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Based on record reviews and interview, the hospital failed to ensure each patient receiving Medicare benefits, or when appropriate, the patient's representative, was provided the standardized notice, "An Important Message from Medicare" (IM), within 2 days of admission and a copy of the signed IM was provided in advance of the patient's discharge, but not more than 2 calendar days before the patient's discharge. The hospital had no documented evidence that Patient #4 had signed the IM within 2 days of admission and that Patient #5 had received the signed copy of the IM no more than 2 calendar days before she was discharged. Three (#1, #4, #5) Medicare patient records were reviewed.
Findings:

Patient #4
Review of Patient #1's medical record revealed he was admitted on 10/16/17. Further review revealed no documented evidence that he received and signed the IM within 2 days of admission.

In an interview on 10/26/17 at 3:55 p.m., S8CM confirmed Patient #4 did not sign and receive the IM at the time of or within 2 days of his admission.

Patient #5
Review of patient #5's medical record revealed she was admitted on 10/06/17 and was discharged on 10/20/17. Further review revealed no documented evidence that she received the signed copy of her IM within 2 calendar days of discharge.

In an interview on 10/26/17 at 3:05 p.m., S8CM indicated she could find no evidence in Patient #5's medical record that she had received a signed copy of the IM prior to discharge.

Based on record reviews and interview, the hospital failed to ensure the patient was provided written notice of the hospital's decision in its resolution of a grievance that contained the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion as evidenced by the hospital failing to send a written resolution letter to the complainant for 1 (#3) of 1 patient grievance reviewed.
Findings:

Review of the policy titled "Patient/Family Grievance", submitted as a current policy by S1CEO, revealed that if by the seventh day the grievance still cannot be resolved, the patient and/or their representative will be sent a written letter informing them that the investigation is still underway and that a resolution letter will be sent to them within 21 days by the Director of Social Services. A copy of all letters sent to patients will be maintained in the Director of Social Services or case manager's office. There was no documented evidence that the policy addressed when a letter of resolution would be sent if the grievance was resolved prior to seven days and what was required to be included in the resolution letter.

Review of a "Patient Complaint Form" documented by S8CM on 09/22/17 at 1:00 p.m. revealed that Patient #3's family members voiced multiple complaints regarding Patient #3's care. Further review revealed S8CM referred the information to S2ADM.

Review of a typed report dated 09/29/17, with no documented evidence of the signature of the person who typed the report, revealed that S2ADM and S3DON met with Patient #3's son and sister. Further review revealed the report included a review of the medical record with Patient #3's son and sister related to the concerns that had been voiced regarding Patient #3's care.

Review of the information presented by S3DON revealed no documented evidence that a letter of resolution had been sent to the family of Patient #4 following the investigation of the grievance.

In an interview on 10/26/17 at 4:45 p.m., S3DON indicated she typed the report of the meeting with Patient #3's son and sister. She confirmed that a letter of resolution had not been sent to Patient #3's son or sister.

Based on record reviews and interviews, the hospital failed to ensure the RN supervised and evaluated the nursing care of each patient as evidenced by:

1) The RN failed to ensure the nursing staff implemented the physician's order for assessing the patient's weight daily/weekly for 2 (#1, #4) of 5 patient records reviewed for implementation of physician orders related to weights from a sample of 5 patients.
2) The RN failed to ensure to ensure the physician's order for sliding scale Accu-checks was implemented as ordered for 1 (#5) of 1 patient record reviewed with physician orders for sliding scale Accu-checks from a sample of 5 patients.
3) The RN failed to ensure a patient's medical record included documentation of an assessment by the RN after a fall for 2 (#1, #3) of 2 patient records reviewed for patients experiencing a fall from a sample of 5 patients.
4) The RN failed to ensure a patient's wound was assessed, the physician was notified for orders for treatment, and treatment was implemented as ordered as evidenced by failure to have documented evidence of an assessment of patients' wounds for 1 (#1) of 2 (#1, #3) patient records reviewed with wounds from a sample of 5 patients.
Findings:

1) The RN failed to ensure the nursing staff implemented the physician's order for assessing the patient's weight daily/weekly:
Patient #1
Review of Patient #1's medical revealed an admit order on 10/10/17 at 4:15 p.m. to weigh him upon admission and weekly.

Review of Patient #1's "Nursing Graphic Sheet" revealed Patient #1 was weighed on admit. There was no documented evidence that he was weighed since admit, specifically on 10/17/17 and 10/24/17 (ordered to be done weekly).

In an interview on 10/26/17 at 5:10 p.m., S3DON confirmed Patient #1's medical record had no documented weights weekly as ordered.

