Baptist Health Medical Center-Drew County

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 51070 Based on review of policy, clinical record review, and interview, it was determined the facility failed to provide safe effective care for two (#1 and #3) of ten (#1-#10) records reviewed. The failed practice allowed patients to experience harm. The failed practice had the likelihood of affecting all patients receiving inpatient care. Findings follow: A. Review of Policy titled “Fall Prevention and Post Fall Management Procedure” approved 6/2025, showed patients will be screened for fall risk “every shift and post fall via Morse Fall Scale”. Fall prevention procedures include utilizing safety precautions which include assessing toileting needs and providing accommodation as indicated. Additionally, the policy showed that following a fall the Registered Nurse (RN) will complete the “Post Fall Assessment flow sheet to include post fall vital signs, fall observations, updated Morse Fall Risk Scale, and post fall nursing actions”. Also a Post Fall Huddle should be completed with staff to gather information and learn from the event and the RN should complete an incident report in the Safety Event Reporting system. B. Review of policy “Wound Photography” approved 06/2025, showed “Photo documentation with wound assessment will be done for wounds and/or pressure injuries on admission, upon identifying hospital acquired pressure injuries and/or wounds, to assess wounds and/or pressure injury status, and by the wound care team with dressing changes on or about weekly or by health care team members as needed.” C. Review of “Safety Event Reporting System” approved 2024, and “Serious Reportable Events” last revised 12/18/23, showed that falls and pressure ulcers should be reported into the incident reporting system for use to improve quality and safety. Additionally, “Any stage 3, stage 4, or unstageable pressure ulcers are identified as a serious reportable event.” D. Review of two Patients (#1 and #3) of twenty-five (#1-#25) records reviewed showed the following: E. Patient #1: 1) Review of the Admission Assessment flowsheet dated 07/15/25 at 11:00 PM, showed Patient #1 was disoriented to place, time, and situation, also had impaired vision in both eyes, generalized weakness, limited movement, was chairfast, and required assistance with toileting using a bedside commode. 2) Review of Nursing Note dated 07/17/25 at 10:12 PM, showed the nurse was “called to Patient #1’s room by staff at 7:09 PM” and “Patient was found lying on floor on left side and now has 4-centimeter (cm) bump on forehead beside right eye”. The note also showed staff had placed Patient #1 on the bedside commode and left the room. 3) Review of Physician Note dated 07/18/25 at 7:11 AM, showed Physician had been notified that Patient #1 experienced a fall and had a hematomoa on forehead. Additionally, the not showed Patient #1 has been “very weak and debilitated now with exacerbation of her hip and back pain.” 4) Review of Case Management Note dated 07/18/25 at 8:13 AM, showed a family member was concerned about Patient #1’s fall and bump on head, and Case Manager noted they would notify Physician to see if they would like to order any testing prior to discharge. 5) Review of Computed Tomography (CT) dated 07/18/25 at 10:57 AM, showed “No acute intracranial abnormality and Moderate Cerebral Atrophy.” 6) Evidence was requested on 09/23/25 at 9:30 AM, which showed Patient #1 was assessed and monitored as directed in the “Fall Prevention and Post Fall Management Procedure” approved 6/2025. None was provided. 7) During an interview with the Chief Nursing Officer and Quality Assurance Manager on 09/23/25 at 10:15 AM, they confirmed the findings in a-f, and confirmed that staff had not reported the fall in the Safety Event Reporting System for quality review and improvement. F. Patient #3: 1) Review of History and Physical dated 07/21/25 at 7:52 AM, showed Patient #3, a paraplegic, was admitted for severe back pain and fecal incontinence. 2) Review of Wound Flowsheet dated 07/21/25, showed eight (#1-#8) wounds present on admission, all documented between 8:18 AM and 12:14 PM. Wound locations were shown to be “Left lower posterior arm, anterior right leg, right heel, left toe, pretibial right, left proximal pretibial, posterior neck, and left lower posterior arm.” None of the wounds documented provided a description or staging, measure of size and/or depth, color, drainage, if dressing is present or if wound care was provided. 3) Evidence was requested on 09/23/25 at 10:15 AM, which showed if orders had been placed for wound care or if a consult was made to wound care upon admission. None was provided. 4) Review of eight (#1-#8) of nine (#1-#9) wound photos showed multiple wounds and pressure injuries in various states of healing. Additionally, Photos (#1, #2, #4, and #6) show more than one wound and/or pressure injury which was not shown to be documented in the clinical record. 5) Review of one (#9) wound photo dated 07/24/25, showed a large circular unstageable, left heel pressure injury with black eschar tissue. Evidence was requested on 09/23/25 at 10:30 AM, which showed if this wound was assessed and cared for. No evidence was provided which showed left heel wound had been assessed and cared for beyond being photographed several days after admission. 6) None of the photos reviewed showed a description that included wound and/or pressure injury properties such as staging, measure of size and/or depth, color, drainage, or any other wound characteristics. 7) Review of Nurse Note dated 07/24/25 at 2:28 PM, showed “Right heel wound busted open” and that consults were placed for wound care and general surgery. A nutrition consult was also placed on 07/24/25 at 2:59 PM with reason documented as “wounds”. 