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Based on record review and interview, the hospital failed to ensure that the grievance process was implemented as evidenced by failing to thoroughly investigate grievances for 2 of 3 patient grievances reviewed (Patient #1, R1) from a total sample of 5.
Findings:

Review of the hospital policy titled, Complaint/Grievance Process (Policy 1-4.5.0), revealed that a grievance will be recorded on the complaint/grievance form. The form will include a thorough description of the grievance and the parties involved. The completed form will be forwarded to the administrator/assistant administrator or designee. The hospitals administrator/assistant administrator will be responsible for the review, investigation and resolve of all patient grievances.

Patient #1
Review of a letter sent to the hospital by the son of patient #1 revealed "The biggest concern I have was his wound care." The letter further revealed that there were different nurses that tended to the wound and they had very little supervision. The complaint letter further stated that after his father was transferred to a rehabilitation center at discharge on 12/29/16, his wound was still very bad and had not improved and that a piece of gauze had been found in the wound.

Review of the investigation documentation, dated 01/16/17, provided by S1DON revealed that she had talked to the wound care nurse and the physician and they stated that they had looked at the wound on the day prior to discharge (12/28/16) and found no foreign material. There was no further documented investigation regarding the complaint of the patient's wound care.

Review of the patient's medical record revealed the patient had a Stage IV pressure sore to the buttocks upon discharge from the hospital on 12/29/16. There was no documented evidence in the record that assessments of the wound were performed every shift by nursing or that the wound received treatments as ordered by the physician.

On 02/16/17 at 12:30 p.m., interview with S1DON and S7Administrator confirmed that a thorough investigation was not performed on the above grievance. S1DON stated that she had not reviewed the patient's chart to ensure that treatments were carried out as ordered and that assessments were performed of the wound at least every shift. She further confirmed that wound assessments were not performed every shift and treatments to the wound were not performed as ordered by the physician, but she did not identify this during her investigation of the grievance.

Patient #R1
Review of the Complaint/Grievance Form dated 01/03/17 revealed that a family member of Patient #R1 phoned S1DON and complained that the therapy department did not know "how to exercise a patient" and they acted as if "they did not care" about the patient. The complaint further revealed that the family member stated that she stood outside the therapy gym and listened to the therapists talk about their holidays and would tell the patient every now and then to move his feet. The therapists did not try to walk the patient and he was walking prior to this hospital admit. The family member further complained about the patient having blood in his catheter and the nursing staff would not tell her why.

Review of the area on the Complaint/Grievance Form titled "Actions Taken" revealed that S1DON documented that she discussed events with charge nurse and staff nurses responsible for patient. Reinforced need for explanation about his care. Also discussed their attitude and an illusion of lack of knowledge. There was no documented evidence that a thorough investigation had been conducted regarding the grievance.

On 02/16/17 at 1130 a.m., interview with S4 Director of Therapy revealed that he was not aware of the above grievance regarding Patient #R1. On 02/16/17 at 12:30 p.m., interview with S1DON and S7Administrator confirmed that a thorough investigation was not performed on the above grievance.

Based on record review and interview, the hospital failed to ensure the RN supervised and evaluated the nursing care of each patient as evidenced by 1) failing to perform complete wound assessments upon admit for 3 patients (#1, 3, 5) with wounds and 2) failing to perform reassessments of wounds for 3 patients (#1, 3, 5) with wounds in a total sample of 5.
Findings:

Review of the hospital policy titled Patient Assessment/Reassessment (policy 9-1.1.0) revealed in part that an RN shall be responsible for the initial patient assessment. The initial patient assessment is completed within 8 hours of admit. The initial patient assessment performed by nursing will include the following information:......wound assessment. All wound dressings will be removed and wounds will be visualized, assessed and measured. All pressure sores will be staged by and RN within 8 hours of admission. At a minimum, all wounds or wound dressings will be re-assessed each shift. Assessment of the wound will include documentation of the wound bed, surrounding tissue, drainage and odor. For wounds that do not require a dressing change during the shift, an assessment of the condition of the dressing will be documented. All wounds will be measured at least weekly and prn. Within 2 days of a planned discharge, all wounds/pressure ulcers will be assessed, measured and staged.


Patient #1
Review of the medical record revealed the patient was admitted to the hospital on 11/18/16 with diagnoses including MRSA sepsis and infected right buttock decubitus ulcer. An admit order was written to consult the Wound Care Nurse/Specialist.

