Based on policy and procedure, medical records, and staff interviews. The facility failed to follow its policy and procedure by obtaining an order for restraints within minutes of initiation of restraints. In one of three patient record reviews. (Patient #1) Findings included: Review of the Policy and Procedure titled, Patient Restraint/ Seclusion. Policy #CSG.CSG.001, Reviewed: 05/30/2020. Order for restraints must be obtained from a LIP/physician responsible for the care of the patient before the application ... When a LIP/physician is not available to issue the restraints, an RN with demonstration competence may initiate restraint use based on face-to-face assessment. In an emergency situation, the order must be obtained during the emergency application or immediately (within minutes) after the restraint initiated .... A review of the Medical record for Patient #1 revealed that on 06/24/2020 9:00 PM, Patient #1 was restrained for attempts to remove devices. Further review of Patient #1 Medical records on 06/24/2020 at 11:56 PM, an order was obtained for the use of restraints to prevent pulling out treatment devices. Medical record review shows no evidence that an order was obtained within minutes. The order for the restraint was two hours, and 56 minutes after Patient #1was already in restraints. An interview was conducted with the VP of quality and the Director of Quality confirmed the above.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on a review of the Policy and Procedure, Clinical Record reviews, and staff interviews. It was determined that the facility failed to exercise patient/ family's rights concerning end-of-life decisions and failed to give the family information to make an informed decision regarding end of life decision for one of three patients reviewed (Patient #1). Findings included: Review of the facility policy, Do Not Resuscitate (DNR), Policy # ADMIN.RI.006.600, Revision: 09/2019, states that all persons will be given lifesaving treatment (cardio-Pulmonary Resuscitation, CPR) unless there is a physician order to withhold lifesaving treatment. Do Not Resuscitate(DNR). If no current orders are documented in the chart to withhold life-sustaining treatment, all persons will be given active (life-sustaining) treatment. Cardiopulmonary Resuscitation means only those measures used to restore or support cardiac or respiratory function in the event of cardiac or respiratory arrest. Cardiopulmonary Resuscitation includes any stimulation, massage pumping action to the heart by manual, mechanical, pharmaceutical or electric means; and/ or the assistance to respiration by oral (mouth to mouth) or mechanical means. A review of the medical record for Patient #1 revealed that the Patient was full code. Patient #1 was admitted on [DATE] for fall. On 05/28/20 Patient #1 had surgery on left displaced periprosthetic and femur fracture. On 05/30/20 at 2:01 PM, the Physician progress note showed that the Patient had altered mental status and was on respiratory support (BiPAP: non-invasive ventilation is used of breathing support administer n through a face mask or nasal mask). The family expressed that they only wanted the Patient to have medication coding and intubation (Placing a tube in your throat to help move air in and out of your lungs. Mechanical ventilation is the use of a machine to move air in and out of the lungs). They did not want the Patient to have any further chest compression and Defibrillation ( a process in which an electronic device sends an electric shock to the heart). The family informed the Physician of their wishes before and after the Patient was given CPR. On 05/30/20 at 2:20 PM a Nursing note reflected that during catheter placement for dialysis, the Patient went Asystole (cardiac arrest in which the heart stops beating). Compression started, and medication administered. The family stated the Patient isn't to receive CPR or Defib. On 05/31/2020 at 12:36 AM, Death event note: The Patient placed on hemodialysis on May 30th. The family declined an exploratory lap to rule out any intra-abdominal bleeding and also rejected any heroic intervention such as chest compression. The Patient pronounced at 05/31/2020 12:36 AM. An interview on 06/05/2020 at 12:20 PM with the Patient Safety Director and the Director of Quality confirmed that the rights of the Patient and next of kin were not honored and the physician did not explain to the family that the facility only has DNR or full code. Per the Director of Quality, the physician is new to the facility.
