STATE OF RHODE ISLAND AND PROVIDENCE PLANT ATIONS Department of Behavioral Healtheare, Developmental Disabilities and Hospitals Of?ce of the Director 14 Harrington Road Phone 401-462-3201 Cranston, RI 02920-3080 Fax 401?462-3204 September 21, 2015 Nicole Alexander?Scott, MD Director Rhode Island Department of Health 3 Capitol Hill Suite 401 Providence, RI 02903 Re: Eleanor Slater Hospital Response to Compliance Order 9-4?20 1 5 Dear Director Alexander Scott: I am writing in response to the August 20, 2015 hospital survey and the resulting issuance of an ?Immediate Compliance Order? dated September 4, 2015. In my capacity as Director of the Department of Behavioral Healthcare, Developmental Disabilities and Hospitals of the State of Rhode Island I am requesting that you ?nd the following provisions being made at the Eleanor Slater Hospital (herein referred to as the Hospital) acceptable to demonstrate substantial compliance and good progress in meeting the terms of the aforementioned order. First to address Order requiring the Hospital to engage an industry expert by Friday September 18, 2015 ?to provide consultation regarding implementation of a safe patient handling program, required staff training, and analysis of staf?ng levels?. As you may be aware the Hospital has been working to engage a management consulting team which will include not only an industry expeit to address all issues outlined in the Compliance Order but further includes engaging several other key senior level consultants that will provide the coordinated interdisciplinary expertise necessary to guide and direct the hospital. I am asking for your consideration to allow Eleanor Slater Hospital additional time to pursue a contract for this service which has been in the procurement process prior to the August 20, 2015 survey. I had anticipated the management consulting team would be in place to comply with the September 18th deadline as an RFP was issued and the bid process had been completed. The process, however was unexpectedly delayed as the two bid responses were disquali?ed by the Department of Administration as incomplete. The issues underlying the delay have been resolved and the Hospital has identi?ed Applied Management Services as a vendor and is seeking approval for the contract form the Department of Administration as a sole source. AMS has incorporated the provisions of your Compliance Order into their work proposal. The additional time is need for work on finalizing the contract and for RIFAN funding approval. plans to submit a request for a purchase order no later than September 25, 2015. AMS has committed to having a team in place at the H03pital within seven days from the date the contract is awarded. The AMS team will include a Nursing Executive, a nursing Director and a Risk Manager and additional consulting staff from AMS will be brought in to complete the necessary training to implement a safe handling training program. Staf?ng analysis will be completed by the team Within 30 days of their contract commencement. progress reports will be submitted per the Compliance Order. I am certainly willing and prepared to keep you advised should there be any unexpected future delay and am prepared to discuss with you an interim contingency plan should one be required. As to Order items #1 2 the Hospital?s policies and procedures articulate the minimum required staf?ng of each inpatient unit. The Hospital?s policy for minimum staf?ng levels on its patient units have been reviewed by both DOH licensure staff as well as JCAHO surveyors and has been found to be suf?cient. Generally, the Hospital has been in compliance with its own policies for adequate nursing staff on all units and on all shifts. De?ciencies in staf?ng that have been cited in recent DOH investigations have been relatively rare and isolated incidents on non- compliance on the part of the Hospital with its established policies. The hospital acknowledges that it has had dif?culty ?lling nursing vacancies in a timely manner and scheduling temporary nursing staff when unplanned vacancies occur. Due to unplanned absences of nursing staff and limitations in the State?s hiring policies for ?lling temporary vacancies, the hospital has relied on mandatory overtime for certain nursing shifts where staf?ng levels would fall below the hospital?s minimum staf?ng policy. As part of the AMS consulting contact, AMS will provide a Nurse Executive/COO consultant who will review the staf?ng and scheduling processes of all Hospital Departments and oversee their daily operation. The Nurse Executive/COO from AMS will be reviewing current hiring practices and policies of the Hospital and she shall make recommendations for revisions to RI HR policies and contracting policies that should be enacted to improve the Hospital?s ability to manage its staf?ng and scheduling of nurses to ensure adequate levels of staf?ng for all hospital facilities and shift. Any recommended changed in policies or staf?ng patterns will be submitted to you for your review and approval, in compliance with this order, prior to their enactment. This is not to say that the Hospital is waiting to address the concerns noted in the survey. The Hospital has done an assessment based 011 the survey and is submitting herewith a corrective action plan addressing the speci?c DOH ?ndings which includes the following plan to avoid any circumstance in which the nursing staf?ng ratio will fall below the minimum staf?ng per unit that is set in Hospital policy. Those actions include: 0 Increasing the staf?ng pattern for APS units from 1.0 per unit to 1.5 per unit on daytime shifts 0 Increasing the nursing staff on ?rst and second shifts by 3 FTEs (we are posting and hiring into those positions now). 