HospitalInspections.org

Based on document review, interview and observation, the facility failed to ensure a patient received care in a safe setting (Tag 144), failed to ensure adequate staffing (tag 145), failed to obtain restraint orders and failed to ensure the physician signed the restraint order (tag 168), failed to ensure a new physician order for restraints was obtained after a patient had been removed for a period of time (tag 169), failed to ensure patients in restraints were monitored every two (2) hours (tag 175) and failed to ensure restraint training was performed during orientation (tag 208).

The cumulative effects of the above prevented the facility from protecting and promoting patient rights.

Based on document review, interview and observation, the facility failed to provide an adequate number of ancillary personnel (nursing assistants-NA) necessary for the provision of appropriate care to all patients as needed (tag 392) and failed to ensure patients were being bathed daily and turned every two (2) hours per hospital policy (tag 395).


The cumulative effect of these systemic problems resulted in the hospitals inability to ensure safe nursing care was provided.

Based on document review, observation and interview the facility failed to deliver care in a safe setting for one (1) of twelve (12) patients observed on the sixth (6th) floor (Patient # 1).

Findings include:

1. The facility failed to follow the policy titled, "CORE: Abuse of Patient, Elder, Child by Staff Identification - Response & Reporting", policy number H-PC 09-005, indicated standards for the patient's right to receive care in a safe setting. Neglect "is the failure" to provide the prescribed medical care and treatment for the patient's physical needs. This policy was last released in 06/2021.

2. Review of the hospital policy titled, "CORE: Patient Rights and Responsibilities", policy number H-PC 09-001, indicated the policy establishes guidelines to provide an environment that both respects and protects the rights of patients and to conduct all activities related to care. The patient has the right to receive care in a safe setting. This policy was last released in 06/2019.

3. Review of the facilities, "Organizational Plan for the Delivery of Patient Care, Treatment, and Services", indicated the certified nursing assistant (CNA) to patient ratio would be one (1) to ten/eleven (10-11) on the 6th floor.

4. Review of the "Daily Patient Assignment" sheets for August 2021, indicated on 08/01/2021 no CNA was staffed on the 6th floor (night) with a patient census of 12. There should have been one (1) CNA staffed.

5. Based on observation, during the tour of the sixth (6th) floor, on 08/02/2021 at approximately 9:25 am with administrative staff member A # 1 (Chief Clinical Officer-CCO), the floor lacked a staffed CNA. The patient census was twelve (12) which would have required at least one (1) CNA. Nine (9) of the patients were a turn every (Q) two (2) hours, eleven (11) of the patients had wounds and five (5) of the patients required bathing on day shift.
Patient # 1 was observed in the room with his/her urine catheter laying on the patient's leg. The patient's aerosol mask was observed resting on the patient's chest with the string untied from the right side.

6. In interview on 08/02/2021 at approximately 9:30 am with administrative staff member A # 1, confirmed the floor should have had a CNA staffed for a patient census of twelve (12). At 2:00 pm confirmed the staffing policy/matrix was the most current up to date version.

7. In interview on 08/02/2021 at approximately 9:48 am with NS # 1 (Registered Nurse-RN), confirmed he/she had not been in the patient's room yet and at approximately 10:14 am confirmed the patient was observed with his/her aerosol mask string untied, resting on his/her chest and the catheter was observed laying on the patient's leg.

8. In interview on 08/03/2021 at approximately 2:20 pm with administrative staff members A # 1 and A # 2 (Director of Quality Management), confirmed the facility had no further MR documentation related to the above concerns.

Based on document review, observation and interview the facility failed to provide adequate staff to take care of the individual needs and prevent an injury for one (1) of twelve (12) patient medical records (MR's) reviewed (Patient # 1).

Findings include:

1. Review of the hospital policy titled, "CORE: Abuse of Patient, Elder, Child by Staff Identification - Response & Reporting", policy number H-PC 09-005, indicated standards for the patient's right to receive care in a safe setting. Neglect "is the failure" to provide the prescribed medical care and treatment for the patient's physical needs. This policy was last released in 06/2021.

2. Review of the hospital policy titled, "CORE: Patient Rights and Responsibilities", policy number H-PC 09-001, indicated the policy establishes guidelines to provide an environment that both respects and protects the rights of patients and to conduct all activities related to care. This policy was last released in 06/2019.

3. Review of the facilities, "Organizational Plan for the Delivery of Patient Care, Treatment, and Services", indicated the certified nursing assistant (CNA) to patient ratio would be one (1) to ten/eleven (10-11) on the 5th and 6th floors.