Based on policy and procedure review, document review, medical record review, and staff interviews, it was determined the facility failed to provide and ensure a safe discharge as evidenced by the following: 1. Failed to ensure delivery and receipt of durable medical equipment for patients requiring a wheelchair at home. (Refer to A820) 2. Failed to honor patient/family choice of discharge facility. (Refer to A823) 3. Failed to follow physician orders for patient discharges. (Refer to A820) 4. Failed to notify patient's family/representative of the patient's discharge. (Refer to A820) 5. Failed to analyze facility readmissions related to the discharge process. (Refer to A843) See Tags A820, A823, A843
Based on policy and procedure review, medical record review, and staff interviews, it was determined the facility failed to implement and keep the family/legal representative informed of the discharge plan for three (#2, #3, #5) of five medical records sampled Findings included: A review of the policy entitled, Discharge Plan, # PC 402.917, reviewed 04/18, showed Case Manager (CM) is accountable for a prompt, orderly, systematic, and interdisciplinary effort among clinical services, the patient, family, and appropriate community resources and continuity of care post discharge...discharge (DC) planning process is initiated upon admission ...the planning process encourages participation by the patient/family or legal representative including patient/family education post discharge care ... ensure that the necessary services are available at the appropriate level of care...reassessment DC planning is an evolving process that reflects the patient's changing status until the time of DC in order to provide for continuity of care post DC ...patients are DC or transferred from the hospital based on documented physician order... discussion with the patient/family and their understanding of the DC plan and DC instruction is recorded. 1. A review of Patient #2's physician discharge (DC) summary dated 11/27/18 at 7:36 PM showed a DC diagnosis of shortness of breath, chronic obstructive pulmonary disease (COPD) exacerbation, and pneumonia. The physician summary showed the patient was to be DC'd home with an order for a wheelchair. A review of Patient #2's CM notes dated 11/24/18 at 3:22 PM showed a physician order for a wheelchair had been received and a referral was sent to a durable medical equipment (DME) provider for a wheelchair. The note showed the CM called the DME provider call center and was told the local representative would call the CM back. Continued review of the CM notes failed to reveal the CM followed up to ensure the wheelchair was ordered or received. An interview on 1/17/19 at 2:45 PM with the Director of CM confirmed the CM failed to document if the wheelchair was ordered or received by Patient #2. The Director stated she would have to call the DME Company to know for sure if the patient received the wheelchair once she got home. 2. A review of Patient #3's physician discharge summary (DC) documentation dated 12/04/18 at 3:56 PM showed a DC diagnosis of acute respiratory failure and pneumonia. The note showed the patient was discharged to a rehabilitation facility with a sleep study ordered so she could obtain home CPAP/BIPAP prior to returning home. The patient was noted to be awake, alert and oriented. A review of CM documentation dated 11/30/18 at 4:34 AM, showed Patient #3's daughter told CM that she wanted her mother to go to a specific skilled nursing facility (SNF) and she would call back with a second choice. A review of Patient #3's patient choice letter, dated 12/03/18, showed the patient's signature consenting to be transferred to a SNF other than the one specified by the daughter. A complete review of the medical record failed to reveal the presence of any other facility choice letters signed by the patient or patient's representative. A review of the CM notes dated 12/04/18 at 3:31 PM showed the Patient #3 was discharged a SNF other than the one specified by the daughter. On 01/17/19 at 11:15 AM an interview performed with the Director of CM confirmed the only facility Patient #3 and the patient's representative agreed to the original SNF. The CM confirmed the facility failed to implement Patient #3's DC plan and ensure the family/legal representative was informed of the SNF change. The CM Director also confirmed CM failed to document the patient's daughter/legal representative was made aware the patient was DC'd from the facility. 3. A review of Patient #5's physician DC summary dated 12/05/18 at 11:40 AM showed the patient had been admitted for complaints of weakness, lethargy, and mild shortness of breath for 2-3 days. The note showed the patient stated he had chronic anemia for the past 2 years resulting in falls, fainting spells, and chronic dizziness. The note showed the last time the patient reported he fainted and lost consciousness was 2 month ago. The note showed the patient was DC'd to a SNF. A review of Patient #5's physician orders dated 12/05/18 at 6:27 PM confirmed there was an order for the patient to be DC'd to a SNF. A review of Patient #5's facility choice letter dated 11/04/18 at 1:00 PM showed three SNF's chosen by the patient. A review of the CM and RN notes showed the following documentation: 11/30/18 at 3:20 PM - CM note showed the patient stated he lived alone and requested he needed a wheelchair. The note showed the patient transportation home would be a taxicab. 