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Based on interview, record review and policy review the facility failed:
-To ensure staff identified, assessed, treated and documented Patient #12's maxillomandibluar fixation (fractured jaw which is wired shut).
-To have wire cutters available in case of emergency.
-To include Patient #12's wired jaw in the Plan of Care.
-To follow physician's orders for a consult for Patient #16.
-To incorporate a nursing care plan based on patient assessment that addressed all patient needs that included measurable goals, interventions, and time tables for two discharged patients (#12 and #16) of two discharged patients reviewed for nursing care plans.


These failures resulted in the overall non-compliance with 42 CFR 482.23, Condition of Participation: Nursing Services. The cumulative effect of these systemic practices had the potential to place all patients at risk for their safety, also known as Immediate Jeopardy (IJ). The facility census was 30.

On 08/18/17, at the time of survey exit, the facility provided an immediate Plan of Correction sufficient to remove the IJ by implementing the following:
- A policy on the care of the high risk patient with oral fixation was developed to ensure the completion and documentation of an oral assessment by the RN within four hours of admission and every shift thereafter; visual inspections of the mouth, airway and oral mucosa integrity; accessibility of wire cutters; flexible suction catheters compatibly sized for the small openings within the wires; and immediate notification of the attending physician if any wires or hardware appear loose or not intact.
- No patients with oral hardware fixation were to be admitted to the facility until a policy was developed, approved and staff training was completed for 100% of staff caring for designated patients.
- Any patients admitted with oral fixation hardware were considered a high risk patient.
- A picture of a lamp will be placed on the patient door that indicates the patient was a high risk oral fixation hardware patient.
- A high risk sign will be placed above the patient bed.
- Identification of high risk patient with oral fixation hardware will be reported each day and documented at the daily Flash report and on the weekend to the Administrator on Call with documentation on the weekend Flash report.
- Mock drills will be conducted with clearly defined scenarios that focus on a patient with wired jaws and conducted by the Director of Quality Management or his designee for 30 days until 100% compliance has been achieved and then three times a week for thirty days, then weekly to ensure ongoing compliance.
- A review of 100% of inpatient records will be conducted by the House Supervisor for any outstanding consults.
- An escalation process for lack of response by a consultant was developed.
- Any consultation that falls outside of the established timeframe will initiate the escalation algorithm.
- For consults ordered as emergent and cannot be seen within two hours will result in the patient transfer to a higher level of care to receive necessary services.
- Upon entry of a consult order a call will be made to the consulting provider by the responsible nurse and documentation of the call made into the electronic medical record.
- Nursing can not and will not override a physicians consult order.
- Education will be provided to RN's, LPN's, Agency RN's, RT's, OT's, ST's and Physicians. No staff will be allowed to work until the education has been received.

Based on interview, record review and policy review the facility failed to ensure nursing staff identified, assessed, treated and documented a maxillomandibluar fixation (fractured jaw which is wired shut) for one discharged patient (#12) of one patient record reviewed according to hospital policy and failed to follow physician's orders for one discharged patient (#16) of five patient records reviewed when a consult was not completed. This failure had the potential to affect all patients who were admitted to the facility. The facility census was 30.

Findings included:

