HospitalInspections.org

Based on facility policy review, medical record review, facility document review, and interview the facility failed to ensure all patients were free from all forms of neglect and received respectful and dignified care at all times when the therapy staff continued therapy instead of ensuring incontinence care was provided for one (1) of three (3) (Patient #1) sampled patients receiving rehabilitative therapy services.

The findings included:

1. Review of the facility policy titled, "Patient Rights and Responsibilities" revealed, "It is the policy of the hospital to at all times, and in accordance with applicable state and federal laws and regulations, observe and respect a patient's rights and responsibilities...As a patient, you have the right to safe, respectful and dignified care at all times...You have the right to...Receive care in a safe setting free from any form of abuse, harassment and neglect...Receive kind, respectful, safe, quality care delivered with the highest quality of service..."

2. Review of the facility policy titled, "Pressure Injury Prevention/Basic Treatment" revealed, "...Basic prevention measures will be implemented to prevent and treat pressure injuries/ulcers...Unless guided otherwise by physician order or approved protocol, the following prevention and basic aggregate techniques should be included as appropriate...Manage excessive moisture/incontinence of patient...Cleanse skin at time of soiling and minimize skin exposure to moisture..."

3. Medical record review for Patient #1 revealed an admission date of 11/12/2020 with diagnoses that included Acute Left Frontal and Basal Ganglia Infarcts (Basil Ganglia Infarct is a brain lesion in which a cluster of brain cells die when they don't get enough blood) with functional loss and severe Aphasia/Apraxia (Aphasia is the loss of the ability to understand or express speech caused by brain damage - Apraxia is the inability to perform particular purposeful actions as a result of brain damage).

Patient #1 was incontinent of bowel and bladder function.

Review of the Team Conference/Plan of Care Update for Patient #1 revealed, "...At Risk for Injury Rehab Last Updated Date: 11/13/2020...Interventions - Monitor elimination needs..."

Review of the Physical Therapy (PT) Daily Documentation dated 11/20/2020 beginning at 11:00 AM revealed, "...Pt's [patient's] family present for family training today. Demonstrated and educated on sliding board transfers and allowed each family member to perform transfer with patient...Time Spent With Patient...60 [sixty] minutes..."

4. Review of the "Patient Grievance Log" dated 11/20/2020 revealed Patient #1's daughter filed a grievance with the hospital stating Patient #1 had a soiled brief on during the family therapy training session. Patient #1's daughter also voiced concerns regarding Patient #1's skin status. The hospital documented they determined, "pt [patient] was changed immediately..." when notified of Patient #1's incontinence in therapy. The hospital also documented Patient #1 was evaluated by the wound care nurse on 11/23/2020 and "no ulcers noted". There was no documentation the hospital implemented any new interventions involving the therapy staff related to incontinence care following their investigation of the grievance filed by Patient #1's daughter.

5. Review of the patient flowsheet dated 11/20/2020 revealed facility staff provided incontinence care to Patient #1 at 9:39 AM and at 12:35 PM. There was no documentation Patient #1 received incontinence care while in the therapy session from 11:00 AM - 12:00 PM.

6. Review of the Wound Care document for Patient #1 dated 11/23/2020 revealed, "...New consult for this patient. Consulted for pressure ulcer to the sacrum. On assessment patient has small open areas to bilateral buttocks. There is hyperpigmentation to bilateral buttocks as well that extends all the way up to the sacrum but this is likely due to incontinence as opposed to pressure. As for the abrasions, they are both small and based on their location are likely caused from friction. patient is a slide board transfer that requires substantial assistance. Seeing PT transfer patient to bed prior to exam further supports this. [Named Physician #1] at bedside during assessment and is in agreement..."

7. In a telephone interview with Patient #1's daughter on 12/14/2020 at 4:14 PM, the patient's daughter informed surveyor that she was with the patient on 11/20/2020 for the family therapy training session and observed Patient #1 (her mother) was sitting in urine soaked clothing when she arrived and she asked Therapist #1 to clean the patient before performing the therapy session. Patient #1's daughter further stated, Therapist #1 kept Patient #1 in the family gym and completed the family training and therapy session before she took the patient upstairs for incontinence care.

