HospitalInspections.org

Based on interviews, review of medical records, review of hospital documents, including policies and procedures and review of documents from outside professionals, it was determined that the governing body failed to ensure that the rights of all patients to safe care, protection from neglect and the right to self-determination were protected; therefore, this CONDITION IS NOT MET.

Reference deficiencies written the following:
Tag A 0115
Tag A 0117
Tag A 0131
Tag A 0144
Tag A 0145
Tag A 0204
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Based on interviews, review of medical records, review of the hospital's policies and procedures and document review, it was determined that the hospital's governing body failed to ensure that the rights of all patients in the hospital were protected and that their safety was assured.

As evidenced in the findings detailed throughout this report, the cumulative effect of these systemic problems resulted in the hospital failing to protect the safety of Patient #1 and failing to implement corrective measures where necessary to assure the safety of all patients in the hospital and to assure that the rights of all patients in the hospital were protected; therefore, this CONDITION IS NOT MET.

-Failure to inform patients/decision makers of rights prior to providing services
Reference Tag A0117

-Failure to assure that patients were informed of their rights to make informed decisions
Reference Tag A0131

-Failure to assure patients' rights to care in a safe setting
Reference Tag A0144

-Failure to assure patients' rights to freedom from abuse and neglect
Reference Tag A0145

-Failure to assure that patients restraints were released after a reassessment
Reference Tag A0204
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Based on record review and interview, the facility failed to demonstrate that it informed patients/patient representatives of their rights in advance of providing patient care for 2 (#15 and #16) of 3 patients.

Failure to do so created risk that patients will not be informed about their rights and will not be able to exercise those rights in decision making during the course of their care; with potential adverse effects upon their own health.

Findings included:

1. a. On 11/16/18 at 9:30 AM surveyor #2 interviewed the Accounting Specialist (Staff #30) about patient notification of their rights. She stated that a hard copy of patient rights was part of a packet of different types of documents (13) that she reviewed with patients. She stated that she performed these activities at the patient bedside after arrival at the facility. When asked if she could verify that the rights were reviewed with the patients she indicated that one document (not about patient rights) had been signed. However, that document did not contain reference to acknowledgement of receipt of information about patient rights.

b. During that interview, the Accounting Specialist was asked if there was a facility policy and procedure to ensure that patients were informed about their patient rights. She stated that there was not a policy and procedure to ensure offer and/or receipt of information. The Director of Nursing and Clinical Services(Staff #18) acknowledged that finding at 10:00 AM the same day.

2. Review of 3 of 3 patient (Patients #15 -# 17) records indicated that there were hard copies of patient rights in the medical record but there was no way to verify that the patients had been informed about the content of the rights documents.

3. In follow-up interviews by Surveyor #2 on 11/16/18 at 10:30 AM with the above patients, 2 patients (Patients #15 and #16) of 3 stated that they could not recall if they had been informed/provided information about their patient rights at the facility.
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Findings included:

Item #1 - Patient Consent for Transfer to Another Hospital

Based on record review and interview, the facility failed to demonstrate that they ensured patient rights by obtaining evidence of patient consent prior to hospital-to-hospital transfer for medical care from the patients/legal representatives for 5 ( #6, #9, #18, #19, #20) of 5 patients.

Failure to do so created risk that patients/legal guardians would not be informed, comprehend or agree to the rationale for the transfer and the associated health risks, including harm of injury and/or death.

1. a. In review of staff facility policy titled, "Discharge Planning Seattle-Specific Addendum" it defined a transfer as "A patient that leaves Kindred . . . to another facility for urgent or emergent care or a procedure that are not available and mandates the patient get to another facility for this unavailable care. This patient would likely be expected to return to Kindred . . . either immediately or very shortly after transfer."

1. b. In the procedure section it stated that a "Memorandum of transfer document" . . . "may be appropriate to send with a transferring patient". The document included a patient/legal guardian section for selection of a choice for transfer consent, request or refusal; followed by a section for consenting signature by the patient/legal representative (or proxy signature).

2. In review of three documents titled "Memorandum of Transfer" (Version 12/30/14) for Patients #6, 9, 18, 19, and 20 the record indicated that there were no patient/legal guardian signatures demonstrating consent to the transfer to other hospitals. Four of 5 patients had documentation of mental status as alert and oriented. Three of 5 patients were sent to other hospitals for surgical procedures; and the 2 other patients went to an emergency department for care at another facility.

3. a. On 11/20/18 at 12:30 PM Surveyor #2 showed the Memorandum of Transfer documents to the Director of Nursing and Clinical Services (Staff #18) and the staff member acknowledged that documentation of patient/legal guardian consent had not been obtained by the facility staff prior to the patient's departure. She stated that it was the nursing staff's responsibility, with the assistance of the Nursing Supervisor, to ensure that all documents and activities for transfers were completed prior to the patient's departure from their facility to another hospital facility.