12/05/18 at 11:22 AM - CM noted showed the patient stated he refused rehab and home health and wanted to go home. The note showed the physician and nurse were made aware. 12/05/18 at 1145 AM - CM note showed that approximately 23 minutes after the the last CM note, the unit charge nurse told CM that the patient might go to rehab after all. CM Working on authorization for rehab facility. 12/05/18 at 2:15 PM - CM note showed rehab facility was called and voicemail left to expedite authorization 12/05/18 at 3:08 PM - CM note showed insurance company was faxed to request an authorization for the rehab facility. No date and No time - CM note showed the patient refused HH and SNF at last minute. 12/05/18 at 6:17 PM - nursing note the physician was called to inform him the patient was refusing the SNF. The note showed the physician agreed to DC home. 12/05/18 at 6:27 PM - physician order showed the patient was to be DC'd to a SNF. A review of the physician orders failed to reveal the presence of an order for the patient to be DC'd home. 12/06/18 and no time - CM note the day after the patient was DC'd showed the patient had been booked to go to a SNF. An interview with the Director of CM on 01/18/19 at 2:00 PM revealed that Patient #5 decided he wanted to go to rehab on 12/05/18 at 3:08 PM. The Director confirmed the CM notes on 12/05/18 showed the patient went home. The CM confirmed the notes on 12/05/18 were not dated or timed. She confirmed the CM note on 12/06/18 showed the patient was DC'd to SNF. The Director confirmed the notes were conflicting, but the patient actually went home. The Director confirmed the patient had requested a wheelchair for home, but there was no documentation of CM follow-up for the wheelchair or evaluation of a safe DC home instead of a SNF.
Based on policy and procedure review, medical record review, and staff interviews, it was determined the facility failed to honor the patient or patient's representatives choice of facilities for one (#3) of five medical records sampled. Findings included: A review of the policy entitled, Discharge Plan, # PC 402.917, reviewed 04/18, showed the DC planning assessment/evaluation is discussed and confirmed with patient/family/guardian in order to facilitate timely development of a DC plan prior to discharge ...this can include patient/family rejection of the DC plan ...The patient choice form is completed when referral to a skilled nursing facility (SNF) or home health (HH) agency is required post DC. Selection of resources is decided by patient/family with physician recommendation and payer source consideration ...plans will include the participation of family as appropriate and consultation with the physician ....discussion with the patient/family and their understanding of the DC plan and DC instruction is recorded. A review of Patient #3's physician discharge summary (DC) documentation dated 12/04/18 at 3:56 PM showed a DC diagnosis of acute respiratory failure and pneumonia. The note showed the patient was discharged to a rehabilitation facility with a sleep study ordered so she could obtain home continuous positive airway pressure (CPAP) therapy, a common treatment for obstructive sleep apnea. The patient was noted to be awake, alert and oriented. A review of Patient #3's physician orders dated 12/03/18 at 11:00 PM showed an order for the patient to be discharged to a skilled nursing facility (SNF) when a bed is available and for a sleep study while at rehab to assess the need for continuous positive airway pressure (CPAP) therapy. A review of Patient #3's face page showed the healthcare surrogate/durable power of attorney was the patient's daughter. A review of Patient #3's CM documentation dated 11/30/18 at 11:34 AM, showed that physical therapy (PT) recommended a skill nursing facility (SNF). A review of CM documentation dated 11/30/18 at 4:34 AM, showed the patient's daughter told CM that she wanted her mother to go to a specific skilled nursing facility (SNF) and she would call back with a second choice. A review of CM documentation dated 11/30/18 at 11:35 AM, showed CM made a referral to a different SNF. A review of Patient #3's choice letter, dated 12/03/18, showed the patient's signature consenting to be transferred to the SNF other than the one specified by the daughter. A complete review of the medical record failed to reveal the presence of any other facility choice letters signed by the patient or patient's representative. A review of Patient #3's CM notes dated 12/04/18 at 3:31 PM showed the patient was discharged to a SNF other than the one specified by the daughter. On 01/17/19 at 11:15 AM, an interview performed with the Director of CM confirmed the only facility Patient #3 and Patient #3's representative agreed to was the original SNF. The CM confirmed that the SNF where Patient #3 was discharged was not listed as one of the patient's or patient's representative SNF choices. The Director confirmed the CM notes failed to show the patient's representative was notified of the change in SNF's or that the patient had been discharged to that facility.