8) Review of General Surgeon note dated 07/24/25 at 6:12 PM, showed general surgery had performed a wound debridement on the right heel. At that time a foam dressing was applied and wound care orders were placed by the physician for the right heel wound care. 9) During an interview with the Chief Nursing Officer and Quality Assurance Manager on 09/23/25 at 10:15 AM, they confirmed that none of Patient #3’s wounds had been reported in the Safety Event Reporting System for quality review and improvement. G. During an interview with the Chief Nursing Officer and the Nursing Manager on 09/23/25 at 10:40 AM, the findings in A-F were confirmed. Based on review of training materials, observation, and interview, it was determined the facility failed to provide a safe environment in that cleaning chemicals were stored in a hallway accessible to patients and visitors. The failed practice allowed unauthorized access to cleaning chemicals and other cleaning supplies which increased the risk of harm. The failed practice had the likelihood of affecting all patients admitted to inpatient units. A. Review of training materials titled “Cleaning Cart”, dated 2021, showed housekeeping carts should not be left unattended unless stored in their designated location and cleaning chemicals should be stored on the “bottom shelf” which is located inside an area of the cart that can be locked. B. During a tour of the facility on 09/22/25 between 11:20 AM to 12:06 PM, two housekeeping carts were observed in the hallway of an inpatient unit. They were found to be unattended, unlocked, and with cleaning chemicals on the top and bottom shelves giving both patients and visitors access. C. During an interview with the Nursing Manger of Med-Surg on 09/22/25 at 11:40 AM, he confirmed the findings in A-B.”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 51070 Based on review of policy, clinical record review, and interview, it was determined the facility failed to provide physical reassessment for two (#1 and #3) of ten (#1-#10) patient records reviewed. The failed practice did not allow for high quality safe care to be provided, thereby preventing adverse outcomes. The failed practice had the likelihood of affecting all inpatients receiving care within the facility. Findings follow: A. Review of policy titled “Fall Prevention and Post Fall Management Procedure” approved 06/2025, showed following a fall the Registered Nurse (RN) will complete the “Post Fall Assessment flow sheet to include post fall vital signs, fall observations, updated Morse Fall Risk Scale, and post fall nursing actions”. B. Review of policy “Wound Photography” approved 06/2025, showed “Photo documentation with wound assessment will be done for wounds and/or pressure injuries on admission, upon identifying hospital acquired pressure injuries and/or wounds, to assess wounds and/or pressure injury status, and by the wound care team with dressing changes on or about weekly or by health care team members as needed. C. Patient #1: 1) Review of clinical record showed Patient #1 experienced a fall on 07/17/25 at 7:09 PM after being left unattended on a bedside commode. A Nurse note dated 07/17/25 at 10:12 PM, showed the physician had been notified and a set of vital signs were taken. The note also showed the patient had a new 4 centimeter (cm) circular bump on the forehead. 2) Evidence was requested on 09/23/25 at 9:30 AM, which showed Patient #1 was re-assessed and monitored more frequently as directed in the “Fall Prevention and Post Fall Management Procedure” policy. None was provided. D. Patient #3: 1) Review of History and Physical dated 07/21/25 at 7:52 AM, showed Patient #3, a paraplegic, was admitted for severe back pain and fecal incontinence. 2) Review of Wound Flowsheet dated 07/21/25, showed eight (#1-#8), all documented between 8:18 AM and 12:14 PM, wounds were shown to be present on admission. Left lower posterior arm, anterior right leg, right heel, left toe, pretibial right, left proximal pretibial, posterior neck, and left lower posterior arm. None of the wounds documented provided a description or staging, measure of size and/or depth, color, drainage, if dressing is present or if wound care was provided. 3) Evidence was requested on 09/23/25 at 10:15 AM, which showed wound care was consulted or if orders were placed for how the wounds were to be cared for at admission. None was provided. 4) Review of eight (#1-#8) of nine (#1-#9) wound images showed multiple wounds and pressure injuries in various states of healing. Additionally, Photos (#1, #2, #4, and #6) show more than one wound and/or pressure injury which was not shown to be documented in the clinical record. 5) Review of one (#9) wound photo dated 07/24/25, showed a large circular unstageable, left heel pressure injury with black eschar tissue. Evidence was requested which showed when the left heel pressure injury was found and if wound care had been provided for the wound. None was provided. 6) None of the photos reviewed showed a description, staging, measure of size and/or depth, color, drainage, or other wound properties which were present. 7) Review of Nurse Note dated 07/24/25 at 2:28 PM, showed “Right heel wound busted open” and consults were placed to wound care and general surgery. A nutrition consult was also placed on 07/24/25 at 2:59 PM with reason documented as wounds. 8) Review of General Surgeon note dated 07/24/25 at 6:12 PM, showed general surgery had performed a wound debridement on the right heel. At that time a foam dressing and wound care orders were placed for the right heel. No evidence was provided which showed orders or instructions had been provided for how to care for Patient #3s other wounds. E. During an interview with the Chief Nursing Officer and Quality Assurance Manager on 09/23/25 at 10:15 AM, they confirmed the findings in A-D.”