Review of the Skin Integrity/Wound Identification Form revealed 2 pressure ulcers were identified on admit on 11/18/16, including an unstageable pressure ulcer to the right buttock and a Stage I pressure ulcer to the right foot. There was no documented assessment of the pressure ulcer to the right foot and there were no measurements of the unstageable ulcer to the right buttock.

Review of the Pressure Ulcer Wound Assessment Form revealed a full assessment of the above wounds, including measurements, was not conducted until 3 days later, on 11/21/16, by S8Wound Care Nurse. Further assessments with measurements were conducted by S8Wound Care Nurse on 11/30/16 (9 days later), 12/01/16, 12/07/16, 12/13/16, 12/19/16 and 12/29/16 (9 days after previous full assessment).

Review of the physician orders revealed wound treatments and dressing changes were to be performed to the right buttock pressure ulcer daily until 12/02/16, when the treatment order was changed to twice daily. Review of the Wound Care Treatment Flow Sheet revealed no documented assessments of the pressure ulcer to the right buttock on the following dates: 11/29/16, 12/06/16, 12/09/16, 12/14/16, 12/15/16, 12/20/16, 12/21/16, 12/23/16 and 12/28/16.

On 02/14/17 at 3:00 p.m., interview with S1DON confirmed that the initial wound assessment and ongoing re-assessments were not conducted within a timely manner as defined by the hospital policy.

Patient #3
Review of the medical record revealed sampled patient #3 was admitted to the hospital on 01/20/17 at 8:55PM from home with a diagnosis of left foot cellulitis (infected diabetic foot ulcers). An order was noted to consult the Wound Care Nurse/Specialist.

Review of the Skin Integrity/Wound Identification Form revealed 3 wounds were identified on 01/20/17 at 9:00PM and classified as diabetic ulcers - on the left great toe, a left toe and a 3rd toe. There was no signature or initials on the form to indicate who identified the wounds. There was no assessment of the wounds at that time.

Review of the Wound Assessment Form revealed a full assessment of the wounds was not conducted until 01/23/17 at 9:30AM by S8Wound Care Nurse. She assessed wounds to the left great toe (#1), the left 1st MTH plantar (#2), and the left 3rd toe (#3). Further assessments with measurements were conducted by S8Wound Care Nurse on 01/30/17 and 02/06/17. A full assessment including measurement of the wounds was not conducted again prior to the discharge of patient #3 on 02/14/17.

Review of the Wound Care Treatment Flow Sheet revealed there were no assessments of the wounds documented between 01/23/17 and 01/30/17. There were no documented assessments of wound #1 on 01/31/17, 02/02/17, 02/05/17, 02/07/17, 02/10/17, 02/11/17, 02/12/17; no documented assessments of wound #2 on 01/31/17, 02/05/17, 02/07/17, 02/10/17, 02/11/17, 02/12/17; no documented assessments of wound #3 on any shift from 01/31/17 through 02/05/17 and from 02/07/17 through 02/13/17.

Patient #5
Review of the medical record revealed patient #5 was admitted on 02/03/17 at 9:50PM from the acute care hospital with cellulitis of the right lower extremity and right elbow. Orders were noted to consult the Wound Care Nurse/Specialist. There were no orders written for wound care at admission. There were no documented wound care orders for the treatment of wounds until 02/06/17.

Review of the Skin Integrity/Wound Identification Form revealed 3 areas with wounds were identified on 02/03/17 at 10:00PM - classified as a bruise on the right posterior knee and scabs on the right anterior shin and left anterior shin. There was no signature or initials on the form to indicate who identified the wounds. There was no assessment of the wounds at that time.

Review of the Wound Assessment Form revealed an assessment of wounds was not conducted until 02/06/17 at 1:30PM by S8Wound Care Nurse. She identified full thickness wounds on the right wrist (#1), the right elbow (#2), the right lower anterior leg (#3) and a blister on the right upper arm (#4). Further assessment of the wounds with measurements was conducted on 02/14/17.

Review of the Wound Care Treatment Flow Sheet revealed no documented evidence that any of the wounds were assessed on any shift between 06/06/17 and 02/14/17.

On 02/15/17 at 2:00PM, an interview with S1DON confirmed that the initial wound assessments and ongoing assessments were not conducted within a timely manner as defined by the policy.