Item #2 - Patient Consent for Telemedicine Services

Based on record review and interview the facility failed to adequately inform patients through the consent process about the nature and scope of telemedicine services provided through the facility.

Failure to do so created risk that patient/surrogate decision makers would consent to services without adequate knowledge about the nature and scope of the services; thereby impacting their choice(s) about the delivery of their care.

Findings included:

1. Review of document titled, "Telemedicine Services Informed Consent Notice of Privacy Rights" (2017) showed that it was provided to facility patients as a means of informing them about the telemedicine service and to obtain their consent to participate in the telemedicine service as part of the medical services at the index hospital. However, the document did not contain information about the scope of telemedicine services; including days of the week and hours of the day. Additionally, it provided patients with telemedicine contact information as; clinical administrative office hours available to them Monday to Friday during daytime only hours and information technology administrator access (not something most acute care patients would utilize) available to them 24 hours/7 days a week.

2. On 11/16/18 at 9:30 AM Surveyor #2 interviewed the Accounting Specialist (Staff #30) about the patient consent/patient notification about telemedicine services. She stated that each patient signed a hard copy of the agreement upon admission. She also stated that medical services were provided by telemedicine from 7:00 PM to 7:00 AM daily; and noted that this information (about the scope of services) was not part of the agreement to telemedicine services signed by the patient. The document did not advise patients about what to do/who to contact if they had a complaint or grievance about the provision of telemedicine services at or after the time of service, including whether to follow the hospital-based complaint/grievance policy.

3. This finding was confirmed with the Director of Nursing and Clinical Services (Staff #18) at 10:30 AM that day.
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Item #3 - Disclosure of Limitations of Telemedicine Services and ICU

Based on interview, review of documents and review of the hospital's website, it was determined that the hospital failed to inform patients/surrogates of limitations of the telemedicine service.

Failure to do so deprived all patients of their rights to information about the services available.

Findings included:

1. On 11/02/2018, a consultant (MD A) who was a board-certified intensivist [ICU specialist] stated that the ICU had limitations to the kind of care it could provide. S/he stated that the hospital's ICU could not do "paralytics" [medications that paralyze the body], could not do "nitric" [nitric oxide is a medication sometimes used to treat acute respiratory distress], ECMO [Extracorporeal membrane oxygenation, also known as extracorporeal life support, is an extracorporeal technique of providing prolonged cardiac and respiratory support to persons whose heart and lungs are unable to provide an adequate amount of gas exchange or perfusion to sustain life] and could not provide "proning" [placing a patient who is on a ventilator in the prone position, instead of in the supine position].

MD A also stated that the hospital could not provide endoscopy services, which would be needed in the case of acute gastric bleeding. On October 30, 2018, the Chief Executive Officer stated that 26% of all patient returns to short-term acute care (STAC) hospitals were due to acute gastrointestinal bleeding.

On 11/16/18 at 11:00 AM Surveyor #2 interviewed an intensivist physician (MD A). He stated that the facility additionally was unable and did not manage patients on with acute mental status changes requiring CT scans and patients requiring a cardiac intervention in a cardiac catheter lab.

2. Review of the "Kindred Hospital Seattle 2018 Organizational Plan for the Delivery of Patient Care, Treatment, and Services" was reviewed and found to lack information on:

-The presence of telemedicine in the hospital, and the type and extent or limitations of the services provided by the telemedicine service

-The limitations of the hospital's Intensive Care Unit (ICU).

3.The hospital was unable to provide documentation that patients/responsible others had been informed that medical care in the hospital, including the ICU, was provided via telemedicine for 12 hours per day, or that the ICU had limitations to the scope of care that could be provided, including the types of services that were necessary on an emergency basis for patients who developed gastrointestinal bleeding, which Kindred hospital had determined to be 26% of all of it's patient returns to a STAC.

4. The hospital's website, viewed 12/18/2018, contained the statement: "Kindred Hospital Seattle - Northgate is a 30-bed transitional care hospital offering the same in depth care you would receive in a traditional hospital, but for an extended recovery period. We partner with your physician and offer 24-hour clinical care seven days a week so you can start your journey to wellness". The website was not found to note the limitations in onsite physician availability or onsite services available.
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Item #1 - Unsafe Patient Transfer/Discharge

Based on interviews, review of medical records and hospital documents, it was determined that the hospital failed to ensure that Patient #1 was appropriately discharged to a Short Term Acute Care (STAC) hospital.

The hospital's failure to do so placed Patient #1 at risk for unmet care needs at the receiving hospital due to lack of an accepting physician and available ICU bed.

"Reference Tag A2400
[The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24.

Reference Tag A2409

(2) A transfer to another medical facility will be appropriate only in those cases in which ...

...(ii) The receiving facility
(A) Has available space and qualified personnel for the treatment of the individual; and
(B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment.:"

Findings included:

On 10/25/2018 at 2:43 PM, MD F, a Medical Director from an outside hospital stated that Kindred had discharged a patient to the outside hospital without the hospital accepting the patient or a physician accepting the patient.

