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Based on patient and staff interview and record review the facility failed to ensure interventions were provided in accordance with the patients' plans of care. (A396) The cumulative effect of these practices resulted in a risk to the health and safety of all facility patients. The facility census was 46.

Based on record review and staff interview, the facility failed to document an investigation for injuries of unknown origin for one patient (Patient #3) of 10 medical records reviewed. This had the potential to affect all of the facility's 46 patients.

Findings include:

Review of the facility's policy and procedure titled, Risk Management, Significant Patient Injury Unanticipated Outcomes with a most recent revision date of 01/01/2020 directed the purpose of the policy was to provide a mechanism whereby a significant patient injury (unanticipated outcome) was identified and addressed in an efficient and effective manner. These additional procedures are required for significant patient events,
injuries, and/or unanticipated outcomes. The Clinical Supervisor was responsible for notifying the patient's physician, ensuring an incident report is completed by the end of the shift by the employee witnessing the event, and ensuring medical record is accurate and complete.

Review of the medical record revealed Patient #3 was admitted to the facility on 08/28/2020 with diagnoses including coronary artery disease with recent history of coronary bypass graft for four vessels repair, history of respiratory failure with mechanical ventilation, further complicated by the need for hemodialysis treatment and severe protein malnutrition.

Review of the medical record documented the patient was admitted to the facility with history of three areas of wounds on admission: an unstageable pressure wound to the sacrum (triangular area on lower back near the cleft of the buttocks), a healing surgical wound in the left groin, and a healing left lower leg wound.

Medical Staff B assessed Patient #3 on 09/01/2020 and 09/10/2020 and documented the status of the three wounds present on admission.

The medical record revealed on 09/16/2020 at 4:57 PM Staff D took and scanned a color photograph into Patient #3's medical record which captured the patient's left forearm with a large skin tear along with the wound measurements. The photograph captured a beefy red wound with serosanguinous (blood and fluid) drainage that measured 10.5 centimeters long and 5.0 centimeters wide (approximately four inches long and about two inches wide).

Review of Physician Staff B's Surgical Progress Note dated 09/17/2020 at 5:00 PM documented Patient #3 had developed a large skin tear over the left dorsal forearm (top of left forearm) that the wound nurse had discussed with Staff B. Staff B documented the left dorsal forearm wound was measurements as 10.5 centimeters (cm) length (about 4 inches long) by 5 cm width (2 inches wide) with full thickness loss of epidermis (outer most layer of skin) and dermis (this is the thickest layer of skin underneath the epidermis comprised of thick and elastic tissue).

Review of the nursing documentation between 09/16/20 at 4:57 PM until 09/17/2020 at 5:00 PM failed to contain any documentation of Patient #3's large skin tear or what caused this injury.

On 09/23/2020 at 4:14 PM Staff D again took and scanned a color photograph into Patient #3's medical record which now captured a second large skin tear to the Patient #3's right forearm. The photograph captured a beefy red wound with serosanguinous (blood and fluid) drainage that measured 7.0 centimeters long by 5.5 centimeters wide (approximately three inches long and two inches wide).

Again there was no nursing assessment or nursing notes, or documentation between 09/16/20 at and 09/23/2020 at 4:14 PM when the wound nurse completed her weekly assessment.

Interview with Staff Physician Staff B on 12/03/2020 at 8:54 AM believed the Patient #3's left forearm skin tear occurred sometime on the evening or night of 09/16/2020. The facility failed to notify the physician of this injury. Staff B verbalized that she wanted to be notified of these type of injuries as she can often manipulate the skin back into position when it is a fresh wound which leads to faster healing for the patient. Staff B verbalized by the time she saw the wound the outer layer of skin was already crinkled up and dried out. I remember the patient's family member came to visit on 09/20/2020 and wanted to know what happened which I could not answer. Staff B verbalized , a few days later, the Patient #3 incurred another large skin tear to the right dorsal forearm and again I was not notified.