4. Review of the "Daily Patient Assignment" sheets for June 2021, indicated the following staff shortages:
a. On 06/05/2021 no CNA was working on the 6th floor (night) with a patient census of 13. Should have had at least one CNA staffed.
b. On 06/06/2021 no CNA was working on the 6th floor (day & night) with a patient census of 13. Should have had at least one CNA staffed.
c. On 06/08/2021 no CNA was working on the 5th floor (day) with a patient census of 17, no CNA staffed on the 5th floor (night) with a patient census of 18 and no CNA was working on the 6th floor (night) with a patient census of 13. Should have been 1.5 CNA's on days/nights on the 5th floor and one (1) CNA staffed on the 6th floor.
d. On 06/09/2021 no CNA was working on the 5th floor (day) with a patient census of 18. Should have been 1.5 CNA's staffed.
e. On 06/11/2021 no CNA was working on the 5th floor (day) with a patient census of 18. Should have been 1.5 CNA's staffed on days.
f. On 06/14/2021 no CNA was working on the 5th floor (day) with a patient census of 18, no CNA was working on the 5th floor (night) with a patient census of 19 and no CNA was working on the 6th floor (night) with a patient census of 13. Should have been 1.5 CNA's staffed on 5th floor day/night and one (1) on the 6th floor night.
g. On 06/15/2021 no CNA was working on the 6th floor (night) with a patient census of 12. There should have been one (1) CNA staffed on the 6th floor.
h. On 06/20/2021 no CNA was working on the 6th floor (night) with a patient census of 12. There should have been one (1) CNA staffed.
i. On 06/21/2021 no CNA was working on the 6th floor (day) with a patient census of 12. There should have been one (1) CNA staffed.
j. On 06/22/2021 no CNA was working on the 6th floor (night) with a patient census of 12. There should have been one (1) CNA staffed.

5. Review of Patient # 1's medical records (MR's) indicated the following:
a. On 06/14/2021 at 7:30 am NS # 1 (Registered Nurse) documented the patient "remains free of injury during restraint use".
b. On 06/21/2021 at 7:10 am the Restraint Care Plan two (2) page document, indicated the physician ordered (via telephone) a limb right wrist restraint. The nurse failed to sign/time/date the second (2nd) page related to potential for injury related to restraint use which goes through desired outcomes and interventions.
c. On 06/21/2021 at midnight the Restraint Care Plan two (2) page document, indicated the physician ordered (via telephone) a right wrist (lacked type of restraint) and the Physician Assessment/Restraint Order Confirmation wasn't signed until 06/26/2021.
d. On 06/24/2021 the Restraint Monitoring flow-sheet indicated the restraint had been removed at 12:00 pm. No injury was noted and the patient's skin integrity was unchanged. The flowsheet lacked the nurses signature who had removed and monitored the patient's restraint on that morning.
e. On 06/24/2021 at 5:08 pm the patient was observed to have a change of condition. A # 3 (Registered Nurse Wound Care-RNWC) documented "right wrist device related skin tear from restraints".

6. Based on observation, during the tour of the sixth (6th) floor, on 08/02/2021 at approximately 9:25 am with administrative staff member A # 1 (Chief Clinical Officer-CCO), the floor lacked a staffed CNA. The patient census was twelve (12) which would have required at least one (1) CNA. Patient # 1 was observed with a healing right wrist wound.

7. In interview on 08/02/2021 at approximately 9:30 am with administrative staff member A # 1, confirmed the floor should have had a CNA staffed for a patient census of twelve (12). At 2:00 pm confirmed the staffing policy/matrix was the most current up to date version.

8. In interview on 08/02/2021 at approximately 9:48 am with NS # 2 (Registered Nurse-RN), confirmed he/she had not been in the patient's room yet.

9. In interview on 08/02/2021 at approximately 10:00 am with A # 3, indicated the wound care nurse "sees the patient weekly if not more" because the patient was "high risk".

10. In interview on 08/03/2021 at approximately 11:30 am with A # 3, indicated the wrist change of condition was from the wrist restraint rubbing/abrasion over months.

11. In interview on 08/03/2021 at approximately 2:20 pm with administrative staff members A # 1 and A # 2 (Director of Quality Management), confirmed the facility had no further MR documentation related to the above concerns.

