. (Refer to A-395)


C. Patients were assigned to nurses without current demonstrated training and competencies appropriate for patients' needs for 2 (Patients #9 and 11) of 21 records reviewed. (Refer to A-397)

Based on observation, record review and interview, the hospital failed to provide a safe environment free from falls and injury for 2 (patients #1 and 2) of 3 inpatients observed on the medical/surgical unit.

Findings:

Patient #1: a confused and new above-the-knee amputee, was assessed on admission as needing fall precautions; the patient was not placed on fall precautions. Surveyors observed the patient attempting to crawl out of bed and staff assisting patient. Patient #1 was placed on fall precautions after this attempt which included placing a sign on the door, lowering the bed to the lowest position and having the patient's room remain close to the nurse's station. The patient's significant other stayed with the patient most of the time.

On 12/06/17 at 9:00 am, the patient's significant other told the surveyor the patient had rolled out of bed during the night and fallen to the floor.

The medical record did not document the fall; there was no documentation that the physician was notified of the fall. An incident report was completed. The immediate corrective actions included:

1. Instructed not to get out of bed without assistance
2. Bed alarm
3. Fall precautions on chart

12/06/17 at 10:25 am, the CCO and DQM were asked if they felt instructing a patient to not get out of bed without assistance was an appropriate corrective action for a very confused patient. The DQM asked what the surveyors wanted the facility to do about falls. Surveyors explained purpose was to gather information regarding their processes in relation to the conditions of participation. No additional corrective actions were provided.


Patient #2: a confused, spinal cord injury (of 12 years) patient that was admitted on 11/10/17 for wound care and antibiotic therapy. The patient was able to move self from bed to wheel chair, provide self-catheterization and care of the colostomy. The patient had multiple episodes documented of yelling, scratching self, and removing clothing, PICC lines, wound dressings, Foley catheter and colostomy bag. The patient was discharged to another facility on 12/6/17 for repair of stoma.

On 11/27/17 at 6:05 am, Staff T attempted to move this patient from the bed to wheelchair without another staff member's assistance, no gait belt, or mechanical lifting assistance.

Staff T reports that during the transfer, Patient #2's leg was wrapped around the pedal and the patient started to fall. Staff T transferred the patient back to the bed and the right leg was "hung up on something under the bed or on wheelchair". The patient was taken to x-ray and a fracture of the lateral tibial plateau with depression was found. On 11/30/17 at 7:30 am, the patient was taken to an appointment with an orthopedic surgeon. There was no documentation of recommendations or care provided to this patient following the appointment.


Policy titled "Fall Prevention" states that a gait-belt was to be used for patient transfers that require assistance from staff.


In addition to the patient actions documented in the medical record, during interviews on 12/5/17, 12/6/17, 12/7/17 and 12/12/17 various staff members stated this patient had been found drinking soap from the dispenser in the room, had possibly swallowed a ring, had possibly swallowed a fentanyl patch, had been seen trying to exit the floor through a stairwell while in a wheelchair, and staff had removed the patient's wheelchair to prevent patient from leaving room. The patient's medical record did not indicate safety measures for these behaviors were implemented.

Based on record review and interview, the hospital failed to ensure an RN supervised the medical/surgical unit and an RN supervised the ICU, and was immediately available for bedside care of a patient at all times. (Refer to A-395 and A-397)

Findings:

A policy titled "Nursing Staffing Plan" stated the RN supervisor/charge nurse would be immediately available to assist and supervise patient care, as well as respond to emergency situations. Staffing levels would be based on several considerations, including patient acuity and experience of available staff. The CCO had the final decision regarding approval of the staffing plan.

A staff schedule dated 11/28/17 showed a total patient census of 12 with 6 patients in medical-surgical, and 6 patients in ICU. For the 7:00 am to 7:00 pm shift, Staff J was assigned to 3 patients in the ICU, in addition to being assigned to Nursing Supervisor for the shift. Staff U (an LPN) was assigned to the remaining 3 patients in the ICU, and Staff M (an LPN with less than 1 year of experience) was assigned to 6 patients in the medical-surgical unit. Staff J was the only RN in the facility, designated as the supervising nurse for 2 units.

During staff interviews conducted on 12/07/17 and 12/12/17, the following statements were made:

1. Staff M stated he/she was not oriented to the ICU before working in the unit, and frequently the supervising RN was not available to assist because of their own patients' needs.

2. Staff J stated the facility was understaffed almost every day, and discussed the staffing schedule from 11/28/17 as an example; he/she also stated the supervising RN was responsible for monitoring telemetry in the ICU, and other nursing staff were rarely able to assist due to their patient responsibilities. When asked if any monitor technicians or nursing technicians worked in the ICU, Staff J stated no technicians worked in the ICU; a review of employee schedules from 10/01/17 to 11/30/17 confirmed no technicians were scheduled for the ICU.

3. Staff V stated the supervising RN was often unable to assist other nursing staff due to their own patients' needs.

4. Staff F stated the supervising RN was responsible for monitoring the telemetry in the ICU and this duty made it difficult to complete other tasks; was always counted as a staff nurse in the ICU and was given their own patient assignments; additionally, the supervising RN would take the higher acuity patients when an inexperienced nurse was assigned as the second nurse in the ICU.

