Based on policy review, document review and staff interviews it was determined the facility failed to ensure 466 of the 466 actively credentialed physicians and allied health providers with privileges at the facility were in compliance with the Medical Staff bylaws requirement to include evidence of the physicians' demonstrated competence to provide quality medical care to patients. Findings included: 1. It was determined the facility failed to conduct periodic appraisals of 466 of 466 members of the medical staff since 2015(Refer to A0340). 2. It was determined the facility failed to ensure the re-credentialing process included objective measures to establish the physician's demonstrated competence to perform the medical services for which privileges were approved for 466 of 466 actively credentialed physicians and allied health providers.(Refer to A0341). The facility was not in compliance with 42 CFR 482.22, the Condition of Participation for Medical Staff, requirements for hospitals. These failures resulted in a finding of ongoing Immediate Jeopardy, beginning on 3/14/2019, creating a situation that is likely to result in serious injury, harm, impairment, or death to patients and requires immediate corrective action on the part of the facility.
Based on policy review, document review and staff interview it was determined the facility failed to perform periodic appraisals of provider performance in compliance with facility policies for 466 of the 466 actively credentialed physicians and allied health professionals privileged to provide medical care and services in the facility. These failures resulted in a finding of ongoing Immediate Jeopardy, beginning on 3/14/2019, creating a situation that is likely to result in serious injury, harm, impairment, or death to patients and requires immediate corrective action on the part of the facility. Findings included: The policy titled, Focused (FPPE) and Ongoing (OPPE) Professional Practice Evaluation Plan, (no policy number), was approved by the Board of Trustees on 6/2018. The policy applied to all Licensed Independent Practitioners or Allied Health Professionals who had delineated clinical privileges. The policy defined FPPE as a systematic process to ensure that there is sufficient information available to confirm the current competence of practitioners and the competence of those who have been granted privileges and/or were requesting new privileges. The policy defined OPPE as a summary of ongoing data collected for the purpose of assessing Licensed Independent Practitioners' and Allied Health Professionals' clinical competence. The policy included lists of criteria that would be evaluated for each practitioner. The policy indicated Quality Management would compile and analyze the data every six months. The review of the list of actively credentialed practitioners and allied health professionals revealed a total of 466 members of the medical staff. 41 of the 466 were physicians with delineated privileges and Active status. 98 of the 466 were allied health professionals with delineated privileges whose status was Privileges Without Membership. 327 of the 466 were physicians with Courtesy, Consulting, or Associate status. The Bylaws indicated all categories of medical staff required evidence of competence as a qualification of membership. The review of 14 credentialing files of physicians and allied health professionals (sample #A, B, C, D, E, F, G, H, I , J, K, L, M, and N) failed to reveal any evidence FPPE or OPPE activities were conducted for any of the 14 sampled physicians in 2016, 2017, 2018 or 2019. All of the 14 sampled physician files included evidence the Medical Council recommended, and the Governing Body approved, the appointment or reappointment to the medical staff with privileges to provide patient care as requested by the candidate. An interview was conducted with the Director of Physician Services on 3/26/19 at 2:00 p.m. The Director confirmed the finding FPPE and OPPE activities had not been conducted for any of the 14 sampled physicians since the fourth quarter of 2015. The Director indicated no evidence of the quality of care, or competence to provide quality medical care, was included in any of the materials provided to the Medical Council to review prior to recommending a physician to the Governing Body for approval of privileges. The Director indicated none of the 466 actively credentialed physicians and allied health professionals files included periodic FPPE or OPPE performance appraisals since 2015. An interview was conducted with the Assistant Vice President of Quality and Clinical Operations, West Florida Division on 3/29/19 at 12:25 p.m. She confirmed the finding none of the 466 actively credentialed physicians and allied health practitioners approved by the Governing Body were periodically appraised in compliance with facility policies and Federal regulations.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on document review, policy review, medical record review, and staff interviews it was determined the facility failed to ensure the Medical Staff enforced the Bylaws requirement for physicians and allied health providers to have demonstrated competence of their ability to provide quality medical care to patients for 466 of 466 physicians and allied health care providers. These failures resulted in a finding of ongoing Immediate Jeopardy, beginning on 3/14/2019, creating a situation that is likely to result in serious injury, harm, impairment, or death to patients and requires immediate corrective action on the part of the facility. Findings included: The History and Physical dated 3/11/19 indicated Patient #4 was scheduled to undergo elective (non-emergency) laparoscopic gastric sleeve surgery for treatment of morbid obesity by Physician M. The History and Physical indicated Patient #4 was otherwise healthy. The patient had no history of high blood pressure, diabetes, heart disease, respiratory disease or other chronic illnesses. The Pre-operative Assessment indicated Patient #4 was admitted on [DATE] at 8:18 a.m. The untitled form documenting cardiopulmonary resuscitation documented Patient #4 died on [DATE] at 8:48 p.m. The OR (Operating Room) Record documented Patient #4 entered the OR at 9:50 a.m. and was ready for the procedure at 10:20 a.m. The operation began at 11:40 a.m. Patient #4 left the OR at 5:33 p.m. and was transported directly to the Intensive Care Unit in critical condition, indicating Patient #4's surgical procedure took just under six hours to complete. The operative report dated 3/12/19 and signed by Physician M indicated Patient #4 suffered an estimated 5,000 cc (cubic centimeter) blood loss (normal adult circulating blood volume is approximately 6,000 cc) during the surgery as a result of the puncture or laceration of the mesenteric artery early in the procedure. The record indicated Patient #4 received eight units of blood, one unit of fresh frozen plasma and large volumes of intravenous fluid to treat the hemorrhage. The operative report did not provide any description of the size, length, or nature of the damage to the mesenteric artery. The operative report indicated the bleeding was not controlled by suturing. Physician M documented he applied a fibrin product used to control bleeding. After observing the site for 10 minutes, Physician M proceeded to perform the originally scheduled elective procedure and close the initial incisions. Patient #4 had a significant drop in blood pressure at that time. Physician M re-opened the incision to find bleeding again at the previous site. He documented he performed additional suturing of the artery, and used three additional topical products intended to facilitate blood clotting and control bleeding. After observing the site for 15 minutes, Physician M again sutured the main incision and documented Patient #4 was transferred to intensive care in critical condition. The operative report dated 3/13/19 at 4:03 a.m., and signed by Physician M, indicated Patient #4 was returned to the OR for a third attempt at controlling the bleeding from the mesenteric artery. The report described Physician M finding a large amount of blood in the patient's abdomen. The operative report did not include the estimated quantity of blood loss. Physician M documented suturing one of the mesenteric arteries and applying three different topical products intended to promote clotting and control bleeding. Patient #4 was returned to the Intensive Care Unit in critical condition following the surgery. The Consultation report dated 3/14/19 was signed by Physician H. The report indicated Physician M requested Physician H to provide a second opinion. The report indicated Physician