HCA Florida Highlands Hospital

Based on policy review and interview it was determined the facility's chief nursing officer failed to establish and / or review nursing services policies to ensure the policies for the provision of nursing services were reviewed and up-to-date with current nursing standards of care.

Findings include:

On 03/09/2015 at 9:00 a.m. a request for all the facility policies regarding nursing services including medication administration was requested. The following policies were supplied:

1. Ordering & Prescribing Medication, #10-02, Last reviewed 12/2013

2. Admission Nursing Assessment, #NS-13, Last reviewed 08/2013

3. Pharmacist Review of Orders, #11-01b, Last reviewed 02/2014

4. Read-Back of Verbal / Telephone Orders and Critical Tests, #NPSG 2A, Last reviewed 01/2009

5. Routine Vital Signs, #NS-36, Last reviewed 10/2010

6. Skin Integrity Assessment and Interventions, #NS-206, Last reviewed 10/2013

7. Colostomy Care-Changing Appliance, #003-NS-238, Last reviewed 01/2009,

8. Notification of Physicians of Changes in Patient Condition, #003-NS-301, Last reviewed 01/2010,

9. Patient Plan of Care, NS-7, Last reviewed 01/2009

10. Ordering and Prescribing Medication, #10-02, Last reviewed 12/2013,

11. Dispensing: General, #11-01, Last reviewed 12/2013

A review of the above policies revealed the policies had not been reviewed annually. An interview with the Chief Nursing Officer on 03/09/2015 at 2 p.m. confirmed the above findings.

Based on document review and staff interview it was determined the facility failed to develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program for the facility's interventional cardiac program, outpatient wound care that included hyperbaric therapy and the sleep study laboratory clinical programs. The 126 bed facility performed 167 interventional cardiac catheterization procedures since June 2012. The facility:

Failed to ensure an ongoing program with measurable improvement indicators and failed to measure, analyze and track quality indicators to assess the processes of care, service and operations related to the interventional cardiology program, outpatient wound care center that includes hyperbaric therapy and sleep studies laboratory. (Refer to A0273)

Failed to have a process in place to analyze data related to the interventional cardiology program, the outpatient wound care center that includes hyperbaric services and the sleep studies laboratory. (Refer to A0283)

Failed to ensure quality review of the interventional cardiology program, the outpatient wound care center that includes hyperbaric services and the sleep laboratory. (Refer to A0308)

The Chief Executive Officer (CEO) failed to ensure quality review of the interventional cardiology program, outpatient wound care center that included hyperbaric therapy and the sleep studies laboratory. (Refer to A0309)

During the entrance conference on 4/24/13 at approximately 9:00 a.m. the CEO stated the cardiac catheterization laboratory was temporarily closed due to renovation and installation of new equipment. He stated the procedures were being done in the Operating Room utilizing a C-Arm since 4/8/13. Review of the quality documentation revealed no evidence of monitoring while services were being provided in the different location utilizing a C-arm.

The cumulative effect of the lack of a quality assessment performance improvement plan for the interventional cardiology, outpatient wound care with hyperbaric therapy and the sleep study programs resulted in the determination of non-compliance with the Condition of Participation for Quality Assessment and Performance Improvement.

Based on document review and staff interview it was determined the facility failed to ensure an ongoing program with measurable improvement indicators and failed to measure, analyze and track quality indicators to assess the processes of care, service and operations related to the interventional cardiology program, outpatient wound care center that includes hyperbaric therapy and sleep study laboratory.

Findings include:

During review of the quality monitors for the interventional cardiology program on 4/25/13, it was noted there was no documentation of data collection related to the program that was initiated in June 2012. The only data presented was meeting minutes from the STEMI committee. The only physician involved was the only interventional cardiologist on staff. There was documentation the cases were reviewed, but there was no evidence of any quality indicators that would evaluate effectiveness and quality of the services provided. The Director of Critical Care provided documentation that there had been 167 procedures since June 2012.

The Chief Executive Officer was interviewed on 4/25/13 at 12:35 p.m. and confirmed there was no monitoring of the program and patient outcomes beyond the discussions in the STEMI meeting.

Review of the meeting minutes for the quality committee revealed that in addition to there being no review of the interventional cardiology program, there was also no evidence of data collection related to the outpatient wound care center that included hyperbaric services and the sleep study laboratory.

Based on document review and staff interview it was determined the facility failed to have a process in place to analyze data related to the interventional cardiology program, the outpatient wound care center that includes hyperbaric services and the sleep study laboratory.

Findings include:

During review of the quality monitors for the interventional cardiology program, it was noted there was no tracking or trending of patient outcomes related to the service. The only data presented was meeting minutes from the STEMI committee. The only physician involved was the only interventional cardiologist on staff. There was documentation that the cases were reviewed, but no analysis of the findings and no reports generated to quality committee, medical executive committee or governing body.

The Chief Executive Officer was interviewed on 4/25/13 at 12:35 p.m. and confirmed that there was no monitoring of the program and patient outcomes beyond the discussions in the STEMI meetings.

Review of the meeting minutes for the quality committee revealed that in addition to there being no review of the interventional cardiology program, there was also no review of the wound care center including hyperbaric therapy or the sleep laboratory.

On 4/25/13 at approximately 2:00 p.m. the Risk Manager also confirmed there was no documentation of quality monitoring of these programs.

Based on document review and staff interview it was determined the governing body failed to ensure quality review of the interventional cardiology program, the outpatient wound care center that includes hyperbaric services and the sleep study laboratory.

Findings include:

During review of the quality monitors for the interventional cardiology program it was noted that there was no tracking or trending of patient outcomes related to the service. The only data presented was meeting minutes from the STEMI committee. There was documentation the cases were reviewed, but no analysis of the findings and no reports generated to the quality committee, medical executive committee or governing body.

The Chief Executive Officer was interviewed on 4/25/13 at 12:35 p.m. and confirmed there was no monitoring of the program and patient outcomes beyond the discussions in the STEMI meetings. It was also confirmed there had been no review of the program for quality and safety by the governing body.

Review of the meeting minutes for the quality committee revealed that in addition to there being no review of the interventional cardiology program, there was also no review of the wound care center, hyperbaric therapy or the sleep laboratory. The Risk Manager also confirmed there was no documentation of quality monitoring of these programs.

Based on document review and staff interview it was determined the Chief Executive Officer (CEO) failed to ensure quality review of the interventional cardiology program, outpatient wound care center that included hyperbaric therapy and the sleep study laboratory.

Findings include:

During review of the quality monitors for the interventional cardiology program, it was noted there was no tracking or trending of patient outcomes related to the service. The only data presented was meeting minutes from the STEMI committee. The only physician involved was the only interventional cardiologist on staff. There was documentation that the cases were reviewed, but no analysis of the findings and no reports generated to quality committee, medical executive committee or governing body.

The CEO was interviewed on 4/25/13 at 12:35 p.m. and confirmed there was no monitoring of the program and patient outcomes beyond the discussions in the STEMI meetings. He stated that he had relied on the Chief Nursing Officer to oversee the program and failed to recognize the deficiencies until recently.

Review of the meeting minutes for the quality committee revealed that in addition to there being no review of the interventional cardiology program, there was also no review of the wound care center, hyperbaric services or the sleep laboratory.

During interview on 4/25/13 at approximately 2:00 p.m. the Risk Manager also confirmed there was no documentation of quality monitoring of these programs.

During the entrance conference on 4/24/13 at approximately 9:00 a.m. the CEO stated the cardiac catheterization laboratory was temporarily closed due to renovation and installation of new equipment. He stated the procedures were being done in the Operating Room utilizing a C-Arm since 4/8/13. During tour of the cardiac catheterization laboratory on 4/24/13 at approximately 9:30 a.m. it was revealed the laboratory was under going renovations. Review of the quality documentation revealed no evidence of monitoring while services were being provided in the different location utilizing a C-arm.