MD F stated that s/he had a conversation with the attending physician at Kindred and that s/he told the attending physician at Kindred that the outside hospital could not accept the patient because they did not have an available Intensive Care Unit (ICU) bed and there was no accepting physician. MD E, from the same outside hospital, also stated that the Kindred hospital attending was told that the hospital could not accept the patient.

The Admissions Nursing Coordinator (ANC) at the outside hospital stated that all admissions to that hospital were referred through that office, to determine available and appropriate bed placement for incoming patients. The ANC stated that s/he had confirmed with the ICU charge nurse that the patient had been declined due to no bed availability and "some other reason"

The ANC stated that s/he called the charge nurse at Kindred who reportedly told the ANC that the family was very unhappy and wanted the patient moved out immediately. The ANC stated that "management decided the patient had to leave [the hospital]".

On 10/30/2018, at approximately 11:00 AM, the Chief Executive Officer (CEO) stated that the spouse and son of Patient #1 had been "adamant" about the patient's discharge to the outside hospital. S/he stated that the Kindred hospital attending physician had been "involved" and had called the outside hospital several times regarding the discharge. The CEO stated that s/he had made the determination to discharge the patient to the outside hospital, even though the hospital had said they did not have capability or capacity to care for the patient.

Review of the patient's medical record revealed a progress note from the Kindred attending physician, MD D, dated 09/19/2018, which stated in part:

"...I was also told that they do not have an ICU bed at this time. I went back to bedside to inform pt's [spouse and son], while I was giving them the news, pt's husband walked over me [sic] raising [her/his] arms up in the air and started yelling foul language and threatened me as if [s/he] was going to hit me in the face...escorted out of the room...continued to mumble threats...I felt uncomfortable with presence of pt's [spouse] and informed hospital administration that I am not able to continue to do my job as I no longer felt safe in hospital's hallway..."

Kindred leadership confirmed that the hospital did not have onsite security at the Northgate campus, although onsite security was provided at the First Hill campus.

The dictated transfer [discharge] summary from MD D stated that the patient was "stable with anasarca edema, pleural effusions, third-spacing, severe protein-calorie malnutrition with bilateral temporal wasting and now light changes in mental status most likely due to medications, however, patient is in need of an urgent evaluation of mental status including a CT of the head, therefore, transferred to emergency room..."

Under prognosis: "...the patient also has history of TB exposure from the past and these will need to be diagnosed when able to..." It was not clear if the outside hospital had been notified patient's TB [tuberculosis] exposure, since report was not given to the outside hospital. [Surveyor #1 notified the outside hospital of the potential exposure].

On 11/01/2018 at 4:00 PM, the Director of Quality Management (DQM) and the CEO were interviewed and the CMS (federal) requirements for appropriate discharges were discussed. The DQM stated that, while s/he understood that the outside hospital had no available ICU beds, and the ED had said don't send the patient, s/he stated that s/he disagreed with the investigator's assessment because Kindred "had no choice" but to send the patient out.

On 11/02/2018, at 9:25 AM, the CEO stated that after a previous Department of Health investigation [April, 2018] hospital leadership believed that the patient's right to demand to leave the hospital was the primary consideration regarding discharge. The CEO confirmed that s/he had made the decision to transfer/discharge the patient to the outside hospital requested by the patient's family.

The hospital did not have onsite security to deal with violent, or potentially violent, people in the hospital. The hospital sent a patient to an outside hospital when the outside hospital had stated that they had neither capacity or capability to accept the patient, and then bypassed the hospital's ICU admission process by sending the patient directly to the ED. The hospital sent a patient with a potentially communicable disease to the outside hospital, without evidence that the outside hospital had been warned or notified of same.

Item #2 - Not Meeting Patient Needs/Patient Neglect

Based on interviews and review of medical records, it was determined that the hospital failed to assure that patient care needs were met for Patients #3, 7, 8, 9 and 11.

The hospital's failure to assure that call lights were answered and patients needs were met resulted in unmet care needs for 5 patients, and placed all patients of the hospital at risk for the same.

Reference:

Joint Commission "Quick Safety" guide, issue 25, July 2016, viewed online 12/20/2018