0 Using three separate nursing pools for temporary staf?ng (we are working on a training schedule with the three companies to train nurses so they will be readily available). - Supervisory review of all staf?ng schedules, including limiting the number of nurses per hospital facility who can be concurrently out on vacation to avoid shortages due to absenteeism, and ensuring through logs and schedules that nursing coverage is adequate during shift changes and meal breaks. The hospital will have adequate and quali?ed nursing staff for each patient care unit. The Supervising Registered Nurses (SRN) in Medical Services will conduct and track 18 observations of care each month and will observe the number of staff for care. Following the observation, the SRN will con?rm the assigned staffing level on the patient?s individualized care plan and on the C.N.A Daily Care Flow Sheet. All observations will be reported to the Nurse Manager for oversight. The Nurse Manager will report the results of the observations to the Performance Improvement Steering Committee To ensure that there is one nurse on every unit in the Adult Unit, (2), 8 hour overtime coverage blocks have been implemented to provide cafeteria duty, coverage of lunches and supper breaks. On any day when all other options have been exhausted, Supervising Registered Nurses have been directed to provide coverage as needed. Supervising Registered Nurses will grant only 2 vacation days off per shift as opposed to the current 3 days off per shift until permanent positions are hired. By November 6, 2015, staf?ng patterns will increase to 1.5 nurses per unit (one nurse on unit and one nurse on the ?oor to ?oat between mirror units). Three full time RN ?oat positions will be added to both first and second shift. Adult Services will also utilize the following nursing pools: Adil, Maxim and MAS to aid the Hospital with providing appropriate staf?ng as needed. Nursing staffing patterns will be reviewed daily by the Supervising Registered Nurses to ensure staffing levels are maintained in accordance with Regulations. Any issues will be reported directly to the Nurse Manager. I As it relates to training the Hospital has conducted an assessment of all staff training and competency requirements to ensure that all staff are current with required trainings and are suf?ciently quali?ed to work in assigned areas. The Training and Education department will now report to the Performance Improvement Administrator to increase department oversight. The Training and Education department has developed a new tracking system to allow training and competency rates to be tracked in real time and to allow for improved communication across hospital locations. To increase communication among the members of the Training and Education Department, a meeting has been scheduled every two weeks with Nursing Services on both campuses to review the current training schedule, current training needs based on patient population to address any challenges that may be hindering attendance at trainings. A goal has been set of 100% compliance with all mandatory trainings and competencies for nursing staff. The Nurse Managers the Acting Director of Training Education will monitor the corrective action plan and present on a basis at the Performance Improvement Steering Committee. Eleanor Slater Hospital has developed an assessment tool entitled ?Safe Patient Handling/Assessment Tool? to identify the appropriate use of resources for each patient based on their physical and mental condition. All medical patients within the hospital will be assessed using this tool to determine the staff levels for patient care. The information obtained from the assessment tool will be documented on all individualized care plans for medical patients and will be documented 011 the C.N.A Patient Daily Care Flow Sheets to assure that the patients have adequate nursing staff. All Nursing staff will be trained on this new form by October 15, 2015. In addition to the foregoing, attached please ?nd the Hospital?s 12 page corrective action plan, Safe Patient Handling and Assessment Tool, Injury Internal Report Form. Finally be assured thatI appreciate and share in your concern and interest in making Eleanor Slater Hospital a safe and secure environment for the vulnerable population we serve and immediately upon beginning my tenure as Director have made it a priority to improve the safety and quality of the Hospital for all patients. Thank you for your consideration. Maria Director With Attachments CC: Paul De3pres, CEO Jennifer Wood, EOHHS Deputy Secretary General Counsel Manish Desai, Acting Chief Medical Officer Daniel Ballirano, Legal Counsel MaryEllen Benedict, ESH Acting Risk Manager PRINTED: 09/03/2015 FORM APPROVED RI Department of Health STATEMENT OF DEFICIENCIES (x1) (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION A. BUILDING: COMPLETED Hosootbz 5- 08/20/2015 NAME OF PROVIDER OR SUPPLIER STREETADDRESS, CITY. STATE. ZIP CODE 111 HOWARD AVE ELEANOR SLATER HOSPITAL RI 02921 W) .0 SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION (X5) PREHX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) ZO INITIAL COMMENTS 20 A complaint investigation survey was conducted at this facility. State deficiencies were cited. 