1. Record review of the facility policy titled, "Care Coordination and Discharge Planning" release date 06/2017 showed:
This procedure establishes guidelines to assure:
-Care provided to each patient is based on an assessment of the patient's relevant physical, psychological and social needs.
-To outline a systematic process for gathering pertinent information about each patient.
-To establish a comprehensive information base for decision making about each patient care.
-To define initial assessment time frame's.
-To determine the appropriate care, treatment and services to meet the patient's needs during hospitalization.
-All patients will have an initial assessment and appropriate follow up assessments based upon patient specific identified needs including physical, psychological and social-cultural status.
-The goal of the Assessment/Reassessment process is to provide an interdisciplinary approach for assessment(s) and ongoing reassessment(s) of individual patient needs and for planning and implementing patient specific care.
-Assessments and data collection performed by licensed health care professionals will include and address patient specific needs.
-Licensed, qualified staff assess each patient's care needs throughout the patient's hospital stay and provide patient specific care at the time based on assessment data.
-The assessment framework is structured around two components: Initial screening and assessment/reassessment of each patient as appropriate to the clinical discipline and individual patient condition changes.
-Prior to patient admission, as part of the pre-admission referral process, the Clinical Liaison performs a pre-admission assessment. This assessment consists of gathering pertinent clinical and demographic information.
-An admission assessment is performed by a Registered Nurse (RN) and is recorded in the patient record within 12 hours of admission. This assessment is based upon actual observation, patient/family interview, patient medical records accompanying the patient from the referral facility and other staff members.
-The admission assessment data is a primary source for the RN to determine and prioritize nursing care needs specific to the patient.
-Patients are re-evaluated by a licensed nurse (RN, LPN/LVN (Licensed Practical Nurse, LPN; Licensed Vocational Nurse, LVN -according to state specific practice acts) at a minimum every 12 hour shift-based on level of care and patient care needs.
-An RN reassessment of the patient shall occur, at a minimum once every other 12-hour shift.
-Patient reassessment is based on but not limited to response to a significant change in status, diagnosis and/or condition.

2. Record review of Patient #12's Interim History and Physical dated 07/20/17 by Staff T, Attending Physician, showed:
-The patient is a 40 year old male who was driving a scooter and not wearing a helmet and was hit by a truck.
-The patient is comatose (in a state of deep loss of consciousness).
-He sustained multiple fractures as well as basilar skull fracture (fracture at the base of the skull), subdural hematoma (bleeding under the skull and outside the brain), bilateral contusions, skull, facial and mandibular (jaw) fracture and right posterior (in the back) rib fracture.
-He has a tracheostomy (a surgical opening through the neck into the windpipe) shield (a covering).
-Midline mouth and throat could not be evaluated because he will not open his mouth.
Diagnoses include:
-Traumatic brain injury (an extreme force injury of the brain);
-Subdural hematoma (bleeding between the skull and the outside of the brain);
-Diffuse azonal injury (a type of brain injury);
-Respiratory failure;
-Persisting fever;
-Leukocytosis (an increase in white blood cells that frequently is a sign of inflamatory response); and
-Recent traumatic hematuria (blood in the urine).

Record review of the facility Pre-Admission Clinical Evaluation dated 07/14/17 for Patient #12 showed:
-Patient sustained multiple skull, facial and mandible fractures.
-Mandible fracture wire fixation on 07/01/17 will need in place times six weeks and will need follow up with Oral and Maxiofacial specialists (OFMS, specializes in treating injuries of the head and jaw) for removal.

Record review of the Nursing Admission Assessment dated 07/20/17 showed no documentation of the patients wired jaw.

Record review of the 12 hour shift Nurses Notes from 07/20/17 through 08/09/17 showed no documentation of the patients wired jaw.

This failure to assess and document the presence of Patient #12's wired jaw prevented the timely, appropriate and safe individual specific patient care needed including having wire cutters immediately available in an emergency.

During a telephone interview on 08/16/17 at 1:03 PM, Staff BB, RN, stated that she was assigned the patient on admission. He was unresponsive and had his mouth wired shut. Staff BB stated, "Oversight on my part not documenting."

Record review of the Progress Note dated 08/03/17 at 11:07 AM for date of service 08/03/17 by Staff Y, Pulmonologist (a medical specialty which deals with the diseases of the respiratory tract), showed that Patient #12 was in a motor vehicle accident resulting in traumatic brain injury, basal skull fracture, facial fracture, mandibular fracture with wiring and rib fracture.

During an interview on 08/17/17 at 10:18 AM, Staff Y stated that he was aware that the patient had a wired jaw about a week or so before he was transferred to Hospital B. He stated that he had discussed this with Staff T, Attending Physician and advised him to send the patient out. He stated that if he had known that hardware had been found in the patient's mouth; he would be concerned about the patient aspirating (accidental sucking in of food or other objects into the lungs) and would have sent him out.

Record review of the Progress Note dated 08/04/17 at 9:37 AM for the date of service 08/03/17 by Staff CC, Wound Physician showed:
- Respiratory Therapist (RT) points out that the patient has some wires protruding from his mouth;
-Will contact patient's primary physician and oral surgeon about loose wires protruding from the mouth; and
- Discussed with Staff F, Wound Nurse.