"Issue:
Pressure injuries are significant health issues and ...also have a great impact on patients' lives and on the provider's ability to render appropriate care to patients.
... The development of pressure ulcers or injuries can interfere with the patient's functional recovery, may be complicated by pain and infection, and can contribute to longer hospital stays. The presence of pressure ulcers is a marker of poor overall prognosis and may contribute to premature mortality in some patients.
Pressure injuries are commonly seen in high-risk populations, such as the elderly and those who are very ill ...
Pressure ulcers also are called decubitus ulcers, bed sores or pressure sores ...Pressure injuries are staged to indicate the extent of tissue damage. The staging system also was recently updated by the NPUAP, which includes the following definitions:
A pressure injury is localized damage to the skin and/or underlying soft tissue. The injury can present as intact skin or an open ulcer and may be painful. The injury in combination with shear. The tolerance of soft tissue for pressure and shear also may be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue.
Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis - Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may represent as an intact or ruptured serum-filled blister. ..
Stage 3 Pressure Injury: Full-thickness skin loss - Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible ...
Pressure ulcer prevention requires an interdisciplinary approach to care. Some parts of pressure injury prevention care are highly routinized, but care also must be tailored to the specific risk profile of each patient ....
Skin Care. Protecting and monitoring the condition of the patient's skin is important for preventing pressure sores and identifying Stage 1 sores early so they can be treated before they worsen ...
Assess pressure points, temperature and the skin beneath medical devices.
Clean the skin promptly after episodes of incontinence, use skin cleansers that are pH balanced for the skin, and use skin moisturizers. Avoid positioning the patient on an area of pressure injury ...
Positioning and Mobilization. Immobility can be a big factor in causing pressure injuries. Immobility can be due to several factors, such as age, general poor health condition, sedation, paralysis and coma.
Turn and reposition at-risk patients, if not contraindicated ..."

Findings included:

A. Patient Care Events

Patient #3

On 11/01/2018, at 1:00 PM, a family member stated that in April, 2018, the patient had wanted help to get to the bathroom, but the nurse at the bedside refused to assist the patient. The family member stated that the nurse said "We just let 'em go and clean it up later".

The family member stated that the patient developed "lots of bedsores" because the patient did not get turned and cleaned and the hospital staff did not use turn sheets [linens placed under patients to help patients with repositioning in bed, which can help prevent skin damage].

The family member stated that, at one time, the patient had been discharged to another hospital and when it was time to go back to Kindred, the patient was "terrified" to go back. The family member stated that s/he thought the patient was "mistreated and neglected".

Review of medical records revealed that Patient #3 had been admitted to outside hospital #3 in May, 2018. The physician's history and physical (H&P) revealed the following:
" ...was transferred to Kindred Hospital however was not progressing as expected and was readmitted for further evaluation ...
Sacral decubitus ulcer stage 2/3 [reference above]
Case Management dated 05/02/2018 stated " ...family does not want to go back to Kindred ..." and a second case manager note on the same date " ...family is refusing LTACH ..." [Kindred]

The patient was discharged back to Kindred, however, and subsequently readmitted to outside hospital #3 in June, 2018 where the patient was a direct admit to ICU. The physician's H&P stated in part: "The ostomy is in place, erosion of the tracheostomy tube into the skin with cuff leak ..."
Nursing note by a Registered Nurse on the Adult Critical Care Service on the date of the patient's last admission from Kindred stated in part: " ...Skin breakdown with brown (likely necrotic drainage at stoma site. Lt. hand had black blister that popped spontaneously and oozed blood. Has stage 2 pressure ulcer on buttocks w/ sanguinous [bloody] drainage. Large edematous [swollen][ bruise on Rt shin. J tube won't flush. Abdomen is taut ...upon appearance, suspect care was neglectful at Kindred given [her/his] skin issues, clogged Jtube and tubing to JTube and PICC appear unkempt."

Patient #7

A family member of Patient #7 stated that the patient had multiple medical needs and care issues, including obesity, a large wound, a Foley catheter and a colostomy, all of which was confirmed by review of the patient's medical record. The family member stated that on 9/21/2018, that the patient had reported that s/he had put on her/his call light and asked for help because her/his colostomy bag had either spilled or burst and the catheter was leaking. The patient had stated that [Staff #38] had come into the room, uncovered [the patient] and looked at the spilled/burst/leaking devices and turned around and left the room. The hospital staff person did not return, and the patient laid in bodily waste and went without help for the rest of the night.

The patient's family member stated that the patient had reported that s/he had not put the call light on again for fear that staff would retaliate.

The family member stated that on 09/13/2018, s/he posted a notice to social media and instant messaged [named staff] at the hospital. The message was returned by someone who identified her/himself as a "community manager". The family member was then called by a person who identified her/himself as a "interim CEO" and said to the family member "I'll get to it" but the family member never heard back.

On 09/23/2018, the family member stated that s/he left another message for the "community manager". Another [named staff] returned the call and stated "I passed along your concerns to staff".

Review of hospital documentation showed that the staff member named by the patient, Staff #38, had been identified as a Registered Nurse (RN). The hospital confirmed that an internal investigation, conducted on 11/23/2018 after the patient's family posted to Facebook and called what was revealed to be Kindred corporate headquarters, revealed that the RN had answered the light and then left the patient unattended to, all night, as the patient had reported.