Interview with Staff D on 12/02/2020 at 1:31 PM revealed she confirmed the photograph of the Patient #3's left forearm wound was taken on 09/16/2020 at 4:57 PM. Staff D confirmed there was no documentation in the medical record regarding this injury of unknown origin until 09/17/2020 at 5:00 PM by the surgical physician. Staff D again confirmed the presence of a large right forearm skin tear on 09/23/2020 at 4:14 PM during her weekly skin assessment. Staff D was unable to provide nursing documentation of an injury of unknown origin or events surrounding this second injury.

Interview with Administrative Staff E on 12/02/2020 at 1:41 PM confirmed the facility was unable to provide any nursing assessment or nursing documentation of these injures to Patient #3, documentation the shift nursing supervisor was notified or that the physician was notified or that an incident or accident report was completed per the facility policy and procedure.

This deficiency substantiates Substantial Allegation OH00117031.

Based on patient and staff interview and record review the facility failed to ensure interventions were provided in accordance with the patients' plans of care. This finding affected two of ten patients (Patient #3 and Patient #6) whose medical records were reviewed for nursing services adherence to the plan of care. A total of 10 medical records were reviewed. The facility census was 46.

Findings include:

Facility policy Clinical Guidelines and Protocols (revised 10/01/20) was reviewed. Per policy, "To ensure quality patient care, certain standards of care must be upheld." The policy specified "the minimum frequency with which these tasks must be performed to maintain quality care", including weight, turning, pain assessment, and vital signs.

Patient weight, on the same scale, was to be obtained every week. For patients on dialysis, a weight was to be obtained pre and post treatment.

The policy also specified bedfast patients be turned every two hours with position (left side, supine, semi-fowler, etc.) documented.

1. Patient #6 was admitted to the facility 10/07/20 with a diagnosis of impaired wound healing. Patient #6's medical history included End Stage Renal Disease, HIV, colostomy, bilateral lower extremity flaccid paralysis, and bilateral upper extremity spasticity. Patient #6 was identified as "bedfast."

During interview with Patient #6 on 12/08/20 at 9:30 AM he reported being unable to reposition himself. Patient #6 stated he was paralyzed from the waist down with little upper body strength and control. Patient #6 explained that he experiences uncontrollable muscle spasms which sometimes leave his legs in awkward and uncomfortable positions. Patient #6 reported difficulty using the call bell, and that sometimes staff don't check on him/her for three or four hours.

On 10/08/20 a nutritional assessment was completed, which revealed Patient #6 was 72 inches tall (6 feet) and weighed 63.3 kilograms (kg) or 139 pounds, 8 ounces. Improved nutritional status was identified as a goal on Patient #6's Multidisciplinary Care Plan. Members of the interdisciplinary team were to "monitor and assess patient for malnutrition. Monitor patient's weight and dietary intake as ordered or per policy. Utilize nutrition screening tool and intervene per policy."

On 10/15/20 the RD (registered dietician) documented Patient #6's weight was 64 kg. The RD also noted the bed scale was not working. There was no documented evidence of the method by which the weight was obtained (bed scale, hoyer lift, etc.) or by whom. There was also no documented evidence the RD addressed the broken scale. As of 12/07/20 the bed scale was still not working. There was no documented evidence staff had weighed Patient #6 since admission.

Patient #6 received hemodialysis treatment three days a week during his hospitalization. Review of the treatment records for the period 10/25/20 - 11/28/20 revealed no weights were obtained. Dialysis staff repeatedly documented "unable to obtain: scale broken" and "unable to obtain: floor to weigh." There was no documented evidence dialysis staff addressed the broken scale or attempted to obtain Patient #6's weight by other means.

Review of facility Flowsheet Data from admission to 12/01/20, including rounds/safety/alarms, revealed Patient #6 was not turned every two hours and position was not always documented. Documentation revealed Patient #6 sometimes remained in the same position for more than two hours before being repositioned

Between 10/07/20 and 11/02/20 Patient #6 acquired two pressure injuries. A Stage 2 left ischial tuberosity wound measuring 7 inches long by 3.5 inches wide, and an unstageable, necrotic right ischial tuberosity wound measuring 6 inches long by 7.5 inches wide.