175 ORGANIZATION MANAGEMENT 13.1 175 Personnel Section 13.0 Personnel I 13.1 The hospital shall maintain a sufficient that am? number of qualified personnel to provide effective She ?3:1 form A . patient care and all other related services. 9?18?2015 ReqUirement is net met as eVidenCed All RN staff assigned to medical services are to be educated 10/912015 Based upon record review and staff interview it Pam has: be'en the to As part ofThe SafePatientuHandling Programkall medical patients 10,23,2015 mama!? summer? numbers of qualified Personnel to prOVIde effective patient care for relevant ?till he . pans or me I05 pa lens patient sample 4_ and on the Patient Daily Care Flow Sheets (DCFS). All Certi?ed Nursing Assistants assigned to Medical ServiCes will be 10/15/2015 Findings are as follows: Fgfcidgated on Daily Care Flow Sheets with regard to staf?ng levels The Supervising Registered Nurses in Medical Services will conduct and track 18 observations 0 care each month and - 912112015 observe the number of staff for care. Following the observation, the Record review for patient ID #4 reVealed the . S?af?ng 'eVe'mmeDCFS am patient .has diagnoses include All observations will be reported to the Nurse Manager. The Nurse 10/28/2015 sclerosis. osteopema. quadnpiegra With bilateral assess:reassess;seamstress: upper extremity contractures and lower extremity ftaccidlty (weakness/reduced muscle tone) and Obesity. Review of a care plan updated on 7/1/2015 and interview with unit nurses (staff and G) revealed that the patient requires total care for all activities Of daily living, including assistance with repositioning. The patient is incontinent of bowel and bladder and is transferred via mechanical lift to a wheelchair. A 7/30/2015 nurse's note indicates the patient complained of pain to her/his left leg. The patient's left knee was noted to be edematous but no redness or bruising noted and Facilities Regulation LABORATORY OR REPRESENTATIVES SIGNATURE TITLE (X6) DATE STATE FORM ?99 NRT711 If continuation sheet 1 of 12 Rl Department of Health PRINTED: 09/03/2015 FORM APPROVED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) IDENTIFICATION NUMBER: HOSDO102 B. WING (X2) MULTIPLE CONSTRUCTION A, BUILDING: (X3) DATE SURVEY COMPLETED 08/20/2015 NAME OF PROVIDER OR SUPPLIER ELEANOR SLATER HOSPITAL 111HOWARD AVE CRANSTON, RI 02921 STREET ADDRESS. CITY. STATEI ZIP CODE ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGUIATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG CROSS-REFERENCED TO THE APPROPRIATE PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE (X5) COMPLETE DATE DEFICIENCY) 2175 Z185 Continued From page 1 the left leg was warm to touch. A nursing assistant reported the patient?s leg is not "so floppy as usual.? A review of the hospital incident report dated 7/31/2015 revealed that on 7/30/2015 the patient was sent out to the hospital for further evaluation for left leg pain, to rule out for deep vein thrombosis/cellulitis. The patient was admitted to the hospital with a left femur fracture and an old tibial plateau fracture. A review of the hospital history and physical dated 7/31/2015 indicates an assessment and plan which identifies the fractures as suspicious given the patient is bad bound with no known history of fall or trauma. During an interview on 8/12/2015 at 9:00 AM. Nursing Assistant (Staff E) who has been providing care to the patient indicated that, prior to the hip fracture, she had provided care (AM care, including repositioning) to the patient without assistance from other staff. Interview with the unit nurse (Staff F) on 8/13/2015 at 10:00 AM revealed the patient needs total assistance for care and repositioning. The nurse further indicated that the patient is approximately 190 pounds and personal care is to be provided using 2 staff. Additional unit nurses were interviewed, Staff on 8/13/2015 at 9:55 AM, and Staff at 1:15 PM indicated that two nursing assistants are required to provide care and repositioning. ORGANIZATION MANAGEMENT 13.3 Personnel Z175 Z185 Facilities Regulation STATE FORM 6899 NRT711 If continuation sheet 2 of 12 PRINTED: 09/03/2015 FORM APPROVED RI Department of Health A. Core Curriculum: prepare the employee to function with increasing safety and effectiveness in his/her assigned role within the hospital Core I: Core Ii: Annual and Bi-Annual Bi?Yearly Training 4. Body Mechanics Core Competency Training and Assessment The following programs are currently conducted for nursing CNA (nursing assistant) Competencies/Frequency STATEMENT OF DEFICIENCIES (X1) (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A BUILDING. COMPLETED - Hosoo1o-2 3- WING 08I20I2015 NAME OF PROVIDER OR SUPPLIER STREETADDRESS, CITY, STATE, ZIP CODE 111 HOWARD AVE ELEANOR SLATER HOSPITAL CRANSTON, RI 02921 (x4) SUMMARY STATEMENT OF DEFICIENCIES PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 185 Continued From page 2 2185 I I Staff E, k. L. M. have all received in-service training relative 1023/2015 13.3 shall be made for orientation 19 meshamcal lift- Staff Perssn. 005 Currently out on 1909 term and amgeglatel? upogws to Io.t . an ongomg uca Ion programs or,a Ieceive gtrgI?ing in body mechanics by 10/23/15. Staffvgerasono personnel. There she? be written EVIdence that \villrieceive Body Mechanics training immediately upon his return to . wo . staff demonstrate competenoles necessary i'Ih di' (I work in SpeCIflC areas and/or specrfic patient ?0?23?2015 . semce ora ursing ta . populationsThis Requrrement Is not met as ewdenced by: (?23/201 - - - en ca Based on regord reVIew and Intewle'w It has :uarsi?g been determined that the has falied_t0 ensure that personnel have appropriate Safe PatentHand'mgIt! It] 8/201?2015 Onlg?mgteducago I anldl [gafm petenTy PeFiorIFieErlIcg Tmprovg?egtnAd??iierIZPoNo re a IVE 0 mac or samp OVEISIQ - nursing assistants and relative to body The Training and Education department has developeda new . 