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Based on observation, interview, record review and facility policy review the facility failed to protect and promote patient's rights when they did not:
-ensure patients received care in a safe setting;
- investigate all potential complaints;
- ensure all complaints by patients were screened or appropriately identified as
grievances;
-follow the investigation protocols per facility policy to determine if further action would be necessary;
- ensure that complaints which were not immediately resolved should be considered a grievance per facility policy;
- assure prompt resolution of a grievance;
- respond to patient grievances by written notice;,
-staff failed to report potential abuse and neglect to supervisors;
-allegations of abuse and neglect were not investigated per facility policy;
- protect the privacy of patients when their names were displayed on medical charts and on the wall by their doors;
- protect the privacy of patients when video monitoring was used in the Structured Care Unit;

The cumulative effect of these systemic practices resulted in the overall noncompliance with the Condition of Participation of Patient's Rights.

See deficiencies provided at: A 123, 143, 144, 145,164, and 165.

Based on observations, interviews, record reviews and facility policy reviews the facility failed to ensure:
-Facility staff consistently document and measure an existing pressure sore;
-Prevention of the development of two pressure sores on one (#14) of two patients,
-The facility policy for skin assessment and documentation of wounds was followed;
-Treatment was provided for a pressure ulcer as ordered;
-Staffing was adequate to meet the needs of the patients and to provide safety to the patients;
-Staff followed the facility policy on the documentation, treatment and prevention of pressure sores;

The cumulative effect of these systemic practices resulted in the overall noncompliance with CFR 482.23 Condition of Participation of Nursing Services.

See deficiencies at A 392, 395, 396, 405

Based on interview and record review the facility failed to provide patients the correct address and phone number of the Department of Health and Senior Services in the event of a complaint or grievance. This would affect all patients at this facility. The facility census was 57.

Findings included:

Record review of the facility's admission packet which contained "Patient Satisfaction" (grievances) provided by the facility staff on 02/07/11, showed this address: The Missouri Department of Health, 920 Wildwood, Jefferson City, MO 65109 and the phone number of 573-751-6400, both of which are incorrect.

During an interview on 02/10/11 at 1:40 PM, Staff CC, Chief Nursing Officer stated that he/she was not aware the address and phone number to report a complaint or grievance to the state was not correct.

Based on record review, policy review, and interview, the facility failed to ensure that all complaints made by patients were screened or appropriately identified as grievances or issues. The facility failed to ensure that a written response with all required information was provided to patients concerns which met the definition of a grievance for 12 concerns out of 54 concerns reviewed. The facility census was 57.

Findings included:

1. Review of facility policy titled "Patient Complaint/Grievance Policy" revised 2/09, indicated that issues versus grievances are a patient/customer issue and is defined as a concern that meets all of the following criteria:
- Patient/customer issues and grievances require different resolution processes. However, prompt and effective resolution is the goal for resolving patient/customer issues, regardless of whether it is a minor concern or a serious complaint.
- Issue can be immediately resolved by the staff (typically on the spot)
- Issue is of minor nature (i.e. change in bedding, housekeeping issues, room temperature, food, noise level)
- Concern is not a reoccurring issue
- The patient/customer is satisfied with the actions taken.
- A complaint/grievance is defined as an issue that meets any of the following criteria:
- Complaint cannot be immediately resolved to the customer's satisfaction by the staff (including unresolved or reoccurring minor concerns.)
- Complaint/Grievance is of a significant nature such as patient care and treatment issue. Customer is not satisfied with previous actions taken.
- Customer is not satisfied with previous actions taken.
- The section "Grievances-Actions" to be taken states that the hospital must review, investigate and resolve each patient's complaint/grievance within a reasonable time frame. Complaints/grievances involving situations that potentially endanger the patient such as neglect or abuse should be reviewed immediately.
- Upon notification, the patient will be immediately removed from any situation that may endanger the patient.
- The individual (staff) identifying the complaint/grievance is to complete a hospital incident report.
- CEO (chief executive officer) or designee must initiate investigation, in conjunction with facility risk management.
- CEO (chief executive officer) or designee must provide patient/family with a verbal or written progress report within seven business days of receipt of complaint/grievance and maintain ongoing communication until point of resolution (not to exceed 30 days). The initial contact must include a statement acknowledging receipt of the complaint/grievance, specific time frame when the patient/legal representative can expect conclusion/resolution to their expressed complaint/grievance.
- The investigation into the complaint the appropriate follow up actions will continue until the time of resolution.
- Facility Risk Management or designee will follow up with patient and/or family to ensure corrective action has been taken to satisfaction of patient/family.
- Facility risk management will follow up with departmental supervisor for action taken regarding employee issues if indicated.
- In its resolution of the grievance, the hospital must provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion.

2. Review on 2/9/11 of the complaint log for January of 2011 indicated that there were seven patients who had expressed concerns. Four of the seven concerns received were not immediately resolved and only one of the four (1/16/11) received a written response according to the log. The first concern (staff attitude) was received on 12/30/10 and resolved on 1/4/11. The second concern (Poor care) was received on 1/3/11 and resolved on 1/4/11. The third concern (poor care) was received on 1/16/11 and resolved on 1/18/11. The seventh concern (discharge planning) was received by mail following a post hospital discharge survey and indicated it was received in December and resolved on 2/1/11.

3. Review of the complaint/grievance reports from the facility indicated the patient reported a concern (patient care technicians provided poor care and stated they would not provide care) on 12/15/10. The patient had been discharged previously and the incident was reported by a physician's office during a follow up visit. A nurse from the physician's office reported the patient's concerns and requested a follow-up with them on the resolution. An email included in the report indicated that the physician would like the facility to follow up on the issues reported and to provide a follow-up to the physician's office. The facility did provide follow-up in the form of a phone call, but there was no written response to the physician's office.
The file from the complaint/grievance log indicated that no written response was sent by the facility.

4. Review of the complaint/grievance log indicated that on 12/22/10 a patient reported a concern at 3:05 PM, which indicated the patient's room was filthy, a bedside commode provided was of the wrong size and was not clean and that the window blinds in the room were missing. Six hours later housekeeping personnel cleaned the room, and on the morning of 12/23/10 maintenance came to repair the window blinds.
The facility did not immediately resolve the issues and the complaint/grievance log indicated that no written response was given to the patient.

5. Review of the complaint/grievance logs indicated the facility received a concern from a patient's family member on 11/2/10 about a walker he/she thought was stolen at the facility. The outcome of the report stated that there were numerous conversations in an attempt to resolve the issue and on 11/24/10 the facility resolved the issue by replacing the walker. The complaint/grievance log indicated that no written response had been provided to this family member.

6. Review of the facility complaint/grievance log indicated that on 11/23/10 a family member called with a concern about a patient. The concern was that the facility had declined to re-admit the patient after a hospital stay at another facility. The family member stated that the patient should have met the special requirements of this facility for re-admission and still was in need of treatment. The outcome section stated that the medical director did a record review and that this follow-up was not completed until 11/29/10. The log indicated no written response was provided to this person.

7. Review of the complaint/grievance log indicated the facility received a patient concern on 12/23/10 about a potential premature discharge. The outcome section of the form indicated that on 1/4/11 a message was left with the case manager to research the issue and discuss it with the person who expressed the concern. The log from the facility did not indicate if the case manager investigated this further. Facility policy states that the CEO (chief executive officer) or designee must provide patient/family with a verbal or written progress report within seven business days of receipt of complaint/grievance and maintain ongoing communication until point of resolution. The log indicated no written response was provided to this person after 11 days to inform them of the progress or final resolution.

8. Review of the complaint/grievance log indicated that a patient notified a staff person on 1/3/11 at 10:30 PM with a concern. Staff BB, nurse supervisor, then interviewed the patient about his concerns. Under the section of Action/Follow-up Staff BB indicated that he/she had talked to both Patient Care Technicians (PCT's), and they denied the accusations. Under the Response section Staff BB, indicated that the patient stated that this is not the first complaint that he/she has made regarding his/her care. There were no indicated actions provided to this patient other than the interview with the two PCT's at that time.

Staff BB followed up on the statements on the morning of 1/4/11 and interviewed the patient. The patient according to Staff BB, was satisfied that both PCT's would no longer be caring for him/her (assigned to other patients), but that in an emergency they may have to provide care. The patient agreed that was okay.

The concerns of the patient were not immediately resolved as it was the next morning before actions were taken by Staff BB, to resolve the issues and the patient received no written response to his/her concerns and the facility did not regard this as a grievance.

9. Review of the complaint/grievance log showed a concern was received from the patient on 11/29/10 that a patient care technician was rude, slow to answer the call light and that a nurse told him/her to be quiet when he/she asked for a pain pill and to not disturb his/her room-mate. The patient also stated that a mattress in a room used for activities of daily living smelled of mold. The complaint/grievance log states that the patient was called and another notation indicates that the patient provided a home phone number and wanted this concern to be a formal complaint. The log indicated the issue was resolved on 11/30/10. The log indicated no written response was provided to this patient.

10. Record review of the complaint/grievance logs indicated a patient reported a concern on 10/18/10 to the facility. The patient complained of comments made by staff persons and being left on the outside patio area of the facility from 2:30 -6:45 AM, approximately four hours. The facility interviewed this patient and asked if the patient felt safe at the facility and the response was "yes", but that he/she only felt safe if four specific staff persons were no longer caring for him/her. The patient stated he/she wanted to file a grievance on those four staff persons.
Review of the complaint/grievance investigation did not indicate that a written response to the patient had been provided regarding the comments or after the patient had stated that he/she requested a "grievance" on the four staff persons. The log indicated that no written response was provided to this patient.

11. During an interview on 2/8/10 at 3:30 PM, and at approximately 1:00 PM on 2/10/11 Staff A was asked if the facility had classified the above specific instances as grievances or complaints. Staff A, Director of Quality/Risk Management, stated that none of the incidents (highlighted on the log sheet and described above) received a written response as indicated on the log kept by the facility and were not considered as grievances.

Based on observation, interview and record review the facility failed to protect the privacy of patients by:
- Displaying patient names in public view by placing names in large red letters on the spines of medical charts for 57 of 57 charts observed;
- Displaying patient names in public view by placing names in large black letters on the walls outside occupied patient rooms for 57 of 57 patient rooms observed; and
- Video monitoring 12 patient rooms within the Structured Care Unit (SCU) without obtaining informed consent and/or documenting notification that video surveillance would take place for 10 patients who were currently monitored within the SCU. The facility census was 57.

Findings included:

1. Record review of the facility's form titled "Conditions of Admission and Authorization of Medical Treatment," showed the following:
- PATIENT IDENTIFICATION: It is the practice of the hospital to place last name, first initial of patients on the spine of the patient medical records, and first name, first initial of the last name on the door of the patients room. Some chart forms will be kept in patients rooms which will include patient first and last name and date of birth. The undersigned approves of this unless otherwise noted.

Record review of the facility's policy titled, "Structured Care Unit," revised 02/09, showed the following:
- Various rooms are monitored 24 hours by video from nurse's station as needed.
- When a patient is in a video monitored room, privacy will be maintained during personal care.
- When a caregiver is providing personal care to a patient, they will obstruct the front view by placing a card over the quarter of the screen revealing the room they will be working in. When personal care is completed, the card will be removed from the screen.