Patient #4
Review of Patient #4's medical record revealed an admit order on 10/16/17 at 6:45 p.m. to weigh him upon admission and daily.

Review of Patient #4's "Nursing Graphic Sheet" revealed no documented evidence he was weighed daily as ordered on 10/17/17, 10/18/17, 10/19/17, 10/20/17, and 10/22/17.

In an interview on 10/26/17 at 5:25 p.m., S3DON confirmed Patient #4 was weighed daily as ordered by the physician.

2) The RN failed to ensure to ensure the physician's order for sliding scale Accu-checks was implemented as ordered:
Review of Patient #5's medical record revealed an order on 10/06/17 (no time documented) to check CBG Accu-checks ac and hs. Further review revealed an order on 10/06/17 at 5:45 p.m. for the following: if the blood sugar is below 70, and the if the patient is able to swallow, give orange juice and snack to eat; check the blood sugar in 30 minutes; if still below 70, repeat juice and snack; recheck in 30 minutes; if still below 70, give 1/2 amp Dextrose 50 in Water IV push.

Review of Patient #5's "Diabetic Flow Sheet" revealed on 10/14/17 at 7:30 a.m. Patient #5's blood sugar was 64. Review of Patient #5's nurse's notes for 10/14/17 revealed no documented evidence that the blood sugar of 64 was addressed. There was no documented evidence that Patient #5 was given juice and a snack as ordered. His blood sugar was not rechecked in 30 minutes as ordered. The next blood sugar check was done as scheduled at 11:30 a.m.

In an interview on 10/26/17 at 5:30 p.m., S3DON confirmed the above findings.

3) The RN failed to ensure a patient's medical record included documentation of an assessment by the RN after a fall:
Review of the policy titled "Nursing Assessment And Care Of The Patient", presented as a current policy by S3DON, revealed that changes in the patient status will result in a head-to-toe assessment. The reassessment must be performed by the RN charge nurse, and assessment is to be documented in the patient's daily record and communicated to the physician and other disciplines involved in the patient's care. Should the patient status require intervention, the RN will follow physician orders and document any procedures or treatments in the nurse's notes.

Patient #1
Review of Patient #1's medical record revealed an entry on 10/11/17 at 2:55 p.m. by S5RN that Patient #1 was "found on the floor." Further review revealed he stated he was trying to get in the bed. S5RN documented that she educated Patient 31 on the importance of using the call bell and that he denied pain or discomfort. There was no documented evidence of a head-to-toe assessment that included an assessment of neurovascular status and level of consciousness by S5RN and that she notified the physician and family.

Review of an "Incident Report" documented by S5RN on 10/11/17 at 4:30 p.m. revealed she notified the physician on 10/11/17 at 3:15 p.m., Patient #1's spouse at 3:10 p.m., S3DON at at 2:55 p.m., and Patient #1's VS were BP 152/73, pulse 66, respirations 20, and oxygen saturation 97.5%.

In an interview on 10/26/17 at 5:10 p.m., S3DON indicated the hospital doesn't have a separate policy related to the RN's assessment of a patient after a fall. She further indicated the above-listed policy would be used for fall assessments. S3DON indicated after a patient fall, she would expect to see that the RN assessed the patient for injury, notified the physician, and whether new orders were given. She indicated S5RN documented "see incident report" in her nurse's note rather than documenting VS in the patient's record.

Patient #3
Review of Patient #3's medical record revealed an entry on 09/20/17 at 7:30 a.m. by S10LPN that Patient #3 stood at the bedside to transfer to the wheelchair. Patient #3 stated "my legs are weak" and began to sit on the bed. then slid to the floor. S10LPN documented that Patient #3 was gently lowered to the floor by the aide, and there were no visible signs of injury noted. The patient denied pain or injury. There was no documented evidence of an assessment by the RN and that the physician and family were notified.

Review of the incident report documented by S5RN on 09/20/17 at 11:20 a.m. revealed a report received by S11CNA. Further review revealed the nurse practitioner was rounding at the time and gave no new orders. Further review revealed S5RN documented that a call was attempted to Patient #3's son, but there was no answer. She documented VS as BP 129/72, pulse 77, respirations 20, and oxygen saturation of 97.9%.

In a telephone interview on 10/26/17 at 11:45 a.m., S11CNA indicated when Patient #3 went to pivot to get in the wheelchair, she said her legs were weak. S11CNA further indicated Patient #3 slid to the floor with S11CNA assisting her. She further indicated an occupational therapist and 2 nurses came to assist getting the patient back to bed.