Based on document review and staff interviews, it was determined the facility failed to track and analyze readmissions related to the discharge process in order to identify preventable readmissions. Findings included: On 01/18/19 at 1:00 PM a review of the facility patient readmission data showed the facility patient readmission rate within 7 days from skilled nursing facilities (SNF) was 36.6% and from home health (HH) was 45.9%. On 01/18/19 at 1:05 PM an interview with the CM Director confirmed the facility did not track readmission data to see if the DC planning process contributed to the readmission rate. An interview on 01/18/19 at 1:10 PM with the VP of QM & Safety confirmed the above facility patient readmission rate from SNF/HH. She confirmed further analysis to see if the readmission were related to the DC process had not occurred. The VP stated she thought the data collection and analysis had started last month, however, she was made aware by the CM Director that it had not been started.
Based on review of facility policies and interviews it was determined the facility failed to review nursing policies periodically or have a policy in place for when policies should be reviewed. Findings included: A review of facility nursing policies and procedures revealed the following policies were not reviewed to ensure current practice. On 12/27/2016 at 2:00 p.m. a review of the nursing policies revealed the following: 1. RE: Physician Order Management, #PC 307.600, Last Reviewed 03/2014 signed by Chief Nursing Officer 2. Electronic Medication Administration Record System (eMAR), #IM.912.600, Last Reviewed 11/2013 signed by Chief Nursing Officer 3. Patient Care Acuity Levels, #ED-07, Last Reviewed 11/2013, signed by Chief Nursing Officer 4. Admission and Discharge Criteria for Critical Care Unit, #NA, Last Reviewed 03/2015, signed by Chief Nursing Officer 5. Telemetry Standards of Care, #ADM-010, Last Reviewed 08/2012, Department Nursing. On 12/28/2016 at 12:00 p.m. an interview with the Vice President of Quality Management confirmed the findings. The Vice President of Quality Management revealed there was no policy outlining when nursing policies should be reviewed. The Vice President of Quality Management was unable to determine if the policies were in compliance with the national standards of nursing practice and quality of care initiatives with process improvement.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review, facility policy review and interviews it was determined the registered nurse failed to supervise and evaluate nursing care related to notifying the physician of changes in condition and meeting the patient's needs for nutrition and personal care for one (#1) of ten sampled records. Findings included: On 12/27/2016 at 2:00 p.m. a review of Patient #1's record revealed the patient was admitted on [DATE]. The nursing documentation dated 03/15/2016 stated subject alert and oriented to person, place and time. Wife states poor appetite and patient hardly ever eats, but he appears obese. Patient has refused breakfast and lunch because he didn ' t like what was on the tray, family requested we feed him, certified nursing assistant notified of request. A review of the nursing notes and flow sheets documentation did not show evidence of the patient being fed. The review failed to show evidence of substitution meals being offered to the patient. Documentation failed to show daily personal care needs being met. A detailed review of the medical record with the Vice President of Quality Management did not reveal any documentation of nursing assisting with meals as request by the family or documentation activities of daily living. On 12/28/2016 at 11:00 a.m. the Vice President of Quality Management confirmed the above findings. Review of facility policy titled assessment/Reassessment, # PC 004.600 stated: Reassessments are performed a minimum of every 4 hours or more frequently as patient's condition indicates; any changes in the patient's status are to be documented. Policy titled Telemetry Standards of Care, # ADM-010, stated: to document the notification. A review of patient #1's physician orders revealed an order dated 03/12/2016 for BiPAP [Bilevel Positive Airway Pressure] and to keep the oxygen saturation greater than or equal to 92 percent. On 12/27/2016 at 2:00 p.m. a review of patient #1's medical record revealed the patient was admitted on [DATE] at 4:31 p.m. A review of the documentation of vital signs and oxygen saturation showed on 03/12/2016 the Oxygen Saturation was documented as 90 percent. On 