H determined Patient #4 was experiencing multisystem organ failure including renal, respiratory and liver failure as a result of shock due to blood loss. Physician H noted there was blood in the abdominal cavity seen on CT scan performed on 3/14/19 at 9:47 a.m., but no sign of active bleeding. Physician H documented he did not think there was any need to consider additional surgery. The review of the credentialing file for physician M revealed he was reappointed to the medical staff with privileges as he requested in General and Laparoscopic Surgery, Gynecologic Surgery, and Vascular Surgery on 4/1/2013, 4/1/2015, and most recently on 4/1/2017 through 3/31/2019. The file failed to reveal any evidence of the demonstrated competence of Physician M to perform the services and procedures for which he had been approved for privileges. There were no mortality or morbidity statistics, or any information related to the quality of the medical care Physician M provided to patients. The most recent OPPE appraisal had been done in 2015. The National Provider Data Bank (NPDB) report dated 11/29/2018 included in the credentialing file revealed Physician M had been named in 16 malpractice suits between 2000 and 2018. Six of the 16 malpractice actions involved the death of a patient. The review of the credentialing file for Physician H for the previous credentialing period of 4/1/17 through 5/31/19 revealed Physician H was approved for privileges in General Surgery and Vascular Surgery. The review of the established criteria for privileges in Vascular Surgery included a requirement to perform a minimum of 20 procedures in the previous two year period and complete 10 hours of continuing education in the specialty. A hand-written unsigned note dated 4/19(no year) was affixed to the Department Review and Committee Approval form. The note indicated Physician H was requesting approval for privileges in Vascular Surgery although he had not met the criteria. The form was signed by the Medical Staff Department Chair on 5/1/17 attesting the reviewing physician had reviewed the re-credentialing information and recommended approval of privileges as requested. The file included documentation of the approval of the privileges by the Governing Body effective 4/1/17. The file failed to reveal any evidence of the demonstrated competence of Physician H to perform the services and procedures for which he had been approved for privileges. There were no mortality or morbidity statistics, or any information related to the quality of the medical care Physician H provided to patients. The most recent OPPE appraisal had been done in 2015. The review of the Medical Staff Bylaws, revised March 27, 2015 and most recently reviewed and approved March 2019 revealed the Qualifications for Membership were defined under Section 3A, page 5. The Bylaws indicated only physicians, dentists and podiatrists who could document their background, professional experience, education, training, and demonstrated competence with sufficient adequacy to demonstrate to the medical staff and governing body that any patient treated by them in the facility would be qualified for membership on the medical staff. Section 3B, page 6 indicated no individual is automatically entitled to initial or continued membership on the medical staff or to the exercise of particular clinical privileges in the hospital merely because he is duly licensed to practice or because the individual has previously been a member of this medical staff. The policy titled, Focused (FPPE) and Ongoing (OPPE) Professional Practice Evaluation Plan, (no policy number), was approved by the Board of Trustees on 6/2018. The policy applied to all Licensed Independent Practitioners or Allied Health Professional who had delineated clinical privileges. The policy defined FPPE as a systematic process to ensure that there is sufficient information available to confirm the current competence of practitioners and the competence of those who have been granted privileges and/or were requesting new privileges. The policy defined OPPE as a summary of ongoing data collected for the purpose of assessing Licensed Independent Practitioners' and Allied Health Professionals' clinical competence. The policy included lists of physician performance criteria that would be evaluated for each practitioner. The policy indicated Quality Management would compile and analyze the data every six months. The review of the list of actively credentialed practitioners and allied health professionals revealed a total of 466 members of the medical staff. 41 of the 466 were physicians with delineated privileges and Active status. 98 of the 466 were allied health professionals with delineated privileges whose status was Privileges Without Membership. 327 of the 466 were physicians with Courtesy, Consulting, or Associate status. The Bylaws indicated all categories of medical staff required evidence of competence as a qualification. The Oxford Dictionary defines competence as, The ability to do something successfully or efficiently. (https://en.oxforddictionaries.com/definition/competence) The Webster Dictionary defines competence as, the quality or state of being competent: such as the quality or state of having sufficient knowledge, judgment, skill, or strength. (https://www.merriam-webster.com/dictionary/competence) The review of 14 credentialing files of physicians and allied health professionals (sample #A, B, C, D, E, F, G, H, I , J, K, L, M, and N) failed to reveal any evidence establishing the physicians' demonstrated competence for the privileges for which they were approved by the Governing Body. The files contained no evidence of any of the physicians' abilities to perform the services for which they were credentialed in a successful manner. The files contained no evidence any of the 14 sampled physicians applied their knowledge, judgment, or skill in a manner that ensured quality care was provided to patients. The review of 14 credentialing files of physicians and allied health professionals (sample #A, B, C, D, E, F, G, H, I , J, K, L, M, and N) failed to reveal any evidence FPPE or OPPE activities were conducted for any of the 14 sampled physicians in 2016, 2017, 2018 or 2019. All of the 14 sampled physician files included evidence the Medical Council recommended, and the Governing Body approved, the appointment or reappointment to the medical staff with privileges to provide patient care as requested by the candidate. An interview was conducted with the Director of Physician Services on 3/26/19 at 2:00 p.m. The Director confirmed the finding FPPE and OPPE activities had not been conducted for any of the 14 sampled physicians since the fourth quarter of 2015. The Director indicated no evidence of the quality of care, or competence to provide quality medical care, was included in any of the materials provided to the Medical Council to review prior to recommending a physician to the Governing Body for approval of privileges. The Director indicated none of the 466 actively credentialed physicians and allied health professionals files included evidence of the quality of care, or the competence to provide quality medical care to patients in the facility. She confirmed the finding Physician H was approved by the Medical Staff and the Governing Body for privileges in Vascular Surgery despite failing to meet the established criteria. An interview was conducted with the Assistant Vice President of Quality and Clinical Operations, West Florida Division on 3/29/19 at 12:25 p.m. She confirmed the finding none of the 466 actively credentialed physicians and allied health practitioners approved by the Governing Body included the review of evidence of competence to provide quality medical care to patients.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on medical record review, staff interview and review of facility documents it was determined the facility failed to ensure the admitting physician provided a discharge order for one (#1) of three patients sampled. Findings included: Review of the medical record for patient #1 revealed the patient was admitted on [DATE] from a skilled nursing facility. Review of the record revealed the patient was admitted to the service of Physician A. On 11/11/2020 at 2:00 pm a discharge order was written by Consulting Physician B. There was no evidence Physician A wrote a discharge order. Review of the Medical Staff Rules and Regulations, Article I, Section 14, Discharge of Patients, states patients shall be discharged on order by the attending practitioner. An interview was conducted on 1/7/2021 at 11:00 am with the VP of Quality and Patient Safety and the Risk Manager. The above findings were confirmed.
