HospitalInspections.org

Based on document review, observation and interview, the registered nurses failed to ensure that policies and procedures were followed and patients were evaluated for 6 of 9 medical records (MR) reviewed. The facility failed to follow its staffing matrix and ensure adequate numbers of Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and other personnel were available to provide care to all patients for 3 of 9 medical records (MR) reviewed (patients # 2, 4 & 9) - (see tag A 392) and failed to supervise and evaluate the care of all patients and maintained documentation of routine skin assessments for bruising and breakdown for 5 of 10 medical records (MR) reviewed (Patients # 2, 4, 7, 8 & 9) - (see tag A 395) and the facility failed to follow its policies and procedures and ensure patient care plans were developed and maintained for 3 of 10 medical records (MR) reviewed (Patients # 1, 2 & 7) - (see tag A 396) and the Director of Nursing Service failed to ensure non-employee licensed nurses were oriented and compliant with the policies and procedures of the facility for 16 of 16 licensed agency staff (CS1, CS2, CS3, CS4, CS5, CS6, CS7, CS8, CS9, CS10, CS11, CS12, CS13, CS14, & CS15) - (see tag A 398).

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure that Nursing Services provided quality health care in a safe environment.

Based on document review and interview, the facility failed to follow its policy/procedures and ensure that all non-employee direct care staff maintained documentation of training in non-physical intervention skills for 15 of 15 direct care staff (CS1, CS2, CS3, CS4, CS5, CS6, CS7, CS8, CS9, CS10, CS11, CS12, CS13, CS14 & CS15).
Findings include:

1. Review of the policy/procedure Use of Temporary Agency Staff and Independent Contractors (revised 8-17) indicated the following: "Temporary agencies provide personnel to departments that have a need for help during periods when a department may be temporarily short-staffed...Temporary help, however, is expected to adhere to all hospital and departmental policies and procedures. The department to which the temporary employee is assigned is responsible for providing adequate orientation to the job and department, including...for caregivers, the environment of care..."

2. Review of the policy/procedure Staff Orientation and Training for Restraint and Seclusion (reviewed 2-17) indicated the following: "During orientation, direct care staff are assigned to attend non-physical intervention training (CPI) [Crisis Prevention Intervention]."

3. Review of the policy/procedure Crisis Prevention Intervention (reviewed 5-17) indicated the following: "The Nonviolent Crisis Intervention training program focuses on preventative techniques to avoid the use of restraint and seclusion by equipping staff with strategies to intervene through verbal and nonverbal means to create a respectful environment...Prevention and de-escalation are the primary focus of the Nonviolent Crisis Intervention training program...The Nonviolent Crisis Intervention training program instructs participants in recognizing when additional assistance is needed."

4. On 10-10-17 at 1035 hours, the Director of Nursing, staff A3 and the Director of Patient Relations, staff A7 were requested to provide documentation of training in non-physical intervention skills for the nursing staff (CS1, CS2, CS3, CS4, CS5, CS6, CS7, CS8, CS9, CS10, CS11, CS12, CS13, CS14 & CS15) identified on the Agency Staffing Sign In & Out Sheet for September, 2017 and no documentation was provided prior to exit.

5. On 10-11-17 at 1400 hours, the Director of Nursing, staff A3 and the Director of Patient Relations, staff A7 confirmed the facility lacked documentation of training in non-physical intervention skills for non-employee nursing staff currently providing direct patient care.

Based upon document review and interview, the facility failed to follow its staffing matrix and ensure adequate numbers of Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and other personnel were available to provide care to all patients for 3 of 9 medical records (MR) reviewed (patients # 2, 4 & 9).

Findings include:

1. Review of the initial staffing matrix (effective 2-17) provided in response to a request indicated the following: "Night Shift RN's: for a Patient Census of 17, 18, 19, and 20 patients, 3 RN's are indicated. For a Patient Census of 21 and 22 patients, 1 RN is indicated."

2. On interview on 10-10-17 at 1205 hours, the Director of Nursing, staff A3 indicated they began employment at the facility in May 2017 and had no explanation why the matrix dropped from 3 RNs with 20 patients to 1 RN with 21 or 22 patients.