Patient #8

On 11/09/2018 at 10:48 AM, the patient's spouse stated that s/he "...wasn't too happy" with the care provided at Kindred. S/he stated that the hospital told her/him that the patient was not an ICU patient, but the patient was on a ventilator and unable to push a call light. S/he stated that the patient's nurse was frequently out of the room "on the floor". S/he also stated the [attending physician] would come in and ask if s/he had questions. When s/he did ask a question, the physician replied "that's a good question, I'll get back to you" but the physician did not ever get back to her/him.
The spouse also stated that s/he did not recall being informed about medical care being provided via telemedicine for 12 hours per day.

Patient #9

Review of a portion of the medical record for Patient #9 revealed that prior to self-decannulating, the patient had been noted to touch her/his tracheostomy, and the staff frequently reminded the patient not to touch the tracheostomy and frequently checked on the patient.

Review of nursing documentation revealed that the patient's wrist restraint had been discontinued on 11/05/2018. No nursing reassessment of behavioral changes was found prior to removal of the restraints, and the lack of a documented nursing reassessment prior to discontinuation of the wrist restraint was confirmed by the Director of Nursing and Clinical Services.

Review of the hospital's policy and procedure "Physical Restraints (Violent and Non-Violent Behavior) and Seclusion" found the following:

"7. Criteria for Release of Restraint(s): The clinical team...work collaboratively to observe the patient and remove the restraints...as soon as possible, based on an assessment. This includes documentation that indicates:
a. The unsafe situation is resolved
b. The RN determines if the current restraint should be continued..."

Review of the medical record revealed that on 09/18/2018, Patient #9 decannulated her/himself. Staff subsequently found the patient patient "non-responsive, decannulated and hypoxic [low levels of oxygen] and a "code" [emergency resuscitation] was called.

The patient was discharged that date, on an emergent basis, to outside hospital #2 and then discharged to another hospital. The patient's spouse stated that the patient had pulled out her/his "trache" and was discharged to home from the third hospital for comfort care and died at home.

The hospital's failure to assure that the patient was reassessed for the appropriateness of the discontinuation of the restraints may have contributed to the patient's self-decannulation, emergency discharge to another hospital and subsequent death.

Patient #11

On 11/02/2018 at 1:50 PM, the patient's spouse was asked if the patient's call lights were answered promptly, and the spouse replied "it just depends, it varies." S/he stated that Monday through Friday was "ok", but weekends and evenings were her/his concern, especially after 8 PM. S/he stated that during those times, Patient #11 used her/his own phone to call the spouse who would in turn call the nursing station to tell the nurses to answer the patient's call light.

The spouse repeatedly stated that the nurses were "busy" and s/he "didn't want to get anybody in trouble".

When asked if s/he and/or the patient felt safe and secure at the hospital, the spouse replied that s/he was concerned about safety, especially at night. S/he stated that the hospital had added a camera to one entrance which made her/him feel better.

Lack of P&P Regarding Answering Call Lights/Providing Care

On 09/19/2018, the hospital was requested, in writing, to provide its policy and procedure regarding answering call lights. As of the end of the onsite survey, November 20, 2018, the hospital was unable to provide a policy and procedure that described the role and responsibility of specific staff to promptly answer patient call lights, and the attendant responsibilities of the staff to assure that patient care needs were met.

Not Following Own Patient Rights

The hospital failed to follow it's own list of "PATIENT/FAMILY/SURROGATE RIGHTS":
"8. The patient has the right to care in a safe setting
9. The patient has the right to be free from all forms of abuse or harassment"

Emotionally Safe Setting

Based on interviews, it was determined that the hospital failed to provide an emotionally safe setting for patients #2, 3 by assuring that Registered Nurses and other caregivers were fluent in the same language as the patients, and could understand and be understood.

The hospital's failure to do so resulted in 2 of 2 patients being unable to communicate with staff and/or feeling that they were being mocked.

Patient #2

On 11/06/2018 at 8:00 AM, a family member of Patient #2 stated that the care provided at Kindred was "horrific". S/he gave examples of medical care concerns and also stated that "it was hard to understand the multilingual staff". S/he stated that, on one occasion, the patient had been lying in her/his own urine. Four (4) staff members came to the patient's bed, 3 men and 1 woman, to clean the female patient. All 4 staff were "laughing and joking in another language and [the patient] thought they were making fun of her".

Patient #3

On 11/01/2018 at 9:00 AM, a family member of Patient #3 stated that the patient "was scared" to be in the hospital. S/he stated that most of the nurses were from different cultures and English was a second language and the nurses could not communicate with the patient or with her/him. Other patients families reported to the family member that they had the same challenges and the family member should not go for a day without checking on the patient.

The hospital failed to follow it's own list of "PATIENT/FAMILY/SURROGATE RIGHTS":
14. The patient has the right to considerate and respectful care...

Item #3 - Lack of Physician Evaluation and Oversight

Based on interviews and review of hospital documents, it was determined that the hospital failed to provide physician evaluation and oversight to MD D.

The hospital's failure to do so placed all patients of the hospital at risk for unmet care needs and negative health outcomes.