Based on observation and interview with the Director of Facilities Management (DFM) and the Vice President of Quality and Patient Safety (VPQPS), the facility failed to properly manage compressed medical gas cylinders (oxygen) in accordance with NFPA 99, standard for Health Care Facilities. Improper management of medical gas cylinders could result in the rupture of the cylinders and subsequent accelerated development of fire, smoke and fire gasses in a fire situation. Findings included: During the facility tour with the DFM and the VPQPS on 07/13/2020 between 11:45 a.m. and 12:45 p.m., it was revealed that there were seventeen e-size oxygen cylinders stored with combustible materials (plastics, paper) adjacent to them in the 3 west respiratory oxygen storage room located on the third floor. The volume of the compressed oxygen in the room exceeded 300 cubic feet. An interview was conducted with the DFM and the VPQPS concurrent with the observations and confirmed the findings. per NFPA 99 (2012 Edition) 11.3.2.3
Based on policy review, document review, and staff interviews it was determined the Governing Body failed to ensure any of the 466 physicians and allied health professionals actively credentialed to the medical staff met the established criteria for competence, in compliance with facility policy and the Medical Staff Bylaws. Findings included: The policy titled, Focused (FPPE) and Ongoing (OPPE) Professional Practice Evaluation Plan, (no policy number), was approved by the Board of Trustees on 6/2018. The policy applied to all Licensed Independent Practitioners or Allied Health Professional who had delineated clinical privileges. The policy defined FPPE as a systematic process to ensure that there is sufficient information available to confirm the current competence of practitioners and the competence of those who have been granted privileges and/or were requesting new privileges. The policy defined OPPE as a summary of ongoing data collected for the purpose of assessing Licensed Independent Practitioners' and Allied Health Professionals' clinical competence. The policy included lists of criteria that would be evaluated for each practitioner. The policy indicated Quality Management would compile and analyze the data every six months. The review of the Medical Staff Bylaws, last revised March 27, 2015 and most recently reviewed and approved March 2019 revealed the Qualifications for Membership were defined under Section 3A, page 5. The Bylaws indicated the requirements for privileges included documented professional experience, education, training, and demonstrated competence. The Bylaws indicated the evidence must be documented with sufficient adequacy to demonstrate to the medical staff and governing body that the physician would provide quality medical care to any patient for services provided in compliance with approved privileges. Section 3B, page 6 indicated no individual is automatically entitled to initial or continued membership on the medical staff or to the exercise of particular clinical privileges in the hospital merely because he is duly licensed to practice or because the individual has previously been a member of this medical staff. The review of the list of actively credentialed practitioners and allied health professionals revealed a total of 466 members of the medical staff. 41 of the 466 were physicians with delineated privileges and Active status. 98 of the 466 were allied health professionals with delineated privileges whose status was Privileges Without Membership. 327 of the 466 were physicians with Courtesy, Consulting, or Associate status. The Bylaws indicated all categories of medical staff required evidence of competence as a qualification. The Oxford Dictionary defines competence as, The ability to do something successfully or efficiently. (https://en.oxforddictionaries.com/definition/competence) The Webster Dictionary defines competence as, the quality or state of being competent: such as the quality or state of having sufficient knowledge, judgment, skill, or strength. (https://www.merriam-webster.com/dictionary/competence) The review of 14 credentialing files of physicians and allied health professionals (sample #A, B, C, D, E, F, G, H, I , J, K, L, M, and N) failed to reveal any evidence establishing the physicians' demonstrated competence for the privileges for which they were approved by the Governing Body. The files contained no evidence of any of the physicians' abilities to perform the services for which they were credentialed in a successful manner. The files contained no evidence that any of the 14 sampled physicians applied their knowledge, judgment, or skill in a manner that ensured quality care was provided to patients. The review of 14 credentialing files of physicians and allied health professionals (sample #A, B, C, D, E, F, G, H, I , J, K, L, M, and N) failed to reveal any evidence FPPE or OPPE activities were conducted for any of the 14 sampled physicians in 2016, 2017, 2018 or 2019. All of the 14 sampled physician files included evidence the Medical Council recommended, and the Governing Body approved, the appointment or reappointment to the medical staff with privileges to provide patient care as requested by the candidate. An interview was conducted with the Director of Physician Services on 3/26/19 at 2:00 p.m. The Director confirmed the finding FPPE and OPPE activities had not been conducted for any of the 14 sampled physicians since the fourth quarter of 2015. The Director indicated no evidence of the quality of care, or competence to provide quality medical care, was included in any of the materials provided to the Medical Council to review prior to recommending a physician to the Governing Body for approval of privileges. The Director indicated none of the 466 actively credentialed physicians and allied health professionals files included evidence of the quality of care, or the competence to provide quality medical care to patients in the facility. An interview was conducted with the Assistant Vice President of Quality and Clinical Operations, West Florida Division on 3/29/19 at 12:25 p.m. She confirmed the finding none of the 466 actively credentialed physicians and allied health practitioners approved by the Governing Body included the review of evidence of competence to provide quality medical care to patients.