3. On 10-10-17 at 1615 hours, the Director of Nursing, staff A3 provided a revised staffing Matrix with a footnoted date of 02/01/2017 in the lower left hand corner. The staffing matrix indicated 3 day shift RNs and 3 night shift RNs were indicated for a patient census from 17 to 22 patients and the Director of Nursing confirmed the revised staffing matrix was the proper one for use at the facility.

4. Review of the One Week Staffing Pattern Worksheet for September, 2017 provided by the Director of Nursing, staff A3 indicated the following:
a census of 22 patients from 9/3-13/17, 9-21, 9/23-25/17 and 9-29-17,
a census of 21 patients on 9/14-15/17, 9/19-20/17, 9-22-17 and 9-28-17,
a census of 20 patients on 9/16-18/17,
a census of 19 patients on 9/26-27/17,
and indicated the following:
14 day shifts were staffed with 1 RN (9-3, 9-4, 9-8, 9-9, 9-10, 9-12, 9-14, 9-15, 9-17, 9-22, 9-26, 9-27, 9-29 and 9-30),
12 day shifts were staffed with 2 RNs (9-5, 9-6, 9-7, 9-11, 9-13, 9-16, 9-18, 9-21, 9-23, 9-24, 9-25 and 9-28),
2 day shifts were staffed with 3 RNs (9-19 and 9-20),
and indicated the following:
6 night shifts were staffed with 1 RN (9-7, 9-8, 9-9, 9-12, 9-13 and 9-21),
15 night shifts were staffed with 2 RNs (9-4, 9-5, 9-6, 9-10, 9-11, 9-15, 9-16, 9-18, 9-19, 9-20, 9-23, 9-24, 9-26, 9-27 and 9-28),
6 night shifts were staffed with 3 RNs (9-3, 9-14, 9-22, 9-25, 9/29-30/17), and
1 night shift was staffed with 4 RNs (9-17).

5. On 10-10-17 at 1645 hours, the Director of Nursing, staff A3 confirmed the Nursing Daily Assessment forms (revised 9-17) for Patient #2 lacked documentation from 9-12-17 thru 9-17-17 indicating any new areas of bruising were identified in the boxed area for documenting the location of bruises prior to the 6 areas identified on the 9-17-17 Weekly Skin Assessment tool.

6. On 10-11-17 at 1440 hours, the Director of Nursing, staff A3 confirmed the Nursing Daily Assessment forms for Patient #4 lacked documentation from 9-6-14 to 9-13-17 indicating the bruising on the patient's left thigh present on the day of discharge 9-14-17 was previously identified during routine patient assessments by nursing staff.

7. On 10-11-17 at 1715 hours, the Director of Nursing, staff A3 confirmed the Nursing Daily Assessment forms for Patient #9 lacked documentation from 9-20-17 to 9-25-17 indicating the bruising on the patient's left thigh present on the day of discharge 9-26-17 was identified and monitored during routine patient assessments by nursing staff.

8. On 10-10-17 at 1605 hours, the Director of Nursing, staff A3 and the Corporate Director of Revenue, staff A6 confirmed the facility was consistently not staffing with the number of Registered Nurses in accordance with the staffing matrix for the day shifts and night shifts.

Based upon document review and interview, the Registered Nurse (RN) failed to supervise and evaluate the care of all patients and maintained documentation of routine skin assessments for bruising and breakdown for 5 of 10 medical records (MR) reviewed (Patients # 2, 4, 7, 8 & 9).

Findings include:

1. Review of the policy/procedure Nursing Assessments (reviewed 7-17) indicated the following: "Each patient's needs shall be assessed... and documentation completed within the first 24 hours upon admission by the RN...The assessment includes information regarding the...integumentary [skin]...[and]...daily reassessments will be completed each shift and PRN [as needed]. The licensed nurse will complete and document a patient-specific assessment."

2. Review of the policy/procedure Content of the Medical Record (reviewed 5-17) indicated the following: "...Reassessments are conducted at predetermined and regular intervals or whenever a change in the patient's condition requires his or her re-evaluation."

3. Review of the MR for Patient #2 on 9-12-17 indicated no skin breakdown or bruising was present on admission and review of the Nursing Daily Assessment forms from 9-12-17 thru 9-17-17 lacked documentation indicating any new areas of bruising were identified during patient assessments performed by the nursing staff N11, N12, N14, N15, N17, N18 and N19 in the boxed area for documenting the location of bruises on a simple line drawing of the front and back of a human with space to record a description of the tissue injury.