During an interview on 08/22/17 at 5:00 PM, Staff CC stated that he was covering for another physician and did not go to this facility often. He stated that an RT told him about the piece of wire protruding from the patient's mouth. He stated he saw the patient and talked with the wound nurse that the Attending Physician and Surgeon should be called.

During a telephone interview on 08/23/17 at 10:30 AM, Staff F, Wound Nurse, stated that Staff CC telephoned her and stated that the RT (name unknown) had called him into the room of Patient #12 because of a wire protruding from the patient's mouth. Staff F stated that Staff CC said there was no damage from the wire and that he would inform the attending physician.

During an interview on on 08/16/17 at 9:40 AM, Staff L, Wound Physician, stated that he was asked to evaluate the patient on or about 08/07/17 because a wire was protruding from the patients mouth. He assessed the patients mouth and found that a wire was protruding from the left side of his mouth. Staff L stated that he assessed the mobility of the screws observed on the loose wire and they were not loose. He stated that he put gauze around the wire to protect the patients mouth. Staff L stated that he did not document the assessment or the treatment.

During an interview on 08/16/17 at 9:52 AM, Staff M, RT, stated that he treated Patient #12 approximately six to seven days before discharge (08/09/17) and observed the wire protruding approximately one inch from the left side of his mouth. Staff M stated that it is not an expectation that he would document the finding of a wire protruding from the patients mouth but it would be an expectation that he document the referral to nursing about his finding. No documentation was found of the referral in the RT notes.

During an interview on 08/16/17 at 11:30 AM, Staff N, RN, stated that an RT told her that a wire was protruding from the patients mouth. Staff N stated that she used the wire cutters to put the wire back under "where it should have been". Staff N stated that she specifically looked in the patients mouth and did not observe anything unusual. She stated that she did not document her assessment or of replacing the wire in the patients mouth.

During an interview on 08/17/17 at 9:00 AM, Staff V, RN, stated that on 08/08/17 she discovered the patients' jaw was wired when she proceeded to do oral care and saw the protruding wire in the left side of his mouth. She had not received in handoff report from the night RN that the patient had a wired jaw. She stated that she informed the House Supervisor that there were no wire cutters in the room. Staff V stated that the wire cutters were found in the patients belongings in the closet. She stated that she placed trach pads (pads with cushion) between the wire and his lip to prevent any cuts. She stated that she examined his mouth and found two rubber bands in his mouth which she removed. She stated that she informed the Physician who said he was aware and was trying to get the patient "out". She stated that she did not document her findings because she was told that "they don't want us to put in our notes because of law suits except for documenting a change of condition".

During an interview on 08/16/17 at 1:17 PM, Staff Z, House Supervisor (HS), stated that she was informed on 08/08/17 of the wire protruding from the patients mouth by Staff V. She stated that she informed Staff A, Director of Quality Management, and was directed to contact the patients surgeon for an evaluation of the wired jaw. She stated that she began calling his office to make arrangements for the evaluation at approximately 8:30 AM on 08/08/17.

Record review of the facility's document titled, "Change of Condition" documented by Staff Z on 08/08/17 showed:
- House Supervisor (HS) contacted family of Patient #12 to inform them of Physician's order for transport of patient to Hospital B for evaluation of appliance of jaw.
- HS spoke with HS at Hospital B and faxed requested patient information.
- HS spoke with Maxiofacial Surgeons office nurse and she stated that she would speak with the surgeon if it would be best to admit to Hospital B instead of seen at the office.
- HS at Hospital B said no beds were available and they will call back when they have a plan.
- Call was received from a Nursing Supervisor at Hospital B and the patient had missed an appointment with surgeon and now must be seen in the surgeon's office before he can be seen at Hospital B.
- Call received from surgeon's office that a Dr to Dr call will be necessary to initiate a direct admission to Hospital B.
- The office number was given to Staff T, Attending Physician, by the HS for the follow up call.
- The patient was transferred by ambulance to Hospital B for evaluation and treatment.
The documentation for the Change of Condition was initiated at 11:54 AM and completed at 2:23 PM.