03/13/2016 the Oxygen Saturation was documented as 89 percent. On 03/14/2016 the Oxygen Saturation was documented as 86 percent. On 03/15/2016 the Oxygen Saturation was documented as 90 percent and 88 percent. On 0316/2016 the Oxygen Saturation was documented as 89 percent and 85 percent. On 03/17/2016 at 6:33 a.m. nursing documented patient did not sleep much throughout the night as he was struggling to keep his BiPAP mask on all night. Patient was getting very frustrated .... Respiratory Therapy... increased his oxygen level . . . also attempted to place patient on non-re-breather however his oxygen saturation would only reach 78 percent.... A detailed review of the medical record with the Vice President of Quality Management did not reveal documentation the physician was notified of the patient's change in condition. On 12/28/2016 at 11:00 a.m. the Vice President of Quality Management confirmed the above findings.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on review of hospital policy and medical records and staff interview, the facility failed to update the Plan of Care for one (#7) of ten sampled records for nutritional needs. Findings include: Review of the facility policy titled Documentation of Patient Care: Patient's Plan of Care #IM904.600, indicated The Plan of Care is initiated and approved by the RN ...the RN will then be responsible for reviewing and prioritizing all problems identified for the patient ...the RN must update the care plan's problem list, goals and interventions a minimum of every twenty-four hours (24) hours. On 12/28/16 at 8:55 a.m. a review of patient #7's medical record revealed the patient was admitted on [DATE]. Review of patient #7's Plan of Care (POC) revealed it was initiated on 12/26/16 by an RN. It indicated on the priority list the patient had Impaired Neurological Function with dysphagia (difficulty swallowing) and at risk protocol screen should be performed as soon as possible and before eating. Swallow tool will be added to the chart and nursing interventions should include 1. Nothing by Mouth 2. Head of Bed up. Review of physician orders revealed a Heart Healthy Diet was ordered on [DATE] by the attending Physician. There were no restrictions on oral intake ordered by the physician. Review of the patient's daily intake revealed the patient was eating 70 percent of meals on 12/27/16 and 12/28/16. Review of the patient's oral intake revealed 500 milliliters (ml) of oral fluids were taken on 12/27/16 and 800 ml of oral fluids were taken on 12/28/16. Review of Patient #7's POC revealed the following nursing documentation: On 12/25/16 at 10:26 p.m. the POC acknowledged Impaired Neurological Function with dysphagia still listed on the problem list. There were no changes made to the POC. On 12/26/16 at 8:15 a.m. the POC acknowledged Impaired Neurological Function with dysphagia still listed on the problem list. There were no changes made to the POC. On 12/26/16 at 8:00 p.m. the POC acknowledged Impaired Neurological Function with dysphagia still listed on the problem list. There were no changes made to the POC. On 12/27/16 at 8:00 p.m. the POC acknowledged Impaired Neurological Function with dysphagia still listed on the problem list. There were no changes made to the POC. On 12/28/16 at approximately 12:30 p.m. an interview conducted with Vice President of Quality Management confirmed Patient #7's POC was not updated as required by hospital policy.
Based on record review, facility policy review and interviews it was determined the facility failed to ensure a patient's legal representative was notified of changes in condition for one (#1) of ten sampled patients. The facility had no policy addressing notification of the patient's personal primary care physician Findings included: On 02/22/2016 at 2:30 p.m. a review of the patient's medical record for admissions dated 11/30/2015 to 12/07/2015; 12/14/2015 to 01/12/2016 and 01/14/2016 to 02/09/2016 revealed during the 12/15/2015 admission the patient developed a redden area on the sacrum area. There was no documentation the patient's legal representative or attending physician was notified of the change in condition. On 02/23/2016 at 10:00 a.m. an interview with the Director of Patient Safety/Risk Management confirmed the above findings On 02/23/2016 at 10:00 an interview with the Vice President of Quality and the Director of Patient Safety/Risk Management confirmed the facility did not have a policy regarding the notification of a patient's personal primary care physician whether on staff or not at the facility of an admission.