Based on document review and interview, the facility failed to ensure a verbal restraint order which had been received from a physician was confirmed/signed by that same physician for one (1) of ten (10) patient medical records (MR's) reviewed (Patient # 1) and failed to ensure a physician order was obtained for restraints for one (1) of ten (10) patient MR's reviewed (Patient # 5).

Findings include:

1. Review of the facility policy titled, "CORE: Physical Restraints (Violent and Non-Violent Behavior) and Seclusion", policy number H-PC 07N-009, indicated for current inpatients a restraint order from the physician "is required" immediately or within a few minutes from initiating restraints with a maximum duration of seven (7) days. Renewal orders are not permitted. If restraint use "is needed" beyond the order date plus seven (7) calendar day period, a "NEW' episode "is required" with "new orders" This policy was last released in 06/2021.

2. Review of the hospital policy titled, "CORE: Patient Rights and Responsibilities", policy number H-PC 09-001, indicated the policy establishes guidelines to provide an environment that both respects and protects the rights of patients and to conduct all activities related to care. This policy was last released in 06/2019.

3. Review of the Restraint Care Plan (Non-Violent Non-Self Destructive Behavior) form, indicated the "Restraint Order Confirmation" should be completed within one (1) calendar day from initiation of the restraint.

4. Review of the medical record (MR) for patient # 1 indicated a telephone order was received on 06/05/2021 at approximately 11:38 am by NS # 2 (Registered Nurse-RN) for a soft limb right wrist restraint. The restraint was applied at approximately 11:40 am by NS # 2. The "Restraint Order Confirmation" lacked the physician signature, time and date the physician completed the assessment.

5. Review of the MR for patient # 5 indicated the physician order for restraints was obtained on 06/19/2021 at 8:00 am and would have been good until 06/26/2021 at midnight. The restraint monitoring flowsheet indicated the patient was in restraints from 06/19/2021 through 06/28/2021 at 7:00 am. The MR indicated the next physician order was dated 06/28/2021 at 7:10 am.

6. In interview on 08/02/2021 at approximately 3:10 pm with administrative staff member A # 1 (Chief Clinical Officer-CCO), indicated the physician should sign the confirmation order and the nurse should have obtained a new order for restraints.

7. In interview on 08/03/2021 at approximately 2:20 pm with administrative staff members A # 1 and A # 2 (Director of Quality Management), confirmed the facility had no further MR documentation related to the above concerns.

Based on document review and interview, the facility failed to ensure a new physician order was obtained for patients who had been released from their restraint and then had it reapplied in three (3) of ten (10) medical records (MR's) reviewed (Patient # 3, Patient # 5 & Patient # 8).

Findings include:

1. Review of the facility policy titled, "CORE: Physical Restraints (Violent and Non-Violent Behavior) and Seclusion", policy number H-PC 07-009, indicated if the restraints are removed for any reason other than to provide care (temporary release), the removal would be viewed as the end of the restraint episode and the restraint order would be discontinued. A new order must be written to initiate any restraint. This policy was last released in 06/2021.

2. Review of the hospital policy titled, "CORE: Patient Rights and Responsibilities", policy number H-PC 09-001, indicated the policy establishes guidelines to provide an environment that both respects and protects the rights of patients and to conduct all activities related to care. This policy was last released in 06/2019.

3. Review of the medical record (MR) for patient # 3 indicated the patient was removed from his/her restraints on 05/20/2021 at 8:30 am. The nurse documented "Family at bedside" until 10:00 pm (2000) when he/she began monitoring the restraint intervention. The MR lacked a physician order on 05/20/2021 at 10:00 pm to reapply the restraint. On 05/21/2021 the nurse documented "off" at 12:00 pm, 2:00 pm, 4:00 pm and 6:00 pm. At 10:00 pm (2000) the nurse reapplied the restraint and began monitoring the restraint intervention. The MR lacked a physician order on 05/21/2021 at 8:00 pm to reapply the restraint.

4. Review of the MR for patient # 5 indicated the patient was removed from his/her restraints on 06/28/2021 at 8:00 pm. The nurse documented the patient was off restraints until 4:00 am on 06/29/2021 when he/she began monitoring the restraint intervention. The MR lacked a physician order on 06/29/2021 to reapply the restraints.

5. Review of the MR for patient # 8 indicated the patient was removed from his/her restraints on 06/15/2021 at 8:00 pm. The nurse documented the patient was off restraints until 12:00 am on 06/16/2021 when he/she began monitoring the restraint intervention. The MR lacked a physician order on 06/16/2021 to reapply the restraints.