4. Review of the Weekly Skin Assessment form completed on 9-17-17 by the RN staff N14 indicated 6 previously unidentified areas of bruising were present on Patient #2 including the left arm (site unspecified), right elbow, left leg (site unspecified), left outer knee, left inner knee, and right upper thigh and documented with length and width measurements recorded in centimeters.

5. On 10-10-17 at 1645 hours, the Director of Nursing, staff A3 and the Director of Patient Relations, staff A7 confirmed the MR for Patient #2 lacked documentation indicating daily skin assessments conducted by nursing staff identified and/or periodically reassessed any areas of skin bruising prior to the 6 areas identified on the 9-17-17 Weekly Skin Assessment tool.

6. Review of the narrative entry for Patient #2 on 9-18-17 at 2038 hours by the RN staff N12 indicated a family member had called to express their concern about a bruised area observed on the patient's hand (left vs right hand not specified) and no additional skin assessment documentation indicated the area was identified and reassessed during the hospital stay.

7. On 10-10-17 at 1645 hours, the Director of Nursing, staff A3 and the Director of Patient Relations, staff A7 confirmed the MR for Patient #2 lacked additional documentation of bruising on the patient's hand or of multiple bruised areas on the patient's left shoulder photographed shortly after discharge.

8. Review of the Admission Skin Assessment for Patient #4 on 9-6-17 indicated only a minor amount of bruising was present in the inner elbow areas (and associated with blood specimen collection) and review of Nursing Daily Assessment forms from 9-7-17 thru 9-13-17 lacked documentation indicating any new areas of bruising were observed during routine patient assessments or personal care. The 9-14-17 Discharge Skin Assessment for Patient #4 indicated a 2.1 cm x 3.7 cm bruise was present on the patient's left lateral thigh and no other documentation indicated the area was identified during the hospital stay.

9. On 10-11-17 at 1440 hours, the Director of Nursing, staff A3 and the Director of Patient Relations, staff A7 confirmed the Nursing Daily Assessment forms for Patient #4 lacked documentation indicating the bruising on the patient's left thigh was identified prior to the day of discharge.

10. Review of the MR for Patient #7 on 9-11-17 indicated 4 areas of bruising were present on the patient's left hand, left forearm, right hand and right forearm and no other MR documentation including the Nursing Daily Assessments indicated the 4 bruised areas were routinely assessed and present or resolved prior to discharge on 9-15-17.

11. On 10-11-17 at 1655 hours, the Director of Nursing, staff A3 and the Director of Patient Relations, staff A7 confirmed the MR for Patient #7 lacked documentation indicating the areas of bruising present on admission were routinely assessed and present or resolved on the day of discharge.

12. Review of the MR for Patient #8 indicated an area of bruising was present on the patient's right forearm and lacked documentation indicating the right forearm bruise was periodically assessed and monitored. Review of the 9-25-17 Discharge Skin Assessment indicated a left forearm bruise was present and the MR lacked documentation indicating the right forearm bruise was present or resolved.

13. On 10-11-17 at 1655 hours, the Director of Nursing, staff A3 and the Director of Patient Relations, staff A7 confirmed the MR for Patient #8 lacked documentation indicating the right forearm bruising present on admission was present or resolved on the day of discharge.

14. Review of the 9-20-17 Admission Skin Assessment for Patient #9 indicated no skin breakdown or bruising was present and review of the Nursing Daily Assessment forms and shower sheets from 9-21-17 thru 9-25-17 lacked documentation indicating any new areas of bruising were observed during routine patient assessments or personal care. The 9-26-17 Discharge Skin Assessment for Patient #9 indicated a 1.2 cm x 3.0 cm bruise was present on the patient's left lateral thigh and no other documentation indicated the area was identified during the hospital stay.

15. On 10-11-17 at 1715 hours, the Director of Nursing, staff A3 and the Director of Patient Relations, staff A7 confirmed the Nursing Daily Assessment forms for Patient #9 lacked documentation indicating the bruising on the patient's left thigh was identified prior to the day of discharge.

Based upon document review and interview, the facility failed to follow its policy/procedures and ensure patient care plans were developed and maintained for 3 of 10 medical records (MR) reviewed (Patients # 1, 2 & 7).