Based on observation, record review and interview, the hospital failed to ensure an RN evaluated care for 3 (Patients #1, 2, and 11) of 21 records reviewed.

This failed practice resulted in:

1. Patient #1 not being treated as a high fall risk and subsequently sustained a fall;

2. Patient #2's repeated removal of invasive lines and repeated acts of self-harm, including ingestion (and/or suspected ingestion) of multiple objects and substances; and

3. The potential for deterioration of multiple medical conditions for Patient #11 due to the lack of supervision of nursing staff without current training or demonstrated competencies providing care.


Findings:


1. Patient #1 was admitted to the medical-surgical unit on 12/01/17.

A policy titled "Fall Prevention" stated upon admission, the patient's risk for falls would be assessed using the "Morse Fall Scale". Those patients assessed to be high risk for falls would have interventions added to their care plan, including:

A. Use of "Fall Prevention" yellow magnet applied to the door frame;

B. A yellow wrist band for the patient to wear, indicating the patient was at high risk for falls; and

C. Use of a "low bed".


On 12/05/17 at 1:30 pm, the surveyors observed Patient #1 sitting up on the side of the bed (not in a low position) and attempting to stand without assistance. There were no fall precautions posted on the patient's door. Two staff members entered the room to assist the patient and requested that he/she not get up without assistance.

A review of the nursing admission assessment showed the patient was confused and a recent lower leg amputee. The patient was assessed to be at high risk for falls upon admission. There was no documentation falls precautions were initiated.


On 12/06/17 at 9:00 am, the patient's spouse reported he/she had fallen out of bed that night.


During staff interviews conducted on 12/04/17, 12/05/17, 12/07/17 and 12/12/17, the following statements were made:

A. Staff K stated there was no information provided that the patient was at high risk for falls.

B. Staff A stated he/she did not know why the patient was not placed on fall precautions on admission.

C. Staff M stated there was no documentation in the clinical record about the fall, and the fall was not mentioned in shift report.


2. Patient #2 was admitted to the medical-surgical unit on 11/11/17.

A policy titled "Assessment-Reassessment Interdisciplinary Patient" defined an acute change of condition as a change from the patient's baseline in physical, cognitive, behavioral, or functional domains. The policy stated an acute change in condition required patient reassessment and updates to the plan of care as appropriate to address needs/problems.

A review of the clinical record showed documentation of the following incidents:

A. Upon admission on 11/11/17, the patient was described as alert and oriented;

B. On 11/12/17 at 3:50 am, the patient was screaming, pulling off wound dressings, and had pulled out his/her PICC line;

C. On 11/12/17 at 12:30 pm, the patient was screaming, "unable to verbally talk", and had pulled out her urinary catheter;

D. On 11/13/17 at 6:45 am, the patient was in bilateral wrist restraints and yelling;

E. On 11/13/17 at 9:14 am, the patient was combative and Zyprexa (an antipsychotic) 5mg IM was administered;

F. On 11/13/17 at 9:40 am, the patient's Fentanyl patch (a narcotic pain medication) was not found on the patient's body or in the patient's room, and staff suspected the patient had swallowed it;

G. On 11/13/17, the patient's IDT care plan showed the patient was stable, with no documentation of the patient's behaviors;

H. On 11/14/17 at 2:30 am, the patient pulled out his/her urinary catheter;

I. On 11/14/17 at 4:10 am, the patient again pulled out his/her urinary catheter;

J. On 11/14/17, the patient's IDT care plan showed no changes related to the patient's altered mental status;

K. On 11/15/17 at 12:00 am, the patient was restrained with bilateral wrist restraints;

L. On 11/16/17 at 1:25 am, the patient pulled out her urinary catheter and was placed in bilateral wrist restraints;

M. On 11/18/17 at 8:00 am, the patient told staff he/she had swallowed a ring (no evidence was found and the patient later reported it had passed);

N. On 11/19/17 at 7:30 am, the patient pulled out his/her urinary catheter;

O. On 11/19/17, the patient's IDT care plan showed no documentation of the patient being restrained on 11/13/17, 11/15/17 or 11/18/17, or any modifications to the plan of care;

P. On 11/20/17 at 6:30 am, the patient had pulled out his/her PICC line;

Q. On 11/21/17, the patient's IDT care plan showed no changes related to the patient's altered mental status, restraints, suspected ingestion of multiple objects, and/or removal of invasive lines;

R. On 11/28/17 at 5:30 am, the patient had pulled out his/her PICC line;

S. On 11/12/17, 11/14/17, 11/28/17, 12/01/17 and 12/04/17, nursing staff documented the patient had removed his/her wound dressings;

T. From 11/27/17 to 12/03/17, nursing staff documented daily (or more frequently) that the patient had removed his/her colostomy bag.


On 12/06/17 at 1:30 am, nursing notes showed the stoma was enlarged and irritated, and the current ostomy supplies no longer fit.