9,17,2015 . tracking system to allow training and competency rates to be mechanics TOT Of sample geckedriln real time and to allow forimproved communication across ospl a ionsFindings are as follows: Wu? @2133 rg??gw?ii?tin?ung??tee 5 training schedule, current training needs based on patient . population and to address ark!) challer?ges'that?nay irate hintcterlilrtg Review of the hospital's policy and procedure 32:39:35; tyiigrixln entitled "Staff Education/Program? indicates: 3519"? areas- A goal has been set of 100% compliance with all mandatory 9/30/2015 trainings and competencies for nursing staff. The Nurse Managers the Acting Director of Training Education will monitor the corrective action plan and present on a basis at the Performance Improvement Steering Committee. STATE FORM Facilities Regulation 6899 NRT711 If continuation sheet 3 of 12 Department of Health PRINTED: 09/03/2015 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDERISUPPLIERICLIA IDENTIFICATION NUMBER: FORM APP ROVED (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY A. BUILDING: COMPLETED 3' 08I2012015 NAME OF PROVIDER OR SUPPLIER ELEANOR SLATER HOSPITAL 111 HOWARD AVE CRANSTON, RI 02921 STREET ADDRESS, CITY, STATE, ZIP CODE (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG CROSS-REFERENCED TO THE APPROPRIATE PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE (X5) COMPLETE DATE DEFICIENCY) Z185 2216 Continued From page 3 Annual 1. InvacarelHoyer (mechanical lift)?CNA Bi-yearly 3. Body Mechanics Review of personnel files relative to "skill competency validation" for mechanical lift revealed no evidence that the training or skill competency were done yearly for 7 of 15 sample (Staff E, K, L, M, N, O, and P). Further review of the abCVe personnel files revealed no evidence of training nor skill competency for body mechanics were done every two years for 12 of 15 sample (Staff and W). During an interview with the Clinical Training Instructor (Staff J) on 8/18/2015 at 8:55 AM, she indicated that are required to have training and skill competency relative to mechanical lifts yearly. These are also required to have? training and skill competency relative to body mechanics every two years. She was unable to provide evidence that the above received training and skill competencies necessary to work with the specific patient populations requiring these services. ORGANIZATION MANAGMENT 13.11 Safe 7 Patient Handling Safe Patient Handling Z185 2216 Facilities Regulation STATE FORM 6599 NRT711 If continuation sheet 4 of 12 PRINTED: 09/03/2015 FORM APPROVED RI Department of Health STATEMENT OF DEFICIENCIES (X1) (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION A BUILDING, COMPLETED HOSOO1 02 3- WING 08/20/2015 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY. STATE. ZIP CODE 111 HOWARD AVE LE AL - ANOR SLATER HOSPIT RI 02921 (X4) SUMMARY STATEMENT OF DEFICIENCIES PLAN OF CORRECTION (X5) PREHX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX. (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG TO THE APPROPRIATE DATE DEFICIENCY) 216 Commued From page 4 216 The Hospital has established a Safe Patient Handling Committee. I Introductory meetings have been held'on 8/25. 9/4, 9/8 and 9116. The 11 hospital comply With committee is Chaired by a professional nurse and is comprised of more the following as a condition of licensure: than50%hw?vl ?On-managerialsla? I The State of RI is in the process of contracting with an independent 10,1,2015 a) Each Iicensed hospital shall establish a safe Industry Expert to assist the hospital to develop a comprehensive Safe - - - Patient Handling Program that will improve the safety of the patients patLent CommIttee' Shall be and prevent musculosketal disorders among ourhealthcare staff. chaired by a professmnal nurse or other 8 r0 Hate licensed health care professional A The Hospital will conducta patient handling hazard assessment to 11/15/2015 pp . . . . . identify the appropriate use of the safe patient handling policy for each hospital may utilize any appropriately con?gured patient based on the patient?s physical and mental condition: the committee to perform the responsibilities of patient?s choice and the availability of lifting equipment. IeaSt Of the members of the The Hospital developed the "Safe Patient Handling Assessment Tool? 9/13/2015 committee shall be hourly, non-managerial to identify the appropriate use of resources for each patient based on - - - their physical and mental condition; the patient's choice; and the employees who prowde direct patient care. availabmt . . . of lifting equment. b) Each ?censed hospital Sha? develop a Written ?0?9?20?5 safe patient handling program. from the include a means to address circumstances under which it would be I safe patient handling Gor~nr~nitteeI to prevent medically contraindicated to use Iiiting or transfer aids or other musculoskeletal disorders among health care 355mm dev'cesforpamcmarpauems? workers and injuries to patients, AS part Of The Hospital will designate and train a RN to serve as an expert 10/23/2015 . - - . resource. who in collaboration with other trainers, will train all clinical programl eaCh Ilcensed health care faculty Shall? staff on safe patient handling policies, equipment and