HospitalInspections.org

Based on review of the Patient's Rights Notice document and interview, it was determined the facility failed to include the State Agency's address on the Patient Rights documents given to patients on admission to the facility. The failed practice did not allow patients to place their complaints in writing and send to the State Agency. The failed practice had the likelihood to affect all patients admitted to the facility. Findings follow:

A. Review of the WITH (Wellness Information & Tools for Health) booklet, received from the Director of Quality and Risk at 10:45 AM on 05/29/18, showed the State Agency's address was not listed on the form highlighting where complaints could be filed.

B. During an interview with the Chief Executive Officer at 11:15 AM on 05/30/18 the findings in A were verified.

Based on observations and interviews, it was determined the facility failed to promote and protect the dignity and personal privacy of one of one (Patient #16) patient in that the urinary drainage bag was not covered. Failure to cover the urinary drainage bag allowed other patients, staff and visitors to view the bag containing urine which had the potential to embarrass and compromise the dignity and privacy of Patient #16. The failed practice affected Patient #16 on 05/30/18. Findings follow:

A. Observation at 12:00 noon on 05/30/18, showed Nursing Technician #1 pushing Patient #16, in a wheelchair, to the facility dining room. Observation showed the urinary drainage bag hanging in full view, on the right side of the wheelchair armrest.

B. During an interview with Registered Nurse (RN) #1 at 12:05 PM on 05/30/18, she stated the urinary drainage bag was supposed to be covered by a bag.

C. Observation in the facility dining room at 12:10 PM on 05/30/18, with the Director of Quality and Risk showed Patient #16 sitting at a dining table with the urinary drainage bag still hanging on the right side of the wheelchair armrest.

D. During an interview with the Director of Quality and Risk at 12:20 PM on 05/30/18, she stated the urinary drainage bags are supposed to be placed in another bag so the bags are not visible to others.

Based on clinical record review and interview, it was determined the facility failed to follow standards of practice in the organization of Nursing Services in that there was no implementation of the Arkansas Department of Health Rules and Regulations for Hospitals and related Institutions in Arkansas, 2016, in that a Registered Nurse (RN) did not observe each patient at least once a shift and document such in the clinical record for nine (Patient #2-6, #10, #12-14) of 15 (#1-15) patients. Failure to ensure a RN observed each patient each shift did not allow a professional nurse to plan, supervise, and evaluate the nursing care for each patient. The failed practice affected Patients #2-6, #10, and #12-14. Findings follow:

A. Review of Patient #2's clinical record showed a RN did not observe and document the observation on the 7 AM to 7 PM shift 7 (04/27/17, 04/29/17, 04/30/17, 05/03/17, 05/09/17-05/11/17) of twenty (04/25/17-05/4/17) shifts. During an interview with the Hospital Educator at 3:21 PM on 05/29/18 the above findings were verified.

B. Review of Patient #3's clinical record showed a RN did not observe and document the observation on the 7 AM to 7 PM shift three (05/02/17, 05/11/17 and 05/15/17) of 21 (04/28/17 - 05/18/17) shifts. During an interview with the Hospital Educator at 4:27 PM on 05/29/18 the above findings were verified.

C. Review of Patient #4's clinical record showed a RN did not observe and document the observation on the 7 PM to 7 AM shift six (05/04/17 - 05/09/17) of seven (05/03/27 - 05/09/17) shifts. During an interview with the Hospital Educator at 10:02 AM on 05/20/18 the above findings were verified.

D. Review of Patient #5's clinical record showed a RN did not observe and document the observation on the 7 AM to 7 PM shift 13 (05/05/17, 05/09/17, 05/11/17 - 05/16/17, 05/18/17-05/21/17, and 05/24/17) of 22 (05/03/17 - 05/24/17) times. During an interview with the Hospital Educator at 9:39 AM on 05/30/18 the above findings were verified.

E. Review of Patient #6's clinical record showed a RN did not observe and document the observation on the 7 AM to 7 PM shift one (05/25/18) of six (05/24/18-05/29/18) times. During an interview with the Hospital Educator at 10:41 AM on 05/30/18 the above findings were verified.

F. Review of Patient #10's clinical record showed a RN did not observe and document the observation on the 7 AM to 7 PM shift one (05/25/18) of two (05/25/18 -05/26/18) times. During an interview with the Hospital Educator at 12:56 PM on 05/30/18 the above findings were verified.