During an interview on 08/17/17 at 10:30 AM, Staff T, Attending Physician, stated that he called the answering service of the Maxiofacial Surgeon several times and received no response. He stated that he was not aware of bands found in the patients mouth.

During an interview on 08/17/17 at 3:05 PM, Staff B, Chief Clinical Officer, stated that the expectation is that the initial nursing assessment for a patient should include a head to toe assessment and all findings should be documented. Staff B stated that RN's are to make a head to toe assessment each shift and document all findings. She stated that she would have expected to see documentation each shift on the condition of the wired jaw of Patient #12.

Record review of the H&P dated 08/09/17 from Hospital B showed:
-Hardware has been loose for unknown amount of time;
-Pt has grossly audible course breath sounds (breath sounds very easy to hear);
-On xray, it also showed that the patient had swallowed two screws from his oral fixation and they were seen in his abdomen; and
-Right lower lobe pneumonia.

Record review of the OMFS Consultation documentation from Hospital B on 08/09/17 showed:
-Arch bars, bands and fixation wires were removed. Total of seven screws, five maxillary and two mandibular were removed from mouth (the operative report states originally the patient had five maxillary and seven mandibular placed).

Record review of the facility document titled, "Medical Staff Rules & Regulations," dated 01/26/16 showed that stat (immediate) consultations should be performed within three (3) calendar days. If there is a consultation request on record, documentation by the Consulting Physician is required.

This failure to assess/reassess and follow physician order for transfer to a higher level of care, delayed treatment and intervention with potential or actual patient harm.

3. Record review of Patient #16's H&P showed:
-The patient was admitted on 11/15/16 with a coccygeal (tailbone) and right below the knee amputation (removal of) stump wound for wound care and Intravenous (IV, within the vein) antibiotics;
-A past medical history of coronary artery disease (heart disease); peripheral arterial disease (circulatory condition of narrowed blood vessels that reduce blood flow to limbs); end-stage renal disease (kidney failure) with dialysis (substitute filtration process of the blood for the normal function of the kidney) and diabetes (chronic condition that affects the way the body processes blood sugar); and
-He had a percutaneous endoscopic gastrostomy (PEG, endoscopic medical procedure in which a tube is passed into the stomach through the abdominal wall to provide a means of feeding when oral intake is not adequate) for his nourishment and medication administration.

Record review of Patient #16's medical record showed the following:
-Change of condition on 08/01/17 at 9:00 PM PEG tube was clogged;
-The last medication administered through the PEG tube was on 08/01/17 at 10:26 PM;
-Telephone order dated 08/02/17 at 9:01 AM from Staff S, Physician for sodium chloride (normal saline, sterile IV solution to supplement the body with fluid) 1000 milliliters (ml, unit of measure) IV infusion, rate of 50 ml per hour to discontinue after patient resumes tube feeding;
-Physician order dated 08/02/17 at 11:30 AM by Staff S, Physician for general surgery consult for PEG placement, cannot get IV fluids due to fluid retention and need to resume feeding as soon as possible (ASAP);
-Nursing note dated 08/03/17 at 2:15 AM that a telemedicine (remote diagnosis and treatment of patients by phone or video communication) physician was called to see if anything could be done because the PEG tube was not working. The telemedicine physician replied that nothing could be done at that time;
-The patient had received five 10ml (50ml) IV flushes of normal saline from 08/03/17 at 12:10 AM to 08/04/17 at 12:01 AM; and
- Change of condition on 08/04/17 at 4:10 AM, patient expired.

Record review of a progress note dated 08/03/17 at 12:15 PM, showed that Staff S, Physician, documented that the PEG tube had been clogged for over 24 hours and that it had been discussed with the multi-disciplinary team to get the surgeon to see the patient as soon as possible for replacement of the PEG tube as the patient wasn't a candidate for IV fluids due to recurrence of pulmonary edema (excess fluid in the lungs). The patient was currently receiving normal saline IV at 50 cc per hour.