Based on policy review, document review, and staff interview it was determined the facility failed to ensure data related to physician quality of care was tracked, trended, analyzed and reported for purposes of improving patient outcomes and providing data to assist in the determination of physician competency. Findings included: The Quality Management Plan, revised 03/2019, indicated data metrics are analyzed for trends and process improvements (PI's) are put into place as identified. The plan indicated the Medical Staff were accountable for ensuring the ongoing program for performance improvement demonstrated patient safety and the quality of care provided to patients. The policy titled, Focused (FPPE) and Ongoing (OPPE) Professional Practice Evaluation Plan, (no policy number), was approved by the Board of Trustees on 6/2018. The policy applied to all Licensed Independent Practitioners or Allied Health Professional who had delineated clinical privileges. The policy defined FPPE as a systematic process to ensure that there is sufficient information available to confirm the current competence of practitioners and the competence of those who have been granted privileges and/or were requesting new privileges. The policy defined OPPE as a summary of ongoing data collected for the purpose of assessing Licensed Independent Practitioners' and Allied Health Professionals' clinical competence. The policy included lists of criteria that would be evaluated for each practitioner. The policy indicated Quality Management would compile and analyze the data every six months. The review of 14 credentialing files of physicians and allied health professionals (sample #A, B, C, D, E, F, G, H, I , J, K, L, M, and N) failed to reveal any evidence FPPE or OPPE activities were conducted for any of the 14 sampled physicians in 2016, 2017, 2018 or 2019. All of the 14 sampled physician files included evidence the Medical Council recommended, and the Governing Body approved, the appointment or reappointment to the medical staff with privileges to provide patient care as requested by the candidate without evidence of any of the physicians' or allied health providers' competence to provide quality medical care to patients. An interview was conducted with the Director of Physician Services on 3/26/19 at 2:00 p.m. The Director confirmed the finding FPPE and OPPE activities had not been conducted for any of the 14 sampled physicians since the fourth quarter of 2015. The Director indicated no evidence of the quality of care, or competence to provide quality medical care, was included in any of the materials provided to the Medical Council to review prior to recommending a physician to the Governing Body for approval of privileges. The Director indicated none of the 466 actively credentialed physicians and allied health professionals files included evidence of the quality of care, or the competence to provide quality medical care to patients in the facility. On 03/28/19 at 1:45 p.m., an interview was conducted with two Quality Coordinators and the Vice President of Quality and Safety. All interviewees confirmed the finding the facility was not tracking, trending, analyzing or reporting physician specific data for purposes of establishing the competence of the physician to provide quality patient care, or to identify problems or concerns for performance improvement related to the quality of medical services provided to patients. An interview was conducted with the Assistant Vice President of Quality and Clinical Operations, West Florida Division on 3/29/19 at 12:25 p.m. She confirmed the finding the Quality Department ceased FPPE and OPPE data collection activities in the fourth quarter of 2015, indicating no data has been collected to track, trend, analyze or report the quality of care provided by any of the 466 currently credentialed physicians and allied health practitioners providing medical services to hospital patients.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on medical record review, staff interview and review of policy and procedure it was determined the facility failed to ensure the discharge planning process was reassessed on an on-going basis. The facility failed to ensure policy and procedure for patients leaving against medical advice was followed for one (#3) of thirteen patients sampled. Findings include: Patient #3 was admitted on [DATE] with a diagnosis of intractable pain and kidney stones. Review of the admitting orders revealed an order for a urologist consultation. On 6/27/2015 documentation revealed a urologist consultation was completed. The consultation revealed the patient complained of pain on movement with some shortness of breath. The urologist documented review of the CT scan revealed a 5 mm (millimeter) non-obstructing kidney stone. The physician documented the patient denied urinary frequency, urgency, dysuria or nausea/vomiting. He noted consideration for other causes of the patient's flank pain should be considered. The urologist recommended follow-up on an outpatient basis with no intervention necessary at that time. Review of nursing documentation revealed a note dated 6/27/2015 at 12:16 p.m. that stated the patient was seen by the urologist who stated there was no obstruction from the renal stone therefore no interventions were needed at that time. The patient requested to leave AMA (Against Medical Advice). Nursing documentation revealed the risks of leaving were explained to the patient but the patient refused to stay. Review of the facility policy Patient Refusal of Further Medical Treatment and Leaving Against Medical Advice last reviewed 10/2014 stated (1)(a) the attending physician will be informed of the patient's intent to leave. Review of the record revealed no evidence the attending physician was informed of the patient's request to leave AMA. Review of the attending physician's discharge summary indicated the urologist recommended follow-up on an outpatient basis, the patient was stable for discharge on 6/27/2015 and the patient would follow up as an outpatient with the urologist. Review of the physician's orders revealed no order for discharge. Interview with the director of patient safety/risk manager on 8/4/2015 at approximately 3:45 p.m. confirmed the findings.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on medical records review, policies review and staff interview it was determined the facility staff failed to assess and provide medications according to physician orders and policy for two (#3, #5) of ten sampled patients who received care in the Emergency Department (ED). Findings include: 1. Patient #3 (MDS) dated [DATE] at 10:27 p.m. with a chief complaint of chest pain, back pain and scapula pain. Triage documentation at 10:37 p.m. noted the vital signs were obtained. Nursing documentation at discharge on 3/1/2014 at 1:40 a.m. noted the vital signs were obtained, approximately 3 hours later. No documentation was found that interim vital signs were taken. The findings were confirmed by the Chief Nursing Officer and a Registered Nurse on 4/17/2014 at approximately 3:45 p.m. Review of policy Assessment and Reassessment in the Emergency Department #EME 010:2:1 with final approval date 4/5/2013 part B Reassessment line 4 revealed vital signs are to be monitored at least every two hours and/or indicated for patient's condition and length of stay. 2. Patient #5 (MDS) dated [DATE] at 9:23 a.m. with a chief complaint of chest and flank pain. ED physician orders at 9:55 a.m. included Aspirin 325 milligrams (mg). The order was initialed by the ED RN with no time documented. Review of pharmacy automated dispensing documentation revealed 162 mg of Aspirin was removed at 11:06 a.m. Review of policy and procedure Medication Administration Policy #RXDNV MM.1.2 dated 3/7/14 Part B section E revealed to verify the medication being administered is the correct medication and correct dose. The findings were confirmed with the Pre Hospital Coordinator on 4/17/14 at approximately 11:00 a.m. that the wrong dose was administered and there was no documentation of the time the Aspirin was given.