Findings include:

1. Review of the policy/procedure Treatment Plan (revised 9-17) indicated the following: "Every patient shall have an individualized comprehensive Master Treatment Plan ... Within twenty-four (24) hours of admission, the Registered Nurse (RN) will initiate the treatment plan ... Within 72 hours of admission, members of the treatment team shall further develop the treatment plan ...The team will consist of the Physician, Licensed Independent Practitioners, the RN, Social Worker, Activity Therapist and other members, as appropriate. All members of the treatment team must sign the treatment plan ..."

2. Review of the treatment plan for Patient #1 lacked documentation indicating it was initiated and/or staffed by a RN within 24 hours of admission or during the initial team review on 9-7-17.

3. On 10-11-17 at 1425 hours, the Director of Nursing, staff A3 confirmed the MR for Patient #1 lacked documentation indicating the MTP was initiated and/or staffed by a Registered Nurse within 24 hours of admission or during the initial team review on 9-7-17.

4. Review of the treatment plan for Patient #2 lacked documentation indicating it was initiated and/or staffed by a RN within 24 hours of admission or during the initial team review conducted on 9-13-17.

5. On 10-10-17 at 1050 hours, the Director of Nursing, staff A3 confirmed the MR for Patient #2 lacked documentation indicating the Multidisciplinary Treatment Plan (MTP) was initiated and/or staffed by a Registered Nurse within 24 hours of admission or during the initial team review on 9-13-17.

6. The MR for Patient #2 indicated admission orders for seizure precautions and assault precautions and review of Patient #2's MTP failed to include seizures or aggressive/combative behaviors on the Problem List and lacked documentation indicating treatment plans for (a) seizures or for (b) aggressive/combative behaviors were developed for the patient including any specific interventions to be implemented for the protection of the patient and others on the unit.

7. On 10-10-17 at 1645 hours, the Director of Nursing, staff A3 and the Director of Patient Relations, staff A7 confirmed the MTP for Patient #2 lacked treatment plans for seizures or for aggressive/combative behaviors

8. Review of the treatment plan for Patient #7 lacked documentation indicating a RN initiated or staffed the initial treatment plan within 24 hours of admission or during the initial team review on 9-12-17.

9. On 10-11-17 at 1635 hours, the Director of Nursing, staff A3 confirmed the MR for Patient #7 lacked documentation indicating the MTP was initiated and/or staffed by a Registered Nurse within 24 hours of admission or during the initial team review on 9-12-17.

Based upon document review and interview, the Director of Nursing Service failed to ensure non-employee licensed nurses were oriented and compliant with the policies and procedures of the facility for 15 of 15 licensed agency staff (CS1, CS2, CS3, CS4, CS5, CS6, CS7, CS8, CS9, CS10, CS11, CS12, CS13, CS14 & CS15).

Findings include:

1. Review of the policy/procedure Use of Temporary Agency Staff and Independent Contractors (revised 8-17) indicated the following: "Temporary agencies provide personnel to departments that have a need for help during periods when a department may be temporarily short-staffed ... Temporary help, however, is expected to adhere to all hospital and departmental policies and procedures. The department to which the temporary employee is assigned is responsible for providing adequate orientation to the job and department, including...for caregivers, the environment of care..."

2. Review of the policy/procedure Recognizing and Reporting Suspected Abuse/Neglect/Exploitation (reviewed 8-17) indicated the following: "The hospital will provide in-service training annually, designed to assist employees and healthcare providers associated with the hospital in identifying patient abuse and neglect ..."

3. Review of the policy/procedure Incident Reports (revised 3-17) indicated the following: "An incident report should be completed immediately when an incident occurs...The following are some instances when an Incident report would be completed: ...all injuries..."

4. On 10-10-17 at 1035 hours, the Director of Nursing, staff A3 and the Director of Patient Relations, staff A7 were requested to provide documentation of facility and policy/procedure orientation for the nursing staff (CS1, CS2, CS3, CS4, CS5, CS6, CS7, CS8, CS9, CS10, CS11, CS12, CS13, CS14 & CS15) identified on the Agency Staffing Sign In & Out Sheet for September, 2017 and no documentation was provided prior to exit.

5. On 10-11-17 at 1400 hours, the Director of Nursing, staff A3 and the Director of Patient Relations, staff A7 confirmed the facility lacked documentation of department-specific orientation for non-employee nursing staff currently providing direct patient care and confirmed the facility failed to provide a means for the agency nursing staff to access the policies and procedures in use at the facility.