During an interview on 08/16/17 at 8:40 AM Staff S stated that she had ordered a surgery consult to have the PEG tube replaced. She stated that the consult was never done and that she wanted the patient to be sent out for the tube replacement. Staff S stated that she was informed by Staff A, Director of Quality Management that this was a procedure that could be taken care of "in-house." She stated that the facility didn't have a sense of urgency with transferring patients out for procedures because of the cost involved.

Record review of a progress note dated 08/03/17 at 9:53 AM showed the following documentation by Staff Y, Physician:
- Gastric tube was not working;
- Fluids were discontinued per nephrology (kidney specialist);
- The patient optimally should have gone to interventional radiology (IR, a medical sub-specialty of radiology that utilizes minimally invasive image guided procedures) for replacement of the tube feeding;
- Patient should go out today to IR for tube replacement and if unable then a Foley catheter (flexible tube that is generally used to drain urine from the bladder) could be put in, verify the position then resume the feeding until an appointment was made to change the tube feeding; and
- Plan first and foremost was the need to replace the tube feeding ASAP to resume his feedings and administer his medications through it since both of these were on hold.

During an interview on 08/17/17 at 11:15 AM, Staff Y stated that he was very concerned about Patient #16's non-functioning PEG tube. He stated that he discussed it with Staff A and was told that surgery had been consulted and that they could take care of it in house. Staff Y stated that the consult was never done and that it should have happened within 24 hours of the consult being written. He stated that the patient went two to three days without feeding or medications. Staff Y stated that he was aware of other cases where he felt patients needed to be sent out for procedures or emergent needs and that management over-rode the physicians' orders because of the cost to the facility to transfer patients out.

During an interview on 08/17/17 at 4:30 PM, Staff W, Physician Advisor stated that Patient #16 had a surgery consult that had been written on 08/02/17. He stated that he had spoken to the surgeon that received the consult on 08/02/17 or 08/03/17 and that the consult was given to another surgeon to carry out. Staff W stated that the consulting surgeon came to see Patient #16 on 08/04/17 but the patient had already died earlier that morning. Staff W verified that there was no documentation in the patients medical record in regards to this consulting surgeon of having attempted to see the patient.

During an interview on 08/17/17 at 3:10 PM, Staff B, RN stated that she was aware of situations where administrative staff, specifically Quality Management, decided when a patient would be sent out or not, even if there was a physician order to send the patient out.

During an interview on 08/17/17 at 2:45 PM, Staff A stated that physicians' orders were to be followed and if a patient needed to be sent out then they would be sent out.

Patient #16 was unable to receive nutrition, fluids, or medication through his PEG tube until his death on 08/04/17 at 4:10 AM, a total of approximately 52 hours. The surgery consult was never completed to replace the PEG tube and resume feedings and medications.

The lack of nutrition, fluids, and medications put Patient #16 at risk for dehydration, malnutrition and medical complications related to lack of needed medication and potential or actual harm, including death.






















































32280

Based on interview, record review and policy review, the facility failed to ensure nursing staff followed facility policy for the devlopement of a Patient Plan of Care based on patient assessment that addressed all patient needs that included measurable goals, interventions, and time tables for two discharged patients (#12 and #16) of two discharged patients reviewed for nursing care plans. This failed practice had the potential to affect all patients admitted to the facility by not meeting individual needs identified from assessments. The facility census was 30.

Findings included:

Record review of the facility policy titled, "Assessment/Re-Assessment - Interdisciplinary Patient" dated 06/2017 showed that the admission assessment data is a primary source for the RN to determine and prioritize nursing care needs specific to the patient and a Patient Plan of Care is developed and recorded within 24 hours of admission by the RN based on identified problems and patient specific needs.

Record review of the facility Pre-Admission Clinical Evaluation dated 07/14/17 for discharged Patient #12 showed:
- Patient sustained multiple skull, facial and mandible (jaw) fractures.
- Mandible fracture wire fixation on 07/01/17 will need in place times six weeks and will need follow up for removal with Oral and Maxiofacial (OFMS, specializes in treating injuries of the head and jaw).

Record review of the facility document titled, "Plan of Care" initiated 07/21/17 showed no problem, interventions or goals for the wired jaw of Patient #12.

Record review of discharged Patient #16's History and Physical (H&P) showed he was admitted to the facility on 11/15/16 for wound care and Intravenous (IV, within the vein) antibiotics for his coccygeal (tail bone) and a right below the knee stump wound.