G. Review of Patient #12's clinical record showed a RN did not observe and document the observation on the 7 AM to 7 PM shift two (05/24/18 and 05/28/18) of nine 9 (05/21/18 - 05/29/18) shifts. During an interview with the Hospital Educator at 1:47 PM on 05/30/18 the above findings were verified.

H. Review of Patient #13's clinical record showed a RN did not observe and document the observation on the 7 AM to 7 PM shift three (05/26/18 - 05/28/18) of four (05/26/18 - 05/29/18) shifts. During an interview with the Hospital Educator at 2:00 PM on 05/30/18 the above findings were verified.

I. Review of Patient #14's clinical record showed a RN did not observe and document the observation on the 7 PM to 7 AM shift two (05/24/18 and 05/25/18) of six (05/23/28 - 05/29/18) shifts. During an interview with the Hospital Educator at 2:35 PM on 05/30/18 the above findings were verified.

J. During an interview with the Hospital Educator at 3:15 PM on 05/29/18 she stated it was not facility policy for an RN to observe the patient every shift.


Based on clinical record review and interviews, it was determined a Registered Nurse failed to supervise and evaluate the nursing care of eight of eight (Patients #2-5, #7, #8, #12, and #15) patients in that dietary supplements were not given to the patients as ordered. Failure to ensure the patients received the dietary supplements as prescribed by the attending physician had the potential for weight loss and poor wound healing for Patients #2, #7, #12, and #15. The failed practice had the potential to affect Patients #2-5, #7, #8, #23 and #15. Findings follow:

A. Review of Patient #2's clinical record showed physician's order dated 04/27/18 for Enlive TID (three times a day). Review of Patient #2's clinical record showed no documentation Patient #2 received the Enlive TID 10 (04/27/17 to 04/29/17 and 05/01/17 to 05/07/17) of 11 (04/27/17 to 05/07/18) days. Review of the physician's orders showed an order was issued on 05/08/17 at 2:51 PM to reduce the number of Juvens from TID to BID (two times a day). Review of the clinical record showed Patient #2 did not receive the Juven BID four (05/08/17 and 05/12/17 to 05/14/17) of seven (05/08/17 to 05/14/17) days. During an interview with the Hospital Educator at 2:04 PM on 05/29/18 the above findings were verified.

B. Review of Patient #3's clinical record showed physician's order dated 05/01/17 for Enlive BID. Review of Patient #3's clinical record showed no documentation Patient #3 received the Enlive BID eight (05/03/17, 05/05/17, 05/06/17, 05/09/17, 05/12/17, 05/13/17, 05/17/17 and 05/18/17) of 18 (05/01/17 through 05/18/17) days. During an interview with the Hospital Educator at 4:00 PM on 05/29/18 the above findings were verified.

C. Review of Patient #4's clinical record showed physician's orders dated 05/03/17 for Glucerna TID. Review of Patient #4's clinical record showed no documentation Patient #4 received the Glucerna TID for seven of seven (5/04/17 to 05/10/17) days. During an interview with the Hospital Educator at 10:08 AM on 05/30/18 the above findings were verified.

D. Review of Patient #5's clinical record showed physician's orders dated 05/04/17 for Enlive QID (four times a day). Review of Patient #5's clinical record showed no documentation Patient #5 received the Glucerna QID for 19 of 19 (05/05/17 to 05/23/17) days. During an interview with the Hospital Educator at 9:39 AM on 05/30/18 the above findings were verified.

E. Review of Patient #7's clinical record showed physician's orders dated 05/25/18 for Ensure TID as tolerated and to notify the Registered Dietitian if the patient refused. Review of Patient #7's clinical record showed no documentation Patient #7 received the Ensure TID for four of four (05/26/18 to 05/29/18) days. Review of the clinical record did not show any documentation of refusal by the patient. During an interview with the Hospital Educator at 10:55 AM on 05/30/18 the above findings were verified.

F. Review of Patient #8's clinical record showed physician's orders dated 05/25/18 for Juven BID. Review of Patient #8's clinical record showed no documentation Patient #8 received the Juven BID five of five (05/25/18 to 05/29/18) days. During an interview with the Hospital Educator at 11:26 AM on 05/30/18 the above findings were verified.