6. In interview on 08/03/2021 at approximately 1:40 pm with administrative staff member A # 1 (Chief Clinical Officer-CCO), confirmed the staff should not reapply a restraint, once removed for anything other than patient care, without a new physician order to imitate the restraint.

7. In interview on 08/03/2021 at approximately 2:20 pm with administrative staff members A # 1 and A # 2 (Director of Quality Management), confirmed the facility had no further MR documentation related to the above concerns.

Based on document review and interview, the facility failed to ensure the patients in restraints were monitored every two (2) hours for three (3) of ten (10) patient MR's reviewed (Patient # 1, Patient # 3 and Patient # 5).

Findings include:

1. Review of the facility policy titled, " CORE: Physical Restraints (Violent and Non-Violent Behavior) and Seclusion", policy number H-PC 07-009, indicated ongoing safety checks and monitoring at least every two (2) hours by the patient's clinical team of the patient's response to the restraint. This policy was last released in 06/2021.

2. Review of the hospital policy titled, "CORE: Patient Rights and Responsibilities", policy number H-PC 09-001, indicated the policy establishes guidelines to provide an environment that both respects and protects the rights of patients and to conduct all activities related to care. This policy was last released in 06/2019.

3. Review of patient # 1's MR indicated the following:
a. The patient was placed in a right wrist limb restraint on 06/14/2021 at 7:00 am per physician order.
b. The MR lacked the daily restraint monitoring flowsheet for 06/16, 06/17, 06/18 and 06/19 of 2021.
c. The patient was placed in a right wrist freedom splint on 07/05/2021 at 7:10 am per physician order.
d. The MR lacked the daily restraint monitoring flowsheet for 07/05/2021.
e. The patient was placed in a right wrist freedom splint on 07/19/2021 at 7:00 am per physician order.
f. The MR lacked the daily restraint monitoring flowsheet for 07/19/2021.

4. Review of patient # 3's MR indicated the patient was placed in left and right arm freedom splints on 06/07/2021 at 7:00 am per physician order. The MR lacked the daily restraint monitoring flowsheet for 06/07, 06/08, 06/09, 06/10 and 06/11 of 2021.

5. Review of patient # 5's MR indicated the following:
a. The patient was placed in left and right wrist limb restraints on 06/19/2021 at 8:00 am per physician order.
b. The flowsheet dated 06/24/2021 lacked every two (2) hour monitoring from 8:00 am to 8:00 pm on 6/25/2021.
c. The patient was placed in left and right wrist limb restraints on 06/28/2021 at 7:00 am per physician order.
d. The flowsheet dated 06/29/2021 lacked every two (2) hour monitoring from 6:00 am to 8:00 pm by the clinical staff.

6. In interview on 08/02/2021 at approximately 9:38 am with administrative staff member A # 1 (Chief Clinical Officer), confirmed the nurses should assess the patients in restraints every two (2) hours.

7. In interview on 08/02/2021 at approximately 10:14 am with NS # 2 (Registered Nurse), confirmed we assess the patients every two (2) hours while they are in restraints.

8. In interview on 08/03/2021 at approximately 2:20 pm with administrative staff members A # 1 and A # 2 (Director of Quality Management), confirmed the facility had no further MR documentation related to the above concerns.

Based on document review and interview, the facility failed to ensure restraint competency was completed during orientation in one (1) instance (PS # 1-Nursing Assistant).

Findings include:

1. Review of the facility policy titled, "CORE: Physical Restraints (Violent and Non-Violent Behavior) and Seclusion", policy number H-PC 07-009, indicated competency requirements including information about hospital policy and procedure, appropriate restraint use, orders, assessments and monitoring expectations are required upon hire. This policy was last released in 06/2021.

2. Review of the hospital policy titled, "CORE: Patient Rights and Responsibilities", policy number H-PC 09-001, indicated the policy establishes guidelines to provide an environment that both respects and protects the rights of patients and to conduct all activities related to care. This policy was last released in 06/2019.

3. Review of the personnel file for PS # 1, indicated he/she had no documentation related to general and/or department specific orientation.

4. In interview on 08/03/2021 at approximately 2:20 pm with administrative staff members A # 1 (Chief Clinical Officer) and A # 2 (Director of Quality Management), confirmed they had no additional documentation related to PS # 1's personnel file. A # 1 indicated the orientation paperwork should have been in PS # 1's personnel file.

Based on document review, observation and interview the facility failed to ensure an event report was completed related to an injury while the patient was in a restraint for one (1) of ten (10) medical records (MR's) reviewed (Patient # 1).

