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Based on observation, interviw and record review the facility failed follow grievance procedures [see A-122], failed to promote methods to allow patients and/or patient representatives to make informed decisions about care [see A131], failed to promote a safe setting for patients [see A144] and failed to promote patient confidentiality [see A146].

Based on observation, interview, and record review, it was determined that the facility failed to ensure that appropriate nursing services were provided for patient skin/would care [see tag A-0395].

Based on interview and record review the facility failed to follow policy and respond to patient grievances in a timely manner for 2 (#12 and # 21) of 3 records reviewed. Findings include:

On 4/5/10 at approximately 1400, facility policy #C06-A, titled "Complaint and Grievance Process" was reviewed. Page 2, #7, states: "The investigative procedure should be completed, corrective action taken and a written response sent within 7 days of receipt of complaint." A facility nurse completed a Complaint/Grievance form for patient #12 on 3/1/10. On 4/5/10 the Director of Quality Management verified that there was no documentation that a response letter in the file, dated 3/18/10, had been sent. Patient #21's complaint form was completed on 2/3/10. A response letter dated 3/18/10 was sent on 3/26/10 per facility documentation. On 4/5/10 at approximately 2:00 p.m. the Director of Quality Management verified these findings.

Based on interview and record review the facility failed to ensure that the patient or his or her representative are being informed of his or her health status, and being involved in care planning and treatment. Findings include:

On 4/5/10 at 1250 an interview with patient #4's daughter and significant other took place. When the representatives were queried about the care the patient was receiving and about the care plan the daughter of the patient stated "we are concerned and questioned them about why my mother can't have something to eat. She is on TPN, but can't she have some chicken broth? We want to take her home but they (meaning staff) keep talking about putting her in a nursing home. We have been through this before and want to take her home, we can take care of her. We are also concerned about the insurance paying for her TPN." When asked if they have talked and questioned health care staff, the daughter of the patient responded by stating "they don't tell us why".

On 4/6/10 at approximately 0900 while reviewing the chart of a complaint (patient #12) due to a statement made by the complainant read "I have asked patient #12's nurses if patient #12 has any other wounds other than the wound on her right inner thigh which patient #12 did not have prior to admission to the facility. To date, I have not received a definitive answer regarding the status of patient #12's skin." Patient #12's medical record did not contain any documentation to reflect updating patient #12's representative of the additional wounds that presented while being hospitalized at the facility on the tracheostomy site and the buttocks. These findings were confirmed by the Wound Nurse.

Based on observation, 1 (#20) patient was not protected from access to a potentially harmful substance. Findings include:

On 4/5/10 at approximately 0850, patient #20 was observed undressed, ambulating in the hallway. The Director of Clinical Services stated that the patient is disabled. Review of patient #20's clinical record revealed a diagnosis of "decreased mental capacity."

On 4/5/10 at approximately 0900, unattended bottles of Hydrogen Peroxide 3% were observed on bedside tables in patient rooms #335 and #342. The bottle warning directs users to contact poison control if ingestion occurs. The Director of Clinical Services verified these findings.

Based on observation, interview, and policy and procedure review the facility failed to ensure the confidentiality of patient records. Findings include:

On 4/5/10 between the hours of 0900 to 1400 while touring the unit it was noted that all patient medical records are kept in unlocked Wall-a-Roos. Wall-a-Roos are cupboards that are installed outside of the patient rooms to hold medical records and can also be opened and has a space to lay the medical record and document if needed. In addition, specifically at 1120 on the above mentioned date while walking to a patient's room two (2) patient case management files that contained personal health information (PHI) were observed laying on a counter (charting cubby) in the hallway and unattended. The observations were witnessed and confirmed by the Director of Quality and the Infection Control Nurse.

On 4/6/10 at approximately 1400 review of the facility's policy and procedure titled "Security & Accessibility of Medical Records" reads under section F. "Medical records shall not be left unattended in areas accessible to unauthorized individuals."

Repositioning and Observation:

On 4/5/10 from 1000-1430, 3 patients were observed for position status at 1000, 1030, 1100, 1130, 1200. 1230. 1300, 1330. 1400 and 1430. 3 of the patients (#13, #14 and #19) were observed to be in the same positions (on their backs) at each observation time. Patient #13 had documentation of a Stage IV pressure ulcer on her sacrum. Patient #14 had no documentation of impaired skin integrity and was assessed as at "mild risk" for skin breakdown. On 4/5/10 at 1530, observation of patient #14's buttocks revealed 3 open areas, each approximately 1 centimeter by 1 .5 centimeters, with scant bloody drainage at each site. Per facility policy titled "Wound Prevention" (W05-N), "Patients that are bed bound or with limited activity should be repositioned every two hours."

Wound Care:

On 4/5/10 between 1100-1500 wound treatment orders were compared with treatment records. Record review revealed that wound care was not provided as ordered for patient #13. Per facility policy S05-G wound care is to be documented with each assessment provided.