Findings included:

Physician Bylaws Related to Oversight

On 10/29/2018, the hospital was requested to provide documentation about how the medical practice of MD D, who was the only full-time attending physician for all patients in the hospital, was evaluated. Hospital personnel provided the "Bylaws of the Medical Staff of Kindred Hospital Seattle - Northgate Kindred Hospital Seattle - First Hill. The document was undated.

Personnel tagged the document for reference: "Article IX Medical Staff Committees and Performance Improvement Functions The medical Staff is responsible for establishing and maintaining patient care standards and oversight of the clinical performance of individuals with delineated clinical Privileges..."

Review of the document "Kindred Hospital Seattle 2018 Organizational Plan for the Delivery of Patient Care, Treatment and Services" revealed the following:

"STRUCTURES WITH FUNCTIONS
Medical Staff
It is the goal of the organized, self-governing, medical staff to oversee the provision of quality care, treatment and services delivered by practitioners credentialed and privileged through the medical staff process."

The hospital was also asked to provide the last evaluation for MD D. On 10/30/2018, the hospital provided the last evaluation for the attending physician, dated 08/30/2018. The evaluation had multiple directives listed, all from the Director of Quality Management (DQM), a non-physician. Examples of the directives included: "Please review medical management of complex patients with ICU and hemodialysis needs" and "review patients overall care with particular management of critical care needs". The evaluation was signed by the attending physician at the First Hill campus, MD I, who was a peer of MD D.

Medical Management of Patients

As of 10/30/2018, hospital personnel stated that the evaluation had not been reviewed by the Medical Executive Committee (MEC) as of that date.

The hospital did not produce evidence of the oversight of MD D by the end of the survey.

Also on 10/30/2018, the DQM and the Chief Executive Officer stated that another physician at the hospital, MD C, reviewed 100% of all returns to STACs (short-term acute care hospitals).

On 10/30/2018, the hospital was asked to provide criteria for return to STACs and the quality indicators regarding returns to STAC. The information was not provided by the end of the survey.

On 11/01/ 2018, the CEO and the DQM stated that medical oversight consisted of the Kindred physician, MD C, reviewing all returns to STAC for trends and quality of care and the returns were all evaluated by the MC as well. Both stated that any concerns would be sent forward to the MC.

On 11/02/2018, MD C was asked to explain her/his role in the review of returns to STAC. The physician stated that the clinicians decide which patients get transferred and where. S/he stated that s/he did not perform a review of the medical care provided or of the reasons for the transfer, s/he only reviewed the cases to see if the patients could have received the care at Kindred. S/he stated the review was "very retrospective". The physician was asked if that level of review required a physician and replied that it did not, but s/he had been asked to do the reviews and so s/he did them.

MD C stated that s/he did not have any criteria to use and was not reviewing the cases for appropriateness of care, s/he just looked to see if the care could have been provided at Kindred hospital. S/he stated some of the care that could not be provided at Kindred were patient who had "GI bleeds" because the hospital could not perform endoscopies, NT [ear, nose and throat] cases and emergency CT [computerized axial topography] scans.

On 11/01/2018, the CEO and the DQM stated that the hospital conducted RCA's (root cause analyses) on every patient return to a STAC to determine appropriateness of care and necessity for the transfer/discharge.

On 11/16/2018, the hospital was presented with a written request for "RCA's for the following returns to STAC..." and 13 patient names were listed. On 11/20/2018, Staff #33 and #34 confirmed that RCA's had not been conducted on any of the patients.


Item #4 - Qualifications and Oversight of Staff Delivering Critical or Intensive Care Services

Based on interviews, it was determined that the hospital failed to assure that the hospital's ICU was staffed with physicians and other staff whose qualifications to work in the ICU had been established by the medical staff.

The hospital's failure to do so placed all patients in the ICU at risk for unmet care needs and/or care and services provided by unqualified staff.

Findings included:


On 10/29/2018, hospital leadership was presented with a list of requested documents. Included in the list was a request for evidence that the hospital had defined the qualification and oversight of staff delivering critical or intensive care services. The documentation was re-requested on 11/02/2018, but as of the end of the survey, the documentation had not been provided and hospital leadership confirmed that there was no such documentation.


Item #5 - Inadequate Numbers of Qualified Staff

Based on interviews and review of hospital documents, it was determined that the hospital failed to assure that the hospital was staffed with adequate numbers of qualified staff.

The hospital's failure to do so resulted in unmet healthcare needs and placed all patients in the hospital at risk for unmet care needs, injury or death due to same.

Findings included:

Inadequate Numbers of Leadership Positions Filled

On 10/29/2018, the hospital was presented with a list of requested documents, including a copy of the organizational chart. The chart was provided and reviewed. The administrator confirmed that the organizational chart provided was accurate and that the Northgate campus had open positions for a Food Services Manager, a Director of Quality Management and a Director of Respiratory Services.