Based on record review, facility policy review and interviews it was determined the registered nurse failed to supervise and evaluate nursing care related to implementing the policies regarding daily weights and medication administration for one (#1) of ten sampled records. Findings included: On 02/22/2016 at 2:30 p.m. a review of patient #1's medical record from 11/30/2015 to 12/07/2015 revealed the physician ordered Norvasc to be given daily at 9:00 a.m. On 12/1/2015 the medication was given at 10:38 a.m., 38 minutes past the policy time frame. A detailed review of the medical record revealed no documentation why the medication was given late. There was no documentation the physician was notified of the late administration per facility policy title Medication Management-Administration and Monitoring. On 02/22/2016 at 2:30 p.m. a review of patient #1's medical record from 12/15/2015 to 01/12/2016 and 01/14/2016 to 02/19/2016 revealed the patient was on a daily diuretic (Lasix). There was no documentation of daily weights as required per facility policy titled Medical Surgical Standards of Care. On 02/23/2016 at 10:00 a.m. an interview with the Vice President and Director of Patient Safety/Risk Management confirmed the above findings.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on records review and staff interview it was determined the registered nurse failed to supervise and evaluate nursing care to meet the needs of patients with seizures for 2 (#3, #8) of 10 sampled patients. Findings include: 1. Patient #3 was admitted to the facility on [DATE] with a chief complaint of abdominal pain. The initial nursing assessment dated [DATE] at 4:30 a.m. indicated the patient arrived to the nursing unit in stable condition. The patient was assessed and the physician was contacted for orders. The nursing documentation on 12/14/13 at 10:17 a.m. signed by the Registered Nurse (RN) stated at 9:49 a.m. the patient experienced a seizure. 12/15/14 the neurology consultant recommended to place the patient on seizure precautions. The review of nursing documentation from 12/14/2013 to 12/20/2013 failed to reveal evidence the nursing Plan of Care was updated to include seizure precautions and that seizure precautions were implemented. 2. Patient #8 was admitted on [DATE] at 12:11 p.m. with syncope and possible seizure. Review of the patient's Plan of Care indicated the nursing intervention for seizure precautions was added to the care plan on 5/1/14 at 10:46 a.m., a period of approximately 22 hours following admission. The detailed review of the nursing assessments performed between 4/30/14 at 4:08 p.m. and 5/1/14 at 8:00 p.m. failed to reveal evidence seizure precautions had been implemented. On 5/2/14 at approximately 4:10 p.m. an interview with the 2C Unit Clinical Coordinator revealed the care plan for seizure precautions includes the padding of the side rails. The Risk Manager confirmed the findings of failure to update the care plan for seizure precautions and implementation of seizure precaution for both patients on 5/2/2014 at approximately 4:15 p.m.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on clinical record review, policy review and interview it was determined the facility staff failed to provide discharge instruction concerning the administration of insulin to a patient/ representative for 1 (#2) of 10 sampled patients. Findings include: Patient #2 was discharged on [DATE] with a prescription for Insulin to use according to a sliding scale. Review of nursing documentation from time of admission on 2/19/13 to discharge on 2/28/13 did not reveal any evidence the patient or responsible representative received appropriate discharge education relating to the self administration of insulin. An interview was conducted with staff nurse #2 on 4/16/13 at 11:25 a.m. The nurse was questioned concerning who is responsible for insulin injection education. The nurse responded the patient's nurse is the one responsible for the injection education. A review of the facility's policy, Discharge Plan policy #PC 402.917, revised 1/12, page 5, section (3) Nursing revealed nursing is to provide educational material to the patient and family members.
Based on record review and staff interview it was determined the facility failed to comply with 42 CFR 489.24 and 489.20 related to providing on-call specialty services for Ophthalmology for 1 (#1) of 20 sampled patients. Record review revealed on 1/26/13 a patient presented to the Emergency Department with a chief complaint of a right eye injury following being hit with a piece of metal from welding. The eye exam noted a visual acuity of 0/0 with injury. The ED physician indicated the ophthalmologist on call had been called for approximately an hour with no response. The lack of response from the on call ophthalmologist lead to the patient being transferred to another acute care hospital for eye surgery. Refer to A2404. The facility has taken corrective actions.