Findings include:

1. Review of the hospital policy titled, "CORE: Physical Restraints (Violent and Non-Violent Behavior) and Seclusion", policy number H-PC 07-009, indicated nursing shall document in the patient's MR any injuries that occur during restraint use. The entry should include treatment provided for the injury, patient response, any other pertinent information and should complete an even report. This policy was last released in 06/2021.

2. Review of the hospital policy titled, "CORE: Event Reporting", policy number H-ML 04-001, indicated hospital personnel were responsible for reporting in a timely and efficient manner. An event - any occurrence or situation which may have caused an injury to the patient. This policy was last released in 06/2021.

3. Review of Patient # 1's MR indicated the following:
a. The patient had a change of condition documented on 06/24/2021 at approximately 5:10 pm by A # 1 (Wound Care Registered Nurse-WCRN).
b. Right Wrist Device Related Skin Tear from Restraints.
c. On 06/30/2021 at 4:10 pm the completed weekly wound care was completed by A # 4 (RN Wound Care Coordinator) and he/she documented "new skin growing in superficial ulcer".
d. On 07/14/2021 at 5:27 pm wound care was completed, and a photo taken.
e. On 07/20/2021 at 3:28 pm wound care was completed, and a photo taken.

4. During tour on 08/02/2021 at approximately 9:40 am accompanied by A # 1 (Chief Clinical Officer), this writer observed patient # 1's wrist. The right wrist wound wasn't healed.

5. In interview on 08/03/2021 at approximately 8:45 am with A # 1, confirmed A # 3 should have completed an event report according to hospital policy.

Based on document review, observation and interview the facility failed to provide an adequate number of ancillary personnel (nursing assistants-NA) necessary for the provision of appropriate care to all patients as needed for 24 of 63 days reviewed.

Findings include:

1. Review of the facilities, "Organizational Plan for the Delivery of Patient Care, Treatment, and Services", indicated the certified nursing assistant (CNA) to patient ratio would be one (1) to ten/eleven (10-11) on the 5th and 6th floor.

2. Review of the "Daily Patient Assignment" sheets for June 2021, indicated the following shortages:
a. On 06/01/2021 one CNA was staffed on the 5th floor (day & night) with a patient census of 20. Should have been two (2) CNA's staffed.
b. On 06/04/2021 one CNA was staffed on the 5th floor (night) with a patient census of 18. Should have been 1.5 CNA's staffed.
c. On 06/05/2021 no CNA staffed on the 6th floor (night) with a patient census of 13. Should have had at least one CNA staffed.
d. On 06/06/2021 no CNA staffed on the 6th floor (day & night) with a patient census of 13. Should have had at least one CNA staffed.
e. On 06/07/2021 one CNA was staffed on the 5th floor (day) with a patient census of 17. Should have been 1.5 CNA's staffed.
f. On 06/08/2021 no CNA staffed on the 5th floor (day) with a patient census of 17, no CNA staffed on the 5th floor (night) with a patient census of 18 and no CNA staffed on the 6th floor (night) with a patient census of 13. Should have been 1.5 CNA's on days/nights on the 5th floor and one (1) CNA staffed on the 6th floor.
g. On 06/09/2021 no CNA staffed on the 5th floor (day) with a patient census of 18. Should have been 1.5 CNA's staffed.
h. On 06/10/2021 one CNA was staffed on the 5th floor (day) with a patient census of 18. Should have been 1.5 CNA's staffed.
i. On 06/11/2021 no CNA staffed on the 5th floor (day) with a patient census of 18, one CNA was staffed on the 5th floor (night) with a patient census of 19. Should have been 1.5 CNA's staffed on days and nights
j. On 06/12/2021 one CNA was staffed on the 5th floor (day) with a patient census of 19. Should have been 1.5 CNA's staffed.
k. On 06/13/2021 one CNA was staffed on the 5th floor (day) with a patient census of 19, one CNA was staffed on the 5th floor (night) with a patient census of 18. Should have been 1.5 CNA's staffed day/night.
l. On 06/14/2021 no CNA staffed on the 5th floor (day) with a patient census of 18, no CNA staffed on the 5th floor (night) with a patient census of 19 and no CNA staffed on the 6th floor (night) with a patient census of 13. Should have been 1.5 CNA's staffed on 5th floor day/night and one (1) on the 6th floor night.
m. On 06/15/2021 one CNA was staffed on the 5th floor (day) with a patient census of 18, one CNA was staffed on the 5th floor (night) with a patient census of 19 and no CNA staffed on the 6th floor (night) with a patient census of 12. There should have been 1.5 CNA's staffed for day/night on the 5th floor and one (1) CNA staffed on the 6th floor.
n. On 06/20/2021 no CNA staffed on the 6th floor (night) with a patient census of 12. There should have been one (1) CNA staffed.
o. On 06/21/2021 no CNA staffed on the 6th floor (day) with a patient census of 12. There should have been one (1) CNA staffed.
p. On 06/22/2021 no CNA staffed on the 6th floor (night) with a patient census of 12. There should have been one (1) CNA staffed.
q. On 06/24/2021 no CNA staffed on the 5th floor (day) with a patient census of 12. There should have been one (1) CNA staffed.