devices by 10/9/15 and annually thereafter. All new staff will receive the training Implement a safe patient handling policy for ?Mmema?m- all and Of the The Hospital?s Performance Improvement Administratorwill conduct 10,2016 the maximum reasonable reduction of manual an annual performance evaluation ofthe Hospital's Safe Patient . . . . . Handling Program. The evaluation writ determrne to what extent the lifting. tranSfemngi and repOSItlonmg Of a? or implementation ofSafe Patient Handling Program has resulted in a most of a patientls weightI except in restIJctiortilin musculoskeletal disoc?der claims oflost work . - - - attri uta eto patienthandling an will also incu erecommendation life-threatening. or otherwise exceptional to increaseme program effectiveness Circumstances; The Hospital's nursing leadership will submit an annual report to the 10,2016 .. . . Safe Patient Handling Committee of the facility on activities related to (II) COHCIUCI a patient handling hazard the identi?cation, assessment. development, and evaluation of assessment. assessment Should consider strategies to control the risk of injury to patients, nursesand other such variables as patient handling tasks types of associated With the lifting, transfemng, reposi ioning. or movement 0 a patient. nursing units, patient populationscorrec Ive mom ore Beginning Phi/5103' enV'ronment Of Pat'ent care areas: Hospital Performance ImprovementAdministrator and 1112015 Develop a process to identify the appropriate use of the safe patient handling policy based on the patient's physical and mental condition, the patient's choice, and the availability of lifting equipment or lift teams. The policy shall include a presentations will be made by the Chair of the Safe Patient Handling Committee to the Hospital Performance Improvement Steering Committee. The Hospital will also report annually on the quality and effectiveness of the Safe Patient Handling Program. The Hospital's Contracted independent industry expert will provide ongoing progress reports regarding the status and performance of the Hospital's compliance order. Facilities Regulation STATE FORM 6899 NRT711 If continuation sheet 5 of 12 PRINTED: 09/03/2015 FORM APPROVED RI Department of Health STATEMENT OF DEFICIENCIES (x1) (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A BUILDING, COMPLETED H0800102 8- 0812012015 NAME OF PROVIDER OR SUPPLIER STREETADDRESS, CITY. STATE. ZIP CODE 111 HOWARD AVE ELEANOR SLATER HOSPITAL CRANSTON, RI 02921 (x4) (.3 SUMMARY STATEMENT OF DEFICIENCIES (D PROVIDERS PLAN OF CORRECTION (x5) (EACH DEFICIENCY MUST BE PRECEDEO BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR IDENTIFYING INFORMATION) TAG TO THE APPROPRIATE DATE DEFICIENCY) 216 Continued Frompage 5 216 means to address circumstances under which it would be medically contraindicated to use lifting or transfer aids or assistive devices for particular patients; (iv) Designate and train a registered nurse or other appropriate licensed health care professional to serve as an expert resource, and train all clinical staff on safe patient handling policies, equipment, and devices before implementation, and at least annually or as Changes are made to the safe patient handling policies, equipment and/or devices being used; Conduct an annual performance evaluation of the safe patient handling with the results of the evaluation reported to the safe patient handling committee or other appropriately designated committee. The evaluation shall determine the extent to which implementation of the program has resulted in a reduction in musculoskeletal disorder claims and days of lost work attributable tO musculoskeletal disorder caused by patient handling, and include recommendations to increase the program's effectiveness; and (vi) Submit an annual report to the safe patient handling committee of the facility, which shall be made available to the public upon request, on activities related to the identification, assessment, development, and evaluation of strategies to control risk of injury to patients, nurses and other health care workers associated with the lifting, transferring, repositioning, or movement of a patient. C) Nothing in this section precludes lift team members from performing other duties as assigned during their shift. Facilities Regulation STATE FORM 6899 NRT711 lfcontinuation sheet 6 of 12 RI Department of Health PRINTED: 09/03/2015 FORM APPROVED (X1) IDENTIFICATION NUMBER: STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION B. WING (X2) MU LTIPLE CONSTRUCTION A. BUILDING: (X3) DATE URVEY COMPLETED 08/20/2015 NAME OF PROVIDER OR SUPPLIER ELEANOR SLATER HOSPITAL STREET ADDRESS. CITYI STATE, ZIP CODE 111 HOWARD AVE CRANSTON, RI 02921 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) ID PREFIX TAG ID PREFIX TAG PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 2216 Continued From page 6 d) An employee may, in accordance with established facility protocols, report to the committee, as soon as possible. after being required to perform a patient handling activity that he/she believes in good faith exposed the patient and/or employee to an unacceptable risk of injury. Such employee reporting shall not be cause for discipline or be subject to other adverse consequences by his/her employer. These reportable incidents shall be included in the facility's annual performance evaluation. This Requirement is not met as evidenced by: Based on record review and staff interview, it has been determined that the hospital has failed to develop a safe patient handling