The administrator stated that the responsibilities of those positions were being covered by staff from another hospital campus. The administrator confirmed that the Northgate campus had a vacant position for a Nurse Manager, and stated that the nurse manager responsibilities were being temporarily covered by the Director of Clinical and Nursing Services and the staff nurses.

On 10/29/2018, the Chief Executive Officer (CEO) stated that the hospital was recruiting for a Director of Quality Management (DQM) specifically for the Northgate campus, a Nurse Manager and a Director of Respiratory Services. The CEO acknowledged that the positions had not actually been posted as of that date.

On 11/16/2018, DOH surveyors were informed that the DQM position for the First Hill campus (previously covering for both campuses) and the Chief Clinical Officer for the First Hill campus (previously covering for both campuses) had been vacated and those employees were no longer with the organization.

Inadequate Numbers of Qualified Licensed Nursing Staff

Review of the hospital's policy and procedure "Nurse Staffing Plan", effective 02/2018, revealed the following directives for nurse staffing:

"NURSING ROLES & RESPONSIBILITIES
...3. The house Supervisor is a Registered Nurse responsible and accountable to supervise and coordinate the activities of the hospital personnel...
4. The Registered Nurse is responsible for the provision of the direct patient care provided to all patients and is accountable to assess, plan, implement, and evaluate the nursing care...

"2. Core Staffing by Shift
a. The schedules are based on average patient census on a daily and shift basis. Current core needs are 7 licensed nurses (no more than 2 LPN and 5 RN) and 4 nursing assistants for each shift 24/7.
b. A minimum of two ACLS certified staff, one being an RN, shall be assigned to the unit at all times.
c. Within the core licensed nurses, the schedule will have at least one ICU trained nurse within the core along with the supervisor who is ICU trained...."

On 10/30/2018 at 11:25 AM, the Director of Clinical and Nursing Services (DCNS) stated that the house supervisors provided relief to the Intensive Care Nurses, and were ICU-qualified.
A list of RNs, and their qualifications as ICU nurses, was reviewed with the DCNS to determine if the hospital had been adequately staffed with qualified nurses.

Review of the patient census/nurse staffing schedules for the current week revealed shortages based on core staffing requirements:

10/25/2018
First shift: 5 RNs, no LPNs - short 2 licensed nurses, including 1 qualified ICU nurse
Second shift: 4 RNs, no LPNs - short 2 licensed nurses

10/26/2018
First shift: 4 RNs, 1 LPN - short 2 licensed nurses
Second shift: 3 RNs, 1 LPN - short 3 licensed nurses, including 1 qualified ICU nurse

10/27/2018
First shift: 5 RNs, no LPNs - short 2 licensed nurses
Second shift: 5 RNs, no LPNs - short 2 licensed nurses

10/28/2018
First shift: 4 RNs, 1 LPN - short 2 licensed nurses
Second shift: 4 RNs, no LPNs - short 3 licensed nurses

10/29/2018
First shift: 5 RNs, no LPNs - short 2 licensed nurses
Second shift: 5 RNs, no LPNs - short 2 licensed nurses

10/30/2018
First shift: 5 RNs, 1 LPN - short 1 licensed nurse
Second shift: 5 RNs, no LPNs - short 2 licensed nurses

The above finding regarding licensed nurse staffing levels, and the hospital's core staffing requirements, were confirmed onsite with the Chief Executive Officer.

Item #6 - ICU/Medical Surgical Patient Admission Criteria

Based on interview, it was determined that the hospital failed to assure that criteria for patient admission to the Intensive Care Unit (ICU) had been identified and approved by the medical staff.

The hospital's failure to do so placed patient's at risk for inappropriate bed placement with resulting unmet care needs or cross-contamination of patients.

Findings included:

On 11/01/2018, hospital leadership was given a verbal request for admission criteria for all patients, ICU and medical surgical. By the end of the survey, the information had not been provided.

Item #7 - Emergency Services

Based on record review and interview, the facility failed to demonstrate that it developed and implemented policies and procedures to manage services for patients with medical emergencies; as a facility without an emergency department services.

Failure to do so created risk for patient harm due to inadequate implementation of emergency medical services and/or delays in arranging for those medical services at an off-site location(s).

Findings included:

1. a. In review of staff facility policy titled, "Resuscitative Services: Emergency Advanced Life Support Notification System" it described general procedures for providing emergency advanced life support to patients. It addressed documenting the start of oxygen and/or suctioning, completing the Code team record, and notification of "physician". The procedure did not address actions to be taken in other types of patient emergency situations (including arrangements per hospital transfer agreements) or reference to any medically approved policy and procedure. It also did not address the difference between a "rapid response" and a "code" procedures for emergency patient care.

b. In review of staff facility policy titled "Rapid Response Team" (RRT) described actions to be taken for hospital patients that have a change in condition outside of established parameter and/or early signs of clinical deterioration. It described the types of intervention protocols that may be utilized. The plan included nurse communication with the attending physician. The procedure did not address actions to be taken for other types of emergency situations that required medical strategies to be performed off-site or reference related policy and procedure.

c. No policy and procedure describing post-code reviews/evaluations had been received by the end of the onsite survey.