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review, policy review and staff interview it was determined the registered nurse failed to assess, plan, intervene, and evaluate nursing care related to skin care and pain management for 4 (#4, #6, #8, #9) of 10 sampled patients. This practice does not ensure patient goals are met and may lead to a prolonged hospital stay. Findings include: The facility's policy Skin Care Protocol, #WC 004 revised 3/12 required patients at risk of pressure ulcer development with a Braden score of 15 or less are to have photos of any alteration of skin integrity are to be taken and placed in the patient's medical record. In addition pressure ulcer prevention measures, including repositioning every two hours are to be initiated. 1. Patient #8 was admitted to the facility on [DATE]. The initial Braden assessment on 10/8/12 was 15. The nurse documented a skin tear on the right forearm, ecchymosis of the left arm and a pressure ulcer on the left buttock. Review of the medical record revealed no photos were present. The nurse manager who was present during the medical record review on 10/11/12 at approximately 1:00 p.m. reviewed the medical record and checked with other sources confirmed the photos had not been taken. Review of the nursing documentation for patient #8 revealed the Braden score was 13 on 10/9/12 and 10/10/12. Review of the nursing documentation revealed no evidence the patient was repositioned as required by policy. Impaired skin integrity was not listed as a problem on the plan of care. 2. Patient #9 was admitted to the facility on [DATE] for abdominal surgery. Review of the skin assessment section of the medical record revealed the Braden score on admission was 12. Review of the nursing documentation revealed no evidence that the patient was repositioned every two hours as required. The nurse manager, who was present during the record reviews on 10/11/12 confirmed the above findings. 3. Review of the facility's policy Pain Assessment and Management, no number, revised 4/12 revealed the staff was to evaluate the intensity of pain by using the Wong Baker scale, which ranks pain level from 0 (no pain) to 10 (worst pain ever). It also required the patient to be reassessed for response to the pain medication given IV within 30 minutes. Patient #6 was admitted to the facility on [DATE] for repair of a hip fracture. Review of the post-operative physician orders revealed orders for Morphine 2 mg IV every 3 hours as needed for mild pain (1-3), Morphine 4 mg IV every 3 hours as needed for moderate pain (4-7) and Morphine 6 mg IV every 3 hours as needed for severe pain (8-10). Review of the Medication Administration Record (MAR) revealed the patient received Morphine 2 mg IV at 12:03 a.m. on 10/8/12. The nurse documented pain level of 5, which required 4 mgs, not 2. There was no reassessment to determine the effectiveness of the medication. The patient received Morphine 2 mg at 6:14 a.m. on 10/8/12. There was no assessment of the pain level prior to the administration of the medication to determine the accuracy of the dose. There was no reassessment of the pain level following the administration of the medication. 4. Patient #9 was admitted to the facility on [DATE] for surgery. The post-operative orders included an order for Morphine 2-5 mg IV every 2 hours as needed. Review of the MAR revealed: 10/1 at 11:50 p.m. 2 mg of Morphine was given with no pain assessment before or after administration 10/3 at 5:46 p.m. 2 mg of Morphine was given with no pain assessment after administration 10/8 at 10:00 a.m. 2 mg of Morphine given with no assessment before or after administration 10/8 at 12:17 a.m. 2 mg of Morphine was given with no assessment after administration 10/9 at 9:37 a.m. 2 mg of Morphine was given with no assessment before or after administration 10/9 at 3:27 p.m. 2 mg of Morphine was given with no assessment before or after administration 10/9 at 5:58 p.m. 2 mg of Morphine was given with no assessment after administration 10/10 at 8:47 a.m., 12:35 p.m. and 4:23 p.m. 4 mg of Morphine was given with no assessment before or after administration 10/11 at 10:23 a.m. 2 mg of Morphine was given with no assessment before or after administration. 5. Patient #4 was admitted on [DATE] for abdominal surgery. The Med/Surg Nursing Flow sheet revealed no documentation of hygiene care provided by the nursing staff or that the patient was independent in her personal hygiene on 10/3, 10/4, 10/5, and 10/6/2012. An interview and record review was conducted with the Director of Nursing on 10/11/2012 at approximately 2:45 p.m. She confirmed the above findings.
**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 medications were administered as ordered by the physician for 1 (#7) of 10 sampled patients. This practice does not ensure safe administration of medication. Findings include: Patient #7 was admitted to the facility on [DATE] with physician orders for Levoquin 750 milligrams (mg) intravenously (IV) every 24 hours on 10/8/12. A second order was written by the physician changing the order to 750 mg IV every 48 hours on 10/9/12 at 2:40 p.m. Review of the Medication Administration Record revealed the first dose of the medication was given at 11:42 p.m. on 10/8/12. A second dose was administered on 10/9/12 at 9:25 p.m., which was 22 hours after the last administration. The order had been changed to every 48 hours. The nursing manager confirmed the nurse should not have administered the medication on 10/9/12 during interview on 10/11/12 at approximately 2:00 p.m.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review, policy review and interviews it was determined the facility failed to ensure the nursing staff followed the policy for culturing patients admitted with a known history of Methicillin-Resistant Staphylococcus Aureus (MRSA) infection for one (#3) of ten sampled patients. This practice does not ensure patients are safe from infections. Findings include: Patient #3 was admitted on [DATE] for surgery. The Patient History dated 9/26/2012 noted the patient stated he had a previous history of MRSA infection. A review of the record failed to reveal documentation that a screening test for MRSA had been performed at the time of the admission to the facility. The facility Policy #IC 1.08, MRSA Screening Protocol indicated patients with a stated history of MRSA will have cultures collected on admission to rule out MRSA. An interview was conducted with Patient #3 on 10/10/2012 at approximately 1:30 p.m. He stated he had been placed on contact precaution isolation on 10/6/2012 due to a MRSA infection in his surgical wound. Patient #3 stated he had MRSA infections in the past and had informed the staff at the time of admission. An interview with the Director of Infection control was conducted on 10/11/2012 at approximately 10:30 a.m. She stated when a patient had a history of previous MRSA infections, the protocol was for the nursing staff to initiate isolation precautions pending test results, perform a MRSA screening test and inform the physician of positive or negative results. The Chief Nursing Officer confirmed the MRSA screening test had not been performed as required by policy on 10/11/2012 at approximately 11:00 a.m.
Based on clinical record review, staff interview and policy review it was determined that facility failed to obtain a informed blood/blood products consent form for 1 (#22) of 30 sampled patients. This practice does not ensure the patient's right to an informed decision. Findings include: Patient #22's physician order dated 6/13/11 at 3:20 p.m. indicated to transfuse 2 units of Fresh Frozen Plasma. A review of the transfusion records revealed the patient received the first unit at 2:15 a.m. and was completed at 3:00 a.m. Review of the clinical record revealed a signed Informed Consent for Administration of Blood and/or Blood Products, dated and timed for 6/14/11 at 12:00 p.m., approximately 9 hours after the transfusion had been completed. An interview conducted with the Director of Intensive Care Services on 6/14/11 confirmed the findings. The Director stated she had spoken with the nurse involved and she confirmed she had not obtained a consent prior to the transfusion. A review of the facility's policy for Transfusing Blood and Blood Components, policy # 5.5 (BBTS), reviewed 5/11 revealed paragraph #2, Be sure that informed consent had been signed.