In a telephone interview on 10/26/17 at 3:30 p.m., S5RN indicated she didn't remember if she assisted in getting Patient #3 off the floor. She further indicated she would have to review the record to refresh her memory.

4) The RN failed to ensure a patient's wound was assessed, the physician was notified for orders for treatment, and treatment was implemented as ordered:
Review of the policy titled Wound Care: Pressure Ulcer Prevention & (and) Management of Pressure Ulcers", presented as a current policy by S1CEO, revealed that skin tear dressing treatment included treatment for skin tears with a skin flap and treatment for skin tears with light to moderate drainage with or without a flap. There was no documented evidence that the policy addressed what the wound assessment done by the RN was to include, how often wounds needed to be assessed, and what was to be documented for each assessment.

Patient #1
Review of Patient #1's "Skin Injury/Wound Assessment Flowsheet" revealed skin tears were documented on 10/15/17 to the bruise area, 10/16/17 to the right arm, 10/17/17 to the right upper arm, 10/18/17 to the right posterior forearm. Further review revealed photographs were taken on 10/16/17 of the right arm skin tear, on 10/22/17 of the right posterior forearm skin tear, and on 10/23/17 of the right posterior upper arm skin tear. Review of the medical record revealed no documented evidence that physician orders were obtained for treatment of the skin tears. There was no documented evidence whether the skin tears had a flap, whether there was drainage present or absent, and whether wound care was implemented in accordance with hospital policy.

In an interview on 10/26/17 at 5:10 p.m., S3DON indicated there should be an assessment documented of Patient #1's wounds. She confirmed there was no physician order for treatment.

Based on record reviews and interview, the hospital failed to ensure the RN assigned the nursing care of each patient in accordance with the specialized qualifications and competence of the nursing staff available as evidenced by failure to have documented evidence of competency evaluations for 4 (S3DON, S7RN, S10LPN, S13RN) of 4 nurses' personnel files reviewed for competency from a total of 5 personnel files reviewed.
Findings:

S3DON
Review of S3DON's personnel file revealed she was hired on 08/14/17. Further review revealed orientation was conducted with no documented evidence of an assessment of competency in performing nursing skills required of her as DON.

S7RN
Review of S7RN's personnel file revealed she was hired on 12/09/16. Review of her cardiopulmonary resuscitation certification revealed it expired in December 2016. There was no documented evidence of current certification in cardiopulmonary resuscitation. Review of her "Preceptor Assessment of Competency" revealed no documented evidence of the signature and credentials of the person who evaluated S7RN's competency.

S10LPN
Review of S10LPN's personnel file revealed she was hired on 09/15/15. Review of her "Preceptor Assessment of Competency" revealed no documented evidence of the signature and credentials of the person who evaluated S10LPN's competency.

S13RN
Review of S13's personnel file revealed she was hired on 06/28/17. Review of multiple tests in her personnel file revealed no documented evidence that the tests had been reviewed, scored for accuracy, and signed by the person who reviewed the test answers. Further review off the file revealed no documented evidence that S13RN had been evaluated for competency in performing the required skills of a RN.

In an interview on 10/26/17 at 4:45 p.m., S3DON confirmed the above findings from the personnel file reviews.

Based on record reviews and interview, the hospital failed to ensure drugs were administered in accordance with the orders of the practitioner as evidenced by failure to administer Clonidine prn as ordered by the physician for 2 (#2, #5) of 2 patient records reviewed with orders for Clonidine prn from a sample of 5 patients.
Findings:

Patient #2
Review of Patient #2's medical record revealed a physician's order on 09/29/17 at 6:00 p.m. to administer Clonidine 0.1 mg po Q 6 hours prn SBP > 160 or DBP > 100.

Review of Patient #2's "Nursing Graphic Sheet" revealed his BP on 10/01/17 at 6:00 p.m. was 172/81. There was no documented evidence that Patient #2 received Clonidine as ordered for SBP > 160.

In an interview on 10/26/17 at 5:20 p.m., S3DON confirmed Patient #2 should have received Clonidine as ordered on 10/01/17 at 6:00 p.m.

Patient #5
Review of Patient #5's medical record revealed a physician's order on 10/07/17 at 9:00 a.m. to administer Clonidine 0.1 mg po Q 6 hours prn SBP > 180 or DBP > 105.

Review of the "Nursing Graphic Sheet" revealed Patient #5's BP on 10/07/17 at 6:00 p.m. was 188/78. There was no documented evidence that Patient #5 received Clonidine as ordered for SBP > 180.