3. Review of the "Daily Patient Assignment" sheets for July 2021, indicated the following shortages:
a. On 07/04/2021 no CNA staffed on the 6th floor (day) with a patient census of 10. There should have been one (1) CNA staffed.
b. On 07/15/2021 no CNA staffed on the 6th floor (day) with a patient census of 12. There should have been one (1) CNA staffed.
c. On 07/16/2021 no CNA staffed on the 6th floor (day) with a patient census of 10. There should have been one (1) CNA staffed.
d. On 07/17/2021 no CNA staffed on the 6th floor (night) with a patient census of 9 and no CNA staffed on the 5th floor (night) with a patient census of 12. There should have been one (1) CNA staffed for each floor.
e. On 07/18/2021 no CNA was staffed on the 6th floor (night) with a patient census of 9. There should have been one (1) CNA staffed.
f. On 07/31/2021 no CNA staffed on the 6th floor (night) with a patient census of 12. There should have been one (1) CNA staffed.

4. Review of the "Daily Patient Assignment" sheets for August 2021, indicated on 08/01/2021 no CNA was staffed on the 6th floor (night) with a patient census of 12. There should have been one (1) CNA staffed.

5. Based on observation, during the tour of the sixth (6th) floor, on 08/02/2021 at approximately 9:25 am with administrative staff member A # 1 (Chief Clinical Officer-CCO), the floor lacked a staffed CNA. The patient census was twelve (12) which would have required at least one (1) CNA.

6. In interview on 08/02/2021 at approximately 9:30 am with administrative staff member A # 1, confirmed the floor should have had a CNA staffed for a patient census of twelve (12). At 2:00 pm confirmed the staffing policy/matrix was the most current up to date version.

Based on document review and interview the nurse failed to ensure patients were being bathed daily and turned every two (2) hours per hospital policy for four (4) of ten (10) patient medical records (MR's) reviewed (Patient # 1, Patient # 2, Patient # 3 and Patient # 4).

Findings include:

1. Review of the hospital policy titled, "CORE: Clinical Guidelines for Non-Pressure Related Wounds", policy number H-PC 10-005, indicated standard interventions for all patients can include repositioning orders at a minimum of every two (2) hours. This policy was last released in 06/2019.

2. Review of the hospital policy titled, "CORE: Clinical Guidelines for Pressure Injury", policy number H-PC 10-004, indicated standard interventions included skin/wound assessment and repositioning orders at a minimum of every two (2) hours.

3. Review of the hospital policy titled, "CORE: Chlorhexidine Bathing & Decolonization", policy number H-IC 02-013, indicated established guidelines for the reduction of healthcare associated infections were implemented by reducing the bacterial load on the patient's skin. Chlorhexidine Gluconate (CHG) bathing should be used daily. This policy was last released in 06/2021.

4. Review of the hospital policy titled, "CORE: Patient Rights and Responsibilities", policy number H-PC 09-001, indicated the policy establishes guidelines to provide an environment that both respects and protects the rights of patients and to conduct all activities related to care. This policy was last released in 06/2019.

5. Review of the Job Description for a Registered Nurse (RN), indicated he/she maintains the standards of nursing care and implements policies and procedures of the hospital and nursing department. The RN directs, supervises and evaluates the nursing care provided to the patients.

6. Review of the Job Description for a Nursing Assistant (NA), indicated he/she should be able to release, remove, and reapply restraints under the direction of an RN. Provide general nursing care such as positioning the patient, turning and bed baths.

7. Review of Patient # 1's MR indicated the patient was a 29 y/o (year/old) admitted to H # 2 (Long Term Acute Care Hospital) on 11/07/2020 post motor vehicle accident, post intracranial bleed, left side paralysis and multiple fractures. The patient had a physician order to be repositioned every two (2) hours.
The MR lacked documentation related to the patient being turned and/or repositioned on the following dates/times:
a. June 01, 2021 at 0000, 0200, 0400, 0600, 2000 and 2200.
b. June 02, 2021 at 0000, 0200, 0400 and 0600.
c. June 06, 2021 at 2000, 2200, 0000, 0200, 0400 and 0600.
d. June 08, 2021 at 1000.
e. June 12, 2021 at 0200, 0400 and 0600.
f. June 14, 2021 at 1800 and 2200.
g. June 15, 2021 at 0000, 0200, 0400, 0600 and 2200.
h. June 16, 2021 at 0000, 0200, 0400, 0600, 1400, 1600 and 1800.
i. June 17, 2021 at 0600, 0800, 1200, 1400 and 1800.
j. June 18, 2021 at 0200, 0400 and 0600.
k. June 26, 2021 at 1600 and 1800.
l. June 27, 2021 at 0600 and 1800.
m. June 28, 2021 at 0400 and 0600.
n. June 30, 2021 at 1600 and 1800.
o. July 1, 2021 at 1400, 1600 and 1800.
p. July 4, 2021 at 1200 and 1800.
q. July 5, 2021 at 2200.
r. July 6, 2021 at 0000, 0200, 0400 and 0600.
s. July 13, 2021 at 0000, 0200, 0400, 0600, 1400, 1600 and 1800.
t. July 14, 2021 at 0000, 1200, 1400, 1600 and 1800.
u. July 15, 2021 at 0800, 1200, 1600 and 1800.
v. July 16, 2021 at 0800, 1000, 1200, 1400, 1600 and 1800.
w. July 18, 2021 at 0000, 0200, 0400, 0600, 2000 and 2200.
x. July 19, 2021 at 0000, 0200, 0400, 0600, 1000, 1400, 1600 and 1800.
y. July 21, 2021 at 0800, 1000 and 1200.
z. August 02, 2021 at 0800, 1000 and 1200.

8. Review of Patient # 1's MR lacked documentation on the following dates related to the patient being bathed daily:
a. June 3, 6, 7, 9, 14, 15, 16, 17, 18, 20, 21, 23, 28, 29 and 30 of 2021.
b. July 1,5, 6, 7, 9, 13, 15, 17, 19, 21, 22, 24 and 29 of 2021.
c. August 01, 2021.

9. Review of Patient # 2's MR indicated the patient was a 19 y/o admitted to H # 2 on 12/05/2020 post gunshot wound, post craniotomy, post tracheostomy and chronic respiratory failure. The patient had a physician order to be repositioned every two (2) hours.
The MR lacked documentation on the following dates/times related to the patient being turned and/or repositioned:
a. June 01, 2021 at 2000 and 2200.
b. June 02, 2021 at 0000, 0200, 0400 and 0600.
c. June 05, 2021 at 1800.
d. June 06, 2021 at 2000 and 2200.
e. June 07, 2021 at 0000, 0200, 0400 and 0600.
f. June 12, 2021 at 0400 and 0600.
g. June 14, 2021 at 2200.
h. June 15, 2021 at 0000, 0200, 0400, 0600, 1600, 2000 and 2200.
i. June 16, 2021 at 0000, 0200, 0400, 0600, 0800, 1400, 1600 and 1800.
j. June 17, 2021 at 0600 and 0800.
k. June 18, 2021 at 0200, 0400 and 0600.
l. June 23, 2021 at 1800.
m. June 25, 2021 at 1800.
n. June 27, 2021 at 0600, 0800, 1600 and 1800.
o. July 05, 2021 at 2200.
p. July 06, 2021 at 0000, 0200, 0400, 0600 and 1800.
q. July 07, 2021 at 0000, 0200 and 0400.
r. July 13, 2021 at 0000, 0200, 0400 and 0600.
s. July 14, 2021 at 1600 and 1800.
t. July 15, 2021 at 1200 and 1400.
u. July 17, 2021 at 0600, 2000 and 2200.
v. July 18, 2021 at 0000, 0200, 0400, 0600, 2000 and 2200.
w. July 19, 2001 at 0000, 0200, 0400 and 0600.
x. August 02, 2021 at 0800 and 1000.

10. Review of Patient # 2's MR lacked documentation on the following dates related to the patient being bathed daily:
a. June 6, 7, 9, 10, 13, 14, 16, 17, 18, 19, 21, 24 and 29 of 2021.
b. July 4, 11, 13, 15, 16, 19, 21, 22 and 24 of 2021.