Based on record review, staff interview, and review of policy and procedures it was determined the Registered Nurse failed to evaluate and supervise the nursing care for six (#12, #18, #21, #26, #27, #28) of thirty patients sampled. This practice does not ensure that patient's goals are met and may cause a delay in discharge. Findings include: 1. Review of patient #18's physician order dated 6/8/11 at 10:20 a.m. instructed for the patient to have Accuchecks before meals and before bedtime with the emergency room sliding scale for insulin coverage. Review of the nursing documentation revealed on 6/8/11 at 4:00 p.m. and 9:00 p.m. no blood glucose results were documented. Review of physician order dated 6/10/11 at 8:50 a.m. instructed for the patient to have Accuchecks before meals and before bedtime and insulin coverage per sliding scale. Review of nursing documentation revealed on 6/11/11 at 8:30 a.m. the blood glucose was 204. Four units of insulin was to be given according to the sliding scale. There was no insulin documented in the Medication Administration Record (MAR). At 8:00 p.m. no blood glucose was documented. Documentation on the MAR revealed two units of regular insulin was given. Review of nursing documentation on 6/13/11 at 11:30 a.m. revealed no blood glucose was documented. At 9:00 p.m. the blood glucose was documented as 160. There was no documentation in the MAR of insulin being given according to the sliding scale. 2. Patient #21's physician order dated 6/12/11 at 8:40 a.m. instructed for the patient to received Labatelol 10 milligrams (mg) intravenously (IV) over one to two minutes for systolic blood pressure(SBP) greater than two hundred or diastolic blood pressure(DBP) greater than one hundred and twenty two readings 15 minutes apart. Review of nursing documentation on 6/12/11 at 11:35 p.m. revealed the blood pressure was 181/95 and no second reading was found. Documentation on the MAR indicated the nurse gave 10 mg of Labatelol IV. Patient #21's physician order dated 6/12/11 at 8:40 p.m. instructed for oxygen two to three liters via nasal canula. The order stated to check the oxygen saturations every shift while on oxygen and to call the physician if the oxygen saturation was less than ninety percent. Review of nurses' and respiratory therapists' documentation revealed no documentation of oxygen saturation every shift. Interview with the Chief Nursing Officer on 6/15/2011 at approximately 2:45 p.m., confirmed the above findings. 3. Patient #27's physician order dated 6/13/11, no time, instructed for an incentive spirometer every hour while awake and maintain oxygen saturation at more than ninety three percent. Review of nursing and respiratory therapy documentation revealed no documentation of incentive spirometer use every hour while awake. Patient #27's physician telephone order dated 6/14/11 at 10:40 p.m. instructed for Lopressor 2.5 mg intravenously every four hours as needed for systolic blood pressure more than one hundred and eighty and diastolic blood pressure of more than one hundred and ten. Review of nursing documentation revealed on 6/15/11 at 12:00 a.m. the systolic blood pressure was two hundred and five over ninety one. There was no documentation to indicate the patient received Lopressor. Review of nursing documentation for 6/15/11 at 8:00 a.m. revealed the systolic blood pressure was two hundred and ten over seventy eight. There was no documentation to indicate the patient received Lopressor. Review of nursing documentation revealed on 6/15/11 at 8:00 a.m. the systolic blood pressure was two hundred and twenty one over one hundred and seven. There was no documentation to indicate the patient received Lopressor. Patient #27's physician telephone order dated 6/13/11 at 5:05 p.m. instructed for the patient to use an incentive spirometer every hour while awake. No documentation could be located for the use of the incentive spirometer. Interview with respiratory therapist on 6/15/11 at 2:30 p.m. indicated that he did not have any orders in his assignment for the patient to use the incentive spirometer. Interview with unit secretary on 6/15/11 at 2:40 p.m. indicated that the order had been entered for respiratory therapy on 6/13/11 at 6:32 p.m. Interview with unit Registered Nurse (RN) on 6/15/11 at 2:45 p.m. indicated that it was both nursing and respiratory's responsibility to ensure patient was using incentive spirometer. 4. Patient #28's physician order dated 06/03/11 9:50 a.m. instructed for a psychological consult due to depression. Review of the progress and consult notes did not reveal that a psychologist had evaluated the patient. Interview with the manager of the nursing unit , on 06/15/11 at 10:25 a.m., revealed that the psychologist reported that he had been to see the patient but the patient was having a procedure done and was not available. Review of the medical record revealed that the procedure to which he referred had been completed on 06/07/11. Review of the care plan did not reveal that depression had been included as a problem for the patient . Patient #28's physician order dated 06/02/11 was noted for a fluid restriction and strict I&Os (input and output). A second physician's order dated 06/05/11 was noted for daily weights. Review of the daily weights revealed no weight had been documented on 06/06/11, 06/07/11, 06/08/11, 06/09/11, and 06/10/11. Interview with the Registered Dietitian on 06/15/11 at 2:15 p.m. revealed the physician had confirmed that the fluid restriction, strict I&O's and daily weights were due to the patient's edematous lower extremities at admission.
5. Patient #26's physicians post operative orders written on 6/10/11 at 2:00 p.m. revealed an order for vital signs every 4 hours. Review of nursing documentation revealed the vital signs were obtained once a shift (every 12 hours) from 6/10/11 at 10:30 p.m. to 6/13/11 at 7:30 a.m. Then every 8 hours from 6/13/11 at 7:30 a.m. to 6/14/11 at 10:44 p.m. The vital signs were obtained on 6/15/11 at 12:00 a.m., 7:00 a.m., and 1:30 p.m. A interview was conducted on 6/14/11 with the Unit Charge Nurse, who confirmed the findings. 6. Patient #12's nursing documentation and MAR revealed the patient was medicated for pain with a physician ordered dose of Morphine at 5:32 p.m. Review of the documentation did not reveal where the patient's pain was located or a measurement of the patient's pain intensity. Review of the documentation did not reveal if the medication was effective. On 5/30/11 at 8:00 p.m. patient #12 was assessed as having a pain level of 5 on a scale of 1 to 10 with 10 being the worst possible pain. Review of the documentation did not reveal where the patient's pain was located. Review of the MAR revealed the patient was medicated with Percocet, as ordered by the physician, at 8:48 p.m. Review of the nursing documentation did not reveal if the pain was effective. Review of the facility's policy, Pain Assessment and Management Program - Hospital Wide, last reviewed 5/2011, stated the pain assessment includes five elements: quality, intensity, radiation, duration and location. The policy also stated the patient's response to an intervention should be completed within 30-60 minutes (PO/IM within 60 minutes and IV within 30 minutes). The above findings were confirmed on 6/14/11 at 2:20 p.m. with the director of staff development.