committee and program. Findings are as follows: During record review and interview on 8/20/2015 at 12:10 PM, the Administrator of Joint Commission and Continuous Quality Improvement was unable to produce evidence of the implementation of a written safe patient handling program, with inputfrom the safe patient handling committee, to prevent musculoskeletal disorders among health care workers and injuries to patients. PATIENT CARE SERVICES 19.2 Patient Care Management 350 19.2 There shall be evidence that medical, nursing and other services are provided under an integrated 2216 350 Facilities Regulation STATE FORM 8899 Ifconlinualion sheet 7 of 12 RI Department of Health PRINTED: 09/03/2015 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDERISUPPLIERIC LIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED new diagnosis of osteopenia was identified. A 7/30/2015 nurse's note indicates the patient Resource? books for Medical Service Treatment Team Facilitators. AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: Hosooma 3- 08I2012015 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. ZIP CODE 111HOWARD AVE . ELEANOR SLATER HOSPITAL CRANSTON, RI 02921 (X4) SUMMARY STATEMENT OF DEFICIENCIES PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 350 Continued From page 7 350 written plan of care for each patient. Written care plans shall identify problems, goals, and interventions. Goals shall be measurable. This Requirement is not met as evidenced by: Based on record review and staff interview, it has been determined that the hospital failed to provide evidence of nursing interventions. and revision of the plan of care for 2 of 2 relevant sample patients (ID #4 13). - Findings are as follows: 1. Record review for patient ID #4 revealed the I . patient has diagnoses which include multiple 9?14?15 sclerosis, quadriplegia with bilateral upper ?Emma?- extremity contractures and lower extremity Training and Education observed patient#13?s care over3 days. It 10/551015 ?300'le (weakness/Faduced toHe) alid Obesity Education Department began retraining on bed baths $eptember4 - and September 8 With all CNA staff In the Regan BUilding. lgservicescto be by October 5 for all Medical Services] I rans on ampus . . s. Rev1ew of a care plan updated on 7/1/2015 and interview with unit nurses (staff and 6) revealed (I Ch 'Ilb dd d, Th I that the patient requires total care for a? activmes of daily livmg, Including aSSistance With DainCareFIew . . . . . . . as . reposmomng' patlent IS Incentment Of_b0we An ?Injury of Unknown Origin Internal Report Fonn' (See attached 9118,15 and bladder and is transferred Via mechamcaf Appendix B) was developed to assist Nursing Service and Risk Management in the investigation and subsequent actions related to to a wheelchan? any injury of unknown origin including documentation of Interventions on the patient?s care plan- . AIIS dN 'IIbt'd Ihl? On 2/4/2013 the patient complained of leg pain earteRepgrr'tsei b; gag; Re; M: [gage 1015:15 and an x?ray of a left forearm and left hip were Obtained. The x_ray results revealed a new All RN staff in Medical Serviceswill be trained on the Injury of 10/19/15 I I Unknown Ongin Internal Report Form by the Supemsmg diagnose of osteopenia (a bone condition RegisteredNurse. characterized by bone loss) in the left forearm .. . . . . Treatment Team Facmtators rewew all medical patient care 1019,2015 and ISTI: lens on a quarterly basis to assure any new diagnoses and interventions are properly documented on the care plan. Any non- compliance is to be reported to the Nurse Manager Weekly. . ev. Further .record [Bylaw revealgd. no [dance The Nurse Manager will present data at the Performance 11/122015 Interventions and t0 the care plan lmprolvementfl?eenng Commiitee?an basis regarding had been done for this patient when the above comp'ancew' Propemrepa" Requisition placed to order ?Allin one Nursing Care Planning 91181201 5 Facilities Regulation STATE FORM 6899 NRT711 If continuation sheet 3 of 12 PRINTED: 09/03/2015 FORM APRROVED Rl Department Of Health STATEMENT OF DEFICIENCIES (x1) (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A BUILDING. COMPLETED HOSOO102 3- WING 08/20/2015 NAME OF PROVIDER 0R SUPPLIER STREET ADDRESS. CITY. STATE. ZIP CODE 111 HOWARD AVE ELEANOR SLATER HOSPITAL CRANSTON, RI 02921 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION (X5) FREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING TAG TO THE APPROPRIATE DATE DEFICIENCY) 350 Continued From page 8 350 complained of pain to her/his left leg. The patient's left knee was noted to be edematous but no redness or bruising noted and the left leg was warm to touch. A nursing assistant reported the patient's leg is not "so floppy as usual." A review of the hospital incident report dated 7/31/2015 revealed that on 7/30/2015 the patient was sent out to the hospital for further evaluation for left leg pain, to rule out for deep vein thrombosis/cellulitis. The patient was admitted to the hospital with a left femur fracture and an Old tibial plateau fracture. A review of the hospital history and physical dated 7/31/2015 indicates an assessment and plan which identifies the fractures as suspicious given the patient is bed bound with no known history of fall or trauma. During an interview on 8/12/2015 at 9:00 AM, Nursing Assistant (Staff E) who has been providing care to the patient indicated that, prior to the hip fracture, she had provided care (AM care, including repositioning) to the patient without assistance from other staff. Interview with