2. a. In review of the medical record Patient #4 was admitted to Kindred with respiratory problems, severe chronic encephalopathy (brain injury) after surgical repair of aortic aneurisms in 2 locations. The patient was with family in the family room when she developed shortness of breath and became unresponsive at 5:10 PM on 06/30/18.

b. Documents titled, "Rapid Response Team And Code H Record" and "Code Blue Flowheet" were intiated at the same time; 5:10 PM. The "Code Blue Flowsheet" record showed that the patient had a spontaneous pulse rate with chest compressions of 141, 134, 128 and 129 (incompatable description; cannot have spontaneous pulses measured during chest compressions) while at the same time the pulse was described as "PEA" (pulseless electrical activity). At 5:14 PM and 5:20 PM the patient was recorded as having PEA. The record did not indicate whether or not the patient had spontaneous respirations although it indicated that the patient had a tracheostomy and an ambu bag was used.

c. In summary, the Code record did not indicate whether or not the patient was without spontaneous respirations (respiratory arrest) and it provided inconsistent information about presence or absence of spontaneous pulses. There was not a policy and procedure to reference for initiating and perform

Based on interviews, review of medical records and hospital documents, it was determined that the hospital failed to ensure that all patients were free from all forms of abuse, harassment or neglect.

The hospital's failure to do so placed all patients in the hospital at risk for abuse, harassment and/or neglect.

Findings included:

Reference:

State Operations Manual
Appendix Q - Guidelines for Determining Immediate Jeopardy
(Rev. 102, Issued: 02-14-14). Viewed online on 12/13/2018.

"The following definitions apply to all certified Medicare/Medicaid entities:
Immediate Jeopardy - "A situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident." (See 42 CFR Part 489.3.)
Abuse - "The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish." (See 42 CFR Part 488.301.)
Neglect - "Failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness." (See 42 CFR Part 488.301.)...

Issue
Triggers
A
1. Failure to protect from abuse....
3. Unexplained serious injuries that have not been investigated...
B Failure to Prevent Neglect
1. Lack of timely assessment of individuals after injury...
2. Lack of supervision for individual with known special needs...
10. Failure to adequately monitor individuals with known severe self-injurious behavior;
11. Failure to adequately monitor and intervene for serious medical/surgical conditions...
C Failure to protect from psychological harm...
3. Lack of intervention to prevent individuals from creating an environment of fear..."


Refer to all evidence cited in Tag A0144.

The hospital failed to implement it's own "Patient Rights and Responsibilities" statement, provided in writing to patients/representatives upon admission, which stated in part:

" ...8. The patient has the right to care in a safe setting.
9. The patient has the right to be free from all forms of abuse or harassment...
14. The patient has the right to considerate and respectful care..."
.

Based on interview, review of medical records and review of hospital policy and procedure, it was determined that the hospital filed to assure that 1 of 3 patients who had restraints removed, had a reassessment of specific behavioral changes prior to removal of the restraints.

The hospital's failure to do so potentially contributed to Patient #9 decannulating [removal of a tracheostomy tube or cannula] her/himself, and placed all patients whose restraints were removed without a reassessment at risk for harm or death.

Findings included:

Review of the patient's medical record revealed that prior to self-decannulating, the patient had been noted to touch her/his tracheostomy, and the staff frequently reminded the patient not to touch the tracheostomy and frequently checked on the patient.

Review of nursing documentation revealed that the patient's wrist restraint had been discontinued on 09/05/2018. No nursing reassessment of behavioral changes was found prior to removal of the restraints, and the lack of a documented nursing reassessment prior to discontinuation of the wrist restraint was confirmed by the Director of Nursing and Clinical Services.

Review of the hospital's policy and procedure "Physical Restraints (Violent and Non-Violent Behavior) and Seclusion" found the following:

"7. Criteria for Release of Restraint(s): The clinical team...work collaboratively to observe the patient and remove the restraints...as soon as possible, based on an assessment. This includes documentation that indicates:
a. The unsafe situation is resolved
b. The RN determines if the current restraint should be continued..."

Review of the medical record revealed that on 09/18/2018, Patient #9 decannulated her/himself. Staff subsequently found the patient patient "non-responsive, decannulated and hypoxic [low levels of oxygen] and a "code" [emergency resuscitation] was called.

The patient was discharged that date, on an emergent basis, to another hospital and then discharged to a third hospital. The patient's spouse stated that the patient had pulled out her/his "trache" and was discharged to home from the third hospital for comfort care and died at home.

The hospital's failure to assure that the patient was reassessed for the appropriateness of the discontinuation of the restraints may have contributed to the patient's self-decannulation, and subsequent death.
.