Based on clinical record review, staff interview and policy review it was determined that the nursing staff failed to administer medications according to the physician orders for 1 (#22) of 30 sampled patients. The practice does not ensure safe and effective medication therapy. Findings include: Patient #22's physicians order written on 6/13/11 at 1:40 p.m. instructed for Decadron 2 milligrams (mg) every 6 hours as needed. A clarification order was obtained by nursing on 6/13/11 at 8:10 p.m. for Decadron 2 mg intravenously (IV) every 6 hours, 7 1/2 hours after the initial order. A review of the Medication Administration Record for 6/13/11 revealed the patient received the first dose of Decadron at 9:17 p.m. and a second dose was administered at 11:28 p.m., only 2 hours apart. A interview with the Director of Pharmacy on 5/16/11 at 1:00 p.m. revealed he had reviewed the administration records and confirmed the Decadron had been pulled from the Pyxis and administered by the nurse at the above times. The Director also confirmed there was no documentation as to why the second dose was given when the nurse had to override the system to obtain the medication. A review of the facility's policy for Medication Administration, General Guidelines, policy #MPC 003:1, revised 5/11, revealed paragraph #2, Compliance with Medication Orders, Medications shall be prepared and administered in accordance with the orders of the prescriber or practitioner responsible for the patient's care and accepted standards of practice.
Based on observation and interview with the Manager for Plant Operations, the facility failed to ensure that the dumpster/compactor was located on an impervious surface with a drain that prevented water from pooling and becoming a breeding or harborage area. This practice does not ensure a safe and sanitary environment. Findings include: On 06/14/11 at 10:40 a.m., a two foot by two foot pool of brown, foamy water was observed to have collected under a corner of the dumpster/compactor. On 06/15/11 at 1:30 p.m. the pool of water was again noted under the same corner of the dumpster/compactor. There had been no rain either day as an explanation for the water and there was no other standing or surface water indicating the area had been hosed down. The pool of water was noted to be in a depression that was rimmed with cracked cement. Interview by the Life Safety Surveyor on 06/15/11 at approximately 10:00 a.m. with the Manager of Plant Operations revealed that the surface of the cement pad had fallen below the drain, probably from the compactor consistently being dropped onto the cement. This depression left the drain above the surface of the cement and ultimately unable to drain water, unless the level of collected water rose above the top of the drain.
Based on observation, policy review and interview it was determined the facility failed to ensure the availability of a defibrillator for all 8 operating room suites. This practice could result in a delay in treatment or negative outcomes for a surgical patient. Findings include: A tour of the surgical department was conducted on 6/15/11 at approximately 1:00 p.m., accompanied by the Surgical Services Director, the Chief Nursing Officer, the Director of Pharmacy and the Risk Manager. During the tour it was observed there were 8 Operating Room Suites and 1 Code Cart with a Defibrillator next to the nursing desk. An interview with the Director of Surgery was conducted during the tour. The Director confirmed that none of the 8 surgical suites contained a defibrillator. When questioned on the process for when the defibrillator would be required she stated someone would bring it into the surgical suite. This would leave the other 7 surgical suites without the access to a defibrillator. A review of the facility's policy, Cardiopulmonary Resuscitation in the Operating Room (Code Blue), policy # SUR 006.9, revised 5/11, revealed the Emergency crash cart is brought into operating room immediately by assisting personnel or scrub tech. Post Code procedure, Code cart was to be returned to Central Supply immediately and another obtained.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on clinical record review, staff interview and policy review it was determined the nursing staff did not follow policy and procedure for the discharge of 1 (#1) of 10 sampled patients reviewed. Findings Include: 1. Patient #1 (MDS) dated [DATE] at 7:29 p.m. by ambulance. The patients triage vitals were blood pressure of 150/91, pulse 108, respirations 18, temperature of 98.9 and pain level of 5 out of 10. The patient was assigned a triage level of IV, non-urgent and was seen in the ED Fast Track area. The ED physician assessed the patient at 7:30 p.m. The chief complaint was listed as right knee pain status post fall. The Physicians impression was knee sprain and the patient was ready for discharge at 10:01 p.m. The patient received the following radiology exams while in the ED; Computed Topography (CT) scan of the cervical spine and head, x-rays of the knees, lumbar spine, pelvis, sacrum and coccyx. 2. The Nursing discharge documentation for 4/12/11 at 9:57 p.m., revealed the patient was discharged home, awake in no distress, taken via stretcher to his car then he was carried to his family's car for comfort. The Patients family refused to get and pay for wheelchair transport service. The family stated they will carry him to his bed from their car. There were no vital signs documented from the time of triage to the time of discharge. a. The Director of Quality, the Interim Director of Emergency Services, the Director of Risk Management and the Chief Nursing Officer, reviewed the patient's clinical record on 5/26/11 at approximately 4:45 p.m., and confirmed the above findings. 3. A review of the Radiology report for the Pelvis AP x-ray revealed findings suspicious for a sub capital fracture of the right femur. The findings were called to the ED physician at 8:22 a.m. on 4/13/11 by the radiologist. The patient's family was called by the ED charge nurse on 4/13/11 at 9:11 a.m., to bring the patient back to the facility. 4. An interview was conducted on 5/26/11 at 4:00 p.m., with an ED RN. The RN was questioned concerning the protocol for discharge from the ED. The RN stated that usually the patient is ambulated prior to discharge to verify they are ambulatory. The patients vital signs are obtain to ensure they are stable for discharge and that the patient's pain level is at a tolerable level. When presented with the scenario of the subject of the complaint, the nurse stated he could not see how the patient could have been discharged by stretcher. The ED MD would have to be notified if the patient was unable to ambulate. 5. A review of the policy, Patient assessment and reassessment in the emergency department, policy # EME 010:2:1, reviewed 1/11, revealed on page 2 of 2, section B. reassessment, paragraph (4), vital signs are to be monitored at least every 2 hours and/or indicated for patient's condition and length of stay. Vital signs will be taken and documented prior to discharge. 6. A Telephone interview was conducted with the Director of Physical Therapy (PT) on 5/26/11 at 5:00 p.m. During the telephone interview the Director was questioned concerning the initial PT evaluation following the patient's surgery on the second admission on 4/13/11. According to the initial PT evaluation the patient was Home ambulatory prior to the fractured hip. The meaning of home ambulatory according to the Director is that the patient ambulates around the home, short distances.