2. Observation on 02/07/11 at 1:25 PM on the fourth floor showed the last names of patients on the spines of the charts at the nursing station and in full view of the public, and showed the first names of patients posted on the wall next to the patient room doors on the third floor of the hospital.

During an interview on 02/07/11 at 1:30 PM, Staff TT, fourth floor Nursing Manager, stated that the patients may sign a release on admission and agree to have their names on the charts and on the walls by their rooms.



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3. Observation on 02/07/11 at 1:00 PM, showed patients first names and first initial of last names in large block letters posted outside the entrance of each occupied patient room on the second floor nursing unit and within the Structured Care Unit, (SCU) .

Observation on 02/07/11 at 1:45 PM, showed medical records in a chart rack behind the nursing station and lying on counter tops. Each medical record had a sticker on the spine of the record with the patient's last name and first initial.

4. Observation on 02/07/11 at 1:10 PM, showed a sign on the locked entry doors into the SCU which stated video surveillance was conducted within the unit.

Observation on 02/07/11 at 1:20 PM, showed 12 video screens mounted in the center of the SCU nursing station. Some screens observed patients who were resting in bed. Other screens observed what appeared to be a patient room that had not been assigned a patient. Anyone at the nursing station could view the patients in these 12 rooms, including persons not directly involved in the care of these patients.

Review of the facility's form titled "Conditions of Admission and Authorization of Medical Treatment" showed that consent for video surveillance was not addressed on the form.

Observation on 02/08/11 from 8:45 AM to approximately 11:00 AM, showed the video monitors continued to provide surveillance of patient rooms. Patient care, including dressing changes that required clothing to be removed or displaced, was provided throughout the morning in the monitored patient rooms. Video monitors at the nursing station were not turned off, and video monitors were not covered during this timeframe while patient care was being given in the monitored rooms.

5. During an interview on 02/07/11 at 1:15 PM, Staff A, Quality Improvement/Risk Manager, stated the following:
- The patient consent form gave the facility permission to display patient names in public view on chart spines and outside patient rooms. Further, the consent form gave the facility permission to leave personal health information inside patient rooms - although this was not observed.
- The facility did not have a policy for video surveillance, nor did they have a policy regarding display of patient names within the facility.
- A consent form for video surveillance was not utilized.
- Most patients cannot sign forms due to their disease, so the patient's family is notified of the surveillance via the signage on the entrance doors.
- Employees were instructed to cover the video surveillance screens when providing patient care.
- The video surveillance in SCU was in place to add an extra layer of observation, but staff did not monitor the video surveillance screens continually.

Based on interview and record review, the facility failed to ensure patients were provided care in a safe environment by failing to ensure patients had usable, appropriately placed call lights available to them, failing to answer call lights within an appropriate amount of time, and failing to discipline staff who were reported as threatening and or aggressive for six patients (#14, #30, #34, #44, #35, #36) out of 43 patients. This had the ability to affect all patients in the facility. The census was 57 when the survey began.
Findings included:
1. During an interview on 02/08/11 at 9:05 AM, Patient #14 (who is a quadriplegic and unable to move his/her arms and legs) stated that when he/she was admitted to the facility, the patient was given a call light that would ring by touching his/her cheek to it. The patient stated that he/she was in a neck brace at the time and could not move his/her head well enough for the call light to be depressed, leaving the patient without a way to call for staff. The patient stated that after a while, a physical therapist mounted a call light on the patient's bed that was controlled by the patients mouth. The patient stated that the staff failed repeatedly to put the call light in a place where the patient could reach it with his/her mouth, and that if the patient needed help, he/she had to yell until staff came to assist him/her. Patient #14 stated that when he/she was able to use the call light, it would take an hour, especially on evenings, for staff to respond.
2. During an interview on 02/08/11 at 9:05 AM, Patient #14's family stated that the patient was moved several weeks ago to the ADL (Activities of Daily Living) room to prepare the patient for discharge home. This ADL room is similar to a small apartment with a kitchen, living room, and a bedroom. The family arrived to find the patient had been sitting in a motorized wheelchair which was turned off (the patient cannot turn the wheelchair on him/herself), in the ADL room for approximately 45 minutes. The patient was alone and without a call light. When the family requested a call light for the patient, the facility staff said, "You don't have call lights at home". The family added that the patient requires frequent suctioning (removal of secretions from a patient's mouth to prevent choking), and that a suction machine was sitting on a table in the ADL room. This suction machine was not plugged in, and required an extension cord to supply electrical power for usage. The patients family had to request facility staff to bring in an extension cord for the suction machine.
3. During an interview on 02/08/11 at 2:10 PM, Patient #30 (who is a quadriplegic and cannot move his/her legs) stated that the facility required the patient be observed by a staff member when he/she was transferred in or out of his/her wheelchair. On 02/07/11, staff failed to respond to his/her call light for 15 minutes to observe a wheelchair transfer. The patient stated that he/she was assisted only after a State surveyor stopped at his/her room with Staff C, CNO (Chief Nursing Officer). Patient #30 stated that he/she has waited 30 minutes for staff to respond to his/her call light, and was recently left alone in the bathroom waiting for staff to respond to his/her call light. The patient stated that he/she waited so long for staff to respond that he/she shaved and washed up while waiting. The patient stated that he/she finally got out of the bathroom, got his/her walker, and transferred into the hospital bed, all without staff assistance or observation.
4. During an interview on 02/08/11 at 4:15 PM, Patient #34 stated that call light response is "bad" and that he/she waits over an hour for staff to come to his/her room. Patient #34 stated that one night he/she put his/her call light on every 15 minutes between 2:30 AM and 5:00 AM, and that every time staff would answer the call light through the intercom system. When the patient would request the nurse, whomever was on the intercom would respond that they would send the nurse right in, but the nurse never came.
5. Record review of a "Post Fall Investigation Tool" dated 12/13/10 showed that Patient #44, who was on fall precautions, fell when transferring from a bed to a wheelchair. The patient was with an OT (Occupational Therapist) who placed the call light on, but there was no response. The OT placed the call light on again as well as overhead paged staff to respond "stat" (immediately), before staff responded.
During an interview on 02/09/11 at 10:10 AM, Staff C, CNO stated that Patient #44's call light may have been turned off by staff and not answered the first time, based on the documentation of a second call light request. Staff C stated that if a call light is placed on and is not answered, the call light which rings first, slowly begins ringing louder and faster, if it is not answered within three minutes. Staff C stated that if a call light was placed on a second time, staff had to shut it off the first time.
During an interview on 02/09/11 at 9:20 AM, Staff C, stated that there is no facility policy on call lights or rounding (checking on patients for needs and safety) on patients.
6. During an interview on 02/09/11 at 12:50 PM, Staff JJ, RN (Registered Nurse) stated that he/she is usually assigned seven or eight patients to take care of, sometimes nine. Staff JJ stated that he/she cannot safely take care of eight or nine patients because they require a lot of care. Staff JJ also said that staff are not able to answer patient call lights because of the heavy work load and that patients are not satisfied when call lights are not answered.
During an interview on 02/10/11 at 10:50 AM, Staff II, RN (Registered Nurse) stated that something needed to be done about staffing and that they (the facility) need to staff more people. Staff II stated that on 02/09/11 that five or six of his/her patients were total care (requiring complete medical assistance) out of eight patients he/she was assigned to care for. Staff II also stated that he/she only received a 15 minute lunch break during the day. Staff II stated that he/she told Staff EE that he/she was "overwhelmed", and Staff EE responded, "Yeah, I am too". Staff II stated that he/she again informed Staff EE that he/she couldn't get his/her patient's taken care of and Staff EE said, "We're staffing within the grid". Staff II stated that he/she usually has to stay one hour beyond his/her scheduled work time approximately 50 percent of the time and 30 minutes beyond his/her scheduled work time approximately 25 percent of the time, in order to get his/her work completed.
7. During an interview on 02/09/11 at 3:17 PM, Staff EE, Third Floor Manager stated that a grievance was filed by patient #35 and his/her family on 08/28/10 related to Staff DD, RN being "gruff"(speaking harshly) with the patient and family. Staff EE stated that he/she knew Staff DD was "a little curt with the patient", but cannot remember if he/she spoke with staff DD regarding staff staff DD's behavior toward patient #35 and his/her family.
Record review of an email dated 09/08/10 at 12:09 PM, showed that Staff EE had not spoken with staff regarding the incident.
8. Record review of a handwritten note dated 10/01/10 from Staff EE's private notebook showed that discharged Patient #36 and a family member requested that Staff DD not provide care for the patient after Staff DD coerced the patient into taking a pill that he/she refused to take. When the patient asked to speak with the doctor about refusing the medication, Staff DD responded, "I know what is going on here, you don't". Further notes showed that Patient #36 was "very upset", didn't want Staff DD back, and was "afraid of repercussion".
During an interview on 02/09/11 at 3:17 PM, Staff EE said "Lot's of our patients are afraid of repercussions."
Record review of an unsigned handwritten note dated 10/10/(without year) showed that Staff DD would not be allowed to work until he/she was addressed with Patient's #35 and #36's grievances against him/her with a resolution.
During an interview on 02/09/11 at 3:17 PM, Staff EE stated that the facility scheduled seven to eight meetings with Staff DD to discuss Patient #35 and #36's grievances, but that Staff DD would not show up, and that administration did not attempt to meet or discuss the grievances with Staff DD during his/her scheduled shifts.
Record review of a typed memo dated 01/13/11 showed that Staff DD was informally counseled, which was approximately three to five months after the grievances were filed.
9. During an interview on 02/08/11 at 2:10 PM, current Patient #30 stated that over the weekend, Staff DD, RN came into his/her room after he/she placed the call light on and said, "I'm not gonna come in every time you ring". Patient #30 stated that he/she put the call light on because of severe leg cramps (patient is a new paraplegic) and asked Staff DD to rub his/her leg. Patient #30 stated that Staff DD refused to rub the patient's leg and told the patient that he/she was not going to be responsible if the patient had a blood clot and said, "I'm gonna call your doctor and get you something to sleep".
10. During an interview on 02/08/11 at 3:02 PM, current Patient #34 stated that the second or third night he/she was in the facility, Staff DD entered the room, "jerked off my shorts and underwear" and said to the patient, "We only wear gowns here at night". Patient #34 stated that when Staff DD was pulling off the clothing, they became caught on the therapy boot on his/her right foot. Staff DD continued to pull on the clothes, while caught on the therapy boot, jerking the patient's leg causing the patient pain. The patient stated Staff DD then started yelling at the patient that the therapy boot was only supposed to be worn on the left foot. Patient #34 added that a few nights later, his/her call light was on from 2:30 AM until 5:00 AM. The patient stated that he/she would put the light on every 15 minutes and a staff member would tell the patient, over the room intercom, that Staff DD would be right in, but Staff DD never came. Patient #34 also stated that during the previous weekend, Staff DD entered the patient's room and started "yelling and screaming" about how the patient's IV (intravenous catheter - a small plastic tube placed in the vein to deliver medications or fluids) should have been removed. The patient explained to Staff DD that the catheter was scheduled to be removed tomorrow then Staff DD responded, "Well, it's coming out tonight".
During an interview on 02/08/11 at 3:28 PM, Staff C, CNO and Staff EE, Unit manager were both informed by the State Surveyor of the allegations made against Staff DD by Patients #30 and #34. Staff C stated that Staff DD was "just one of those employees".
During an interview on 02/09/11 at 3:17 PM, Staff EE stated that he/she had never heard about any issues with Staff DD that were "extreme" regarding patients, "only co-workers".
Record review of Staff DD's time card showed that he/she was allowed to work with patients on 02/11/11 from approximately 7:00 PM until 7:00 AM on 02/12/11, and 02/12/11 from approximately 11:00 PM until 7:00 AM on 02/13/11, after Patient #30 and #34's allegations were shared with administration.
During an interview on 02/15/11 at 11:00 AM, Staff FF, Human Resource Director stated that he/she believed Staff EE was going to investigate and follow-up regarding the allegations made against Staff DD by Patients #30 and #34, but did not know if it had been done since Staff DD was not working.