17450

Based on record review and interview, the hospital failed to ensure that drugs and biologicals were administered in accordance with the orders of the practitioner responsible for the patient's care. This deficient practice is evidenced by failure of the nursing staff to administer medication as ordered for 1 sampled patient (#1) and failure to perform wound care treatments as ordered for 2 sampled patients (#1, #3 ) in a total sample of 5.
Findings:

Review of the hospital policy titled, Medication Administration (Policy 9-4.13.0), revealed that the nurse shall document on the MAR or in the nurses narrative notes the reason the drug was not given. If the patient refuses a medication or is unable to take a medication, the physician must be notified on his/her next visit or via phone call depending on the clinical situation and patient need for the medication.

Patient #1
Review of the medical record for sampled patient #1 revealed the patient was admitted to the hospital on 11/18/16 with diagnoses including MRSA sepsis, infected right buttock ulcer and malnutrition. Review of the physician order dated 11/30/16 revealed an order for Megace (used as an appetite stimulant) 800mg by mouth twice daily. Review of the patient's November and December 2016 MAR revealed documentation that the patient received 13 of 32 total Megace doses, due to the patient refusing the medication. The physician wrote an order on 12/16/16 to hold the Megace. There was no documented evidence in the record that the patient's physician was notified that the medication was not being administered as ordered.

Further review of a physician order, dated 12/02/16, revealed a new order for the treatment to the patient's right buttock pressure sore. The order revealed the treatment was to be performed twice daily. Review of the December 2016 Wound Care Treatment Flowsheet revealed no documented evidence that the patient's right buttock pressure sore was treated twice daily as ordered by the physician on the following dates: 12/09/16, 12/15/16, 12/17/16, 12/20/16, 12/23/16, 12/27/16, 12/28/16. Further review revealed no documented evidence that the patient's right buttock pressure sore received any treatment on 12/06/16.

On 02/14/17 at 3:00 p.m., interview with S1DON confirmed that there was no documented evidence in the record that Megace was administered as ordered or that the physician was notified of the patient's refusal to take the medication. Further interview with S1DON confirmed that there was no documented evidence on the above dates that the patient's right buttock pressure sore received treatment as ordered by the physician.


Patient #3

Review of the medical record revealed sampled patient #3 was admitted to the hospital on 01/20/17 at 8:55PM from home with a diagnosis of left foot cellulitis (infected diabetic foot ulcers). An order was noted to consult the Wound Care Nurse/Specialist.

On 01/21/17 an order was noted for saline wet to dry dressing to the left foot daily.

New orders were noted on 01/23/17:
#1 left great toe, #2 first toe: rinse with wound cleanser, apply skin prep to periwound, apply Aquacel AG or Durafiber to open wound, cover with gauze, ABD pad, secure with kerlix - change daily and as needed
#3 3rd toe: clean with wound cleanser, apply skin prep, 4x4, secure with kerlix - change daily and as needed.

Review of the Wound Care Treatment Flow Sheets for patient #3 revealed no documented evidence that treatments were performed to wound #1 (left great toe) and wound #2 (left 1st toe plantar) on 01/27/17 or 01/28/17. Further, no documented evidence was noted that treatments were performed to wound #3 (left 3rd toe) on 01/25/17, 01/26/17, 01/27/17 or 01/28/17.

New orders were noted on 01/30/17:
#1: rinse with wound cleanser, apply protective ointment to periwound, solosite gel to open wound, cover with piece of Mepital gauze, secure with kerlix, change daily and as needed;
#2: rinse with wound cleanser, apply protective ointment to periwound, solosite gel to wound, cover with gauze, ABD, secure with kerlix and tape, change daily and as needed.

Review of the Wound Care Treatment Flow Sheets for patient #3 revealed no documented evidence that treatments were performed to wound #1 (left great toe) and wound #2 (left 1st toe plantar) on 02/02/17 or 02/05/17. Further, no documented evidence was noted that treatments were performed to wound #3 (left 3rd toe) on 02/01/17, 02/05/17 or 02/11/17.

On 02/15/17 at 2:00 p.m., an interview with S1DON confirmed that there was no documented evidence that the above wound treatments for sampled resident #3 were performed as ordered by the physician.