Based on clinical record review, staff interview and policy review it was determined the on-call specialist for ophthalmology did not respond when requested by the emergency department physician for 1 (#1) of 20 sampled patients. This resulted in the unnecessary transfer of the patient and a delay in treatment. Findings include: Patient #1 presented to the Emergency Department (ED) on 1/26/13. The patient was triaged at 12:49 a.m. with a chief complaint of a friend welding metal and some went into the right eye. The pain level was listed as 9 out of 10 on the pain scale of 0-10. The vital signs were within normal limits. A review of the ED nursing notes revealed an eye assessment was completed at 1:06 a.m. with a right eye acuity of 0/0 and left eye 20/20. A review of the ED physician's documentation revealed the patient was evaluated on 1/26/13 at 1:01 a.m. The chief complaint was an infected eye, decreased vision and pain after the right eye was hit with a metal fragment from grinding. The physical assessment listed the visual acuity of right eye as abnormal, laceration, abnormal cornea, the iris was torn medially, hyphema with possible globe rupture and a complex corneal laceration. Further review of the ED physician's documentation revealed the first call to the ophthalmologist on-call was made at 1:12 a.m. and multiple attempts over the next hour. At 2:15 a.m. alternate facilities were contacted. At 3:20 a.m., the ED physician spoke with the receiving facility's physician. The patient was transferred on 1/26/13 at 5:04 a.m. to another acute care facility for ophthalmology care. An interview was conducted on 2/13/13 at 2:20 p.m. with the Vice President of the Risk Management. After review of patient #1's clinical record, she confirmed the above findings. A review of the facility's license revealed that ophthalmology was offered as one of the emergency services. A review of the Hospital Emergency Services, AHCA form 3130-8001 revealed ophthalmology is provided on-site 24 hours per day, 7 days per week. A review of the Medical staff Rules and Regulations, adopted 1/27/12, page 1, paragraph 1, revealed if after the initial examination by the Emergency Department physician, the physician determines it is medically necessary that the patient receive the services of a physician listed by the Hospital on its list of on-call physicians for that day, the on-call physician shall be notified and must respond/appear to the Emergency Department within a reasonable period of time for further assessment.... .... In either event, the on-call physician must respond/appear to the ED upon request of the ED physician. A review of the ED on-call schedule for January 2013 revealed the ophthalmologist in question was on call for 1/26/13. A review of the facility's policy, EMTALA- Florida Provision of On-Call Coverage, policy # RI 020.780 G, revised 6/12, page 5 of 6, revealed Physician's Responsibility paragraph 1,immediate availability, at least by telephone, to the ED physician for his or her scheduled on-call period, or to secure a qualified alternate if appropriate. A review of paragraph 4 revealed, the on-call physician has a responsibility to provide specialty care services as needed to any individual who comes to the ED either as an initial presentation. A review page 6 of 6, paragraph titled, Physician Appearance Requirements, if a physician on the on-call list is called by the hospital to provide emergency screening or treatment and either fails or refuses to appear within a defined period of time, the hospital and that physician may be in violation of EMTALA as provided for under section 1867 (d) (1) (C) of the Social Security Act ... ..... If as a result of the on-call physician's failure to respond to an on-call request, the hospital must transfer the individual to another facility for care. The patient was transferred to another acute care facility due to the ophthalmologist failure to respond to on-call duties.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review, staff interview and policy review it was determined that the registered nurse failed to ensure accurate and timely assessments of the condition for two (#1,#8) of ten sampled patients. This practice does not ensure patients' nursing needs are met or appropriate interventions initiated. Findings include: 1. The facility policy Assessment /Reassessment #PC 004.600, last revised 6/11 requires a shift assessment each shift. The nursing staff works 12 hour shifts. Assessment of the Intravenous (IV) site is included in the shift evaluation. 2. Patient # 1 was admitted to the facility on [DATE] with the chief complaint of headache. The history and physical indicated the patient had a history of lupus, diabetes, osteo[DIAGNOSES REDACTED] and hypertension. Patient #1 had an original IV line inserted in the left hand at 5:17 p.m. on 5/13/11. There was no assessment of the IV site for the 7 a.m. - 7 p.m. shift on 5/4/11. The assessment documented at 8:00 p.m. on 5/4/11 at 8:00 p.m. indicated the IV site was the left forearm. There was no documentation of when the a new IV catheter had been inserted or the reason for discontinuing the old one. The assessment on 5/6/11 documented the site as the right forearm with the date of insertion as 5/5 instead of 5/4. There was no documentation of assessment of the site. The assessment documented on 5/7/11 at 11:38 p.m. indicated the site was still the right forearm, but the insertion date was changed to 5/6/11. Again there was no documentation