Based on interview and record review the facility failed to:
- Ensure that all patients received care in a safe setting;
- Investigate all potential complaints meeting the facility definition of abuse and neglect per policy;
- Immediately report all instances of potential neglect per facility policy to supervisors or to follow the investigation protocols established by the facility to determine if further action would be necessary for four patients out of 54 patient concerns reviewed.
- Ensure patients were protected from abuse, neglect, and harassment by failing to identify, fully investigate, and prevent additional episodes of abuse, neglect, and or harassment for two current patients (#30 and #34), and four discharged patients (#28, #35, #36, and #39) out of 43 patients. Additional documentation showed previous undisclosed patients were also affected by the facility failure. This had the potential to affect all patients in the facility. The facility census was 57.
Findings included:
1. Record review of the policy titled "Allegation of Abuse" (dated 5/09) stated the purpose of the policy is to protect patients from physical abuse/sexual abuse/molestation/harassment (collectively abuse). The facility will take all necessary steps to ensure that patients are kept safe from abuse and those allegations of abuse by employees or visitors are investigated promptly, thoroughly, and reported to the proper authorities as necessary.
The procedure section states that the immediate response of staff will be guided by whether there has been a witnessed/confirmed act of abuse or whether there have been reports or suspicions of abuse that have not been witnessed/confirmed. Section B for un-witnessed reports of abuse state to take immediate action to protect the patient from harm. Unit staff must contact their supervisor and or a supervisor on duty immediately upon notification of allegation/findings of any form of abuse. The patient must be : (i) examined immediately for injury: (ii) treated, if necessary: (iii) secured from harm by taking any additional necessary actions to ensure the patient's safety and welfare, including, but not limited to (i) moving the patient to another unit; (ii) reassigning staff and or suspending accused staff pending investigation and (iii) restricting visits from alleged abusers. The supervisor must immediately notify the hospital Chief Executive Officer (CEO), Chief Nursing Officer (CNO), or designee who will promptly contact Corporate Risk Management;
Record review of the facility's policy titled, "Allegation of Abuse" dated 05/09, showed the facility staff will ensure that patients are kept safe from abuse and that all allegations of abuse by employees are investigated promptly, thoroughly, and reported to the proper authorities through the following direction:
-Take immediate action to protect the patient from further harm;
-For all acts of or alleged acts of abuse, the Hospital CEO/CNO/designees must contact the Hospital Risk Manager, Human Resource Director, Corporate Human Resources, and the legal guardian/responsible party of a vulnerable adult, when allegations involve an employee;
-The investigation shall include interviews with the person reporting the incident, the alleged victim, and all pertinent staff (including the alleged abuser) that may have knowledge of the events surrounding the alleged incident;
-Documentation of the investigation and conversations should be recorded and kept with the incident report and maintained separate from the employee's personnel file.
Record review of the facility's policy titled, "Abuse-Adult" revised 05/08, showed the following direction:
-Patient abuse may take the form of physical, sexual, or emotional injury or harm, as well as neglect and exploitation;
-Abuse, neglect and exploitation may be indicated through the caregiver being hostile, frustrated, showing little concern, blaming the patient, impatience, or the patient having unjustified fear.
2. Review of the policy for Patient complaint/grievances states under the section "Grievances-Actions to be taken" states that the hospital must review, investigate and resolve each patient's complaint/grievance within a reasonable time frame. Complaints/grievances involving situations that potentially endanger the patient such as neglect or abuse should be reviewed immediately.
3. Record review on 02/9/11 of the complaint and grievance log for Patient #28 indicated that the family requested a meeting with the care team of the patient on 08/30/10. The issues discussed by several family members included that the patient was not cleaned adequately after a bowel movement, medicines were not administered by staff and left at bedside and that the patient reported that he/she had been "hit" by staff when treatment was refused.
The staff persons present during this meeting were the attending physician, director of quality management, nurse manager and the case manager. The notes on the meeting indicated a response by the physician concerning the issues including patient being struck by a staff person and indicated that the patient's response to staff persons was inconsistent and the patient often refused treatment. The physician was noted as saying he/she could see that staff may be frustrated with the patient's response, but did not believe the patient's statements were always accurate. The notes indicated that some family members were satisfied with this response, but others were not. A further note on the incident of patient allegedly being struck by staff indicated the issue was selected to be dropped in lieu of the care issues and the importance of attendance in therapy sessions.
A follow-up note from the complaint/grievances log concerning this patient was dated 09/23/10 and indicated that a family member had requested a copy of the patient's medical record. Notes indicated that the family member asked about the resolution or information on the alleged abuse of the patient.
During an interview on 02/9/11 at 9:20 AM, Staff A, Director of Quality Improvement/Risk Management, stated that there is no other investigation that could be found concerning the staff allegedly striking the patient other than the noted conversation that was done for the potential abuse of the patient.
4. Record review, on 02/9/11, of the complaint/grievance logs indicated an incident reported on 10/18/10 to the facility where Patient #29 complained of comments by staff persons and the report detailed one incident in which the patient and a staff person had a negative verbal interaction at 2:00 AM. Staff persons suggested that the patient return to his/her room to sleep, but the patient requested to go outside to a patio area. The patient also reported being left on the outside patio area of the facility from 2:30 AM -6:45 AM. The patient stated that at 3:00 AM two staff were present in the patio area, but did not provide or ask if he/she needed assistance.
Review of the follow-up done by staff included an interview with the agency nurse assigned to this patient during this time period. The agency nurse did refer to the incident with another staff person at 2:00 AM, and stated that at approximately 3:00 AM they could not locate the patient in his/her room or the corridor area and located the patient on the patio area. They located the patient on the patio area asleep in the smoking area. The right wheel of the patient's wheelchair was "jammed" against the handrail on the ramp and two staff persons assisted the patient to free his wheelchair and took him inside.
The facility staff interviewed this patient and asked if the patient felt safe at the facility and his/her response was "yes" but that he/she only felt safe if four specific facility staff were not providing care to him/her. The patient stated he/she wanted to file a grievance on those four facility staff.
Record review on 02/10/11 of the patient's record did not provide further details clarifying if the patient had remained on the patio for one hour as stated by staff or four hours as stated by the patient.
Review of the complaint/grievance investigation did not include a written response to the patient in response to his/her comments or after the patient had stated that he/she requested a "grievance" on the four facility staff.
The log sheet for complaints/grievances indicated that the follow-up to this was completed on 10/25/10 and under outcome it stated the patient was not satisfied with the explanation and the other issues brought forth.
Under the section of customer satisfaction on the complaint/grievance records it was indicated that the patient stated "no" as to level of satisfaction and that ongoing issues occur with this patient and the patient has several new complaints each week.
Records provided by the facility did not indicate any further investigation or resolution to this incident concerning the patient's comments on being left alone on the patio for allegedly four hours or the comments by a staff person regarding his care provided.
The records did not indicate any follow-up investigation to determine if any potential abuse or neglect had occurred to this patient through a facility internal investigation other than with the complaint/grievance follow-up which had been done.
5. Review of the complaint/grievance reports from the facility indicated an incident was reported on 12/15/10. The patient had been discharged and the incident was reported by a physician's office during a follow up visit. A nurse from the physician's office reported to the facility the patient's concerns and requested a follow-up with them on the resolution. An email included in the report indicated that the physician would like the facility to follow-up on the issues reported to the physician's office. The facility did provide follow-up in the form of a phone call, but there is no written response from the facility to the physician's office.
The patient's concerns indicated that treatment by the Patient Care technicians (PCT's) was "very bad" . The patient reported that during the night the PCT's had assisted him/her to the beside commode several times during the night and that after several times one PCT stated that he/she had been assisted to the commode 10 times that evening and the PCT was not going to get the patient up again and the PCT "would just not do it". According to the staff in the physician's office the patient was upset by this comment. According to facility notes the spouse of the patient reported this to the supervisor on the floor and that the supervisor was very responsive to this incident.
The note from the incident/grievance file indicated that the facility had no other investigations on the comments made by the PCT allegedly refusing to provide necessary care of the patient's needs.
6. Review of a complaint/grievance received on 01/3/11 at 10:30 PM, indicated that the nurse supervisor interviewed the patient about his/her concerns. The patient stated that a patient care technician (PCT) is rough with him/her, did not clean him/her thoroughly after a bowel movement, is disrespectful and rude and hangs up the call light without responding to the patient's requests. The PCT argues with the patient and the patient reported in this same statement that he/she wanted his/her own clothes on because he/she does not like to sleep in the nude. The PCT argued with the patient that he/she only wanted his/her own clothes on so that the patient can go smoke.
The patient stated that he/she feels the PCT puts the needs of other patients as a priority over his/her own needs. The patient stated that this PCT and another PCT talk and snicker about him/her and that the PCT is trying to get him discharged from the facility.
Under the section of Action/Follow-up the nurse supervisor indicated that he/she had talked to both PCT's and they denied the accusations. Under the Response section the nurse supervisor indicated that the patient stated that this is not the first complaint that he/she has made regarding his/her care at this facility.
Staff BB, Nurse Supervisor, followed up on the statements on the morning of 01/4/11 and interviewed the patient. The patient according to staff was satisfied that both PCT's would no longer be caring for him/her (assigned to other patients), but that in an emergency they may have to provide care. The patient agreed that was okay.
During an interview on 02/10/11 at 10:10 AM, Staff BB stated he/she had interviewed the patient the following morning regarding his/her comments to gather more details. Staff BB stated that the facility prefers patients wear gowns instead of regular clothes. The patient was persistent at keeping his/her clothes on at all times. The staff did state the patient was wearing a gown at the time of comments.
Staff stated that due to the comments, behaviors and complaints from this patient that they had rotated quite a few staff to provide his/her care. Staff BB did interview other staff. Staff BB stated the original staff filled out a form with the patients comments and did so as night shift supervisor. When Staff BB interviewed the patient later the next day the patient said he/she would be satisfied if one staff person (indicated by name) would no longer provide his/her care.
When Staff BB was asked if this should have been investigated as a potential abuse and neglect case Staff BB stated that in combination with other complaints received the patient was rough on staff and when talking with the patient there was no indication that abuse and neglect was occurring. None of his/her statements that day indicated potential abuse and neglect. The charge nurse who took the original statement the night before would have done the interview and if seeing no problems would give it to Staff BB the next day.
The facility had no other investigation to determine if the staff person had actually provided adequate care or to determine that abuse or neglect had or had not occurred until the next day when subsequent interviews were done. The shift supervisor did interview the patient at the time (night shift), but no action is noted other than interviewing the two PCT's.