20310

Based on record review and interview, the hospital failed to ensure that patients with documented weight loss were assessed and monitored by the Registered Dietician and recommendations were made to prevent further weight loss for 1 of 5 sampled patients with weight loss (Patient #1).
Findings:

Review of the medical record for Patient #1 revealed the patient was admitted to the hospital on 11/18/16 with diagnoses including MRSA sepsis, infected right buttock ulcer and malnutrition. Further review revealed other diagnoses including type 2 diabetes, coronary artery disease and hyperlipidemia. Review of the admit assessment dated 11/18/16 revealed the patient weighed 188.7 pounds. The patient's physician ordered daily weights upon admit. Review of the patient's daily weights revealed they included the following:
11/19/16, 191.7, "Reweighed" was written beside the weight
11/20/16, 185#
11/21/16, 182.5#
11/24/16, 172.6#
11/26/16, 170.6#
11/30/16, 164.4#
12/06/16, 166#
12/11/16, 165#
12/19/16, 158.7#
12/21/16, 165.4#
12/28/16, 173.5#

Review of the initial dietary assessment, dated 11/21/16 and conducted by R6Registered Dietician, revealed that she changed the patient's diet to diabetic with interventions to increase intake by mouth. Review of the next RD note, dated 11/28/16, revealed patient confused at times per physicians notes and documentation revealed that patient eats approximately 50% of meals. The RD documented the patient's weight had decreased to 164.4 pounds but no recommendations were made. This was a 24.3 pound weight loss since admit.

Review of the next RD note, dated 12/06/16, revealed the patient was on Nepro nutritional supplement twice daily and eating approximately 50% of all meals. Continues with wound care. Weight of 166 pounds (weight fluctuations). Megace added, patient refuses per MAR and patient also refuses Prostat. No recommendations were made by the RD at this time.

Review of the next RD note dated 12/13/16 revealed that patient was on a diabetic diet with Nepro supplements with meals. Wound care continues to coccyx. Good intake overall, weight 165.7 pounds.

The next RD note dated 12/19/16 revealed that patient continues with decreased intake and family brings in food for patient. Patient is receiving diabetic diet and Nepro supplements three times daily. Megace was discontinued. Weight has decreased to 158.7 pounds. The RD made no recommendations, although a 30 pound weight loss had been documented.

The next RD note dated 12/21/16 revealed that the patient was now on a regular diet with Ensure supplements. Continues with poor overall intake. Weight 165.4 pounds (weight decreased overall from admit). Continue with wound care and encourage intake by mouth. No recommendations were made by the RD.

Review of the physician orders revealed the physician initiated the orders for the appetite stimulant, Megace 800mg twice daily (on 11/30/16) and the Ensure supplements, one can three times daily (on 12/04/16). Further review of the physician orders revealed the Megace was put on hold on 12/16/16 and discontinued on 12/18/16. No documented reason was given for stopping the Megace.

Review of the patient's medical record revealed no documented evidence that Ensure was provided to the patient as ordered by the physician. Further review of the patient's November and December 2016 MAR revealed that the patient frequently refused the Megace, and only received it a total of 13 out of 32 doses, with no documented evidence that the physician was notified.

Review of the patient's Intake and Output sheets, which included meal intake, revealed no meal intake was documented for 12/28/16, and no dinner intake was documented for 11/20-11/23/16, 12/05-12/23/16, and 12/25-12/27/16.

On 02/14/17 at 3:00 p.m., S1DON reviewed the record for patient #1 and confirmed that there was no documented evidence that the patient was receiving ensure three times daily as ordered. She further confirmed the above missing meal intake documentation.

On 02/15/17 at 2:00 p.m., an interview was held with S6Registered Dietician and she reviewed the patient's record. She stated that she believed that the patient had lost weight, but was not sure if the weights were correct. When asked if she had gotten the staff to reweigh the patient in order to get a confirmed weight, she stated no. The RD stated that she would ask the staff how the patient was eating and drinking the nutritional supplements that were ordered. When asked if she was aware that there was no documented evidence in the record that the patient was receiving the Ensure supplements, she stated no. Further interview with the RD revealed that she reviewed the patient's Intake and Output forms for meal intake documentation. When asked if she was aware that there were very few entries made for dinner intake, she stated no. She further stated that she was unaware why her notes stated the patient was on Nepro, when the physician ordered Ensure supplements.

Further interview with S6Registered Dietician confirmed that the patient's weight dropped from 188.7# on admit 11/18/16 to 164.4# on her next visit on 11/28/16. She confirmed that the patient continued to slowly lose weight, and she made no recommendations to prevent further loss. She further stated that she likes to look at the trend.