Record review of the patient's plan of care showed documentation on 08/01/17 for the problem of increased nutrient needs with a goal that patient was to tolerate enteral (tube) feedings with a target date (anticipated date the goal would be met) of 08/15/17. There was no documentation within the plan of care from 08/01/17 to 08/04/17 updating the tube feeding condition/totals or the fact that it had been non-functioning (clogged with possible hole) from 08/02/17 until the patients death on 08/04/17.



27727

Based on interview, record review and policy review, the facility failed to ensure that medications were administered per physician's orders for one discharged patient (#16) of five patient records reviewed for physician's medication orders. This had the potential to affect all patients in the hospital who received medications. The facility census was 30.

Findings included:

Record review of the facility's policy titled, "Timely Administration of Scheduled Medications," dated 06/17 showed:
- The policy's purpose was to establish guidelines for the timely administration of scheduled medications while maintaining patient safety and the required therapeutic effect of the administered medications;
- A scheduled medication is defined as a maintenance dose of a medication administered according to a standard repeated cycle of frequency based on standard administration time schedules; and
- Non-time-critical scheduled medications (medications where early or delayed administration within a specified range of time usually one or two hours should not cause harm or result in substantial sub-optimal therapy or drug effect) prescribed more frequently than daily, but no more frequently than every four hours shall be administered within one hour before or after the scheduled time.

Record review of discharged Patient #16's History and Physical (H&P) showed he was admitted to the facility on 11/15/16 for wound care and Intravenous (IV, within the vein) antibiotics for his coccygeal (tail bone) and a right below the knee stump wound. The patient remained at the facility until he expired on 08/04/17 at 4:10 AM.

Record review of the Medication Administration Record (MAR) showed the following medication orders with the date the medication was last administered:
- Cholestyramine powder (cholesterol medication) per feeding tube, one packet last administered on 08/01/17 at 10:02 PM;
- Amiodarone HCL (heart medication that is used to treat life-threatening heart rhythm disorders) per feeding tube 300 milligram (mg. a unit of measure) every 12 hours last administered on 08/01/17 at 10:02 PM;
- Pancrelipase (Pancreaze, pancreatic enzyme replacement to help with digestion) per feeding tube one capsule, medication ordered on 07/27/17 no documentation that medication was ever given;
- Celecoxib (Celebrex, nonsteroidal anti-inflammatory drug to treat pain) per feeding tube 100 mg. capsule once daily last administered on 08/01/17 at 10:24 PM;
- Metoprolol tartrate (to treat high blood pressure) per feeding tube 25 mg. tablet every 12 hours last administered on 08/01/17 at 10:02 PM;
- Lexapro (to treat depression and generalized anxiety disorder) per feeding tube 5 mg. tablet once daily last administered on 08/01/17 at 10:26 PM;
- Metoclopramide (to treat acid indigestion caused by gastroesophageal reflux disease) per feeding tube 10 mg. tablet every six hours last administered on 08/01/17 at 5:30 PM;
- Guaifenesin (cold/cough medicine that thins mucus from head, throat and lungs) per feeding tube liquid 20 milliliters (ml. unit of measure) every six hours last administered on 08/01/17 at 5:30 PM;
- Omeprazole suspension (liquid) (to treat heartburn) per feeding tube, 40 mg. once daily last administered on 08/01/17 at 10:24 PM; and
- Linagliptin (to treat type 2 diabetes [chronic condition that affects the way the body processes blood sugar]) per feeding tube 5 mg. tablet once daily last administered on 08/01/17 at 10:26 PM.

Patient #16 did not receive his scheduled dosing of 10 medications from 08/01/17 at 10:26 PM to 08/04/17 at 4:10 AM when he expired.

During an interview on 08/15/17 at 8:40 AM, Staff S, Physician stated that the patient had not received his medications or tube feedings due to his feeding tube needing replaced due to the tube being clogged with a possible hole. Staff S stated that an order had been written for a surgery consult to replace the tube and the consult was never completed.

These missed medication administrations placed Patient #16 at risk for medical complications with actual or potential harm, including death.