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7. Record review of the complaint/grievance files indicated that the facility had the following incidents reported and were not investigated nor indicated as being reviewed for the potential of abuse or neglect. The initial issues reported all contain concerns that meet the facility definition of potential abuse or neglect:
-07/14/10 A patient complained that a physical therapist was rough and made him/her cry. The facility reassigned the patient to another physical therapy team and the patient was satisfied.
-07/26/10 A patient complained of pain in the genital area. The patient was interviewed about probable cause which was determined to be due to a catheterization during the night. The patient was satisfied.
-07/30/10 A patient's family member complained that PCT's did not catheterize the patient all night as ordered and that the family did not want the agency PCT to provide care to the patient again. The facility placed the PCT's on "Do not assign list".
-08/19/10 A patient complained that he/she did not receive adequate care, that the patient sat in urine for up to 45 minutes some days, that the PCT's were rude and refused to get the patient a large (appropriately sized) adult diaper. The patient left the facility against medical advice.
-08/30/10 A patient's family complained that the patient was soiled with bowel movement and that the nurse was not prompt with pain medication. The facility moved the patient to a private room so that family could stay with the patient.
-10/17/10 A patient's family complained that the patient was receiving no care with poor mannerisms from staff. The facility interviewed the family who refused to return the patient (who was currently in the Emergency Department at another facility) to the facility, due to care concerns. The family complained that when the patient requested a bedpan, a staff member shrugged their shoulders, sighed, and said, "I'll get to it when I have time". After the patient used the bedpan, the family found the patient with bowel movement on his/her fingers and the family was told by staff to clean the patient up, "it's your (family member)". The patient placed a call light on two times, then had an accidental bowel movement in the bed when staff did not come. The patient was afraid and would tell the family "don't leave me", but the family was told they could not stay with the patient. No follow-up was documented by the facility.
-10/20/10 A patient complained of lack of care on the night shift on 10/19/10 and that staff had treated the patient roughly. The facility spoke with staff member about customer service and safety and removed the staff from the patient's care. A follow-up occurred with the patient and the family who seem satisfied.
-10/23/10 A patient complained that his/her bowel routine was not being done properly and that patient is not checked on or turned frequently enough. The nurse manager followed up with patient who complained of no further issues.
-10/26/10 A patient's family complained that the patient is not receiving pain medication in a timely manner. The facility changed the staff assignment and the family was satisfied.
-10/26/10 A patient complained that he/she was not getting medication or tube feedings (nutrition provided into the stomach through a tube inserted in the nose or stomach) on time. The nurse manager followed up and the patient was satisfied.
-11/29/10 A patient complained about staff attitudes and responsiveness. The CNO called the patient and the patient was satisfied.
-12/02/10 A patient's family member complained that no one came into the patient's room and that the patient's leg bag had not been emptied. The patient's family also complained that an argument occurred between the nurse and family. The nurse manager informed the patient's family that he/she would speak with the nurse.
-12/04/10 A patient complained that he/she did not receive his/her pain medications as ordered. The supervisor found that not all medications pulled from the medication dispensary were documented as given. The facility would continue the investigation.
-12/29/10 A patient's family complained they felt the patient was not safe, that the family needed to stay with the patient 24 hours a day, that they were afraid the patient would fall, and that the bed alarm did not work. The facility place a new bed alarm on the bed, but the patient fell the next day and was transported to another facility emergency room.

8. During an interview on 02/10/11 at 12:58 PM, Staff KK, House Supervisor stated that when he/she gets complaints from a patient about a staff being rough, for example when they turn a patient or clean a patient, he/she will speak with the patient. Staff KK stated that if the patient says everything is "ok" after he/she speaks with them, Staff KK does not fill out an incident report. Staff KK did not say if he addressed the staff who were accused of being rough.

During an interview on 02/15/11 at 9:30 AM, Staff FF, Director of Human Resources stated that there were no formal investigations done on the following grievances:
-02/04/10 when a patient complained staff were rough;
-03/11/10 when two patients complained a PCT bathed them with cold water and that one of the patients was handled rough;
-07/30/10 when a patient's family complained the patient was not catheterized all night and requested PCT's to not be assigned to them again.
Staff FF stated that these grievances were concerning and that they should have been investigated.

During an interview on 02/15/11 at 10:45 AM, Staff C, (CNO) Chief Nursing Officer stated the facility did not have any reportable abuse or neglect cases over the previous year.

9. Record review of an email undated, found in Staff EE's, Third Floor Nurse Manager private notebook, showed that he/she notified Staff C, CNO of the following:
-a recent multitude of patient/family complaints that concerned Staff EE about the evening/night shift;
-several patients were not turned on 08/11/10;
-a patient did not get pain medication after calling for one to two hours;
-a patient waited one to one and a half hours to be put to bed;
-a newly admitted patient wanted to go home because no one would get him/her ready for the day;
-day staff complaining that nights were not placing a large patient in appropriately sized adult diapers that were large enough for the patient;
-a patient's family member complained that the patient was soaked in urine in the morning and that staff had not checked on the patient since the previous night;
-a patient who asked for pain medication at 9:00 PM did not receive them until 11:00 PM;
-a patient waited over an hour for pain medication;
-a family member of a patient on fall precautions found the patient without the ordered sitter (someone who remains in the room with the patient at all times to observe for safety). The patient was sitting on a bed side commode (portable potty) without supervision. The bed was not in low position (for fall safety) and there were no mats on the floor (for fall safety).There was no documented response from the CNO provided by the facility regarding this memo.

10. Record review of a Patient Grievance dated 08/28/10 showed family members of discharged Patient #35 had reported staff as being "nasty" and "disrespectful" and treating Patient #35 poorly. Documentation showed the family attempted by phone to get directions to the facility for 10 - 15 minutes to visit Patient #35, but the staff refused to talk to them. The family requested to speak with the supervisor, but the request was refused by staff who said the supervisor didn't have a phone number. Investigation documentation of the grievance showed Staff EE verified the details of the grievance with another staff member, and that follow-up action would include visiting with the patient daily to make sure there were no additional complaints.

During an interview on 02/09/11 at 3:17 PM, Staff EE, stated that the details regarding the grievance by Patient #35 and his/her family, filed on 08/28/10, was confirmed with Staff HH, PCT who was present during the incident. Staff HH reported that Staff DD was the nurse caring for Patient #35 during the phone call, that Staff DD was gruff with the patient and family, and that Staff DD stated to Patient #35, "just give me the phone" after the family became upset. Staff EE stated that he/she knew Staff DD was "a little curt with the patient", but cannot remember if Staff DD was spoken to or interviewed regarding the grievance.

Record review of Staff DD's annual evaluation dated 09/03/10 at 7:35 PM, showed Staff EE reviewed the evaluation with Staff DD but there was no documentation showing staff EE had discussed the grievance filed by Patient #35 with staff DD.

Record review of an email dated 09/08/10 at 12:09 PM, showed that Staff EE communicated to Staff A, Risk Manager, and Staff C, that he/she contacted Patient #35's family regarding follow-up with the grievance filed on 08/28/10. Staff EE wrote that he/she communicated to Patient #35's family that he/she still needed to speak with Staff DD regarding the incident.

During a phone interview on 02/10/11 at 10:30 AM, Patient #35's family member stated that the patient's nurse was "really nasty" to him/her.

Record review of a handwritten note by Staff EE, found in staff EE's private notebook, dated 10/01/10 at 3:35 PM, showed discharged Patient #36 and a family member requested that Staff DD not provide care for the patient again. According to the documentation, Staff DD attempted to give Patient #36 a pill which the patient refused to take. Staff DD became upset and threw away the medication. Later in the night, Staff DD brought the patient the same medication, and the patient explained to Staff Dd that the medication made him/her light-headed. When the patient asked to speak with the doctor, Staff DD responded, "I know what is going on here, you don't". Further notes showed that the patient was "very upset", didn't want Staff DD back, and was "afraid of repercussion".

During an interview on 02/09/11 at 3:17 PM, Staff EE stated that he/she interviewed patient #36, who knew which pill he/she was taking by the size of the pill. Staff EE stated that Patient #36 took the pill because he/she felt overwhelmed with the situation when Staff DD brought the same medication back a second time. Staff EE stated that he/she reviewed Patient #36's medical record and the medication the patient refused to take was documented as given by Staff DD. Staff EE stated that the patient did not want Staff DD spoken to regarding the complaint until Patient #36 was discharged from the facility because he/she was afraid of repercussions. Staff EE added that "lot's of our patients are afraid of repercussions".

Record review of an unsigned handwritten note from Staff EE's private notebook, dated 10/10/(without year) showed that Staff DD would not be allowed to work until he/she was addressed with Patient #35 and #36's grievances against him/her and a resolution was reached.

During an interview on 02/09/11 at 3:17 PM, Staff EE stated that the facility had scheduled seven to eight meetings with Staff DD to discuss Patient #35 and #36's grievances, but that Staff DD would not show up for the meetings or not respond to the meeting request. Staff EE stated that he/she requested the presence of Staff C, CNO and Staff FF, Human Resources (HR) Director during the meetings with Staff DD, "because of the way (Staff DD) is". Staff EE stated that Staff DD was allowed to work even though Staff DD had not yet been counseled, and that administration did not attempt to meet and discuss the grievances with Staff DD during his/her scheduled shifts on weekend nights.

Record review of a typed memo dated 01/13/11 showed that Staff FF, Staff C, and Staff EE met with Staff DD to review patient, family, and co-worker grievances and complaints. The memo was not documented on an Employee Discipline Form. This meeting occurred approximately three to five months after the grievances were filed, and three months after the hand written note dated 10/10/(without year), which stated that Staff DD would not be allowed to work until he/she was addressed with the grievances and a resolution was reached. The documentation did not show any type of discipline was taken against staff DD.

11. During an interview on 02/08/11 at 2:10 PM, current Patient #30 stated that over the weekend, Staff DD came into his/her room after he/she placed the call light on and said, "I'm not gonna come in every time you ring". Patient #30 stated he/she had put his/her call light on because of severe leg cramps (patient is a new paraplegic) and asked Staff DD to rub his/her leg. Patient #30 stated that Staff DD refused to rub the patient's leg, and told the patient that he/she was not going to be responsible if the patient had a blood clot and said, "I'm gonna call your doctor and get you something to sleep".

