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Based on policy review, medical record review, internal document review, and staff interviews, the facility failed to follow state laws and notify the Health Care Personnel Registry (HCPR) of an allegation of staff to patient neglect within twenty-four hours, after becoming aware of the allegation.

The findings included:

Review of the policy titled "Abuse of Patient, Elder, Child by Staff Identification - Response & Reporting" dated 10/20/2018, revealed "POLICY ...Prohibit abuse and describe the procedures for preventing and responding to allegations of abuse, neglect or mistreatment of a patient. To identify the hospital's position regarding employees who are suspected of patient abuse, neglect and or exploitation. ... Neglect/Mistreatment is the failure or refusal by any person having the care or custody of another (child, elder and adult) to exercise the degree of which a reasonable person in a like position would exercise. Neglect includes, but is not limited to: a. Failure to provide the prescribed medical care and treatment for their physical and mental health needs; b. Actions by an employee contrary to prescribed treatment; ... e. Deliberate refusal to implement the individual's treatment program ... The first person to receive the report should document the allegation as an event report. ...The Chief Executive Officer, Director of Quality Management, or their designee, reviews federal reporting requirements ... Any required reporting to licensing agencies as mandated by law will be made by the Chief Clinical Officer or the Director of Quality Management after consultation with the law department and Hospital Chief Executive Officer. ..."

Open medical record review of Patient #4 revealed a 53-year-old female admitted 11/15/2018 for management of wound cellulitis and other comorbidities. Record review revealed on 04/24/2019 at 1805, MD (Medical Doctor) #1 ordered "Metoprolol Tartrate (medication to lower blood pressure) oral tablet, 25mg (milligrams) BID (twice a day, 0900, 1800) with hold if my systolic BP <105 mm (millimeters) hg (mercury) ". Review revealed a blood pressure of 147/71 which was documented on 05/31/2019 at 1703 by CNA #1 (Certified Nurse Assistant). Review of the Medication Administration Record (MAR), revealed documentation by RN (Registered Nurse) #2 that she administered 25mg Metoprolol Tartrate orally to Patient #4 on 05/31/2019 at 1700.

Review of the internal documents on 08/22/2019, revealed on 06/07/2019 the Nursing Supervisor presented the involved employee a discharge notification. The employee was terminated on 06/07/2019 for "...Falsifying medical records and ... Any action that is considered to be threatening to the health and safety of others..." Review revealed CNA #1 failed to perform the duties in caring for a patient which resulted in the discharge of the employee CNA #1. Review of the investigative report revealed an interview with Patient #4 revealed the patient reported to a Nursing Supervisor that her blood pressure was not taken by the CNA prior to the administration of her blood pressure medication. Interview revealed an investigation was done and the CNA admitted that she falsified the patient's blood pressure. Interview revealed a video review was done as part of the investigation and the facility found that the CNA failed to round on her assigned patients.

Interview with the Director of Quality Management on 08/22/2019 at 1550, revealed an investigation was initiated on 06/01/2019 regarding the allegation of a staff member falsifying patient information. Interview revealed the employee who was the subject of the allegation was terminated. Interview revealed, the employee involved admitted to falsification of patient information (blood pressure results). Interview with the Director of Quality Management revealed, "...At the time I didn't look at this situation as a neglect issue. ..." Interview revealed, as part of the process for suspected need for reporting to the HCPR, would be to have a round table discussion with the Chief Executive Officer and Medical Director. Interview revealed, notice of the neglect allegation had not been filed with the State Regulatory Agency.

Cross Reference: 10A NCAC 130 .0102

Based on review of hospital policy and procedures, observations during tours, patient and staff interviews, the hospital staff failed to ensure the patient's privacy for 1 of 1 inpatients. (#4).

The findings include:

Review of the facility's "Patient's Rights and Responsibilities" (with no date), revealed "(Named Hospital) and its medical staff have adopted these Patient's Rights in the belief and with the expectation that understanding and observation of the rights will result in more effective patient care and in promotion of the confidence and trust which must exist between the patient, the physician, and (named facility). It is recognized that the patient and the physician must have a personal relationship in order for the patient to receive proper and effective medical care, and that the patient's stay in (named facility) adds a new dimension to this relationship. It is also recognized that (named facility) has responsibilities and duties of its own to the patient. With due regard and respect for these factors, (named facility) and its medical staff present and support the following Patients' Rights: 1. A patient has the right to respectful care given by competent personnel....4. A patient has the right to have all records pertaining to his/her medical care treated as confidential except as othewise provided by law or third party contractual arrangements...."