Based on observations of 10 patient tracers, interview and document review it was determined the hospital failed to ensure the development and implementation of infection control policies that include following manufacturers' guidelines for disinfectants, hospital isolation related cleaning policies, manufacturer's guidelines for equipment cleaning, aseptic technique for intravenous (IV) access, sharps disposal and use of personal protective equipment (PPE) by staff and visitors. This practice does not ensure the prevention of cross contamination.

Findings include:

1. On 7/23/12 a sign posted on a wall in the surgical holding area read Sani wipes: clean, leave five minutes!!! That's the rule.

On 7/23/12 at 1:55 p.m., after a surgical procedure, surgical technician #17 was observed to wipe down the surgical table in Operating Room (OR) #3 with Sani-Cloth disinfectant. The surgery table began to dry in 2-3 minutes.

Review of manufacturer's guidelines for Sani-Cloth Plus revealed the recommended contact time (wet time) was 5 minutes. The container instructed treated surface must remain visibly wet for a full 3 minutes. Use additional wipes if needed to assure continuous 3 minute wet contact time... for TB a 5 minute contact time.

On 7/23/12 at 4:35 p.m., after a tuberculosis (TB) isolation patient was discharged , housekeeper #9 was observed to spray Dispatch disinfectant on the bed and allowed to dry. Approximately 10-15 minutes later she wiped the bed with Virex solution and allowed it to dry.

An interview was conducted on 7/23/12 at 4:43 p.m. with housekeeper #9. The housekeeper explained for isolation rooms she was given the Dispatch and followed it with the Virex. She said she must wait 8-10 minutes for dry time. She does not make the bed while it was still wet. She said the disinfectants stayed wet for about 5 minutes. She was unaware of the isolation patient's diagnosis.

Review of manufacturer's guidelines for Dispatch revealed disinfection procedure: Spray 6-8 from surface until surface is completely wet. Let stand for 5 minutes.

On 7/24/12 at 9:20 a.m. housekeeper #10 was observed to wipe surface areas in room 202 with a cloth dampened with Virex solution. The surfaces were dry in a few minutes.

An interview was conducted on 7/24/12 at 9:22 a.m. with housekeeper #10. She stated she waited 15 minutes for the Virex solution to dry but indicated that it dries in a couple seconds.

On 7/24/12 at 11:55 a.m. OR aide #13 was observed to wipe down a gurney in the surgical holding room #8 with Quat disinfectant. The gurney was mostly dry after 5 minutes.

An interview was conducted on 7/24/12 at 11:55 a.m. with surgical technician (ST) #17. The ST was unaware of the wet time for the Quat disinfectant he was using.

Review of manufacturer's guidelines for Quat revealed contact time for the viruses, fungi, and bacteria listed on this label is 10 minutes except for Polio virus which is 30 minutes.

The wet contact times observed, were less than the manufacturers' guidelines and the hospital staff was unaware of these guidelines.

2. On 7/23/12 at 4:43 p.m. housekeeper, #9 was observed terminally cleaning isolation room 301. She sprayed Dispatch disinfectant on the bed. She wiped the pillow 3 times on each side with a cloth wet with Virex disinfectant and set aside to dry. About 2/3 of the pillow surface was wet.

An interview was conducted on 7/23/12 at 4:43 p.m. with housekeeper #9. The housekeeper stated she was leaving the pillow in the room after the cleaning.

Review of policy Isolation Terminal Cleaning #14 revealed cleaning and/or disposition of the pillow was not addressed. Supplemental procedures for Clostridium difficil (C-diff) instructed to use disinfecting product such as Dispatch in a pail and use cleaning rags.

The interview on 7/23/12 at 4:43 p.m. with housekeeper #9 revealed that for isolation rooms she was given the Dispatch by her supervisor. She said she was not aware of patient's diagnoses (the patient from room 301 had TB, not C-diff).

An interview was conducted on 7/24/12 at 9:06 a.m. with the Environmental Services Director. The Director indicated they use Dispatch for terminal cleaning on isolation rooms. Some (housekeepers) have preferences, some use the spray and some use liquid, I don't think we have a policy.

The isolation terminal cleaning policy was inadequate and not followed.

3. On 7/23/12 at 11:45 a.m. Respiratory Therapist #7 was observed to clean the pulse oximeter with Sani-Cloth after using it for patient #9.

Review of hospital policy for Measurement of SaO2 (oxygen saturation) #CP-58 revealed Before and after each use wipe probe and surfaces with mild detergent or 10% bleach solution, may use alcohol or Sani-Wipe.

Review of the oximeter manufacturer's cautions revealed Do not use caustic or abrasive cleaning agents or any cleaning agent containing ammonium Chloride or isopropyl alcohol.

Sani-Cloth Plus active ingredients include ammonium chloride. The hospital policy and practice failed to follow the equipment instructions.

4. On 7/23/12 at 1:12 p.m. during a surgical procedure on patient #1 the Certified Registered Nurse Anesthetist (CRNA) was observed to administer several injections into the patient's intravenous (IV) line without swabbing the access port. At 1:40 p.m. the CRNA injected Toradol into the IV line, again without swabbing port.

In an interview on 7/23/12 at 2:08 p.m. the CRNA confirmed he did not swab ports on the IV line before administering the medications. He explained he did not swab ports if the IV tubing was placed new in the OR. The Director of Surgical Services interjected there had been a recent emphasis on always swabbing the hubs.

The hospital was aware of best practice for aseptic IV access but may not be utilizing it.

5. On 7/24/12 at 11:18 a.m. sharps container in the decontamination room was observed to be over-filled. The lid would not close because material exceeded the fill line as well as the opening on the top of the container.

Shortly before the observation the Director of Surgical Services (DSS) said the sharps containers are emptied by a contract service. When the over-filled sharps container was pointed out, the DSS attempted to close the container. She admitted I guess it's full. The service was due to come in 2 days.

The facility failed to dispose of sharps container in a safe manner.

6. On 7/23/12 at 2:10 p.m. a patient tracer observation was conducted in the Intensive Care Unit (ICU) for patient #4. Registered Nurse (RN) #1 obtained a pre-filled 10 milliliter (ml) syringe of sterile normal saline to conduct an IV flush. The RN swabbed the connector, opened the hub and performed the flush without wearing gloves. The surveyor asked the RN when she would utilize gloves while working with open IV lines. She responded only if I see visible blood.

The Infection Control/Nursing Policy was reviewed with the Infection Control Officer. It stated that gloves are to be worn during injections and IV line insertions.

7. On 7/23/12 at 12:55 p.m. tracer observations were conducted for infection control precautions and PPE(Personal Protective Equipment) usage. A sign was posted on the door for patient #10 for contact precautions. The precaution sign instructed to see the nurse and to wear gloves, gown and mask for direct contact with the patient, linen or equipment.

Observation noted 4 visitors were in the room with the patient. One visitor was sitting on a chair wearing only gloves. One visitor was sitting on the patient's bed without any PPE. One visitor was sitting in a chair without any PPE. The other visitor was standing close to the patient and touching him without wearing any PPE.

Review of patient #10's medical record revealed a positive culture on 7/21/12 for Staphylococcus Aureus, MRSA, of the nasal nares.

Based on record review, policy review, on call schedule and staff interview, it was determined that the facility failed to ensure the services of the obstetrics physician on call were available when needed for 1 (#1) of 20 patients. See A 2404.

Based on record review, physician on call schedule, policy review and staff interview, it was determined the facility failed to ensure the physician on call for Obstetrics specialty care was available for care of 1 (#1) of 20 sampled patients. This practice lead to a delay in obtaining obstetric care and an unattended delivery of a premature baby in the Emergency Department.