In an interview on 10/26/17 at 5:30 p.m., S3DON confirmed Patient #5 should have received Clonidine as ordered on 10/07/17 at 6:00 p.m.

Based on observation, record review, and interview, the hospital failed to ensure the drug storage area was administered in accordance with accepted professional principles as evidenced by having patients' individual peel packs of medication stored in the room behind the medication room that also contained a biohazard refrigerator (used to store lab specimens) with a centrifuge (used to spin lab specimens) placed on top of the refrigerator. The medication was stored in an area that included biohazard items and was not designated as current patient medication, medications for discharged patients, or expired medications.
Findings:

Observation on 10/25/16 at 9:30 a.m., with S1CEO and S9ICO present, revealed a room behind the medication storage room that contained a biohazard refrigerator (used to store lab specimens) with a centrifuge (used to spin lab specimens) placed on top of the refrigerator. Further observation revealed a table in the room that had a box on it that contained 34 peel packs of patient medications, 1 box of Ventolin HFA Inhalant Aerosol, and 1 box of Combivent Respinat Inhalation Spray. There was no designation whether the medication was for current patients, discharged patients, or were expired medications.

Review of the "Declaratory Statement Medication Therapy Management in the Practice of Pharmacy", dated 08/06/14, revealed that cognitive services may include participation if the development of policies and procedures for drug therapy including storage, handling, administration, and disposing of drugs and devices.

Review of the policy titled "Medication Administration", presented as a current policy by S1CEO, revealed no documented evidence that the policy addressed the storage of medications in an area separate from dirty/biohazard items.

In an interview at the time of observation on 10/25/17 at 9:30 a.m., S9ICO indicated the room contained a mixture of dirty items with patient medications.

Based on observations and interview, the hospital failed to ensure the infection control officer's responsibility for identifying, reporting, investigating, reporting, preventing, and controlling infections and communicable diseases included the maintenance of a sanitary hospital environment. This was evident by having patient nourishment items and patient medications next to a biohazard refrigerator used to store lab specimens and a centrifuge used to spin lab specimens in the room behind the nursing medication room.
Findings:

Observation on 10/25/16 at 9:30 a.m., with S1CEO and S9ICO present, revealed a room behind the medication storage room that contained a biohazard refrigerator (used to store lab specimens) with a centrifuge (used to spin lab specimens) placed on top of the refrigerator. Further observation revealed a table in the room that had a box on it that contained 34 peel packs of patient medications, 1 box of Ventolin HFA Inhalant Aerosol, and 1 box of Combivent Respinat Inhalation Spray. Further observation revealed the following patient nourishment items on the table next to and behind the biohazard refrigerator: 6.8 fl. oz. cartons of Ensure Clear Therapeutic Nutrition that expired 09/01/17; 22 cans of Glucerna 1.5 Cal Specialized nutrition that expired 10/10/17 (no documented evidence indicating that these items were expired and not available for use); 1 box of multiple 8 oz. Mixed berry Ensure Clear Therapeutic Nutrition; 1 box of multiple Apple Ensure Clear Therapeutic Nutrition; 7 packs, each containing 4 Ensure Original Pudding. Observation revealed a staff member's purse and 2 tote bags were also in the table.

In an interview on 10.25.16 at 9:30 a.m., S9ICO indicated the clean patient care items (medications and nourishments) should not be mixed with dirty items, such as the biohazard refrigerator, centrifuge, and staff belongings.

Based on record reviews and interview, the hospital failed to ensure the patient and family members were counseled to prepare them for post-hospital care as evidenced by failure to provide a list of all medications the patient should be taking after discharge with a clear indication of changes from the patient's pre-admission medications for 2 (#2, #5) of 3 (#2, #3, #5) discharge records reviewed for discharge planning from a sample of 5 patients.
Findings:

Review of the policy titled "Patient Discharge Planning", presented as the current discharge planning policy by S8CM, revealed no documented evidence that patient education related to discharge medications as stated above was included in the policy.

Review of the discharge records for Patients #2 and #5 revealed the "Medication Reconciliation Form" documented at discharge contained the medications ordered at admit and those ordered at discharge. The patients' home medications taken prior to admission were not obtained and documented in the patients' medical records. There was no documented evidence that Patient #2 and patient #5 and their family were provided a list of all medications they should be taking after discharge with a clear indication of changes from their pre-admission medications.

In an interview on 10/26/17 at 5:20 p.m., S3DON indicated the nurses don't document the medications the patient was taking at home prior to admission, and thus at discharge, a clear indication of changes from the pre-admission medications to those being ordered at discharge is not discussed with the patient and his/her family member.