In an interview with the Wound Care Nurse (WCN) on 12/15/2020 at 12:12 PM, the WCN verified she was consulted because Patient #1 had two (2) open areas on her upper buttocks that were very superficial and appeared to be caused from the slide board transfer.

In an interview on 12/15/2020 at 12:02 PM, the facility's Director of Quality/Risk Management (DQRM) informed surveyor that Patient #1's daughter filed a grievance with them when Patient #1 "...was brought down for family therapy training and during the training [Therapist #1] found her to be wet and immediately changed her...her daughter was upset that she [Patient #1] was found that way..."
The DQRM further stated Patient #1's daughter was concerned about the condition of the patient's skin so a Wound Care Nurse was consulted and found no pressure ulcers just a small abrasion.
The DQRM stated on 11/23/2020 at 11:45 AM, " I called and spoke with her [Patient #1's] daughter and gave her this information and she [Patient's daughter] was relieved..." .

In an interview with Therapist #2 on 12/15/2020 at 12:26 PM, the Therapist informed this surveyor she was present during the family therapy training session on 11/20/2020 with Patient #1 and her family members. The Therapist stated the patient's family members informed her they were upset because Patient #1 was in therapy and was soiled due to incontinence.
The Therapist stated, "We were in our out patient gym. I told her [Patient #1's daughter] we would need to take her upstairs to clean her up...I did not physically change her, when we brought her upstairs, we told the nurse manager she needed to be cleaned up..."
Therapist #2 stated she could not remember if she or Therapist #1 was the one who took Patient #1 upstairs to be cleaned up. Therapist #2 informed this surveyor she was not present for Patient #1's entire session, but was present toward the end of the session and the patient had been there for about an hour.
Therapist #2 stated she completed a CALM form (Compose Apologize Listen Make it right - an internal concern form) and gave it to her Supervisor Therapist #3.

In an interview with Therapist #3 on 12/15/2020 at 12:32 PM, the therapist informed this surveyor that Therapist #2 brought her the Calm form which stated Patient #1 had been soiled in family therapy room and the patient was taken upstairs and was cleaned up. The Therapist stated, "I spoke with [Therapist #1] the next day [11/21/2020] and she said at first during the training there was no evidence the patient was soiled, but towards the end, the patient was soiled. [Therapist #2] came down and tried to address other areas of concerns and then we took her [Patient #1] upstairs..."

In an interview with Therapist #1 on 12/15/2020 at 12:49 PM, the therapist informed this surveyor that Patient #1 had a physical therapy session upstairs right before coming down to the area for the family therapy training session. Therapist #1 stated, "When we transferred her [Patient #1 from the wheelchair to the chair with slide board] her family mentioned the pad under her was wet. I didn't notice it. This was about 15 minutes or so into the session. I had a glove on and I touched the pad to see if it felt wet. I don't remember feeling anything obviously wet." Therapist #1 said she and Therapist #2 addressed the family's concerns and informed them they would take the patient upstairs and communicate with nursing to make sure the patient was taken care of.
When asked how long she waited to take Patient #1 upstairs after being informed that she was soiled, Therapist #1 stated, "It was probably about 15 minutes before we took her upstairs after we found the issue."
The Therapist was asked if she checked Patient #1 for incontinence prior to starting her therapy session. Therapist #1 stated, "Admittedly, I didn't check her [Patient #1] before I brought her downstairs."

Facility staff neglected to provide incontinence care to Patient #1 on 11/20/2020 from approximately 9:39 AM until 12:35 PM. During this time, Patient #1 was sitting in urine soaked clothing in a gym with other patients and family members present. Therapist #1 and #2 continued to perform therapy services to the patient even though they were aware the patient was soiled with urine. The facility did not put new interventions in place with therapy staff members to address the issue.