11. Review of Patient # 3's MR indicated the patient was a 81 y/o admitted to H # 2 on 05/14/2021 with acute respiratory failure. The patient had a physician order to be repositioned every two (2) hours.
The MR lacked documentation on the following dates/times related to the patient being turned and/or repositioned:
a. May 20, 2021 at 0800 and 1000.
b. May 21, 2021 at 1600, 1800 and 2000.
c. May 23, 2021 at 0600, 2000 and 2200.
d. May 24, 2021 at 1200, 1400, 1600 and 1800.
e. May 26, 2021 at 1800.
f. May 27, 2021 at 2000 and 2200.
g. May 28, 2021 at 0000, 0200, 0400 and 0600.
h. May 30, 2021 at 0200, 0400, 0600 and 0800.
i. May 31, 2021 at 1400, 1600, 1800 and 2000.
j. June 01, 2021 at 0800, 1000, 1200, 1400, 1600 and 1800.
k. June 04, 2021 at 0200, 0400, 0600, 0800, 1000, 1200, 1400, 1600 and 1800.
l. June 05, 2021 at 0000, 0800, 1000, 1200 and 1400.
m. June 06, 2021 at 2000 and 2200
n. June 07, 2021 at 0000, 0200, 0400, 0600, 1600 and 1800.
o. June 08, 2021 at 2000 and 2200.
p. June 09, 2021 at 0000, 0200, 0400 and 0600.
q. June 16, 2021 at 1400, 1600 and 1800.
r. June 17, 2021 at 0600, 0800, 1000, 1200 and 1400.
s. June 19, 2021 at 0200, 0400 and 0600.
t. June 20, 2021 at 2000 and 2200.
u. June 21, 2021 at 0000, 0200, 0400 and 0600.

12. Review of Patient # 3's MR lacked documentation on the following dates related to the patient being bathed daily: June 11, 13, 15, 18, 19, 20, 21 and 23 of 2021.

13. Review of Patient # 4's MR indicated the patient was a 61 y/o admitted to H # 2 on 05/19/2021 with chronic respiratory failure, chronic obstructive pulmonary disease, aspiration pneumonia and encephalopathy. The patient had a physician order to be repositioned every two (2) hours.
The MR lacked documentation on the following dates/times related to the patient being turned and/or repositioned:
a. May 25, 2021 at 0600, 0800, 1800, 2000 and 2200.
b. May 26, 2021 at 0000, 0200, 0400 and 0600.
c. May 31, 2021 at 1400 and 1600.
d. June 01, 2021 at 2000.
e. June 02, 2021 at 0200, 0400, 0600, 2000 and 2200.
f. June 03, 2021 at 0200, 0400 and 0600.
g. June 06, 2021 at 2000 and 2200.
h. June 07, 2021 at 0000, 0200, 0400 and 0600.

14. In interview on 08/02/2021 at approximately 4:30 pm with administrative staff member A # 1 (Chief Clinical Officer), confirmed the staff should follow policy/procedure related to repositioning/turning. The patients should have been bathed daily and as needed per policy.

Based on document review, observation and interview the facility failed to ensure a staff member followed their policy/procedure by wearing a surgical mask to help reduce the risk of acquiring and transmitting infections among patients/staff in one instance (PS # 1-Nursing Assistant).

Findings include:

1. Review of the facility policy titled, "CORE: Infection Prevention and Control Program", policy number H-IC 01-001, indicated an infection prevention and control program "is designed and implemented to identify and reduce the risk of acquiring and transmitting infections" among patients and staff. The last release date was in 06/2021.

2. Review of the facility policy titled, "CORE: Pandemic Plan", policy number H-IC 01-007, indicated safety coordinators develop and implement and effective control plan including "facemask's and/or respirators". This policy was last released in 07/2021.

3. Review of the "Covid Communication", dated 05/25/2020, indicted all "required" disposable procedure masks are available.

4. Based on observation, fifth (5th) floor, on 08/02/2021 at approximately 12:30 pm, this writer observed PS # 1 wearing a dark cloth facial mask into a patient's room.

5. In interview on 08/02/2021 at approximately 2:00 pm with administrative staff member A # 1 (Chief Clinical Officer), confirmed the hospital staff should be wearing hospital approved masks and not cloth masks.

6. In interview on 08/02/2021 at approximately 4:40 pm with administrative staff member A # 2 (Director Quality Management), confirmed "our facility requires the staff to wear the required surgical staff masks".