the unit nurse (Staff F) on 8/13/2015 at 10:00 AM revealed the patient needs total assistance for care and repositioning. The nurse further indicated that the patient is approximately 190 pounds and personal care is to be provided using 2 staff. Additional unit nurses were interviewed, Staff on 8/13/2015 at 9:55 AM, and Staff at 1:15 PM indicated that two nursing assistants are required to provide care and repositioning. Facilities Regulation STATE FORM 6899 NRT711 If continuation sheet 9 of 12 RI Department of Health PRINTED: 09/03/2015 FORM APPROVED Continued From page 9 When interviewed on 8/14/2015 at 2:00 PM, the Acting Nurse Manager (Staff I) was unable to produce evidence that the patient's care plan had been reviewed and or revised to reflect the new diagnosis of osteopenia. Additionally, no new nursing interventions were put in place. 2. Record review of the hospital incident report dated 7/18/2015 revealed patient ID #13 had two scratches of unknown etiology on the left hip and the scratches were already scabbed with no bleeding noted. A review of the conclusion dated 7/21/2015 indicates "upon investigation and statement taken, no one knows how the scratches happened. Staff stated it could happened during care or during positioning." Record review revealed a current care plan updated 7/7/2015 which indicates the patient has a traumatic brain injury and the patient is non?communicative most of the time. S/he has left hemiplegia (paralysis) with minimal right upper arm movement and both of the upper arms have contractures to the wrists and fingers. The patient requires total care from staff and is dependent for positioning. A nurse's note dated 7/18/2015 indicates the patient's left hip area was "noted to be reddened with two scratches-are scabbed". Further record review revealed that on 7/20/2015 a bruise was noted under the right arm/armpit. Staff documented that the bruise on the right arm "is oblong in shape, approximately 2 inches long, purple in origin". There is no evidence that this patient's care plan STATEMENT OF (X1) (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING. HOSOO102 3' WING 08/20/2015 NAME OF PROVIDER OR SUPPLIER STREETADDRESS, CITY. STATE, ZIP CODE 111 HOWARD AVE ELEANOR SLATER HOSPITAL CRANSTON, RI 02921 (x4) "3 SUMMARY STATEMENT OF DEFICIENCIES ID PLAN OF CORRECTION (X5) PREHX (EACH DEFICIENCY MUST BE PRECEDED BY FULL pREFix (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 350 350 Facilities Regulation STATE FORM 8899 If continuation sheet 10 of 12 RI Department of Health PRINTED: 09/03/2015 FORM APPROVED STATEMENT OF DEFICIENCI ES (X1) (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED indicated that when a nurse covers the dining room, the RN working the adjacent unit covers for Registered Nurses to ensure staf?ng levels are maintained in accordance with Regulations. Any issues will be reported directly to the Nurse Manager. AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: HOSOO102 3- WING 08/20/2015 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 111 HOWARD AVE ELEANOR SLATER HOSPITAL CRANSTON, RI 02921 ID SUMMARY STATEMENT OF DEFICIENCIES PLAN OF CORRECTION (X5) pm:le (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED 0 THE APPROPRIATE DATE DEFICIENCY) 350 Continued From page 10 350 was reviewed and or revised relative to these findings. Additionally, no nursing intewentions were put in place to address the above bruises. During an interview on 8/17/2015 at 2:45 PM, the Nurse Manager (StaffA) was unable to produce evidence that nursing interventions and revision to the care plan had been done for the above pa?ent 790 PATIENT CARE SERVICES 28.2 Nursing SerViCe 790 28.2 There shall be a sufficient number of 8/27/2015 registered nurses on duty at all times to plan. 3231353433 ii?giinirigrae'rgsip ie?giasrgig?? mirror - assign, units. Supawisa and evaluate nursing care as We? 3810 90%? provide direct patient care as required. cafeteria duty, coverage cflunch and supper breaks: 1 28.2.1 There shall be a registered nurse on Gamma Duty hB kC each Inpatient unit at all tImeS. 338$? gaggigh 0333:3513 ESRN [3 Egg}; . . . . 4300PM 5330PM Cafeteria Duty This ReqUIrement 15 not met 83 eVIdenced -RN Supper Break Coverage (SRN to assign; . . - - RN Supper Break Coverage (SRN to assign Based upon surveyor observation, record reVIew mom mm ORSPLIT, 4 Bl ck (11AM 3PM AND and staff interview, it has been determined that mo our 0 the hospital failed to ensure a registered nurse Lunch BreakCoverage (SRN to assign) (RN) IS available for every inpatient unit in the Adolf Meyer building, Adult Services. astigmatism? Emmi/?95 - RN Supper Break Coverage (SRN to assign RN Supper Break Coverage (SRN to assign Findings are as follows: - RN Supper Break Coverage (SRN to assign On agy day \lvhendali have been exhausted, SRNs will ca El'la a Iona Ui'l coverage. On 8/19/2015 at approxrmately 8:10 AM, unit 10 . . . SRNs grant RNs only 2 vacation days off per shift (As opposed to 9/21/2015 (located on the first floor) was observed Without the currentadays off per shift) until permanent positions are hired an present. At approximately AM, the Staf?ng Pattern to increase nurses on unitto 1.5 (one nurse on unit . . and one nurse on the ?oor to ?oat between mirror units) surveyor called the Nurse Manager of the bUIldIng Hf to the unit and asked as to the whereabouts of r3102? will be added to1st shirt. -3 Full Time RN Float will be added to 2nd Shift. was COVering the patient's breakfast in the dining 25,? Pools: 10,12,2015 room located on the 