Timely Assessments:

Patient #19 was admitted to the facility on 3/26/10. He had no documentation of a skin assessment until 3/30/10 when "weepy stage II's" were documented on his buttocks. Per facility policy titled "Wound Assessment" (#W04-N), "All patients will have a skin assessment on admission." Per facility policy S05-G, wound photos are to be done within 24 hours of admission. The Wound Care Specialist verified these findings.




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Based on observation, interview, and record review the facility failed to ensure that the registered nurses supervise and evaluate the nursing care for each patient in 16 out of 20 patients (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, and #19). Findings include:

Repositioning:

On 4/5/10 during a tour of the unit at 0900 the positions of the patients #1, #2, #3, #5, #10, and #11 were noted. A interview conducted with the Director of Quality revealed that the facility has a turning team that is scheduled every 2 hours on the even hour (0800, 1000, 1200, 1400, etc.) to go around and reposition the patients. The RN is responsible for charting the repositioning in the nursing note flow sheet. A purposeful observation schedule was initiated on patients #1, #2, #3, #5, #10 and #11 due to the fact that these patients were unable to reposition themselves independently.

Beginning at 0900 six patients were observed at 1/2 hour intervals for position change. Patient #1, #3, and #10 were not repositioned in the 5 1/2 hour observation period. Review of the 24 hour patient record and plan of care flow sheets that nursing documents care on, dated 4/5/10 for patients #1, #3. ans #10 revealed documentation of repositioning at 0800, 1000, 1200, and 1400.

On 4/6/10 at 1405 an interview was conducted with the PT (Physical Therapy) Director and he stated that "the patients are repositioned every 2 hours we have a schedule for turn teams that go around and turn the patients. I do know that yesterday's 12:00 noon turn team didn't happen". Review of the 24 hour patient record and plan of care flow sheets revealed that patients had been repositioned at 1200 noon.

Facility policy titled "Wound Prevention" # W05-N indicates that "all patients will be repositioned every 2 hours in bed."

Wound Care:

On 4/5/10 between the hours of 1100-1500, record review revealed that wound care orders were not followed as prescribed on patient #1, #3, #5, and #12.
Patient #1 Nursing wound care flow sheet revealed that the patient is to have a daily and as needed wound treatment and dressing to the penile head and scrotum wounds. The nursing flow sheet was absent of documentation between the dates of 3/14/10 through 3/30/10 of care provided on the following dates: 3/20/10, 3/26/10, and 3/28/10.
Patient #1 Nursing wound care documentation sheet revealed that the patient is to have a daily and as needed wound treatment and dressing to the left heal wounds. The nursing wound care flow sheet was absent of documentation between the dates of 3/14/10 through 4/1/10 of care provided on the following dates: 3/20/10, 3/26/10 and, 3/28/10, and 3/31/10.

Patient #3 Nursing wound care documentation sheet revealed that the patient is to have a daily and as needed wound treatment and dressing to the right buttocks. The nursing wound care flow sheet was absent of documentation between the dates of 1/26/10 through 4/4/10 of care provided on the following dates: 1/30/10, 2/1/10, 2/4/10, 2/5/10, 2/7/10, 2/23/10, 3/7/10, 3/8/10, 3/9/10, 3/17/10, 3/23/10, 3/24/10, 4/2/10, and 4/3/10.

Patient #5 Nursing wound care documentation sheet revealed that the patient is to have a daily and as needed wound treatment and dressing to both lower extremities. The nursing wound care flow sheet was absent of documentation between the dates of 3/15/10 through 4/4/10 of care provided on the following dates: 3/17/10, 3/22/10 and, 3/24/10, 3/26/10, 3/27/10, and 4/2/10.

Patient #12 Nursing wound care documentation sheet revealed that the patient is to have a daily and as needed wound treatment and dressing change to both lower extremities on every Monday and Thursday. The nursing wound care flow sheet was absent of documentation between the dates of 2/18/10 through 3/8/10 of care provided on the following dates: 2/25/10, 3/1/10 and, 3/4/10. Patient #12 was also suppose to receive wound care to the tracheostomy site every other day as noted in a nursing wound care flow sheet and documentation of wound care performed was absent on 37/10 between the dates of 2/26/10 through 3/9/10.

On 4/5/10 the absence of wound care treatments on the above mentioned dates was confirmed by the Director of Quality.

Timely Assessments:

On 4/6/10 at approximately 0900 during medical record review of patient #12 documentation revealed that the patient's vital signs were not performed as prescribed by the physician order. Patient #12's physician order dated 2/16/10 indicated that vital signs were to be monitored every 8 hours. The facility's nursing flow sheet titled "24 Hour Patient Record & Plan of Care is where the vital signs are recorded when taken. Between the dates of 2/20/10 through 3/1/10 no documentation is present that represents that the vital signs were taken every 8 hours on any of the days mentioned.

On 4/6/10 this finding was confirmed by the Director of Clinical Services.