of assessment of the site. The assessment on 5/8/11 at 8:00 a.m. indicated that the site was red and swollen. A new IV catheter was inserted in the left forearm. The assessment on 5/8/11 indicated that the site was the right forearm instead of the left. The appearance of the site was not documented. The assessment on 5/9/11 at 9:30 a.m. documented the site was the right forearm instead of the left and the date of insertion was 5/5/11 instead of 5/8/11. The assessment on 5/10/11 at 2:56 a.m. documented the correct site and insertion date, but did not document the assessment of the site. The assessment on 5/10/11 at 9:30 a.m. documented the site was the right forearm instead of the left and indicated the insertion date was 5/5/11 instead of 5/8/11. The patient was discharged on [DATE]. Nursing staff documented that the right forearm was swollen, red and purple. Review of the medical record revealed no evidence that the physician was notified of the condition of the right forearm. The Licensed Practical Nurse who was caring for the patient at the time of the discharge was interviewed on 6/21/11 at approximately 2:30 p.m. She stated that she had notified the physician before the patient was discharged , but did not know if he had actually seen the patient. She stated she did not document that she notified the physician as she does not have time to document everything. 3. Patient #1 was readmitted on [DATE] with an infected IV site of the left forearm, requiring surgery. An IV catheter was inserted into the left hand on 5/14/11 in the ED. The first assessment performed on the nursing unit on 5/14/11 at 9:07 p.m. did not include an IV assessment. The assessment on 5/15/11 at 8:00 a.m. indicated the site was the left hand and the insertion date was 5/13/11 instead of 5/14/11. There was no documentation of the appearance of the site. The assessment on 5/15/11 at 10:00 p.m. indicated the insertion date was 5/16/11, which was inaccurate. On 5/18/11 the IV site was changed to the left antecubital space. The assessment on 5/19/11 at 9:30 a.m. did not include assessment of the site. The assessment on 5/20/11 did not include assessment of the site. The assessment on 5/21/11 did not include assessment of the site. On 5/22/11 the site was changed to the left forearm. The assessment on 5/22/11 at 9:00 p.m. did not include site assessment. The assessment on 5/23/11 at 11:15 a.m. did not include the site assessment. The Nursing Director was present during the review of the record on 6/21/11 at approximately 3:00 p.m. She confirmed the findings but could not explain the inaccuracies in documentation. The VP for Quality was also present during the review. She stated the staff documents by exception. However, the policy she provided Charting Within Defined Parameters, #IM.910.600 last revised 8/09 did not include the assessment of the IV site. 4. Patient #8 was admitted to the facility on [DATE] with the diagnoses of [DIAGNOSES REDACTED] On 6/17/11 there was no shift assessment documented 7 a.m. - 7 p.m. shift. The assessment on 6/17/11 at 2000 had no documentation of site assessment and indicated the insertion date was 6/17 instead of 6/16. The assessment on 6/18/11 indicated there was an IV site in the left forearm with an insertion date of 6/17 and one in the left upper arm with an insertion date of 6/16/11. This was the first documentation of an IV site in the upper arm. The assessment on 6/19/11 at 8:00 a.m. indicated an IV site in the left forearm with an insertion date of 6/17/11 instead of 6/16/11. The left upper arm site was also documented with an insertion date of 6/16/11. The assessment on 6/19/11 at 9:00 p.m. indicated there was an IV site in the left wrist. There was no documentation of the two other IV sites being discontinued, the conation of the sites at the time discontinued or that a new IV site was initiated. The staff nurse who was present during the record review on 6/22/11 at approximately 2:30 p.m. substantiated the findings. 5. The physician ordered daily weights for patient #8. Review of the documentation revealed the weight on 6/16, 6/17, 6/18 was documented as 99.7 kilograms (219.8 lbs). On 6/19 the weight was 69.84 kilograms (154 lbs), on 6/20/11 the weight was 73 kilograms, on 6/21 the weight was 73 kilograms (160.9 lbs.) and on 6/22 the weight was 76 kilograms (176.6 lbs). There was no evidence the accuracy or discrepancies of the documented weights had been investigated or addressed.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review and staff interview, it was determined that the facility did not ensure that medications are administered as ordered by the physician. This practice may result in failure to achieve maximum therapeutic effects. Findings include: Patient #8 was admitted to the facility on [DATE] with the diagnosis of dehydration and acute renal failure. The physician ordered Flagyl 500 milligrams IV every 8 hours on 6/17/11. Review of the Medication Administration Record revealed the medication was administered 1 1/5 hours late on 6/18/11. The dose was due at 2:00 p.m. and was not administered until 3:33 p.m. Additionally the nurse documented that the medication had been scanned early, will give at 2200 at 8:15 p.m. on 6/20/11. There was no documentation that the medication was administered at 10:00 p.m., when it was due. These findings were confirmed by the staff nurse present during the record review on 6/22/11 at approximately 2:30 p.m.
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