G. Review of Patient #12's clinical record showed physician's orders dated 05/23/18 for Enlive once a day. Review of Patient #12's clinical record showed no documentation Patient #12 received the Enlive every day five (05/24/18 to 05/28/18) of seven (05/24/18 to 05/30/18) days. During an interview with the Hospital Educator at 1:31 PM on 05/30/18 the above findings were verified. An interview was conducted with Patient #12 at 3:20 PM on 05/30/18 by the Director of Quality and Risk and Surveyor #1. Patient #12 was shown a bottle of Enlive and asked if she had received this every day. Patient #12 stated she had one in her room now, and had received one only one other time.

H. Review of Patient #15's clinical record showed physician's orders dated 05/23/18 for Enlive once a day. Review of Patient #15's clinical record showed no documentation Patient #15 received the Enlive for six (05/23/18 to 05/26/18 and 05/28/18 and 05/29/18) of eight (05/23/18 to 05/30/18) days. During an interview with the Hospital Educator at 2:46 PM on 05/30/18 the above findings were verified.


Based on clinical record review and interview, it was determined a Registered Nurse failed to supervise and evaluate the care of two (Patient #2 and #12) of six (Patient #2, #6, #7, #12, #14 and #15) patients in that there was no evidence dressing changes were performed as ordered by the physician. Failure of the Registered Nurse to ensure the dressing changes were performed and documented as ordered, did not ensure the patient received the wound care as ordered and did not assure an assessment of the wound was performed to observe for non-healing, enlargement or infection. The failed practice affected Patient #2 and #12. Findings follow:

A. Review of Patient #2's clinical record showed physician's orders dated 04/26/17 at 6:36 AM for daily dressing changes to the left arm using Silva-sorb gel and a bulky dressing. Review of Patient #2's clinical record showed no evidence the dressing change was performed two (05/02/17 and 05/06/17) of 13 (04/26/17 to 05/08/17) days. During an interview with the Hospital Educator at 3:21 PM on 05/29/18 the above findings were verified.

B. Review of Patient #12's clinical record showed physician's orders dated 05/24/18 to change the back dressing every other day using bordered gauze. Review of Patient #12's clinical record showed no evidence the dressing change was performed one (05/28/18) of three (05/24/18, 05/26/18 and 05/28/18) days. During an interview with the Hospital Educator at 1:35 PM on 05/30/18 the above findings were verified.


Based on clinical record review and interview, it was determined a Registered Nurse failed to supervise and evaluate the care of one of one (Patient #2) patients in that the nursing staff failed to perform a skin assessment every eight hours. Failure to perform and document a skin assessment every eight hours did not assure staff were following physician's orders and had the potential for changes in skin and its integrity to go unnoticed. The failed practice affected Patient #2. Findings follow:

Review of Patient #2's clinical record showed physician's orders dated 04/25/17 for a skin assessment to be performed by nursing staff every eight hours. Review of the nursing notes from 04/25/17 to 05/14/17 did not show skin assessments or findings from the skin assessments documented. During an interview with the Hospital Educator at 2:04 PM on 05/29/18 the above findings were verified.


Based on in-service training handouts, clinical record review, and interview, it was determined a Registered Nurse failed to supervise and evaluate the care of three of three (Patient #10, #12 and #13) patients in that there was no evidence TED (thromboembolic disease) stockings were placed on the patients and removed for one hour once a shift and then reapplied as per physician's order. Failure of nursing staff to remove the stockings every shift for one hour did not give nursing staff the opportunity to assess the lower extremities for circulation, skin condition, edema and other abnormalities. The failed practice affected Patients #10, #12 and #13. Findings follow:

A. Review of the Nursing Department Staff Meeting dated 10/30/17 showed the Skin and Wound Care Guidelines, received from the Director of Quality and Risk at 10:31 AM on 05/30/18, were on the agenda for discussion. Review of the Skin and Wound Care Guidelines showed TED hoses were to be removed each shift for a skin assessment and Physician #1's routine admissions orders were for TED hoses to be removed one hour each shift.

B. Review of Patient #10's clinical record showed a physician's order at 6:49 PM on 05/24/18 for TED hose to be applied and to be removed for one hour each shift. Review of the clinical record showed an entry at 11:26 AM on 05/26/18 documenting the TED hose had been applied. Review of Patient #10's clinical record showed no entries the TED had been removed for one hour and then re-applied for three of four (7PM - 7AM on 05/24/18, 7AM -7PM on 05/25/18, 7PM-7AM on 05/25/18 and 7AM - 7PM on 05/26/18). During an interview with the Hospital Educator at 12:56 PM on 05/30/18 the above findings were verified.

C. Review of Patient #12's clinical record showed a physician's order on 05/21/18 for TED hose to be applied and to be removed for one hour each shift. Review of Patient #12's clinical record showed no entries for sixteen shifts (AM and PM shift for 05/22/18 through 05/29/18) that the TED hose were removed for one hour and then reapplied. During an interview with the Hospital Educator at 1:40 PM on 05/30/18 the above findings were verified.

D. Review of Patient #13's clinical record showed a physician's order on 05/25/18 for TED hose to be applied and to be removed for one hour each shift. Review of Patient #13's clinical record showed no entries for four of four (05/26/18 - 05/29/18) 7AM - 7PM shifts and no entries for one (05/27/18) of five (05/25/18 - 05/29/18) shifts the TED were on. Review of all shifts above did not show any entries the TED hose had been removed and reapplied as ordered by the physician. During an interview with the Hospital Educator at 2:00 PM on 05/30/18 the above findings were verified.


Based on review of the North Hall and South Hall bath schedules, clinical record review and interview, it was determined a Registered Nurse failed to supervise and evaluate the care of eight (#2, #3, #5, and #11-#15) of 11 (#1-#3, #5, #6, #9, #11-15) patients in that the patients did not receive four baths per week per the established bath schedules. Failure to ensure the patients received a bath per the bath schedules did not allow the nursing staff the opportunity to observe for skin aberrations, follow their schedules of four baths per week, and assure the patients were clean and comfortable. The failed practice affected Patients #2, #3, #5, and #11-#15). Findings follow:

A. Review of the North and South Halls bath schedules, received from the Director of Quality and Risk on 05/29/18, showed baths were scheduled for certain days per room number; e.g. Room 301 was scheduled to have a bath on Sunday, Tuesday, Thursday and Friday. Room 308 was scheduled to have a bath on Monday, Wednesday, Thursday and Saturday.

B. Review of Patient #2's clinical record showed an admission date of 04/25/17 and a discharge date of 05/14/17. Review of the clinical record showed Patient #2 received three baths the first week, one bath the second week and three baths the third week and there were no notations of baths being refused. During an interview with the Hospital Educator at 3:21 PM on 05/29/18 the above findings were verified.

C. Review of Patient #3's clinical record showed an admission date of 04/28/17 and a discharge date of 05/18/17. Review of the clinical record showed Patient #3 received zero baths the first week, two baths the second week and two baths the third week and there were no notations of baths being refused. During an interview with the Hospital Educator at 8:39 AM on 05/30/18 the above findings were verified.

D. Review of Patient #5's clinical record showed an admission date of 05/03/17 and a discharge date of 05/24/17. Review of the clinical record showed Patient #5 received two baths the first week, one bath the second week, and one bath the third week and there were no notations of baths being refused. During an interview with the Hospital Educator at 9:39 AM on 05/30/18 the above findings were verified.

E. Review of Patient #11's clinical record showed an admission date of 05/24/18 and a discharge date of 05/27/18. Review of the clinical record showed Patient #11 received one bath during the stay and there was no notation of it being refused. During an interview with the Hospital Educator at 1:15 PM on 05/30/18 the above findings were verified.

F. Review of Patient #12's clinical record showed an admission date of 05/21/17. Review of the clinical record showed Patient #12 received only three baths the first week and there was no notation of a bath being refused. During an interview with the Hospital Educator at 1:29 PM on 05/30/18 the above findings were verified.

G. Review of Patient #13's clinical record showed an admission date of 05/25/18. Review of the clinical record showed Patient #13 had did not receive a bath on 05/27/18 per the bath schedule and there was no notation of it being refused. During an interview with the Hospital Educator at 2:00 PM on 05/30/18 the above findings were verified.

H. Review of Patient #14's clinical record showed an admission date of 05/23/18. Review of the clinical record showed Patient #14 did not receive a bath on 05/26/18 and 05/28/18 per the bath schedule and there was no notation of it being refused. During an interview with the Hospital Educator at 2:30 PM on 05/30/18 the above findings were verified.