On 12/05/17 at 2:20 pm, Staff A stated the patient was observed drinking liquid soap; when asked under what circumstances the facility would assign a staff member to sit with a patient, Staff A initially stated the facility did not provide that service, but later stated if a patient was actively suicidal a staff member would be assigned to monitor the patient continuously. Patient #2 was not continuously monitored by staff, but Staff A was attempting to get family to stay with the patient.


On 12/06/17 at 10:45 am, Staff W stated he/she was not told the patient had swallowed soap or a ring.


During staff interviews conducted on 12/07/17 and 12/12/17, the following statements were made:


A. Staff M stated the patient was also observed drinking mouthwash during her stay. When asked how the nursing care plan is updated with new problems and how the information is given to all nursing staff, Staff M reported he/she does not attend IDT meetings and did not use the nursing care plan.


B. When asked how the nursing care plan is updated with new problems and how the information is given to all nursing staff, Staff J stated he/she does not attend IDT meetings and did not use the nursing care plan.


3. Patient #11 was admitted to the ICU from 10/18/17 to 11/17/17.


The patient's diagnoses included acute-on-chronic respiratory failure, pneumonia, rhabdomyolysis, protein-calorie malnutrition, and history of traumatic brain injury. The patient required mechanical ventilation through a tracheostomy. The patient was unable to communicate and required assistance with all activities.

A review of the clinical record showed the patient was assigned to an LPN for all shifts between 10/24/17 and 10/28/17. There was no documentation the patient was assessed by an RN, or that an RN evaluated the care provided. (Refer also to A-397)

During staff interviews conducted on 12/07/17 and 12/12/17, Staff J stated there have been shifts when 2 LPNs were working without supervision in the ICU, and the RN working in the medical-surgical unit was expected to "sign off" the LPNs' documentation.

Based on record review and interview, the hospital failed to ensure patients were assigned to nurses with current demonstrated training and competencies appropriate for patients' needs in the ICU for 2 (Patients #9 and 11) of 21 records reviewed.

This failed practice had the potential to result in increased risk for complications due to lack of nursing staff experience and training in a specialized area (ICU).

Findings:

A policy titled "Department of Nursing Orientation" stated "All Nursing Services employees, who are new to the organization or the department, will receive an orientation of sufficient scope to assure each individual possesses essential job competencies and knowledge." The policy stipulated experienced nurses (no definition of experienced was stated) would complete 6 shifts of unit-specific orientation; a new nurse would receive 4 weeks of orientation, to include 3 weeks of working with a preceptor prior to taking a full assignment of patients.

A policy titled "ICU/High Observation Standard of Care" listed multiple nursing tasks required for each patient, including (as applicable) continuous cardiac monitoring, assessment of tube placement and ventilator settings for mechanically ventilated patients, and endotracheal tube and/or tracheostomy suctioning. The policy stated a Registered Nurse must reassess the patient every 4 hours.

A policy titled "Nursing Staffing Plan" stated all nurses would be oriented to the areas of the hospital in which they would be expected to work; and all supervisors must be ACLS certified to assist in emergency situations.


Patient #9

The patient was admitted to the ICU from 09/13/17-10/01/17. Diagnoses included surgical wound dehiscence, CHF, pneumonia (described as a hospital-acquired infection), and sepsis.

On 09/17/17, Staff M provided care from 7:00 am to 7:00 pm. Staff M's personnel file showed less than 1 year of nursing experience, and no documentation of orientation to the ICU. Documentation showed the patient was not assessed every 4 hours by an RN.


Patient #11

The patient was admitted to the ICU from 10/18/17 to 11/17/17. Diagnoses included acute-on-chronic respiratory failure, pneumonia, rhabdomyolysis, protein-calorie malnutrition, and history of traumatic brain injury. The patient required mechanical ventilation through a tracheostomy. The patient was unable to communicate and required assistance with all activities.

On 10/21/17 to 10/23/17, 10/25 and 10/27/17, Staff N provided care from 7:00 am to 7:00 pm. Staff N's personnel file showed knowledge and competencies for the ICU were last assessed in 2015 by a different organization.

On 10/21/17, Staff I provided care from 7:00 pm to 7:00 am 10/22/17. Staff I's personnel file showed knowledge and competencies for the ICU were last assessed in 2015 by a different organization.

On 10/22/17, Staff L provided care from 7:00 pm to 7:00 am 10/23/17. Staff L's personnel file showed knowledge and competencies for the ICU were last assessed in 2015 by a different organization.

On 10/23/17, Staff F provided care from 7:00 pm to 7:00 am 10/24/17. Staff F's personnel file showed knowledge and competencies for the ICU were last assessed in 2015 by a different organization.

From 10/21/17 to 10/28/17, documentation showed the patient was not assessed every 4 hours by an RN.

On 10/26/17, an employee schedule showed Staff F assigned to the ICU, in addition to being assigned as the Nursing Supervisor. Staff F's personnel file showed no current ACLS certification.

During interviews conducted on 12/07/17 and 12/12/17, Staff M, J, V, and F reported there was no structured orientation program for the ICU, and nurses from the medical-surgical unit were assigned ICU patients without a preceptor when working there.