During an interview on 02/08/11 at 3:02 PM, current Patient #34 stated that the second or third night he/she was in the facility, Staff DD entered the room, "jerked off my shorts and underwear" and said to the patient, "We only wear gowns here at night". Patient #34 stated that when Staff DD was pulling off the clothing, they became caught on the therapy boot the patient was wearing on his/her right foot. Staff DD continued to pull on the clothes, while caught on the therapy boot, jerking the patient's leg causing the patient pain. The patient stated Staff DD then started yelling at the patient that the therapy boot was only supposed to be worn on the left foot. Patient #34 added that a few nights later, his/her call light was on from 2:30 AM until 5:00 AM. The patient stated that he/she would put the light on every 15 minutes and a staff member would tell the patient, over the room intercom, that Staff DD would be right in, but Staff DD never came. Patient #34 also stated that during the previous weekend, Staff DD entered the patient's room and started "yelling and screaming" about how the patient's IV (intravenous catheter - a small plastic tube placed in the vein to deliver medications or fluids) should have been removed. The patient explained to Staff DD that the catheter was scheduled to be removed tomorrow, but Staff DD responded, "Well, it's coming out tonight".

During an interview on 02/08/11 at 3:28 PM, Staff C, and Staff EE, were both informed by the State Surveyor of the allegations made against Staff DD by patient's #30 and #34. Staff C stated that Staff DD was recently counseled regarding feedback from several patient's and patient family members. Staff C added that Staff DD was "just one of those employee's".

During an interview on 02/09/11 at 3:17 PM, Staff EE stated that there had never been any trends regarding patient or staff complaints against Staff DD prior to August 2010. Staff EE stated that Staff DD had been coached regarding responding to another staff member unprofessionally. Staff EE stated that Staff DD was very direct, can be intimidating, but Staff EE had never heard about any issues that were "extreme" regarding patients, "only co-workers".

Record review of Staff DD's time card showed that he/she worked on 02/11/11 and 02/12/11, after the facility had been notified of Patient #30 and #34's complaints against him/her.

During an interview on 02/15/11 at 11:00 AM, Staff FF stated that he/she believed Staff EE was going to investigate and follow-up regarding the allegations made against Staff DD by Patients #30 and #34, but doesn't know if it has been done yet since Staff DD was off the previous two days.

Based on facility policy review and record review, the facility failed to specify the reason for restraint for two (#18 and #9) of two patients reviewed for restraints. The facility census was 57.

Findings included:

1. Review of the facility's policy titled, "Restraints, Use of," revised 06/09, showed the following direction: Orders will contain the reason for restraint.

2. Review of Patient #18's medical record on 02/19/11 at 9:10 AM showed a Restraint Assessment and Physician Order was written on the following dates.
- 01/09/11 The time of the order was not documented. The reason for the restraint was not specified.
- 01/10/11 at 8:00 PM. The reason for the restraint was not specified.
- 01/11/11 at 7:00 PM. The reason for the restraint was not specified.
- 01/28/11 at 7:00 PM. The reason for the restraint was not specified.
- 02/04/11 at 8:05 PM. The reason for the restraint was not specified.


27727

3. Review of Patient #9's medical record on 02/08/11 at 2:30 PM, showed a Restraint Assessment and Physician Order was written on the following dates.
- 01/28/11 at 12:00 PM. The reason for the restraint was not specified.
- 01/29/11 at 3:00 PM. The reason for the restraint was not specified.
- 02/02/11 at 2:50 PM. The reason for the restraint was not specified.
- 02/02/11 at 3:00 PM. The reason for the restraint was not specified.
- 02/04/11 at 4:00 PM. The reason for the restraint was not specified.

Based on facility policy review, record review, the facility failed to specify the type of restraint for two (#18 and #9) of two patients reviewed for restraints. The facility census was 57.

Findings included:

1. Review of the facility's policy titled, "Restraints, Use of," revised 06/09, showed the following direction: Orders will contain the type of restraint.

2. Review of Patient #18's medical record on 02/19/11 at 9:10 AM, showed a Restraint Assessment and Physician Order written on the following dates.
- 01/09/11 The order was not timed. The type of restraint was not specified.
- 01/14/11 7:00 PM. The type of restraint was not specified.


27727

3. Review of Patient #9's medical record on 02/08/11 at 2:30 PM showed a Restraint Assessment and Physician Order was authenticated on the following dates:
- 01/28/11 at 8:30 AM for restraints for the period of time 9:30 PM to 9:30 AM. The type of restraint was not specified.

Based on facility policy review and record review, the facility failed to obtain a restraint order for each episode of restraint for two (#18 and #9) of two patients; and failed to specify a time frame for restraint for one (#18) of two patients reviewed for restraints. The facility census was 57.

Findings included:

1. Record review of the facility's policy titled, "Restraints, Use of," revised 06/09, showed the following direction:
- Order/Renewal: Requires LIP (Licensed Independent Practitioner) reorder every 24 hours; and
- Content of Order/Renewal: Orders will contain the time limitation for restraint.

2. Review of the medical record for current Patient #18 on 02/19/11 at 9:10 AM showed Restraint Assessment and Physician Orders were written on the following dates:
- 01/17/11 at 7:30 PM for Bed Enclosure from 7:00 PM to 7:30 AM. Review of the Daily Flowsheet/Treatment Record showed that siderails were also utilized. There is no order for the use of siderails.
- 01/28/11 at 7:00 PM for Bed Enclosure from 7:00 PM to 7:30 AM. Review of the Daily Flowsheet/Treatment Record showed that siderails were also utilized from 8:00 PM to 7:00 AM. There is no order for the use of siderails.
- 01/29/11 at 10:05 AM for Bed Enclosure from 10:05 AM to 10:00 PM. Review of the Daily Flowsheet/Treatment Record showed that siderails were also utilized. There is no order for the use of siderails.
- 2/2/11 at 7:00 PM for Bed Enclosure. The timeframe was not specified. Review of the Daily Flowsheet/Treatment Record showed intermittent use throughout the day.
- 02/05/11 at 7:30 PM for Bed Enclosure from 7:30 PM to 7:30 AM. Review of the Daily Flowsheet/Treatment Record showed that mittens were also utilized from 7:00 PM to 6:00 AM. There is no order for the use of mittens.

3. Review of the nursing notes for current Patient #18 on 02/19/11 at 9:10 AM showed the patient was restrained in an Enclosure Bed, but there were no physician orders for the restraint.


27727

4. Review of the medical record for current Patient #9 on 02/08/11 at 2:30 PM showed Restraint Assessment and Physician Orders were written on the following dates:
- 01/28/11 at 12:00 PM for a right mitten. There was no order for a bed enclosure.
- 01/29/11 at 3:00 PM for a bed enclosure from 1:45 PM to 5:00 PM. There was no order for mittens.
- 01/30/11 at 9:00 AM for a bed enclosure from 7:00 PM to 9:00 AM. There was no order for mittens.
- 01/30/11 at 9:00 AM for a bed enclosure from 6:00 PM to 7:30 AM. There was no order for mittens.

Based on facility policy review, record review and interview the facility failed to ensure restraint orders for non-violent patients were written and authenticated according to the facility policy and/or renewed every 24 hours for two (#18 and #9) of two current patients reviewed for restraints. The facility census was 57.

Findings included:

1. Record review of the facility's policy titled, "Physician's Orders/Telephone and Verbal," last reviewed 05/09, showed the following direction:
- Verbal orders are to be taken from in-house physicians in emergency situations only.
- Telephone orders are to be taken from physicians that are out of the hospital only.
- All telephone/verbal orders must be co-signed by the responsible physician, ordering or treating practitioner on the next visit or within 48 hours. The chart will be flagged appropriately to alert MD for co-signature.

Review of the facility's policy titled, "Restraints, Use of," revised 06/09, showed the following direction:
- Requires LIP (Licensed Independent Practitioner) reorder every 24 hours.
- Reassessment in person by LIP (Licensed Independent Practitioner) every calendar day.

2. Review of Patient #9's medical record showed:
-An order written on 01/30/11 at 11:00 AM for a bed enclosure (a bed with a netted zipped canopy) and mittens from 11:00 AM to 7:30 AM due to the patient being unaware of physical limitations. The physician signature of the order was dated 02/02/11 at 1:50 PM, three days after the assessment order by the Registered Nurse (RN).
-An order written on 01/30/11 at 7:00 PM for a bed enclosure from 7:00 PM to 7:30 AM due to the patient being unaware of physical limitations. The physician signature of the order was dated 02/02/11 at 1:50 PM, three days after the assessment order by the RN.
-An order written on 01/31/11 at 7:30 PM for a bed enclosure from 7:00 PM to 7:30 AM due to the patient being unaware of physical limitations. The physician signature of the order was dated 02/02/11 at 1:50 PM, three days after the assessment order by the RN.

During an interview on 02/08/11 at 2:00 PM Staff B, Nurse Manager, stated that the physician had not written orders for restraints every 24 hours as required by the policy.


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3. Review of Patient #18's medical record on 02/19/11 at 9:10 AM showed:
- An order written on 01/08/11 at 8:00 PM for a Bed Enclosure from 8:00 PM to 7:30 AM due to the patient being unaware of physical limitations. The physician signature of the order was dated 01/11/11 at 12:30 PM, three days after the assessment order by the RN.
- An order written on 01/08/11 at 8:00 PM for a Bed Enclosure from Midnight to 7:30 AM due to the patient being unaware of physical limitations. The physician signature of the order was dated 01/11/11 at 12:30 PM, three days after the assessment order by the RN.
- An order written on 01/20/11 for a Bed Enclosure from 7:00 PM to 7:30 AM due to the patient being unaware of physical limitations. The physician signature of the order was dated 01/24/11 at 8:00 AM, four days after the assessment order by the RN.
- An order written on 01/21/11 for a Bed Enclosure from 7:00 PM to 7:30 AM due to the patient being unaware of physical limitations. The physician signature of the order was dated 01/24/11 at 8:00 AM, three days after the assessment order by the RN.
- An order written on 01/28/11 for a Bed Enclosure from 7:00 PM to 7:30 AM. The reason for the restraint is not indicated. The physician signature of the order was dated 02/02/11 at 2:50 PM, five days after the assessment order by the RN.
- An order written on 01/30/11 for a Bed Enclosure from 7:30 PM to 7:00 AM due to the patient being unaware of physical limitations. The physician signature of the order was dated 02/02/11 at 1:50 PM, three days after the assessment order by the RN.
- An order written on 02/02/11 for a Bed Enclosure due due to the patient being unaware of physical limitations. The timeframe is not indicated. The physician signature of the order was dated 02/07/11 at Noon, five days after the assessment order by the RN.
- An order written on 02/03/11 for a Bed Enclosure from 7:00 PM to 7:30 AM due to the patient being unaware of physical limitations. The physician signature of the order was dated 02/07/11 at 1:00 PM, four days after the assessment order by the RN.
- An order written on 02/04/11 for a Bed Enclosure from 9:00 PM to 9:00 AM due to the patient being unaware of physical limitations. The physician signature of the order was dated 02/07/11 at 1:00 PM, three days after the assessment order by the RN.

4. Review of Patient #18's medical record on 02/19/11 at 9:30 AM, showed multiple Restraint Assessment and Physician Order sheets that were completed by RN's and utilized as Telephone Orders for restraint, but not written as such. Therefore, the patient was restrained without a valid physician order for the following dates and times:
- 01/08/11 Bed enclosure from 8:00 PM to 7:30 AM
- 01/09/11 Bed enclosure from 8:40 PM to 7:30 AM
- 01/10/11 Bed enclosure from 8:00 PM to 7:30 AM
- 01/12/11 Bed enclosure from 10:15 PM to 7:30 AM
- 01/13/11 Bed enclosure from 7:00 PM to 7:00 AM
- 01/14/11 Bed enclosure from 7:00 PM to 7:30 AM
- 01/16/11 Bed enclosure from 7:30 PM to 7:00 AM
- 01/17/11 Bed enclosure from 7:00 PM to 7:30 AM
- 01/18/11 Bed enclosure from 7:15 PM to 7:30 AM
- 01/20/11 Bed enclosure from 7:00 PM to 7:30 AM
- 01/21/11 Bed enclosure from 7:00 PM to 7:30 AM
- 01/22/11 Bed enclosure from 7:00 PM to 7:30 AM
- 01/23/11 Bed enclosure from 7:00 PM to 7:30 AM
- 01/24/11 Bed enclosure from 7:15 PM to 7:30 AM
- 01/25/11 Bed enclosure from 7:00 PM to 7:30 AM
- 01/27/11 Bed enclosure from 7:00 PM to 7:00 AM
- 01/28/11 Bed enclosure from 7:00 PM to 7:30 AM
- 01/29/11 Bed enclosure from 10:05 PM to 7:00 AM
- 01/30/11 Bed enclosure from 7:30 PM to 7:00 AM
- 01/31/11 Bed enclosure from 7:00 PM to 7:00 AM
- 02/02/11 Bed enclosure from Timeframe not specified. Review of the nursing flow sheet showed restraints were in place from 7:00 PM to 4:00 AM.
- 02/03/11 Bed enclosure from 9:00 PM to 7:00 AM
- 02/05/11 Bed enclosure from 7:30 PM to 7:30 AM
- 02/06/11 Bed enclosure from 7:30 PM to 7:30 AM
- 02/07/11 Bed enclosure from 7:00 PM to 7:30 AM

5. During an interview on 02/08/11 at 2:00 PM, Staff B, Nursing Manager, stated that a new physician order was required if the patient was out of their restraint more than 12 hours except for toileting, physical therapy, occupational therapy etc.

During an interview on 02/08/11 at 2:50 PM, Staff A, Quality Improvement/Risk Manager, stated that if a patient's physician was not in the facility when restraint orders were needed, nurses called the physician via phone to obtain the order. Staff A agreed that the restraint orders for Patient #18 were not clearly identified as telephone orders.

Based on facility policy review and record review, the facility failed to ensure appropriate monitoring and nursing documentation was completed for one (#18) of two patient's records reviewed for restraint use. The facility census was 57.

Findings included:

1. Record review of the facility's policy titled, "Restraints, Use of", revised 06/09, showed the following direction:
- Monitoring: Every two hour monitoring through observation, interaction, direct examination. Monitoring is to include:
- Hydration, nutrition, elimination needs; and
- Circulation and skin condition.
- Documentation: Monitoring results every two hours.

2. Review of current Patient #18's Daily Flowsheet/Treatment Records showed the following documentation during use of restraints:
- On 01/08/11, "Skin Circulation Check" was not documented from 8:00 PM to 11:00 PM.
- "Hygiene/Toileting Needs" was not documented between Midnight and 6:00 AM.
- On 01/09/11, "Hygiene/Toileting Needs" was not documented between 8:00 PM and 11:00 PM.
- On 01/10/11, "Hygiene/Toileting Needs" was documented at 8:00 PM and 10:00 PM only. "Food/Fluid Offered" was documented at 8:00 PM and 10:00 PM only.
- On 01/11/11, "Skin Circulation Check" was documented at 8:00 AM, 8:00 PM and 10:00 PM only.
- On 01/12/11, "Skin Circulation Check" was documented at 10:00 PM only. "Food/Fluid Offered" was checked for 7:00 AM, 8:00 AM and 10:00 PM only. "Hygiene/Toileting Needs" was not documented between 9:00 AM and 10:00 PM.
- On 01/13/11, "Food/Fluid Offered" was documented at 7:00 AM, 8:00 PM and 10:00 PM only. "Hygiene/Toileting Needs" was not documented between 9:00 AM and 7:00 PM.
- On 01/14/11, "Skin Circulation Check" was not documented between Midnight and 6:00 AM. "Food/Fluid Offered" was not documented between Midnight and 6:00 AM. "Hygiene/Toileting Needs" was not documented between 3:00 PM and 11:00 PM.
- On 01/15/11, "Skin Circulation Check" was documented once (2:00 AM) between Midnight and 9:00 AM. "Food/Fluid Offered" was not documented between 4:00 AM and 8:00 AM. Assessment for "Hygiene/Toileting Needs" was not documented between Midnight and 8:00 AM.
- On 01/17/11, "Skin Circulation Check" was not documented between 6:00 PM and 11:00 PM. "Hygiene/Toileting Needs" was not documented between 3:00 AM and 8:00 AM.
- On 01/18/11, "Skin Circulation Check" was not documented between Midnight and 8:00 PM.
- On 01/19/11, restraint use was not documented 9:00 AM and 11:00 PM. Assessments for "Skin Circulation Check,""Food/Fluid Offered," and"Hygiene/Toileting Needs" were not documented between 9:00 AM and 11:00 PM.
- On 01/20/11, there was no nursing documentation on the flowsheet, and no documentation in nursing notes between Midnight and 1:20 PM. A nursing note at 1:20 PM indicates the patient was sent for a physician appointment during the day and was very confused. There is no indication of the time the patient left the facility for the physician appointment or what time he/she returned. The first notation regarding the presence of restraints, and assessments for "Skin Circulation Check," "Food/Fluid Offered," and "Hygiene/Toileting Needs" were documented at 7:00 PM.
- On 01/21/11, "Food/Fluid Offered" was not documented between Midnight and 6:30 AM.
- On 01/22/11, "Skin Circulation Check" was not documented between Midnight and 11:00 PM. "Food/Fluid Offered" was not documented between Midnight and 6:30 AM or after 3:00 PM.
- On 01/23/11, "Skin Circulation Check" was not documented between 9:00 AM and 11:00 PM. "Hygiene/Toileting Needs" was not documented between 6:00 PM and 11:00 PM.
- On 01/24/11, restraint use was not documented between 8:00 AM and 7:00 PM. Assessments for "Skin Circulation Check," "Food/Fluid Offered," and "Hygiene/Toileting Needs" were not documented during this timeframe.
- On 01/26/11, restraint use was not documented between 9:00 AM and 6:00 PM. Assessments for "Skin Circulation Check," "Food/Fluid Offered," and "Hygiene/Toileting Needs" were not documented between 9:00 AM and 7:00 PM.
- On 01/29/11, "Skin Circulation Check" was not documented between 8:00 AM and 5:00 PM. "Food/Fluid Offered" was not documented between 2:00 AM and 5:00 PM, and between 7:00 PM and 11:00 PM. Assessment for "Hygiene/Toileting Needs" was documented at 5:00 PM, 9:00 PM and 11:00 PM only.
- On 02/02/11, restraint use was not documented between 5:00 AM and 7:00 AM, or 4:00 PM and 7:00 PM. Assessments for "Skin Circulation Check," "Food/Fluid Offered," and "Hygiene/Toileting Needs" were not documented during this timeframe.
- On 02/03/11, restraint use was not documented between 7:00 AM and 11:00 PM. "Skin Circulation Check" was not documented between 6:00 AM and 11:00 PM. "Food/Fluid Offered" was not documented between 6:00 AM and 5:00 PM, and between 6:00 PM and 11:00 PM. Assessment for "Hygiene/Toileting Needs" was not documented between 7:00 AM and 4:00 PM, and was not documented after 6:00 PM.
- On 02/05/11, restraint use was not documented between 8:00 AM and 11:00 PM. Assessment for "Hygiene/Toileting Needs" was not documented between Midnight and 5:00 PM.
- On 02/07/11, restraint use was not documented between 9:00 AM and 7:00 PM. "Skin Circulation Check" was documented at Midnight, but was not documented between 1:00 AM and 11:00 PM. "Food/Fluid Offered" was not documented between 6:00 AM and 5:00 PM, and between 6:00 PM and 11:00 PM. Assessment for "Food/Fluid Offered" was not documented between 7:00 AM and 5:00 PM. "Hygiene/Toileting Needs" was not documented between 7:00 AM and 7:00 PM.

Based on interview and record review, the facility failed to ensure staffing adequately met the needs of patients and provided safety to patients by failing to ensure patients were ready for scheduled therapy, by failing to answer call lights within an appropriate amount of time, and by failing to provide staffing according to the care needs of the patients in addition to the patient census. This had the potential to affect all patients in the facility. The facility census was 57.
Findings included:
1. During an interview on 02/08/11 at 8:56 AM, Patient #14 stated that he/she had missed three of his/her physical therapy appointments in one week because staff were not able to get him/her dressed in time. The patient stated that physical therapy is scheduled for 10:30 AM, and that staff would not get him/her dressed until 11:30 AM. Patient #14 stated that a physical therapist had to ask on all three occasions why the patient wasn't ready for therapy.
During an interview on 02/08/11 at 10:20 AM, Staff WW, PT (Physical Therapist) stated that if patients aren't ready for therapy (dressed) by the time they are scheduled, they may miss their therapy for the day.
During an interview on 02/08/11 at 10:40 AM, Staff EEE, PT Manager of the third and fourth floor stated that it can be difficult to get patients ready for PT, even though they try to schedule patients who require complete care as late in the morning as possible. Staff EEE stated that one RN (Registered Nurse) and one PCT (Patient Care Technician) may have three total care quadriplegics (patients that cannot move their arms or legs) assigned to them. Staff EEE stated that he/she has had some problems with specific patients not being ready for therapy. Staff EEE stated that Patient #14 (for example) wasn't ready for therapy two days in a row. Staff EEE spoke with Staff EE, Third Floor Manager, who changed the nursing assignments. The problem still did not improve, and Patient #14 missed another day of therapy because he/she was not ready at the scheduled therapy time. Staff EEE stated that Patient #14 missed a total of 9 out of the 15 hours he/she was scheduled for the week, because the patient was not dressed and ready for therapy.
During an interview on 02/10/11 at 10:50 AM, Staff II, RN (Registered Nurse) stated that he/she cannot get all of the patient cares done because he/she may be assigned five or six total care patients (requiring someone to feed, bath, toilet, and even physically move the patient as they cannot do it on their own) out of eight patients. Staff II stated that he/she has informed Staff EE , Third Floor Manager, that Staff II can't take care of the patients because of the patient assignment. Staff EE told Staff II, "We're staffing within the grid", but did not change the assignments or offer to bring in more staffing.

2. During various patient interviews, the following patients complained of significant delays in call light responses:
-02/07/11 at 3:10 PM, Patient #31 said that call light responses were too long and that he/she had to wait 35 minutes after putting on his/her call light and after his/her family went to request help from the nurses station.
-02/08/11 at 8:56 AM, Patient #14 said that when he/she would put his/her call light on because he/she was in pain, it would take an hour for staff to respond, especially in the evenings.
-02/08/11 at 2:10 PM, Patient #30 said that he/she had waited 15 to 30 minutes for staff to respond his/her call light.
-02/08/11 at 3:02 PM, Patient #34 said that call light responsiveness is "bad", that he/she has waited an hour, especially on evenings, for a response, and that one night, patient #34 put his call light on every 15 minutes for two and one-half hours without someone coming to the room.

During an interview on 02/10/11 at 12:50 PM, Staff JJ, RN stated that patients are not satisfied with their care because call lights are not answered. Staff JJ added that staff don't have time to answer the call lights because staff are taking care of seven to nine patients and he/she cannot take care of eight to nine patients and answer call lights.

3. Record review of a Post Fall Investigation Tool dated 12/13/10 showed that at 5:25 PM Patient #44 fell, that a OT (Occupational Therapist) placed the call light on for staff assistance, but no one came to help. The OT placed the call light on again and had to overhead paged staff to respond "stat" (immediately), before staff responded.
4. During an interview on 02/09/11 at 3:17 PM, Staff EE, Third Floor Manager stated that staffing is based on a grid (a system where that patient census determines the amount of staff working), not based on acuity (a system to determine the complexity of care for a patient).
During an interview on 02/10/11 at 10:50 AM, Staff II, RN (Registered Nurse) stated that something needed to be done about staffing and that they (the facility) need to staff more people. Staff II stated that on 02/09/11, he/she stayed four hours later than his/her scheduled shift to get all of his/her patient care and documentation done. Staff II stated that on 02/09/11 that five or six of his/her patients were total care (requiring someone to feed, bath, toilet, and even physically move the patient as they cannot do it on their own) out of eight patients he/she was assigned to care for. Staff II also stated that he/she only received a 15 minute lunch break during the day. Staff II stated that he/she told Staff EE that he/she was "overwhelmed", and Staff EE responded, "Yeah, I am too". Staff II stated that he/she again informed Staff EE that he/she couldn't get his/her patient's taken care of and Staff EE said, "We're staffing within the grid". Staff II stated that he/she usually has to stay one hour beyond his/her scheduled work time approximately 50 percent of the time and 30 minutes beyond his/her scheduled work time approximately 25 percent of the time, in order to get his/her work completed.
During an interview on 02/10/11 at 12:50 PM, Staff JJ, RN stated that he/she is usually assigned seven or eight patients, sometimes nine, and that he/she cannot take care of eight or nine patients safely.
During an interview on 02/10/11 at 10:50 AM, Staff II stated that when the fourth floor, a lower acuity floor (requiring less medical care) opened, the patients that were easier to care for moved off of the third floor. When this occurred, it allowed more total care patients to be admitted to the third floor, increasing the acuity (requiring more medical care) and increasing the work load. Staff II indicated that when this occurred, the staffing for the floor did not increase.

During an interview on 02/09/11 at 3:17 PM, Staff EE stated that they (the facility) were looking at updating the staffing grid because they did not adjust the grid when the facility opened the fourth floor approximately a year ago.

Based on observation, interview and record review the facility failed to follow their policy for assessment, measurement, prevention and documentation of pressure sores for three patients (#14, #22, #28) of three patients with pressure sores. The facility census was 57.

Findings included:

1. Record review of the facility's policy titled, "Skin Breakdown Management and Documentation" revised 04/09, showed the following direction:
-To provide guidelines for the prevention, assessment and treatment of wounds (pressure ulcers, shear/friction ulcers, diabetic arterial & venous ulcers, acute surgical wounds, burns, skin tears, and chronic wounds) by licensed nurse.
-Wounds will be measured and photographed on admission or at onset, weekly and within 24 hours of discharge.

2. Review of Patient #14's medical record showed he/she was admitted on 12/27/10 with diagnosis of functional impairments following a spinal cord injury. Record review showed:
-The patient was at risk for skin breakdown with a Braden score of 9 (Scores of 18 or less indicate the patient is at high risk).
-The Interdisciplinary Assessment (IDA) dated 12/27/10 showed skin breakdown of a Stage II (partial thickness skin loss and presents clinically as an abrasion, blister or shallow crater) pressure ulcer which was described as "dime size".
-The facility policy was not followed when the wound was not measured and photographed on admission as the facility policy dictated.
- There was no documentation of daily assessments of an existing pressure ulcer, which became an unstageable pressure ulcer due to slough (yellow or white tissue which covers the bed of a pressure ulcer) on 01/17/11.
- There was no documentation of turning and repositioning every two hours while in bed, and no documentation of adjusting position every 1? - 2 hours when up in the wheelchair..
-The patient complained of shoulder pain, but there was no documentation of skin assessment of this area until 01/27/11, when Stage II pressure ulcers were noted on both shoulders.
- Staff K, wound care nurse, documented assessment, measurement and photographs of the Stage II pressure ulcers on both shoulder on 01/27/11.
- Documentation on 02/4/11 showed these two pressure ulcers had progressed to unstageable ulcers.

3. Review of Patient #22's medical record showed he/she was admitted on 01/19/11 with a diagnosis of recent back surgery.
-Record review of the IDA (no date) page five of seven showed the patient was at risk for skin breakdown with a Braden score of 17 (Scores of 18 or less indicate the patient is at high risk). No areas of skin breakdown were documented on admission.
-The Interdisciplinary Daily Documentation (IDD) dated 01/20/11 showed documentation that the patient had a "reddened area" and noted that "cream" would be applied. The location of the reddened area was not identified.
-On 01/20/11 the IDD showed the patient had a small amount of breakdown at the sacrum with a protectant paste being applied.
-No Wound Addendum/Weekly Update form was completed, as facility policy dictated.
-No incident report was completed as facility policy dictated.
-The IDD assessments were inconsistent with the required documentation of location and description.
-Documentation of repositioning in the bed or in the wheelchair was identified on only six of 22 days during the period of 01/19/11 to 02/09/11.

During an interview on 02/15/11 at 10:00 AM, Staff KK, House Supervisor, stated that the expectation would be that nursing would assess and document a skin assessment on a patient daily, especially if the patient was at high risk for skin breakdown, and stated that the documentation for patient #14 did not reflect that daily assessment.


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4. Review of Patient #28's medical record showed he/she was admitted on 11/15/10, and then transferred to another facility due to abdominal distension, rule out obstruction. Patient #28 was readmitted on 11/16/10 with a diagnosis of spinal cord injury secondary to gunshot wound on 11/02/10.
Record review showed the following:
- Staff K, Wound Care Coordinator, measured and photographed 6 wounds present on admission for Patient #28 on the weekly wound documentation sheet. This was completed upon admission per policy on 11/16/10.

-No measurements, photographs or documentation of wounds by Staff K to document wound progress or decline for 12/10/10, 12/17/10, 12/28/10 and 01/04 as policy directs.

During an interview on 02/14/11 at 3:55 PM, Staff K, stated that only he/she takes skin/wound pictures. Staff K stated that he/she tries very hard to get the pictures taken weekly, but that he/she was busy and did not get them done. Staff K stated that additional cameras were in the pyxis (drug dispensing machine), but staff were not taking pictures of skin/wounds.

Based on record review and interview the facility staff failed to develop and/or update comprehensive individualized care plans with attainable goals for four (#7, #9, #10, #11, and #14) of five current patients, and one (#22) of one discharged patient. The facility census was 57.

Findings included:

1. Record review of the facility's policy titled, "Interdisciplinary Plan of Care" revised 05/08, showed the following:
-Each patient will have an individualized care plan based on patient care needs for improvement in functional deficits, neurological deficits, primary medical and co-morbid conditions, and special needs.
-Impairment, co-morbid conditions, and patient family goals will be completed upon admission and updated as necessary to develop, evaluate and update an ongoing plan of care.

2. Record review of Patient # 9's care plan showed the following:
-The standardized "Integumentary System" care plan was not individualized to include a physician order on 02/02/11 to apply Bacitracin (topical antibiotic) to abdominal wall twice a day.
- The "Brain Injury" care plan showed no evidence of a physician's order limiting visitors to two at a time secondary to extreme patient agitation, or reference to the seat belt ordered by the physician, and no reference to the custom helmet with chin strap ordered by the physician.

3. Record review of discharged Patient #22's care plan showed he/she was assessed as having a Stage I pressure sore (redness) on 01/20/11; progressing to a Stage II (a break in the skin). The care plan was not updated to reflect this change.

4. During an interview on 02/15/11 at 3:15 PM, Staff KK Registered Nurse, (RN) stated that the care plans are reviewed weekly by the care plan team and are supposed to be updated then. He/she stated that the nurses use the kardex (a paper based system which has medical information on it) which is kept at the nursing station to inform them of changes in the patients care and not the care plan.


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. Observation on 02/08/11 at 2:40 PM, showed Patient #11 with a C-Pap (Continuous positive airway pressure machine which is a ventilation device that blows a gentle stream of air into the nose during sleep to keep the airway open.) on his/her bedside table.

Review of Patient #11's History and Physical (H & P), and Post-Admission Physician Evaluation, dictated on 02/07/11 showed an admission diagnoses of Obstructive Sleep Apnea (a condition causing obstruction of the airway while a person is sleeping.)

Record review of Patient #11's care plan showed no documented plan of care for the C-Pap machine.

During an interview on 02/08/11 at 3:45 PM, Staff C, Chief Nursing Officer, stated that if the C-Pap was at the bedside then his/her expectation would be for staff to have a documented care plan in the medical record and he/she confirmed there was no plan of care documented for the C-Pap.

Based on observation, interview, record review, and policy review the facility failed to:
- Ensure medications were administered as ordered by the physician for eight (#12, #43, #7, #8, #44, #45, #14, and #19) of ten patients observed during medication administration;
- Ensure that medications were accurately documented on the Medication Administration Record (MAR) for four patients ( #12, #14, #18, and #19) out of ten patient MAR's reviewed.
- Ensure that medications were given via the correct route for one patient (#19) out of ten patients reviewed.
- Ensure that discrepancies in medication route were clarified with the physician and accurately transcribed onto the MAR for one patient (#19) out of ten patients reviewed.
- Document the reason medications were refused or held for one (#12) patient;
- Document the effectiveness of PRN (as needed) medications for one (#23) patient; and
- Complete an Incident Report for medication errors as directed by facility policy for two (#12 and #19) of two patients.

The facility census was 57.

Findings Included:

1. Record review of the facility's policy titled, "Medication Administration," reviewed 12/08, showed the following:
- Medication may not be left at the patient's bedside.
- Medications will be administered on time. Medications are considered to be on time when given as early as 30 minutes before or as late as 30 minutes after the time due. Medications administered outside of this one hour window are considered a variance.
- Documentation in the medical record:
- All entries must be signed and dated and include the actual time of administration.
- Refused or held medications shall be documented in the medical record as well as the reason for holding medication using appropriate codes.
- Medication Inadvertent Incident and Adverse Drug Reaction:
- In all cases of medication inadvertent incident, the following steps must be implemented:
- Complete documentation of event to include physician notification and any follow-up required.

Record review of the facility's policy titled, "Medication Administration Record," reviewed 12/08, showed the following:
- Nursing will review and correct each MAR prior to use.

Record review of the facility's policy titled, "Intravenous Therapy," revised 11/10, showed the following:
- PICC (Peripherally Inserted Central Catheter) line will be maintained by flushing with:
- 5 cc (cubic centimenter, a unit of measurement) normal saline (a sterile solution of salt water) and 2.5 cc heplock (a solution containing an anticoagulant) 100 units/1 cc every 12 hours and/or after each intermittent medication administration. Note: Flush Power PICCs with 10 cc normal saline.
- Document flushes on MAR.

Record review of the facility's policy titled, "Incident Report," reviewed 05/10, showed the following:
- Incident reports must be completed immediately following an event which meets the reporting definition.
- The incident report must be completed by the employee(s) who witnessed the event, who discovered the event, or who received the complaint.
- Choose the appropriate type of incident and check the box that applied. In completing, the following definitions must be utilized:
- Medication Variance - Document on the Medication Inadvertent Incident Report:
- Wrong Route - medication given by the wrong route.
- Wrong Time - dose given greater than 30 minutes before or after time ordered.

2. Observation on 02/08/11 at 3:05 PM, showed Staff H, Registered Nurse (RN), administered Calcium with Vitamin D 500 mg (milligrams)/200 IU (International Units) one tablet to Patient #12.

Review of Patient #12's Medication Administration Record (MAR), for 02/08/11, showed "Calcium/Vitamin D tab, 500 mg plus Vitamin D 200 IU, by mouth TID (three times a day), one tablet to be given with meals." The times listed for administration were 7:30 AM, 1200 Noon, and 5:00 PM. There were initials beside the 7:30 AM time that are identified as Staff H's initials. Staff H failed to document the Calcium given at 3:05 PM and the reason for not giving it at 12:00 noon.

During an interview on 02/08/11 at 4:05 PM, Staff C, Chief Nursing Officer, stated that the administration of the Calcium tablet was not correctly documented.



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3. Record review on 02/08/11 at 9:30 AM, of Patient #43's MAR (Medication Administration Record) showed that a medication (Ferrous Sulfate [Iron]) had not been given at 7:30 AM, as ordered by the physician.

During an interview on 02/08/11 at 9:35 AM, Staff E, RN (Registered Nurse) stated that the medication had not been given at 7:30 AM because he/she was too busy getting another patient off the bedpan and dressed by 8:00 AM for physical therapy.

4. Observation on 02/09/11 at 9:46 AM, showed Staff UU, RN removed medications from the Pyxis (an automated medication dispensing system) in preparation to administer the 9:00 AM medications.

During an interview on 02/09/11 at 9:50 AM, Staff TT, Nursing Manager, stated the 9:00 AM medications should be administered by 9:30 AM at the latest. He/she stated after speaking with the RN; this was the first of four patients who had not yet received their 9:00 AM medications. Staff TT stated that the RN when asked had not passed her medications yet because "There is a lot of crap going on".

Record review of Patient #7's MAR showed the RN documented the administration time as 10:00 AM for the medications which were ordered for 9:00 AM.

Further review at 10:05 AM of the MAR's for (Patient's #8, #44, #45) showed no documentation by the RN that the 9:00 AM medication had been given.




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5. Observation on 02/08/11 at 9:00 AM, showed Staff H, RN,(Registered Nurse) administered medications to Patient #14. During the medication administration, the nurse informed the patient that he/she would place the scheduled Lidocaine Patches (dressing that contains a numbing medication) on after the patient returned from a procedure that was to be done later that morning.

During an interview and observation on 02/08/11 at 9:05 AM, Patient #14's family member showed the surveyor the patient's right and left shoulder blade wounds. Attached to both shoulder blades was a wadded up Lidocaine patch that was not covering the patient's wounds. The patches were dated 02/06/11, indicating they had not been removed or replaced for 48 hours. The family said the patches on the shoulders had not been changed "for days".

Record review of Patient #14's MAR showed the following:
-Four of the 13 medications administered to the patient at 9:00 AM, were due at 7:30 AM,
and documented as administered at 7:30 AM. They were:
-Ferrous Sulfate (an iron supplement), 325 milligrams (mg) by mouth, with breakfast,
daily;
-Metformin (treatment for high blood sugar), 750 mg by mouth, with meals, two times a
day;
-Pioglitazone (controls blood sugar levels), 15 mg by mouth, with meals, two times a
day; and
-Motrin (reduces pain and or inflammation), 400 mg by mouth, three times a day, with
meals.
-Omeprazole (stomach acid reducer), 20 mg by mouth, ordered daily at 7:00 AM was
administered at 9:00 AM, but documented as administered at 7:00 AM.
-Lidocaine Patches, ordered to be placed on the right and left shoulder blade daily at 9:00
AM for 12 hours and then removed for 12 hours, were documented at 9:00 AM as placed
on the patient.

During an interview on 02/08/11 at 1:50 PM, Staff H, RN stated that he/she did not change the 7:00 AM and 7:30 AM administration times to reflect the 9:00 AM administration times because he/she became nervous while being observed during the medication pass. Staff H, RN stated that he/she documented the Lidocaine patch placement as administered because he/she was planning on placing it on the patient later in the day.



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6. Observation on 02/08/11 at 9:18 AM showed Staff S, RN administered Ceftriaxone (antibiotic) 1 gram per intravenous piggyback to Patient #18. Prior to administration, Staff S flushed Patient #18's PICC line with a prefilled syringe of normal saline obtained from the drawer of the bedside table.

Review of the MAR for Patient #18 showed that the normal saline used to flush Patient #18's PICC line was not listed, and was not documented as being given - as instructed by facility policy.

7. Observation on 02/08/11 at 9:30 AM showed Staff S, RN prepared to administer medications to Patient #19. Each medication was checked against the MAR, then all medications were crushed and mixed with water or juice. Staff S stated that patient #19 had a gastrostomy tube (G-tube - a tube surgically placed through the abdomen into the stomach for administration of nutrition, medications, and fluids) and all medications were administered through it. When the medications were prepared, Staff S entered patient #19's room and observed that the Physical Therapist was still working with the patient. Staff S stated that one of the difficulties of doing nursing care was that nurses had to "work around multiple therapies." When the Physical Therapist finished, Staff S administered Patient #19's medications ordered for 9:00 AM and completed administration at 9:50 AM.

Review of the medical record for patient #19 on 02/08/11 at 10:00 AM showed the following:
- A physician order dated 02/03/11 for Celexa (antidepressant) 20 mg PO (by mouth) daily.
- A physician order dated 02/04/11 to increase Protonix (used to treat gastroesophageal reflux disease) to 40 mg PO BID (twice daily).

Review of the MAR for patient #19 showed the following:
- All 9:00 AM medications were initiated by Staff S, indicating that they were administered at 9:00 AM rather than the actual time they were administered.
- The MAR indicated Celexa was to be given PO. However, the medication was crushed and included with other medications given through the G-tube. Review of all MARs in the medical record showed that the Celexa was marked as "PO daily" and each had been initialed, indicating they were administered by mouth.

During an interview on 02/08/11 at 10:30 AM, Staff S stated that the order for Celexa regarding route for administration "probably should have been clarified with the physician by either the pharmacist of nursing staff." Staff S stated that he/she did not notice that the route was ordered as PO for the Celexa.

8. During an interview on 02/10/11 at approximately 1:15 PM, Staff A stated that no incident reports had been turned in regarding late medications between 02/08/11 and 02/10/11, and no incident reports had been completed for administration of medications via the wrong route.

9. Review of the medical record for discharged Patient #23 showed the following:
- 12/23/10
- Review of the MAR showed the following pain medications were ordered:
- Acetaminophen (mild analgesic) 650 mg prn pain. The medication was issued at 9:30 AM.
- Percocet (narcotic analgesic) one tab PO Q six hours prn moderate pain. The patient received this medication at 1:15 PM and 10:30 PM.
- Review of the Daily Flowsheet/Treatment Record showed a section for documentation of pain scale, pain description, and reassessed pain scale after medication. There was nothing marked in this section for the entire day.
- Review of the nursing notes showed no documentation of pain, administration of pain medication, or assessment for effect of medication.

- 12/24/10
- Review of the MAR showed an order for Percocet one tab PO Q six hours prn moderate pain. The patient received this medication at 9:30 AM and 1:10 PM.
- Review of the Daily Flowsheet/Treatment Record showed a section for documentation of pain scale, pain description, and reassessed pain scale after medication. There was nothing marked in this section for the entire day.
- Review of the nursing notes showed no documentation of pain, administration of pain medication, or assessment for effect of medication.

- 12/25/10
- Review of the MAR showed an order for Percocet two tabs PO Q six hours prn severe pain. The patient received this medication at 10:18 AM and 9:20 PM.
- Review of the Daily Flowsheet/Treatment Record showed a section for documentation of pain scale, pain description, and reassessed pain scale after medication. There was nothing marked in this section for the entire day.
- Review of the nursing notes showed a note at 10:18 AM that the patient's pain was rated at seven on a scale of ten. There is no evidence that the patient's pain was re-evaluated after the pain medicine was given. A note at 9:20 PM showed that the patient's pain was rated at seven on a scale of ten. There is no evidence that the patient's pain was re-evaluated after the pain medicine was given.

- 12/26/10
- Review of the MAR showed an order for Percocet two tabs PO Q six hours prn severe pain. The patient received this medication at 4:00 PM.
- Review of the Daily Flowsheet/Treatment Record showed a section for documentation of pain scale, pain description, and reassessed pain scale after medication. There was nothing marked in this section at 4:00 PM.
- Review of the nursing notes showed no documentation of pain, administration of pain medication, or assessment for effect of medication related to the 4:00 PM Percocet.

- 12/27/10
- Review of the MAR showed an order for Percocet one tab PO Q six hours prn moderate pain. The patient received this medication at 9:00 AM (less than six hours after 6:15 AM dose) and 11:45 AM (less than six hours after 9:00 AM dose).
- Review of the MAR showed an order for Percocet two tabs PO Q six hours prn severe pain. The patient received this medication at 6:15 AM and 7:10 PM.
- Review of the Daily Flowsheet/Treatment Record showed a section for documentation of pain scale, pain description, and reassessed pain scale after medication. There was nothing marked in this section for the entire day.
- Review of the nursing notes showed no documentation of pain, no indication of why pain medication was given more frequently than ordered, administration of pain medication was not documented, and there was no evidence of assessment for effect of medication.

- 12/29/10
- Review of the MAR showed an order for Acetaminophen 650 mg prn. The medication was issued at 9:00 AM.
- Review of the MAR showed an order for Seroquel 12.5 mg HS prn. The medication was issued at 9:35 PM.
- Review of the Daily Flowsheet/Treatment Record showed a section for documentation of pain scale, pain description, and reassessed pain scale after medication. There was nothing marked in this section for the entire day.
- Review of the nursing notes showed documentation of G-tube pain 9:00 AM, but no indication of level of pain before or after administration of Acetaminophen. There is no documentation of agitated, administration of Seroquel, or the effect of the medication.

- 12/30/10
- Review of the MAR showed an order for Acetaminophen 650 mg prn. The medication was issued at 9:23 AM.
- Review of the Daily Flowsheet/Treatment Record showed a section for documentation of pain scale, pain description, and reassessed pain scale after medication. There was nothing marked in this section for the entire day.
- Review of the nursing notes showed documentation of G-tube tenderness 9:45 AM and notes Acetaminophen was administered. There is no indication of the level of pain before or after administration of Acetaminophen.