I. Review of Patient #15's clinical record showed an admission date of 05/21/18. Review of the clinical record showed Patient #15 did not receive a bath on 05/27/18 per the bath schedule and there was no notation of it being refused. During an interview with the Hospital Educator at 2:54 PM on 05/30/18 the above findings were verified.

J. During an interview with the Director of Quality and Risk at 2:18 PM on 05/29/18 she stated the facility did not have a hygiene policy.


Based on in-service training handouts, clinical record review, and interview, it was determined a Registered Nurse (RN) failed to supervise and evaluate the care of nine (#2 - #6, #10, #12 - #14) of 15 (#1-15) patients in that a skin assessment was not performed twice a day by a RN. Failure of the RN to perform a skin assessment every shift did not assure the staff were observing and identifying changes in skin, wounds, circulation, turgor and hygiene status. The failed practice affected Patient #2-#6, #10, and #12-14. Findings follow:

A. Review of the Nursing Department Staff Meeting dated 10/30/17 showed the Skin and Wound Care Guidelines, received from the Director of Quality and Risk at 10:31 AM on 05/30/18, were on the agenda for discussion. Review of the Skin and Wound Care Guidelines showed a skin assessment was to be performed on all patients each shift by a Registered Nurse.

B. Review of Patient #2's clinical record showed a skin assessment was not performed and documented on the 7 AM to 7 PM shift seven (04/27/17, 04/29/17, 04/30/17, 05/03/17, 05/09/17-05/11/17) of 20 (04/25/17-05/4/17) shifts. During an interview with the Hospital Educator at 3:21 PM on 05/29/18 the above findings were verified.

C. Review of Patient #3's clinical record showed a skin assessment was not performed and documented on the 7 AM to 7 PM shift three (05/02/17, 05/11/17 and 05/15/17) of 21 (04/28/17 - 05/18/17) shifts. During an interview with the Hospital Educator at 4:27 PM on 05/29/18 the above findings were verified.

D. Review of Patient #4's clinical record showed a skin assessment was not performed and documented on the 7 PM to 7 AM shift six (05/04/17 - 05/09/17) of seven (05/03/27 - 05/09/17) shifts. During an interview with the Hospital Educator at 10:02 AM on 05/30/18 the above findings were verified.

E. Review of Patient #5's clinical record showed a skin assessment was not performed and documented on the 7 AM to 7 PM shift 18 ( 05/05/17 - 05/09/17, 05/11/17 - 05/24/17) of 22 (05/03/17 - 05/24/17) shifts. During an interview with the Hospital Educator at 9:39 AM on 05/30/18 the above findings were verified.

F. Review of Patient #6's clinical record showed a skin assessment was not performed and documented on the 7 AM to 7 PM shift one (05/25/18) of six (05/24/18-05/29/18) shifts. During an interview with the Hospital Educator at 10:41 AM on 05/30/18 the above findings were verified.

G. Review of Patient #10's clinical record showed a skin assessment was not performed and documented on the 7 AM to 7 PM shift one (05/25/18) of two (05/25/18 -05/26/18) shifts. During an interview with the Hospital Educator at 12:56 PM on 05/30/18 the above findings were verified.

H. Review of Patient #12's clinical record showed a skin assessment was not performed and documented on the 7 AM to 7 PM shift two (05/24/18 and 05/28/18) of nine (05/21/18 - 05/29/18) shifts. During an interview with the Hospital Educator at 1:47 PM on 05/30/18 the above findings were verified.

I. Review of Patient #13's clinical record showed a skin assessment was not performed and documented on the 7 AM to 7 PM shift three (05/26/18 - 05/28/18) of four (05/26/18 - 05/29/18) shifts. During an interview with the Hospital Educator at 2:00 PM on 05/30/18 the above findings were verified.

J. Review of Patient #14's clinical record showed a skin assessment was not performed and documented on the 7 PM to 7 AM shift two (05/24/18 and 05/25/18) of six (05/23/28 - 05/29/18) shifts. During an interview with the Hospital Educator at 2:35 PM on 05/30/18 the above findings were verified.

K. During an interview with the Wound Care Coordinator, Hospital Educator and the Director of Quality and Risk at 3:30 PM on 05/29/18 all stated all skin assessments were to be performed once every shift by a RN.