Findings include:

Patient #1 was admitted to the facility's ED on 4/20/12 with the chief complaint of vomiting and low abdominal stabbing pain. She was pregnant with a due date of 5/25/12. Review of the medical record revealed that a medical screening examination was initiated by the Physician's Assistant at 4:54 p.m. on 4/20/12 and reviewed by the ED attending physician. Documentation revealed that the PA documented the patient's chief complaint was intractable vomiting and dehydration. He also noted she was pregnant. Her ordered boluses of intravenous (IV) fluids, Zofran and Reglan. He also determined the patient had a urinary tract infection and ordered rocephin. At 7:00 p.m. he noted the patient should be monitored in OB. Nursing documentation revealed the OB nursing director had assessed the patient and indicated she had felt contractions. The PA documented a consult order at 6:19 p.m. for the OB physician on call. Review of the record of notification of the consult revealed the initial page to the physician on call was made at 6:23 p.m. This was followed with pages at 6:37 p.m. The physician's partner was paged at 7:12 p.m. At 9:00 p.m., the physician, who was on call returned the call. The nursing documentation revealed the patient self-delivered a 4.5 pound male baby at 8:30 p.m., unattended in the ED examination room.

The PA was interviewed on 4/30/12 at approximately 3:00 p.m. He indicated that he and the ED physician wanted to discuss the patient with the OB physician on call before transferring her to the OB department. The facility's Medical Staff Rules and Regulations require that the on call physician to respond within 30 minutes of the call. The Risk Manager and CNO indicated that the failure of the OB physician to respond to the page resulted in a delay in moving the patient to the OB unit. This issue is being addressed by the Medical Executive committee.

Review of the physician on call schedule revealed that the physician who was paged was the physician who was on call on 4/20/12.

Based on record review, policy review and staff interview, it was determined the facility's medical staff failed to ensure compliance regarding care in the Emergency Department for 1 (#1) of 10 sampled patients. This practice does not ensure in provision of quality patient care.

Findings include:

The policy emergency room - Obstetrics Patients, #003 - OB - 029, revised 3/11 requires that patients with a pregnancy of greater than 20 weeks will be registered and transported to the Women's and Children's center. Review of the medical record of patient #1 revealed she presented to the facility's ED with the complaint of nausea, vomiting and stabbing lower abdominal pain. She was 35 weeks pregnant. The patient was not assessed by the ED nurses until. The facility's policy Triage/Evaluation of Patient, #003 - ED - 03, revised 3/11 presenting with abdominal distress with proceed to Obstetrics (OB) with a staff member. There was documentation by both the nursing staff, physician assistant and ED physician that they did not believe the patient was in labor. The PA wrote and order for Fetal Heart Tones (FHT) at 6:00 p.m. The nursing director for OB was asked to evaluate the patient. The ED nurse documented the FHT were 128 and that contractions were felt. There was no documentation of a vaginal examination. The OB nurse manager was interviewed on 5/1/12 at approximately 9:15 a.m. She admitted she only listened to the FHTs with a Doppler. She stated she did not perform a vaginal examination. She stated that she did feel contractions and recommended the patient be transferred to the OB department. The facility's policy Rule Out Labor for Outpatients, no number, effective 4/18/12, approved by the OB nursing director and the Medical Executive Committee, requires that the nurse is to perform assessment of membrane status and Vaginal Examination. Documentation in the medical record noted that a page was placed to the OB physician on call at 6:23 p.m. and again at 6:37 p.m. The physician's partner was paged at 7:12 p.m. There was no further documentation of attempts to reach the physician. There is documentation that the physician returned the call at 9:00 p.m. The facility's Medical Staff Rules and Regulations require the on call physicians are to respond within 30 minutes. The PA documented that he and the ED physician wished to consult with the physician before moving the patient to the OB department. There is documentation at 8:30 p.m. that the patient was found holding the baby who was self delivered by the patient in the ED examination. The delivery was unwitnessed by the ED staff. The PA was interviewed on 4/30/12 at approximately 3:00 p.m. He stated that he did not think the patient was in labor. He had discussed the case with the ED physician and decided a consultation with the on call physician should be requested. He stated that he believed the patient's main problem was the vomiting and subsequent dehydration that needed to be addressed. Intravenous fluids and antiemetic medications can be provided in the OB department. The Risk Manager and CNO were interviewed on 4/30/12. They indicated they had investigated the event and recognized their policies had not been followed, but believed that the failure of the OB physician to respond resulted in a delay of treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and staff interview it was determined the Registered Nurse failed to supervise and evaluate nursing care for 3 (#1, #2, #9) of 32 sampled patients. This practice does not ensure goals of the plan of care are achieved.

Findings include:

1. Patient #1 was admitted on [DATE] with the diagnoses that of diabetes and chronic obstructive pulmonary disease (COPD). The physician ordered blood glucose testing to be done before meals and before bedtime. Review of the Diabetic and Insulin Rotation Record revealed the test was not performed on 9/23/11 at noon. Review of the 24 Hour Nursing Flow Sheet revealed the nursing staff failed to document meal consumption for the evening meal on 9/23/11, the evening meal on 9/24/11, the evening meal on 9/25/11 and all three meals on 9/26/11. The review also revealed no skin assessment on 9/22/11 and no documentation of meeting the patient's hygiene needs on 9/23/11.

The Director of Quality Improvement confirmed the finding on 9/28/11 at approximately 10:30 a.m.

2. Patient #2 was admitted on [DATE] with the diagnoses of diabetes, COPD, chest pain and hypertension. Review of the 24 hour Nursing Flow Sheet revealed the nursing staff failed to documented meal consumption for the evening meal on 9/27/11. A physician's order was written on 9/25/11 that the patient was not to have anything by mouth after midnight. Review of nursing documentation revealed that the patient was provided breakfast on the morning of 9/26/11. There was no documentation that the physician had given an order to provide the breakfast.

The Director of Quality confirmed the findings on 9/28/11 at approximately 12:20 p.m.

3. Review of patient #9's medical record revealed the patient was admitted on [DATE]. Review of the physician's orders dated 9/23/11 at 4:30 p.m. revealed an order to weigh the patient daily. Review of the medical record documentation revealed the patient was weighed on 9/27/11 and 9/28/11. There was no documentation the patient was weighed on 9/23-9/26/11.

On 9/28/11 at 2:15 p.m. an interview with the Director of Surgery confirmed the findings.

Based on record review and staff interview it was determined that the facility failed to ensure that medications were administered as ordered by the physician for 2 (#1, #2) of 32 sampled patients. This practice does not ensure safe medication administration.

Findings include:

1. Patient #1's physician order instructed for accuchecks with novolog insulin coverage according to the aggressive protocol on 9/19/11. Review of the Diabetic and Insulin Rotation Record revealed that on 9/19/11 and 9/20/11 the nursing staff documented that the patient was administering herself via her insulin pump. The number of units administered was not documented for any of the doses on 9/19/11 and not until the 9:30 p.m. dose on 9/20/11. There was no order that the patient could administer via her insulin pump until 9/21/11. The patient's blood glucose was 364 on 9/23/11 at 4:30 p.m. The nurse documented the patient administered 15 units. Review of the protocol revealed the patient should have received 16 unit of insulin.

The Director of Quality confirmed the finding during the record review on 9/28/11 at approximately 10:30 a.m.

2. Review of the medical record of patient #2 revealed the physician ordered accuchecks with novolog insulin coverage according to the aggressive protocol on 9/25/11. Review of the Diabetic and Insulin Rotation Record revealed that the patient's blood glucose was 283 at 4:30 p.m. on 9/26/11. The protocol called for 13 units of insulin. There was no documentation that any insulin was administered or the reason for the omission. The physician ordered glyburide 5 milligrams orally twice daily on 9/25/11 at 9 a.m. The medication was no administered until 5:00 p.m. and only once on 9/25/11.

The Director of Quality confirmed the finding on 9/28/11 at approximately 12:30 p.m.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and staff interview it was determined the facility failed to ensure a History and Physical (H&P) examination was in the medical record within 24 hours of admission for 2 (#1, #9) of 32 sampled patients. This practice does not ensure significant patient information is available to the patient care team members.

Findings include:

1. Patient #1 was admitted to the facility on 9/19/11. Review of the medical record on 9/28/11 at approximately 10:30 a.m. revealed there was no H&P in the medical record.

The Director of Quality, who was present at the time of the record review, confirmed that there was no H&P for the patient.

2. Patient #9's was admitted to the facility on [DATE]. Review of the record revealed there was no H & P located in the record. A note located on a blank physician progress note stated, please dictate H & P.

On 9/28/2011 at 12:45 p.m. an interview with the Director of Surgery confirmed there was no H & P located on the record. The medical records department was contacted and verified there was no H & P dictated as of the date and time of the findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, policy review and staff interview it was determined that the facility failed to ensure a discharge summary was dictated as required by facility policy for 2 (#19, #20) of thirty two records reviewed. This practice does not ensure the recapitulation of stay is available.

Findings include:

Review of the facility's Medical Staff Rules and Regulations revealed that a discharge summary must be written or dictated at the time of the patient's discharge.

1. Patient #19 was discharge on 8/16/11. The record review was performed on 9/29/11. There was no discharge summary in the record

2. Patient #20 was discharged on [DATE]. The discharge summary was dated 6/28/11.

The Chief Nursing Officer confirmed the facility failed to comply with the policy on discharge summary completion during interview on 9/29/11 at approximately 2:30 p.m.

Based on record review and staff interview it was determined the facility failed to ensure reassessment of the discharge plan for 1 (#13) of 32 sampled patients. This practice does not ensure patient's needs are met following discharge.

Findings included:

Patient #13's physician wrote an order that the patient was to be discharged with home health nursing care. The physician also documented in the discharge progress note on 9/7/11 and discharge summary that the patient was discharged with home health care. Review of the case management notes on 9/6/11 revealed that the patient had declined the referral to home health agency. The discharge instructions to the patient indicated the patient was to have home health care. There was no evidence that home health had been arranged by case management or that the physician and nursing staff had been informed hat the patient had declined the home health referral.

The Chief Nursing Officer was interview on 9/28/11 at approximately 3:00 p.m. and confirmed the lack of reassessment and coordination of the discharge plan.

Based on clinical record and policy review and staff interviews it was determined the nursing staff failed to ensure 1 (#4) of 11 sampled patients was assessed, monitored, and treated and physician orders were implemented for an Intensive Care Unit patient. The nursing staff failed to ensure that the medications were administered as ordered by the physician for 1 (#2) of 11 sampled patients.

The nursing staff and telemetry technician did not ensure the telemetry monitor alarms were audible and monitored to alert the staff to changes in a patient's heart rate or a lethal rhythm. This practice caused a delay in treatment and possible death of a patient in the Intensive Care Unit on a telemetry monitor. Refer to A0395

Physician orders for the insertion of a nasogastric tube was delayed for two days despite documentation of continued symptoms. Orders for cardiac enzymes for a patient experiencing chest discomfort was not implemented, the physician ordered monitoring of a patient's intake/output that was not performed. Refer to A0395

A patient did not receive Insulin as ordered by the physician despite two nurses checking the dose. Refer to A0404

Due to the lack of assessment, monitoring, implementation of physician orders, error in medication administration and the extent of an adverse outcome, the Condition of Participation for Nursing Services was found to be out of compliance.

Based on clinical record, document and policy review and staff interview it was determined the facility failed to ensure a Registered Nurse supervised and evaluated the nursing care and implemented physician orders for 1 (#4) of 11 sampled patients, causing an Intensive Care Unit patient's lethal cardiac rhythm to be missed by the nursing staff potentially resulting in death. This practice does not provide for patient safety and achievement of patient goals.

Findings include:

1. Patient #4's physician post-operative orders dated 2/9/11 at 1:15 p.m. revealed an order for Intake and Output. A review of the Graphic/Intake/Output Record from 2/9/11 through 2/21/11 revealed the patient was admitted with a urinary catheter. From 2/9/11 to 2/21/11 there were thirty-seven 37 nursing shifts. Out of thirty-seven 37 shifts there were twenty-one 21 shifts missing the intake and output and thirty-seven 37 of 37 missing the twenty-four hour totals documentation ordered by the physician. The patient had a nasogastric (NG) tube inserted on 2/18/11. The NG tube output was documented only on 3 shifts from 2/18/11 to 2/21/11.

A review of the facility 's policy, Nursing Service General, policy # NS-196, reviewed/revised 1/09, revealed the purpose of the policy is to (1) keep an accurate, pertinent and permanent written record of the patient's hospital stay, and (2) to provide written communication concerning the patient for all members of the health care team involved in the care of the patient. The policy stated this was completed each shift and as required by all appropriate nursing personnel. A review of the section titled, A) Graphic, Vital signs, #7, Intake/Output is recorded in the cc's in appropriate date and time column with the 24 hour totals recorded under the 24 hour total , by the 11-7 shift.

2. Patient #4's physician's progress notes revealed an entry dated 2/11/11 at 8:30 a.m. (Post-Operative day #2) by the Advanced Registered Nurse Practitioner (ARNP). The patient's heart rate was sinus tachycardia with a rate of 100-120 beats per minute. The patient complained the nebulizer treatments were elevating his heart rate. The patient stated he had chest discomfort following the treatments the night before. The ARNP noted that Intravenous (IV) Lopressor was given at 6:00 a.m. that morning. The ARNP ordered Cardiac Enzymes times 2, an electrocardiogram (EKG) and repeat Lopressor IV this am. Review of the clinical record and interview with the Director of Quality on 8/30/11 at approximately 4:00 p.m. confirmed the cardiac enzymes were never completed and a cardiologist was not consulted for the chest pain.

3. Patient #4's physician orders dated 2/16/11 revealed an order for If hiccups or burping persist, or patient vomits, insert nasogastric tube (NG) to intermittent suction. The order was noted on 2/16/11 at 5:42 p.m. by nursing and a 24 hour chart check also was completed. The patient continued to experience burping, nausea and vomiting, per physician and nursing documentation. On 2/18/11 at 1:00 p.m., the NG tube was inserted by the charge nurse, 2 days after the physician had ordered the NG tube.

A review of the facility's policy Gastro-Intestinal Decompression (Insertion and Removal of Nasogastric Tube), policy# 003-NS-204, reviewed/revised 1/09, revealed the NG tube was to be initiated upon physician orders. Nursing was to maintain integrity of suction unit and nasogastric tube, Observe and note stomach contents.

4. Patient #4's Interdisciplinary patient notes dated 2/24/11 at 1:30 a.m. revealed the patient was ambulated from the bed to the chair, the patient's heart rate was elevated to 124 and the patient complained of abdominal and epigastric pain. The patient was placed back in bed, an EKG was performed and pacer pads were placed on the patient. At 3:44 a.m. the cardiologist was paged regarding critical laboratory results. The cardiologist returned the call at 3:50 a.m. He was informed of the cardiac enzymes being elevated. At 6:00 a.m. the patient was out of bed to use the urinal and experienced shortness of breath and chest pain. The pain subsided with the application of oxygen and rest. A review of the Critical Care Nursing notes dated 2/25/11 at 7:30 a.m. revealed a nursing assessment was completed. At 8:15 a.m. the patient was assisted to the side of the bed in preparation for breakfast. At 9:10 a.m., the patient's family member went to the nursing station and stated help, he's unresponsive. A nurse went into the room and the patient was unresponsive with absent respirations. The code blue button was pressed. At 9:29 a.m. the patient was pronounced deceased by the physician.

A review of the telemetry monitoring event report for 2/25/11 at 6:04 a.m. revealed the patient's heart rate was 149 beats per minute and he was experiencing a lethal rhythm.

A review of the discharge summary dictated on 3/4/11 at 1:09 p.m. revealed the following documentation, In the middle of the night, the patient developed acute onset of anterior chest pain. Cardiac enzymes were done which showed moderate elevation of troponin and severe elevations of CPK. An electrocardiogram confirmed the presence of an acute anteroseptal myocardial infarction.

An interview was conducted with the Director of Risk Management and the Director of Quality on 8/30/11 at 4:00 p.m. The interviews revealed the monitor technician was not paying attention to the monitors. The telemetry monitors' alarms at the bedside and at the main monitor viewing station were turned down. The patient's nurse was in another patient's room and did not hear the alarms.

A telephone interview with the cardiologist was conducted on 8/30/11 at approximately 2:20 p.m. The physician was questioned on his input concerning the patient. He acknowledged the patient had suffered an acute myocardial infarction during the night. The physician stated the patient had been in ventricular fibrillation for at least 20 minutes.

A review of the facility's policy Provision of Patient Care, reviewed/revised 2/2011, Intensive Care Unit, leadership responsibilities, revealed the registered nurse is accountable for the complete and total care of the patient assigned to the patient care team and for the documentation and execution of the care ordered by the Physician.

The interviews and review of the clinical record revealed cardiac laboratory studies were not done as ordered by the physician when the patient complained of chest pain. The intake and output was not monitored as ordered by the physician. The nursing staff and telemetry technician did not ensure the telemetry monitor alarms were audible and monitored to alert the staff to changes in a patient's heart rate or rhythm. This practice caused a delay in treatment and possible death of a patient in the Intensive Care Unit on a telemetry monitor.

Based on clinical record review, staff interview and policy review it was determined the nursing staff failed to administered medications as ordered by the physician for 1 (#2) of 11 sample patients. This practice may cause a delay in discharge and does not ensure effective medication therapy.

Findings include:

Patient #2's physician's order dated 1/6/11 revealed the blood sugar level was to be checked before meals and every evening. Review of the Insulin sliding scale revealed if the blood sugar was 151-200 give 6 units of regular Insulin, 201-250 give 8 units, 251-300 give 10 units, 301-350 give 12 units, 351-400 give 14 units and if greater than 400 call for further orders

Review of the Medication Administration Record (MAR) dated 1/6/11 revealed that patient's blood sugar at 5:27 p.m. was 321. The documentation showed 6 units of regular insulin was administered. The dose was checked by second nurse . The physician's order indicated 12 units should have been given.

A review of the facility's policy for Nursing/Administration of Medications, policy #NC- 242, reviewed/revised 4/10, revealed ' administration of medications are performed by authorized personnel only. Further review of the policy revealed the following medication and medication orders will be checked prior to administration and documented by two nurses, or a nurse and a physician in the Medication Administration Record. ( Insulin, Pain Control Administrator/Epidural's)

An interview was conducted with the Director of Quality on 8/30/11 at approximately 4:00 p.m., after review of the documentation she confirmed the findings.

Based on clinical document review, facility documents and staff interview, it was determined that the Governing Body failed to provide a safe care setting for the facility's patient population. As evidenced by the lack of monitoring of the coffee machine temperatures on the patient care units by dietary. The lack of the Quality Assessment Performance Improvement Program developing, implementing and maintaining an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program for monitoring the coffee machines. The lack of the Nursing department to appropriately assess a Mentally Retarded Patient with several co-morbidities and implementing an appropriate plan of care for the safe delivery of care for the patient.

Due to the lack of involvement from these entities, 1(#2) of 10 sampled patients sustained a 3rd degree burn from hot coffee provided by the facility's Nursing staff and placed the remaining patient population in danger of sustaining similar injuries.

Based on these findings the Condition of Participation for Governing is out of compliance.

Based on clinical record review, facility document review, staff interview, and policy review, it was determined the facility failed to protect the Patients Rights related to, notification of rights, investigation of a verbal grievance and resolution , participation in a plan of care, informed consent, notification of admission and ensuring care in a safe setting. As evidence by:

1. Failure of the facility to ensure the guardian for a Mentally Retarded patient was informed of the patients rights prior to the initiation of treatment. (refer to A-0117)

2. Failure of the facility to review, investigate, and resolve each patient's grievance within a reasonable time frame (refer to A-0122)

3. Failure of the facility to communicate the resolution for a verbal grievance and provide the person filing the verbal grievance with a written notice of its decision, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process and the date of completion. (refer to A-0123).

4. Failure of the facility to involve the guardian of 1(#2) of 10 sampled patients in the development and implementation of the patient's plan of care, ensuring the plan of care meets the patient's psychological and medical needs.(refer to A-130)

5. Failure of the facility to obtain a legal consent from the guardian for 1(#2) of 10 sampled patients, ensuring the guardian was able to make informed decisions regarding the patients care. (refer to A-0131)

6. Failure of the facility to follow the policy to notify the guardian of 1(#2) of 10 sampled patients, of the patients admission in a timely manner. (refer to A-0133)

7. Failure of the facility to ensure a safe care setting for 1 (#2) of 10 sampled patients and potentially the current patient population. To ensure a safe and therapeutic care setting for any patient that presents to the facility.( refer to A-0144)

Due to the cumulative effect of these systemic problems, the Condition of Participation for Patient Rights was determined to be out of compliance.

Based on clinical record review, staff interview and policy review, it was determined the facility failed to inform the guardian for 1(#2) of 10 sampled patients of the patients rights.

Findings included:

1. A review of the admission assessment, Emergency Department (ED) Physicians record dated 5/7/11 at 9:16 a.m., revealed Additional review of systems unobtainable due to patient's impaired ability to communicate. Further review of the ED Physicians assessment revealed the patient has a past medical history of Mental Retardation.

2. A review of the patient's clinical record revealed a document dated 6/19/2006 appointing a Guardian for the patient.

3. A review of the patient's Right's and Responsibilitydocumentation dated 5/7/11, revealed the patient's signature acknowledging they had received a copy of the document. Further review of the clinical record failed to reveal that the guardian was notified of the patient's rights.

Interview on 7/12/11 at approximately 2:00 p.m. with the Risk Manager confirmed the guardian advocate had not been notified.

A review of the facility's policy, Patient Rights and Responsibilities, policy # RI-2, revised 1/09, page 2 of 3, the right of the patient's designated representative to exercise rights on behalf of the patient.

Based on facility document review, staff interview and policy review it was determined the facility failed to respond to a telephone grievance made by guardian of 1 (#2) of 10 sampled patients

Findings Include:

An Interview was conducted on 7/12/11 at approximately 5:00 p.m.,with the Risk Manager. The Risk Manager stated patient #2's guardian had left a message on the Risk Manager voice mail. The Risk Manager was unsure as to what the date was when she received the voicemail but stated it was the day before another State Agency had completed their investigation regarding the patient. A review of facility records revealed a State Agency had completed their investigation on 5/12/11 regarding a burn injury to patient #2. The Risk manager stated she did not respond to the voice mail.

A review of the Grievance log failed to reveal any documentation of a verbal Grievance.

A review of the facility policy, Patient Grievance Policy, policy# RI-4, revised 11/10, page 2-3 of 6, revealed paragraph A (1) Receipt of a verbal complaint is to be addressed promptly by the staff present, (2) The patient complaint should be immediately documented stating facts of the complaint and the resolution provided.

Further review of the policy page 3, paragraph B (1) Grievances made about situations endangering the patient, given the seriousness of the allegations and potential harm to patients, require immediate investigation and review.

Based on staff interview, policy review and facility document review it was determined the facility failed to provide the steps taken on behalf of the patient to investigate the grievance process and date of completion for 1(#2) of 10 sampled patients

Findings included:

An Interview was conducted on 7/12/11 at approximately 5:00 p.m., with the Risk Manager. The Risk Manager stated patient #2's guardian had left a message on the Risk Manager voice mail. The Risk Manager was unsure as to what the date was when she received the voicemail but stated it was the day before another State Agency had completed their investigation regarding the patient. A review of facility records revealed a State Agency had completed their investigation on 5/12/11 regarding a burn injury to patient #2. The Risk manager stated she did not respond to the voice mail.

Review of the facility's documentation did not reveal evidence of the patient's guardian's being notified of a resolution of the grievance.

A review of the facility's policy, Patient Grievance Policy, policy #RI-4, revised 11/10, page 3 of 6, paragraph B (2), Grievances require a written notice (response) to the patient (or representative) within seven (7) days. The written response will contain the name of the hospital contact person and identify the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process and date of completion.

Based on clinical record review, staff interview and policy review, it was determined the facility failed to include the patient's guardian in the development and implementation of the plan of care in 1 (#2) of 10 sampled patients.

Findings include:

(1) A review of the facility's policy, Nursing Staff Role in Patient and Family Teaching, policy # NS-43, revised 1/09, revealed the purpose of the policy is to facilitate patient and family understanding of the disease process, interventions and care.

Further review of the policy, section titled Procedure, paragraph (1) revealed nursing staff is responsible to utilize the admission assessment to identify any patient education needs and paragraph (2) review the findings from the assessment with the physician, patient and patient's family to determine a plan of action to meet the patient's education needs in relation to the prescribed medical treatment and care.

(2) A review of the patient #2's clinical record revealed no evidence of the guardian of the patient being notified or included in the development and implementation of the plan of care.

(3) An interview was conducted on 7/14/11 at 3:00 p.m., with the Risk Manager. When questioned whether the patient's guardian had been contacted concerning the patient she answered no.

Based on clinical record review, staff interview and review of policy, it was determined the facility failed to honor the patients right for her guardian to make informed decisions on her behalf for 1 (#2) of 10 sampled patients, regarding her medical care.

Findings included :

1. A review of patient #2's Emergency Department physician's documentation dated 5/7/11 at 9:16 a.m., Additional review of systems unobtainable due to patient's impaired ability to communicate. Further review revealed the patient had a past medical history of Mental Retardation.

2. A review of patient #2's clinical record revealed a legal document appointing a guardian for the patient dated 6/19/2006.

3. A review of the conditions of treatment and admission form revealed the patient #2's signature dated 5/7/11 for consent to hospital care and treatment. There was no evidence of the guardian consent for treatment.

4. A review of the clinical record for patient #2 revealed no evidence of informing the patient's guardian of decisions regarding the patient's care.

5. A review of the facility's policy Informed Consent, policy # RI-64, revised 1/10 revealed on page 2 of 6 paragraph titled Participants in the consent process: When patients are unable to participate in the consent process and there is a legally authorized representative empowered to make such decisions, it is important to obtain the authorization from such individual.

Further review of the policy page 4 of 6, paragraph for Persons under Guardianship, Legal guardian must sign consent forms for persons under legal custody.

6. An interview was conducted on 7/14/11 at 3:00 p.m., with the Risk Manager. When questioned whether the patient's guardian had been contacted concerning the patient she answered no.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on clinical record review, policy review and staff interview it was determined the facility failed to notify the patient's guardian of her admission for 1 (#2) of 10 sampled patients.

Findings include:

(1) A review of the emergency department (ED) records for patient #2 revealed the patient (MDS) dated [DATE] at 9:14 a.m., for complaints of swelling to left side of face and bottom lip.The patient was admitted to the facility at 1:38 p.m.

(2) A review of patient #2's clinical record revealed a legal document appointing a guardian for the patient dated 6/19/2006.

(3) A review of the 24 hour nursing flow sheet for patient #2, from the date of admission 5/7/11 at 3:10 p.m. through 5/09/11 revealed no evidence of informing the patient's guardian of admission. Further review of the patient's clinical record revealed the initial contact with the patient's guardian was the day before discharge, 48 hours after admission.

(4) A review of the facility's policy, Patient Rights and Responsibilities, policy # RI-2, revised 1/09, revealed the patient has the right to have a family member or representative notified promptly of admission to the facility.

(5) An interview was conducted on 7/14/11 at 3:00 p.m., with the Risk Manager. When questioned whether the patient's guardian had been contacted concerning the patient she answered no.

Based on clinical record review, staff interview, facility documents, and review of policies it was determined the facility failed to provide a safe patient care setting for 1 (#2) of 10 sampled patients. The continued use of this practice has resulted in 1 patient injury and places the current patient population at risk for more injuries to occur.

Findings include:

(1.) A review of patient #2's, Nursing flow sheet dated 5/8/11 at 9:00 a.m., revealed, the patient spilled hot coffee on self. A burn was noticed to the upper center chest. A review of the Physician's assessment and plan in the progress note dated 5/8/11, noted the patient had a 3rd degree burn. The continued review of the Physician's progress note dated 5/9/11 by a 2nd Physician also revealed a 3rd degree burn to right upper chest.

(2.) A review of the event report dated 5/8/11 at 9:10 a.m., revealed the admission diagnosis of Facial Cellulitis. An entry under Objective stated patient spilled coffee on chest. The timeline of events revealed at 9:15 a.m., the Physician was notified and Silvadene cream was applied and at 9:40 a.m. the Supervisor was notified. The Risk Manager Designee was notified on 5/9/11 at 10:00 a.m. There was no documentation the Guardian of the patient was notified. A entry was documented eight (8) days after the event occurred, on 5/16/11 by the Risk Manager Designee which stated, Investigated per Risk Manager, will remind nursing staff to ensure safety of hot beverages to patients in next news letter. Disposition- no further action needed.

Further review of the documentation did not reveal any further investigation was conducted by the facility on why and how the patient was burned by hot coffee. There was no documentation of notifying the patients Guardian. There was no documentation on any immediate safeguards put in place for the patient population.

(3.) A review of the Quality Assurance Performance Improvement documenting for dietary services did not reveal any evidence of tracking and trending of the coffee temperature brewed on the nursing units served to patients.

(4.) An Interview was conducted on 7/12/11 at approximately 2:30 p.m. with the Patient Care Technician (PCT) that was involved with patient # 2. The PCT stated the patient had repeatedly requested a cup of coffee. The PCT went to the nursing unit's pantry and obtained a 12 ounces cup of coffee from the coffee machine.

The PCT returned to the patient's room and placed the cup of coffee on the overbed tray. The PCT then left the patient's room. The PCT stated she just got outside the door and down the hall when she was told by another staff person the patient has spilled coffee on her and needed assistance. The PCT gathered towels, ice and cloth for the ice and went into to patient's room. The PCT noticed a bright red burn like area on the patient's chest approximately 5.5 in diameter. The PCT stated she placed the cool cloth on the area and then placed the ice in a cloth on the area.

(5). An Interview was conducted on 7/12/11 at approximately 1:45 p.m. the attending physician of patient #2. The Physician confirmed the patient sustained a 3rd degree burn to the chest area.

(6.) An Interview with the Risk Manager on 5/12/11 stated there was an investigation on file. The Risk Manager presented this surveyor with an Event Report dated 5/8/11. The Risk Manger was documented as notified on 5/9/11 at 10:00 a.m. The Risk Manager Designee was noted to document on 5/16/11 to investigate per the Risk Manager. There no evidence of details of the investigation completed. Further review the event report documentation revealed the Risk Manager Designee will remind nursing staff to ensure safety of hot beverages to patients in the next news letter.

The disposition of the Event Report was documented as no further action needed dated 5/16/11.

(7.) A review of the facility's policy for Patient Rights and Responsibilities, policy # RI-2, revised 1/09, revealed the patient has the right to Personal Safety.

Based on clinical document review, facility documents and staff interview, it was determined that the facility failed to develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program for the monitoring of the coffee machine temperatures on the patient care units. Due to the failure to monitor these, 1(#2) of 10 sampled patients sustained a 3rd degree burn from hot coffee provided by the facility's Nursing staff and placed the remaining patient population in danger of sustaining similar injuries. Due to the lack of monitoring by the Quality Assessment Performance Improvement Program and the Governing Body, the Condition of Participation for Quality Assessment Performance Improvement was found to be out of compliance.

Based on document review and staff interview, it was determined that the facility failed to track and trend quality indicators related to temperature monitoring of coffee machines in the patient care areas and failed to evaluate incidents reported through the facility's Risk Manage Program. This practice results in the failure to take action to improve safe care of the patients and place them at risk for serious harm.

Findings include:

(1.) A review of patient #2's Emergency Department physician's documentation dated 5/7/11 at 9:16 a.m., Additional review of systems unobtainable due to patient's impaired ability to communicate. Further review revealed the patient had a past medical history of Mental Retardation.

(2.) A review of patient #2's Nursing flow sheet dated 5/8/11 at 9:00 a.m., revealed the patient had spilled hot coffee on herself and sustained a burn to her upper center chest. A review of the Physician's progress note dated 5/8/11 revealed the patient was noted to have a 3rd degree burn. A continued review of the Physician's progress note dated 5/9/11 by a 2nd Physician revealed the patient sustained a 3rd degree burn to right upper chest.

(3) A review of the event report dated 5/8/11 at 9:10 a.m., revealed an admission diagnosis of Facial Cellulitis. An entry under Objective stated the patient spilled coffee on chest. The timeline of events revealed at 9:15 a.m., the Physician was notified and Silvadene cream was applied and at 9:40 a.m. the Supervisor was notified. The Risk Manager Designee was notified on 5/9/11 at 10:00 a.m. There was no documentation the Guardian of the patient was notified. A entry was documented eight(8) days after the event occurred, on 5/16/11 by the Risk Manager Designee which stated, Investigated per Risk Manager, will remind nursing staff to ensure safety of hot beverages to patients in next news letter. Disposition- no further action needed.

Further review of the documentation did not reveal any further investigation was conducted by the facility or why and how the patient was burned by hot coffee. There was no documentation of notifying the patients Guardian. There was no documentation on any immediate safeguards put in place for the patient population.

(4) A review of the Quality Assurance Performance Improvement documentation for dietary services failed to reveal any evidence of tracking and trending of the coffee machine temperatures of coffee brewed on the nursing units served to patients.

(5) An interview was conducted on 7/12/11 at approximately 2:30 p.m. with the Patient Care Technician (PCT) that was involved with patient # 2. The PCT stated the patient had repeatedly requested a cup of coffee. The PCT went to the nursing unit's pantry and obtained a 12 ounces cup of coffee from the coffee machine.

The PCT returned to the patient's room and placed the cup of coffee on the overbed tray and left the patient's room. The PCT revealed that she had just gotten outside the door and down the hall when she was told by another staff person the patient had spilled the coffee on herself and needed assistance. The PCT gathered towels, ice and cloth for the ice and went into to patient's room. The PCT noticed a bright red burn like area on the patient's chest approximately 5.5 inches in diameter. The PCT revealed she placed the cool cloth on the area and then placed the ice in a cloth on the area.

5. An interview was conducted on 7/12/11 at approximately 1:45 p.m. with the attending physician of patient #2. The Physician confirmed the patient sustained a 3rd degree burn to the chest area.

6. An interview was conducted with the Risk Manager on 7/12/11 who stated there was an investigation on file. The surveyor was presented with an Event report dated 5/8/11. A review of the event report revealed the Risk Manager was notified on 5/9/11 at 10:00 a.m., and a investigation was documented by the Risk Manager Designee on 5/16/11, eight (8) days after the event occurred. There were no further evidence of the details of the investigation. Further review of the event report documentation revealed the Risk Manager Designee will remind nursing staff to ensure safety of hot beverages to patients in the next news letter.

The disposition of the Event Report was documented as no further action needed dated 5/16/11.

Further interview with the Risk Manager revealed the coffee pots located on the patient's care area were still in service on 7/12/11.

Based on document review and staff interview, it was determined that the facility failed to track and trend quality indicators related to temperature monitoring of coffee machines in the patient care areas and failed to evaluate incidents reported through the facility's Risk Manage Program. This practice results in the failure to take action to improve safe care of the patients and place them at risk for serious harm.

Findings include:

(1.) A review of patient #2's Emergency Department physician's documentation dated 5/7/11 at 9:16 a.m., Additional review of systems unobtainable due to patient's impaired ability to communicate. Further review revealed the patient had a past medical history of Mental Retardation.

(2.) A review of patient #2's Nursing flow sheet dated 5/8/11 at 9:00 a.m., revealed the patient had spilled hot coffee on herself and sustained a burn to her upper center chest. A review of the Physician's progress note dated 5/8/11 revealed the patient was noted to have a 3rd degree burn. A continued review of the Physician's progress note dated 5/9/11 by a 2nd Physician revealed the patient sustained a 3rd degree burn to right upper chest.

(3) A review of the event report dated 5/8/11 at 9:10 a.m., revealed an admission diagnosis of Facial Cellulitis. An entry under Objective stated the patient spilled coffee on chest. The timeline of events revealed at 9:15 a.m., the Physician was notified and Silvadene cream was applied and at 9:40 a.m. the Supervisor was notified. The Risk Manager Designee was notified on 5/9/11 at 10:00 a.m. There was no documentation the Guardian of the patient was notified. A entry was documented eight(8) days after the event occurred, on 5/16/11 by the Risk Manager Designee which stated, Investigated per Risk Manager, will remind nursing staff to ensure safety of hot beverages to patients in next news letter. Disposition- no further action needed.

Further review of the documentation did not reveal any further investigation was conducted by the facility or why and how the patient was burned by hot coffee. There was no documentation of notifying the patients Guardian. There was no documentation on any immediate safeguards put in place for the patient population.

(4) A review of the Quality Assurance Performance Improvement documentation for dietary services failed to reveal any evidence of tracking and trending of the coffee machine temperatures of coffee brewed on the nursing units served to patients.

(5) An interview was conducted on 7/12/11 at approximately 2:30 p.m. with the Patient Care Technician (PCT) that was involved with patient # 2. The PCT stated the patient had repeatedly requested a cup of coffee. The PCT went to the nursing unit's pantry and obtained a 12 ounces cup of coffee from the coffee machine.

The PCT returned to the patient's room and placed the cup of coffee on the overbed tray and left the patient's room. The PCT revealed that she had just gotten outside the door and down the hall when she was told by another staff person the patient had spilled the coffee on herself and needed assistance. The PCT gathered towels, ice and cloth for the ice and went into to patient's room. The PCT noticed a bright red burn like area on the patient's chest approximately 5.5 inches in diameter. The PCT revealed she placed the cool cloth on the area and then placed the ice in a cloth on the area.

5. An interview was conducted on 7/12/11 at approximately 1:45 p.m. with the attending physician of patient #2. The Physician confirmed the patient sustained a 3rd degree burn to the chest area.

6. An interview was conducted with the Risk Manager on 7/12/11 who stated there was an investigation on file. The surveyor was presented with an Event report dated 5/8/11. A review of the event report revealed the Risk Manager was notified on 5/9/11 at 10:00 a.m., and a investigation was documented by the Risk Manager Designee on 5/16/11, eight (8) days after the event occurred. There were no further evidence of the details of the investigation. Further review of the event report documentation revealed the Risk Manager Designee will remind nursing staff to ensure safety of hot beverages to patients in the next news letter.

The disposition of the Event Report was documented as no further action needed dated 5/16/11.

Further interview with the Risk Manager revealed the coffee pots located on the patient's care area were still in service on 7/12/11.

Based on clinical document review, facility documents, policy review and staff interviews, it was determined that the Nursing department failed to appropriately assess a Mentally Retarded Patient with several co-morbidities and failed to implement an appropriate plan of care for the safe delivery of care for 1 (#2) of 10 sampled patients.

Based on these findings the Condition of Participation for Nursing is out of compliance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and staff interview it was determined the facility failed to ensure the Registered Nurse supervised the safe delivery of nursing care for 1 (#2) of 10 sampled patients.

Findings include:

(1.) A review of patient #2's Emergency Department physician's documentation dated 5/7/11 at 9:16 a.m., Additional review of systems unobtainable due to patient's impaired ability to communicate. Further review revealed the patient had a past medical history of [DIAGNOSES REDACTED]

(2) A review of the nursing admission assessment dated [DATE] at 3:10 p.m. revealed the patient to have diabetes, epilepsy, seizures, [DIAGNOSES REDACTED] and mental retardation. A review of the nurses assessment of the patient's functional screen revealed the patient was total dependent for self care, had occasional accidents with excretory function, use of assistive devices on ambulation, and oriented to self only. The screening scoring was documented as a 12 for the patient. A review of the rehabilitation screening in the nursing assessment on 5/7/11 indicates for score of 7-13 that rehabilitation screening is indicated. Further review of the nursing assessment revealed a physical therapy screen request was marked with yes and no on the document. A review of the patient's orders in meditech revealed a physical therapy request was not obtained. A review of the assessment of orientation to environment revealed the patient needs frequent review due to mental retardation.

(3) A review of the Physician's History and Physical for patient #2 dated 5/7/11 at 3:32 p.m. revealed the patient presented with a Chief Complaint of facial swelling to the Emergency Department complaining of swelling to the left side of her face and bottom lip. A review of the physician examination revealed left-sided facial swelling noticed from the left lower eyelid involving the entire left sided cheek.

(4) A review patient #2's clinical record revealed a document sent by the Residential facility documenting the patient was to have soft foods only please, tends to take too large bite and will choke.

(5) A review of patient #2's Nursing flow sheet dated 5/8/11 at 9:00 a.m., revealed the patient had spilled hot coffee on herself and sustained a burn to her upper center chest. A review of the Physician's progress note dated 5/8/11 revealed the patient was noted to have a 3rd degree burn. A continued review of the Physician's progress note dated 5/9/11 by a 2nd Physician revealed the patient sustained a 3rd degree burn to right upper chest.

(6) An interview was conducted on 7/12/11 at approximately 2:30 p.m. with the Patient Care Technician (PCT) that was involved with patient # 2. The PCT stated the patient had repeatedly requested a cup of coffee. The PCT went to the nursing unit's pantry and obtained a 12 ounces cup of coffee from the coffee machine.

The PCT returned to the patient's room and placed the cup of coffee on the overbed tray and left the patient's room. The PCT revealed that she had just gotten outside the door and down the hall when she was told by another staff person the patient had spilled the coffee on herself and needed assistance. The PCT gathered towels, ice and cloth for the ice and went into to patient's room. The PCT noticed a bright red burn like area on the patient's chest approximately 5.5 inches in diameter. The PCT revealed she placed the cool cloth on the area and then placed the ice in a cloth on the area.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on clinical record review and policy review it was determined the facility failed to implement an appropriate nursing care plan for 1(#2) of 10 sampled patients.

Findings include:

(1) A review of the Physician's History and Physical for patient #2 dated 5/7/11 at 3:32 p.m. revealed the patient presented with a Chief Complaint of facial swelling to the Emergency Department complaining of swelling to the left side of her face and bottom lip. A review of the physician examination revealed left-sided facial swelling noticed from the left lower eyelid involving the entire left sided cheek. The patient's past medical history revealed cataracts, [DIAGNOSES REDACTED], depression, Parkinson, seizure disorder, [DIAGNOSES REDACTED], metal retardation, diabetes mellitus, and schizophrenia.

(2) A review patient #2's clinical record revealed a document sent by the Residential facility documenting the patient was to have soft foods only please, tends to take too large bite and will choke.

(3) A review of the emergency room Fax Report for transport to the Medical Unit on 5/7/11 revealed under physical assessment ( will include only findings outside of normal limits) patient is mentally retarded and has [DIAGNOSES REDACTED]. Further review of the document revealed the recommendation for precautions were, skin, fall and seizure.

(4) A review of the Nursing Admission Assessment documentation for patient #2, dated 5/7/11 at 3:10 p.m., revealed the patient has a history of diabetes,epilepsy, seizures, [DIAGNOSES REDACTED], schizophrenia, and mental retardation.

(a) A review of the functional screen completed for the patient stated the patient was totally dependent for self care, had occasional accidents with excretory function, uses assistive devices on ambulation, and is oriented to self only. The screening scoring was documented as a 12 for the patient. A review of rehabilitation screening in the nursing assessment on 5/7/11 indicates for score of 7-13 a rehabilitation screening is indicated. Further review of the nursing assessment revealed a physical therapy screen request was marked with yes and no on the document. A review of patient's orders in meditech revealed a physical therapy request was not obtained.

(b) A review of the assessment of orientation to environment revealed the patient needs frequent review due to mental retardation.

(c)A review of the Level of Consciousness on neurosensory assessment revealed the patient was alert and oriented to place and the patient was mentally retarded.

(d)The speech assessment was marked clear. The assessment did not address the swallowing and chewing that would indicate a speech therapy request.

(e) A review of the nutritional assessment revealed diabetes and difficulty swallowing/chewing. The assessment was documented as no to any abnormal findings.

(f)The bladder assessment revealed the patient was incontinent at times.

(g) The integumentary assessment indicated the patients face was red and swollen on the person diagram.

(5) The review of the interdisciplinary patient plan of care is based on the patient assessment. The plan of care documentation for the nursing problem of nutrition was not address by the nursing staff during the patients stay at the hospital. A review of the Interdisciplinary patient education documentation revealed the patient was educated on activity level and the readiness to Learn was noted to mental impaired and patients response was no indication of learning.

(6) A review of the patient plan of care initiated on admission revealed no documentation of a problem with nutrition, patient mobility, knowledge deficit and discharge planning. The plan of care documented the patient was at risk for falls.

(7) A review of the facility's policy, Nursing Staff Role in Patient and Family Teaching, policy # NS-43, revised 1/09, revealed the purpose of the policy is to facilitate patient and family understanding of the disease process, interventions and care.

Further review of the policy, section titled Procedure, paragraph (1) revealed nursing staff is responsible to utilize the admission assessment to identify any patient education needs and paragraph (2) review the findings from the assessment with the physician , patient and patient's family to determine a plan of action to meet the patient's education needs in relation to the prescribed medical treatment and care.

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