On 11/09/20 a Surgical Progress Note revealed Staff B became aware Patient #6 had developed two pressure injuries while in the facility, one on his left ischial tuberosity and one on his right ischial tuberosity. According to Staff B, he/she was "concerned about newly developed wounds over bilateral ischium and scrotum. Discussed with CNO and charge nurse that patient has developed new wounds while on Dolphin mattress and suggested to get WAVE mattress and also importance of turning the patient side to side every 2 hours that should be implemented by nursing personnel."

On 12/07/20 at 3:11 PM Staff A confirmed the bed Patient #6 was in (for the past 61 days) did not have a functioning scale, and a work order to have it repaired was not generated until today. Staff A also confirmed, per policy, Patient #6 should have been weighed before and after dialysis treatment but was not. In accordance with policy, facility staff also should have weighed Patient #6 once a week.

Staff C, dietician was interviewed on 12/08/20 between 12:00 PM and 12:55 PM. Staff C explained that Patient #6 was seen and evaluated by a dietician at least weekly. Staff C was asked if she was aware Patient #6's bed scale was broken and replied yes. Staff C was asked what she did with that information and replied she would have told the charge nurse. Staff C confirmed there was no documented evidence of this. Staff C also confirmed she did not share the lack of weights or broken bed scale during facility morning huddles.


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Review of the facility's policy, titled pain management, assessment and intervention protocol with a most recent revision date of 10/01/2020 directed: The Hospital will develop a comprehensive approach to safe pain management focusing on the following areas: assessment, patient centered plan of care, patient monitoring, patient/family education, provider resources, opiate stewardship, and performance improvement.
The following basic principles comprise the pain management approach:
1 Please add any state specific policy requirements as an addendum to this policy such as Prescription Drug Monitoring Program queries during stay etc.
2. The following standard will be utilized on all patients. Patients at Hospital will be either without pain or experience pain that is managed effectively according to their reported pain goal.
3. The institution supports the patient's right to the highest level of pain relief that can be realistically and safely provided.

2. Review of the medical record revealed Patient #3 was admitted to the facility on 08/28/2020 with diagnoses including coronary artery disease with recent history of coronary bypass graft for four vessels repair, history of respiratory failure with mechanical ventilation, further complicated by the need for hemodialysis treatment and severe protein malnutrition. The documentation revealed Patient #3 had a history during her hospital stay of chronic pain to the hips and buttocks area.

Patient #3's plan of care prepared at time of admission documented the patient had a plan of care for the management of pain since admission as well as medications for management of mild, moderate and sever pain and directed staff to assess and re-assess for the management of pain and interventions. The physician ordered Acetaminophen 650 milligrams (mg) via tube every four hours as needed for mild pain of 1-3 on the pain scale (scale 0 -10, 10 most severe). The physician placed an order on 09/03/2020 for hydrocodone/acetaminophen 5 mg/325 mg (NORCO) every six hours as needed for moderate pain of 4-6 and severe pain of 7-10 and on 09/05/2020 orders for hydrocodone/acetaminophen 5 mg/325 mg (NORCO) every four hours as needed for moderate pain of 4-6 and severe pain of 7-10.

Review of the Medication Administration Record pharmacy audit dated 09/08/2020 at 4:42 PM revealed Patient #3 complained of pain of 6 out of 10, facility documentation revealed Patient #3 was administered Acetaminophen instead of the ordered NORCO for moderate pain. The facility was unable to provide documentation of a re-assessment and response to the medication within 30-60 minutes post administration. Review of the MARS pharmacy audit on 10/02/2020 revealed Patient #3 complained of pain of 6 out of 10 and again was ordered acetaminophen instead of NORCO for moderate pain, again there was no re-assessment of the effectiveness of the intervention. The medical record documented Patient #3 complained of pain on 09/17/2020 at 9:16 AM as 10 out of 10 to dialysis Nurse F. The facility was unable to provide documentation the patient was medicated for severe pain. Again on 09/17/2020 at 1:06 PM Staff F documented Patient #3 was assessed with severe pain rated as 7/10 (0 - 10 pain scale, 10 is most severe). Review of the Medication Administration pharmacy audit revealed there was no pharmacological pain medication administered again for this severe pain.

These findings were confirmed in interview with Staff C on 12/07/2020 at 9:59 AM.

This deficiency substantiates Substantial Allegation OH00117031.