3rd ?oor' She further Nursing Staf?ng patterns will be reviewed daily by the Supervising Ongoing Facilities Regulation STATE FORM 6559 NRT711 If continuation sheet 11 of 12 PRINTED: 09/03/2015 FORM APPROVED RI Department of Health STATEMENT OF DEFICIENCIES (x1) (X2) MULTIPLE CONSTRUCTION (TO) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A BUILDING, COMPLETED I Hosoot 02 3- WING 08/20/2015 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY. STATE, ZIP CODE 111 HOWARD AVE ELEANOR SLATER HOSPITAL CRANSTON, RI 02921 (x4) SUMMARY STATEMENT OF DEFICIENCIES (D PROVIDERS PLAN OF CORRECTION (x5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAO REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED To THE APPROPRIATE DATE DEFICIENCY) 7'90 Continued From page 11 790 both units. The surveyor, in the presence of the Nurse Manager, walked onto the adjacent unit, 7, and failed to locate the RN. The Nurse Manager then stated that the RN working unit 7 was also covering unit 8, which is located on the second floor. At 8:35 AM, the unit 10 nurse (Staff B) arrived on the unit after observing breakfast. On 8/19/2015 at approximately 8:20 AM. Staff was observed on unit 8. He stated that he is covering 2 units today and it happens occasionally that RN's must cover 2 units. When questioned further, he stated that the units were on different floors. Review of the staffing schedule for the past week revealed that on 8/15/2015 during the day shift. Staff was assigned as the RN to cover 2 units and Staff was assigned as the RN to cover 2 units. When interviewed on 8/19/2015 at 10:45 AM, the Administrator and the Nurse Manager acknowledged that there are times when an RN covers 2 units. Facilities Regulation STATE FORM 6599 lfcontfnuation sheet 12 of 12 Append/Y A ELENOR SLATER HOSPITAL SAFE PATIENT HANDLING AND ASSESSMENT TOOL Directions: The RN will complete this assessment for all patients as part of the Hospital?s Safe Patient Handling Program. The form should also be completed within 24 hours of admission for new patients. The information on this form must be added to the patient?s individualized care plan and CNA daily flowsheet. Also, any changes to a patient?s condition and handling needs must be updated on the patient?s care plan, CNA daily flowsheet and captured in the Nursing Summary. Please file in the assessment section of the patient?s medical record. DATE: PATIENT NAME: UNIT: 1. Patient Weight: I 100?200 200-300 300-400 450+ 2. Patient's Level of Assistance: Independent: Performs safely with or without assistive devices. Dependent: Patient requires to lift more than 35le. of the patient?s weight, or is unpredictable. In this case assistive devices should be used. 3. Weight Bearing Capability: Full Partial None 4. Patient?s Level of Cooperation and Comprehension: Cooperative: May need minimal prompting; able to follow simple commands Uncooperative or Unpredictable: Not able to follow simple commands or a patient whose behavior changes frequently. Altered level of consciousness 5. Special Conditions: _Amputation _Osteoporosis Non-Verbal Hip/Knee/Shoulder Replacement _Contractures/Spasms Other: _Pa ralysis/ Pa resis _Fractu res _Fragile Skin #Fall Risk 6. Transfers: Independent Two Person Assist One Person Assist More Than Two People Appropriate Lift/Transfer Device Needed: 7. Ambulating: Independent One Person Assist Two Person Assist 8. Staffing Level for Care (Care includes bed baths, showering, repositioning, and toileting): 1:1 2:1 3:1 4:1 Other: 9. The staffing level circled above is in effect for all aspects of care- Nurses Signature: Date: Time: 9/15 Append? a) ELEANOR SLATER HOSPITAL INJURY 0F UNKNOWN ORIGIN- INTERNAL REPORT FORM Reporting Requirements: The DOH regulations require that the facility ensure that all allegations of mistreatment, neglect or abuse, as well as injuries of unknown origin, are reported immediatelyto the administrator and to other officials in accordance with State law through established procedures. Directions: The SRN must ensure that family/next of kin was notified and it was documented. Also the SRN must fill out this form and scan it to RISK MANAGEMENT within 24 hours of incident Also submit and scan with this form the followinq documents: 1) The hospital incident report 2) A copy of the patient's current care plan 3) A copy of the progress notes from the incident and 24 hours prior to the incident 4) Statements obtained from Staff who provided care 24 hours (or longer if necessary) prior to found injury 5) Progress note with the patient interview regarding how injury occurred Patient Name: Patient Today?s Date: Date of Incident: Facility/Unit Who reported injury? 7 Title: When was the Nurse Manager Notified? Name: Date: Time: Type of injury (if bruises or skin tears, list the color, location and the size of the injury): Does the patient have a history of falls? Yes No Does the patient have a history of self? abusive behaviors? Environmental Factors: What was (if any) the equipment used to aid in handling the patient? Were there any environmental factors that may have caused the injury? Yes No if yes please explain: (examples may include jewelry on staff or patient; fingernail length of staff or patient; equipment or furniture problems) Were there any medical issues that may have impacted the etiology of the injury (examples may include that patient is on a blood thinner, has osteoporosis, or skin problems)? What interventions were placed on the care plan after the injury was identified (problem, goal and approach)? 9/2015 SRN Signature: