HospitalInspections.org

Based on record review and interview the staff failed to document and evaluate patients needs by failing to complete nursing assessments in 10 of 10 patient's medical records (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9 and #10), failing to document and evaluate certified nursing assistant assignments in 10 of 10 medical records (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9 and #10), and failing to assess patients for falls according to their policy and procedures in 5 of 10 patients assessed for falls (Patient #2, #3, #5, #7 & #10) in a total of 10 medical records reviewed.

Findings include:

Record review of policy titled "Patient Admission Assessment" #7.010, last review date 1/2021 under procedure revealed "The following forms within the Electronic Medical Record (EMR)... are required to be documented within 24 hours of admission: *Nursing Admit History & Assessment * Fall Risk Assessment." Under #9 " A nursing assessment is performed each shift."

Record review of policy titled "Fall Reduction Program and Post Fall Procedures" #7.070 last reviewed 7/2020 Purpose: "to identify intrinsic and extrinsic fall risk factors and reduce the frequency and severity of falls, identify patients at risk and provide a safe environment for the delivery of healthcare." Under required process revealed "Nursing will assess patients, using the Morse Fall Scale: Within 8 hours of admission... If a patient falls... Assessment score will be documented in the patient's chart." Under procedure revealed "nursing evaluates fall risk."

Record review of Fall Incident Report on Patient #1 dated 2/22/2021 indicated Patient #1 had a fall at 4:15 PM.

Record review of Fall Incident Reports on Patient #10 revealed 5 falls during his/her hospitalization 4/06/2021 through 5/08/2021 occurring 4/09/2021, 4/15/2021, 4/16/2021, 4/26/2021 and 4/30/2021.

Patient #1's closed medical record was reviewed and revealed Patient #1 was a 27-year-old with a history of uncontrolled hypertension (high blood pressure) admitted 1/05/2021 with the admitting diagnoses of cardiovascular accident (stroke), hypertension, left hemiplegia (paralysis) and depression, for continued rehabilitation, and discharged 2/26/2021. Reviewed nursing shift assessments and certified nursing assistant (CNA) assignments 2/20/2021 through 2/25/2021. There were no nursing shift assessments documented from 7:00 PM to 7:00 AM on 2/20/21, 2/23/2021 and 2/25/2021. There were no CNA assignments documented 7:00 PM to 7:00 AM on 2/21/2021, 2/22/2021, 2/23/2021, 2/24/2021 and 2/25/2021. 8 of 24 nursing shift assessments or CNA assignments were not documented in 7 inpatient days reviewed.

Patient #2's open medical record was reviewed and revealed Patient #2 is a 71-year-old with a history of parapelegia (paralysis of the lower legs) and a chronic right ischial (lower back part of the hip) wound stage IV (wound with exposed bone, tendon, or muscle) admitted 5/05/2021 for transition to a regular wound VAC (vacuum assisted closure) and IV (intravenous) antibiotics every 6 hours. Reviewed nursing shift assessments and CNA assignments 5/05/2021 thru 5/11/2021. There was no nursing shift assessment documented 7:00 PM to 7:00 AM on 5/11/2021. There were no CNA assignments documented 7:00 PM to 7:00 AM on 5/06/2021, 5/08/2021, 5/10/2021 or 7:00 AM to 7:00 PM on 5/11/2021. 6 of 28 nursing shift assessments or CNA assignments were not documented in 7 inpatient days reviewed. There was no Morse Fall Scale nursing assessment documented on admission 5/05/2021, per the facilities fall prevention policy. .

Patient #3's open medical record was reviewed and revealed patient #3 is a 69-year-old male with a history of IV drug use, chronic wounds sacrum (bottom back of the spine) and arms bilaterally with protein malnutrition, and hypertension, admitted 3/11/2021 for rehabilitation and IV antibiotics. Reviewed nursing shift assessments and CNA assignments 4/30/2021 thru 5/06/2021. There were no nursing shift assessments documented 7:00 AM to 7:00 PM 4/30/2021, 5/02/2021 or 7:00 PM to 7:00 AM 5/05/2021. There were no CNA assignments documented 7:00 PM to 7:00 AM on 4/30/2021, 5/01/2021, 5/02/2021 and 5/03/2021. 7 of 28 nursing shift assessments or CNA assignments were not documented in 7 inpatient days reviewed. There was no Morse Fall Scale nursing assessment documented on admission 3/11/2021, per the facilities fall prevention policy.

Patient #4's closed medical record was reviewed and revealed Patient #4 was a 41-year-old female with a history of a middle cerebral artery ischemic infarct (stroke) with a percutaneous endoscopic gastrostomy (PEG) (feeding) tube, tracheostomy (breathing tube), with left hemiplegia (paralysis of one side of the body) admitted 1/20/2021 for IV antibiotics and rehabilitation. Reviewed nursing shift assessments and CNA assignments 2/17/2021 thru 2/20/2021. There was no nursing assessment documented 7:00 PM to 7:00 AM on 2/19/2021. There were no CNA assignments documented for 7:00 PM to 7:00 AM 2/17/2021, 2/18/2021 and 7:00 AM to 7:00 PM 2/20/2021. 4 of 16 nursing shift assessments or CNA assignments were not documented in 4 inpatient days reviewed.

Patient #5's inpatient medical record was reviewed and revealed Patient #5 is a 59-year-old with a history of chronic heart failure on oxygen at baseline, diabetes, chronic kidney disease stage III, and hypertension with a diabetic foot ulcer and was admitted 4/22/2021 for IV antibiotics. Reviewed nursing shift assessments and CNA assignments 4/30/2021 thru 5/08/2021. There were no nursing shift assessments documented 7:00 PM to 7:00 AM 4/30/2021, 5/01/2021 and 5/02/2021 and 7:00 AM to 7:00 PM on 4/30/2021. There were no CNA assignments documented 7:00 AM to 7:00 PM on 5/05/2021, 5/06/2021 and 7:00 PM to 7:00 AM on 5/06/2021, 5/07/2021 and 5/08/2021. 9 of 36 nursing shift assessments or CNA assignments were not documented in 9 inpatient days reviewed. There was no Morse Fall Scale nursing assessment documented on admission 4/22/2021.

Patient #6's closed medical record was reviewed and revealed Patient #6 was a 58-year-old with a medical history of diabetes mellitus, hypertension, chronic lymphedema (swelling in the lymph nodes) and necrotizing fasciitis (infection) left foot admitted 4/05/2021 for wound care and IV antibiotics and discharged 4/23/2021. Reviewed nursing shift assessments and CNA assignments 4/16/2021 thru 4/20/2021. There was no nursing shift assessment documented 7:00 PM to 7:00 AM on 4/16/2021, 4/17/2021, 4/18/2021 and 7:00 AM to 7:00 PM on 4/19/2021 and 4/20/2021. There were no CNA assignments documented 7:00 AM to 7:00 PM on 4/19/2021 and 7:00 PM to 7:00 AM on 4/16/2021, 4/17/2021, 4/18/2021. 9 of 20 nursing shift assessments or CNA assignments were not documented in 5 inpatient days reviewed.

Patient #7's closed medical record was reviewed and revealed Patient #7 was a 59-year-old with a history of hypertension (high blood pressure), diabetes, and gangrenous (infected) diabetic foot infections admitted 4/01/2021 for wound care and IV antibiotics discharged 4/27/2021. Reviewed nursing shift assessments and CNA assignments 4/02/2021 thru 4/04/2021. There was no nursing shift assessment documented 7:00 AM to 7:00 PM on 4/03/2021. There were no CNA assignments documented 7:00 AM to 7:00 PM 4/02/2021 or 7:00 PM to 7:00 AM 4/02/2021, 4/03/2021 or 4/04/2021. 5 of 12 nursing shift assessments or CNA assignments were not documented in 3 inpatient days reviewed. There was no Morse Fall Scale nursing assessment documented on admission 4/01/2021.

Patient #8's closed medical record was reviewed and revealed Patient #8 was a 49-year-old with a history of cardiovascular accident (CVA) and a diagnosis of encephalopathy (brain damage) and chronic kidney disease admitted 2/04/2021 for rehabilitation and discharged 3/25/2021. Reviewed nursing shift assessments and CNA assignments 2/14/2021 thru 2/22/2021. There were no nursing shift assessments documented from 7 PM to 7:00 AM on 2/19/2021 and 2/22/2021. There were no CNA assignments from 7:00 AM to 7:00 PM on 2/14/2021, 2/19/2021, 2/20/2021, 2/21/2021 and 7:00 PM to 7:00 AM on 2/16/2021, 2/18/2021, 2/19/2021, and 2/21/2021. 10 of 36 nursing shift assessments or CNA assignments were not documented in 9 inpatient days reviewed.

Patient # 9's closed medical record was reviewed and revealed Patient #9 was a 65-year-old with a history of parafalcine hemangioma (brain tumor) and hydrocephalus (water on the brain) requiring a ventriculoperitoneal (VP) shunt (relieves pressure on the brain) and a history of perforated diverticulitis (rupture of the intestines) requiring a colostomy (hole in the abdomen to pass stool), was admitted 4/12/2021 for rehabilitation, and discharged 4/22/2021. Reviewed nurse shift assessments and CNA assignments 4/18/2021 through 4/21/2021. There was no nursing assessment documented 4/18/2021 7:00 PM to 7:00 AM and no CNA assignments documented 4/20/2021 and 4/21/2021 7:00 PM to 7:00 AM. 3 of 16 nursing shift assessments or CNA assignments were not documented in 4 inpatient days reviewed.

Patient # 10's closed medical record was reviewed and revealed Patient #10 was a 62-year-old with a history of cerebrovascular infarction (stroke) admitted 4/06/2021 for rehabilitation and discharged 5/08/2021. Reviewed nurse assessments and CNA assignments 4/26/2021 through 5/03/2021. There were no nursing shift assessments 4/26/2021, 4/29/2021 5/02/2021 and 5/04/2021 7:00 PM to 7:00 AM and 5/01/2021 and 5/03/2021 7:00 AM to 7:00 PM and no CNA assignments documented 4/28/2020, 4/30/2021 and 5/02/2021 7:00 PM to 7:00 AM and 4/29/2021 7:00 AM to 7:00 PM. 10 of 32 nursing shift assessments or CNA assignments were not documented in 8 inpatient days reviewed. There was no Morse Fall Scale nursing assessment documented on admission 4/22/2021. There were no Morse fall nursing assessment scores documented, per the facility's fall policy, on 4/26/2021, 4/28/2021, 4/29/2021, 5/01/2021, 5/02/2021, 5/03/2021 or 5/04/202.

On 5/11/2021 at 5:30 PM during interview with CNO C, when asked C how often the Morse Falls Risk Assessment is done, C stated "The assessment gets done within the 8 hour time frame after admission. If there is fall risk or a documented fall, this gets done daily by the nursing staff."

On 5/12/2021 at 11:06 AM during interview with CNO C and Compliance Director B, CNO C stated each 12 hour shift the nurse is required to complete a patient assessment and the CNA is required to complete an assignment review in the electronic medical record. CNO C stated there is no policy or procedure for what a nursing assessment or CNA assignment consists of or what needs to be documented in the electronic medical record. CNO C and Director B confirmed the electronic documentation was missing nurse shift assessments and CNA assignments. Director B stated "we need to do some chart audits."

On 5/12/2021 at 8:39 PM during telephone interview with Registered Nurse (RN) M, RN M stated you can set automatic time, date stamps in the electronic medical record, charting of assessments is usually done at the end of the shift or mid shift, and the events are not time stamped unless you pull in a time stamp into the system verifying when it was completed.

On 5/12/2021 at 9:10 PM during telephone interview with CNA W, CNA W stated charting is done after you do the patient cares, and stated it is "hard to understand what they want from you."

On 5/12/2021 at 8:39 PM during telephone interview with Registered Nurse (RN) M, RN M stated you can set automatic time, date stamps in the electronic medical record, charting of assessments is usually done at the end of the shift or mid shift, and the events are not time stamped unless you pull in a time stamp into the system verifying when it was completed.

On 5/13/2021 at 9:10 AM during interview, CNO C stated it is the responsibility of the nurse to complete the nursing assessments each shift and confirmed the Adult Fall Risk, which includes the Morse score, was not documented daily after Patient #1 and #10's falls. CNO C confirmed if the requested copies of the nursing shift assessments and CNA assignments were not provided, they were not documented in the electronic medical record.






43264

Based on record review and interview, the facility failed to mitigate risks associated with COVID-19 in all patients receiving care and staff providing care at their facility by failing to maintain the use of goggles or face shields when exposed face to face with patients during patient care with a total census of 26 on 5/10/2021, 26 on 5/11/2021, and 24 on 5/12/2021.

Findings include:

Review of the Center for Disease Control (CDC) infection prevention and control guidance at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html on 5/13/2021, eye protection is required during patient care encounters in facilities located in areas with moderate to substantial transmission of SARS-CoV-2.

Review of the CDC COVID-19 Data Tracker at https://covid.cdc.gov/covid-data-tracker/#county-view on 5/15/2021, revealed all Wisconsin counties are experiencing moderate to high levels of community transmission of COVID-19 virus.

Review of facility personal protective equipment signage "recommended by the Centers for Disease Control" revealed under #4 "eye protection" is recommended before entering the room.

On 5/13/2021 at 9:10 during interview with Chief Operating Officer (COO) D, COO D stated the facility practice is for all staff and patients to wear masks, they removed the requirement for goggles or face shields during patient encounters May 1, 2021 stating "we do the best we can with this patient population."