Observation on 08/20/2019 at 1330 of the front security desk located in the hospital's main lobby revealed a typed sign on 8.5 inch by 11.5 inch paper taped to the counter. The sign read: "PATIENT IN ROOM 208 IS NOT ALLOWED ANY FOOD DELIVERY." Observation revealed the sign did not have a date or signature.

Review of the admitting physician's history and physical dated 11/16/2018 revealed Patient #4 was admitted on 11/15/2018 to room 207, currently patient #4 is in 208. Review of the patients' medical record revealed admitting diagnoses that include, "Morbid obesity. Cellulitis of right anterior lower leg. Lymphedema. Groin pain. Hypothyroidism. Right leg wound. Fevers. Fibromyalgia...Impression: A 53 year old lady with morbid obesity, recent anterior leg cellulitis, hypothyroidism, anxiety disorder, massive lymphedema....PLAN: We will admit to medical floor. We will order nutrition consult for weight loss...."

Interview on 08/20/2019 at 1225 with Patient #4 revealed a sign was at the desk for no food from outside. Interview revealed the patient had been ordering food from area restaurants. Interview revealed the patient felt like everybody could see the sign and know her business. Interview revealed she had a right to order food if she wanted to.

Interview 08/21/2019 at 0845 with dietary director revealed the sign was placed at the desk to assist with discouraging the patient from eating outside food.

Interview on 08/22/2019 at 1320 with MD #1 revealed the sign was placed at the desk to discourage the patient from receiving outside food. Interview revealed the sign was not visible to most people and has been removed.

Based on observations during tours, medical record reviews, interviews with patients and staff, the facility failed to satisfy patient's dietary needs by failing to provide foods based on patient's likes and dislikes in 1 of 1 patients. (Patient #4)

The findings include:

Observation on 08/20/2019 at 1155 revealed meal tray delivery to Patient #4. Observation revealed the meal contained a meal ticket that read "Turkey Burger with bun and two 8 ounce bottles of water." Observation revealed Patient #4 did not eat the food from the tray.

Observation on 08/21/2019 at 1128 of a video recorded on 07/28/2019 at 1742 of patient #4's dinner meal tray served on 07/28/2019 revealed dark meat covered in ketchup. Observation revealed the meat was dark brown with hard looking pieces on the meat. Observation revealed mashed potatoes and carrots and celery were on Patient #4's plate. Observation on 08/21/2019 at 1128 of a video recorded on 07/15/2019 revealed a piece of meat labeled as salmon. Video revealed Patient #4 hitting the 'salmon' on the side of the tray without the meat breaking. Video revealed overcooked vegetables, of green beans and cauliflower showing dark spots. Review of video dated 08/16/2019 at 1735 of Patient #4's dinner plate revealed slices of ham covered in yellow liquid.

Review of the admitting physician's history and physical dated 11/16/2018 revealed Patient #4 was admitted on 11/15/2018 to room 207, currently patient #4 is in 208. Review of the patients' medical record revealed an admitting diagnoses that included, "Morbid obesity. Cellulitis of right anterior lower leg. Lymphedema. Groin pain. Hypothyroidism. Right leg wound. Fevers. Fibromyalgia...Impression: A 53 year old lady with morbid obesity, recent anterior leg cellulitis, hypothyroidism, anxiety disorder, massive lymphedema....PLAN: We will admit to medical floor. We will order nutrition consult for weight loss...." Review of current physician's diet order revealed "1000 calories, 2 liters fluid restriction, sugar substitute, Regular texture, no salt."

Interview on 08/20/2019 at 1225 with Patient #4 revealed the many times that she told the dietary staff of her dislike of butter. Interview revealed multiple times that vegetables were served saturated in butter. Interview revealed the vegetables were often overcooked and inedible. Interview revealed ham slices were recently served saturated with butter.

Interview on 08/21/2019 at 0845 with the Director of Dietary revealed dietary preferences were obtained daily by the technician from Patient #4. Interview revealed the preferences were then written on the dietary order sheet and the patient meals were prepared using guidelines and patient preferences. Interview revealed the dietary clerks return to the dietary office with the patient's preferences. Interview revealed Patient #4 has complained about the meats being too dry and overcooked. Further interview revealed Patient #4 does not eat vegetables. Interview revealed Patient #4's meal trays do contain vegetables when served.

Interview on 08/21/2019 at 1415 with the Dietitian revealed Patient #4 does not eat vegetables. Interview revealed Patient #4 had been served vegetables that she did not like.

NC00153268
NC00153426