Based on interviews with the facilities quality personnel and review of the facilities grievance policy, the requirement for CFR 482.13 , A-0118 was NOT met . Findings include: A review of the facilities grievance policy documented that the governing body of hospital delegated the responsibility for grievance investigation and resolution to the grievance committee. The policy documented the process for filing and responding to grievances. On 3/30/11 at 2:25 P.M an interview was conducted with the risk manager. He presented a file which he stated was 2009/2010 grievances and written responses. The surveyors were not allowed to view these files. He proceeded to open a note book which he stated was his grievance log and written responses for 2011. The surveyors were not allowed to view the content of these pages, just watch as he flipped through pages of the notebook. He stated that he reports to the QI group monthly regarding grievances. He stated that the facility has identified issues through the grievances that have been used as QI monitors and that they have been monitoring laboratory issues regarding labs ordered versus specimens actually received in the lab. He stated that here have been no issues identified from grievances regarding patient rights and that nursing is involved in nonstop monitoring from information received from grievances. The facility refused to provide the grievance log and written responses as well as evidence of the QI involvement with grievances citing Patient safety work product . The surveyors were unable to establish compliance due to lack of evidence. The compliance with this policy was unable to be verified as the facility refused to provide the grievance log and the response letters citing Patient safety work product .
Based on staff interview and review of the policy and procedures it was determined the facility failed to provide documentation that the patient was provided with a written notice of its decision that contained the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. Findings include: On 3/30/11 during the entrance conference the patient's grievance log was requested. On 3/30/11 at 2:25 p.m an interview was conducted with the Risk Manager. He presented a file which he stated was 2009/2010 grievances and written responses. The surveyors were not allowed to view these files. The Risk Manager proceeded to open a note book which he stated was his grievance log and written responses for 2011. The surveyors were not allowed to view the content of these pages only watch as he flipped through pages of the notebook. He stated that he reports to the QI group monthly regarding grievances. He stated that the facility has identified issues through the grievances that have been used as QI monitors and that they have been monitoring laboratory issues regarding labs ordered versus specimens actually received in the lab. He stated that here have been no issues identified from grievances regarding patient rights and that nursing is involved in nonstop monitoring from information received from grievances. The facility refused to provide the grievance log and written responses as well as evidence of the QI involvement with grievances citing Patient safety work product . The surveyors were unable to establish compliance due to lack of evidence. A review of the facilities grievance policy documented that the governing body of hospital delegated the responsibility for grievance investigation and resolution to the grievance committee. The policy documented the process for filing and responding to grievances. The compliance with this policy and regulation could not be verified as the facility refused to provide the grievance log and the response letters citing Patient safety work product.
Based on staff interview, review of administrative documentation, and review of policy and procedures it was determined the facility failed to comply with the death reporting requirements for six of six deaths reported. The facility failed to document in the patient's medical record the date and time the death was reported to CMS. Findings include: Documentation of CMS reporting of deaths associated with the use of seclusion or restraint was requested upon entrance. The documentation was provided and reviewed. Review of the documentation revealed forms were completed and faxed to the CMS central office within 24 hours of the death. A sample of medical records were requested to verify documentation in the record of the date and time CMS was notified. The Risk Manager was interviewed on 3/30/11 at 3:06 p.m. and stated there is no documentation in the medical records. He stated he would be the only one that would document this information and he has never done it since he has been employed as Risk Manager for the facility. Review of the facility ' s policy requires that CMS notification be documented in the patient ' s record. The Risk Manager stated he was not aware of the facility ' s policy or the federal regulation which requires the documentation.
Based on staff interviews, review of clinical records, and review of policy and procedures it was determined that a registered nurse failed to supervise and evaluate the nursing care for one (#7) of eight patients sampled. Findings include: Review of patient #7's medical record revealed on 3/20/11 at 7:00 p.m. a LPN (Licensed Practical Nurse) was assigned to the care of the patient. Documentation revealed on 3/20/11 at 9:30 p.m. the LPN performed a nursing assessment of the patient. There was no evidence an RN (Registered Nurse) supervised or evaluated the nursing care of the patient. On 3/21/11 at 7:00 a.m. the care of the patient was transferred to another LPN. Documentation revealed on 3/21/11 at 8:00 a.m. the LPN performed a nursing assessment of the patient. There was no evidence an RN supervised or evaluated the nursing care of the patient. On 3/21/11 at 7:00 p.m. the care of the patient was transferred to another LPN. On 3/21/11 at 7:20 p.m. the LPN performed a nursing assessment of the patient. There was no evidence an RN supervised or evaluated the nursing care of the patient. On 3/22/11 at 7:00 a.m. the care of the patient was transferred to another LPN. On 3/22/11 at 8:00 a.m. the LPN performed a nursing assessment of the patient. There was no evidence an RN supervised or evaluated the nursing care of the patient. On 3/22/11 at 7:00 p.m. the care of the patient was transferred to an RN. Review of the documentation revealed an RN did not supervise or evaluate the nursing care of the patient for 48 hours. Review of the facility ' s policy, Assessment of Patients , last reviewed 6/2010, stated the patient will be reassessed at least every 8 hours with an RN performing the assessment at least once in each 24 hour period. On 4/01/11 at 1:30 p.m. the risk manager confirmed the findings. Interview with the CNO revealed LPN and RN's rotate each shift so that the patient is assessed by an RN at least once in each 24 hour period.
Based on staff interview, review of personnel files, and review of policy and procedures it was determined the Chief Nursing Officer failed to provide for adequate supervision and evaluation of the clinical activities for one non employee licensed nurse. Findings include: A tour of the ICU was conducted on 3/31/11 at 2:40 p.m. An agency nurse currently working on the unit was interviewed. The nurse stated he had been working in the facility for approximately 3 months. He was asked about the orientation he received at the facility. He stated on his first shift he was to be oriented with the charge nurse but she walked off the unit so he did not receive an orientation. He stated that he just started caring for the patients. The CNO (Chief Nursing Officer) interrupted the agency nurse to tell him this was a surveyor with AHCA and here on a complaint. She stated the surveyor was not here about the other situation. The agency nurse stated that he received about four hours of orientation on his first shift. Review of the facility's policy, Agency Personnel, Orientation, last reviewed 11/2009, states each agency nurse will receive one shift of orientation on an appropriate unit. The policy also states the agency nurse will work with a facility employee on a one-to-one basis for the shift to become familiar with the facilities' routines and policy and procedures. On 4/01/11 the personnel file for the agency nurse interviewed was requested and reviewed. Review of the file revealed a completed orientation form dated 3/31/11. The form stated the above individual has oriented with me and has demonstrated the behavior, competency and understanding of the above . The form was signed by the agency nurse and the Chief Nursing Officer and dated 3/31/11. The Chief Nursing Officer was interviewed on 4/01/11 at 1:00 p.m. The CNO confirmed the form was completed and signed on 3/31/11. The CNO was questioned if she oriented and observed the agency nurses competencies. She denied she oriented or observed the nurses competencies. Review of the facility's policy, Agency Personnel Evaluation, last reviewed 6/2010, states an evaluation form will be completed at the end of the orientation shift, first shift and whenever deemed necessary. It was determined the chief nursing officer failed to ensure adequate supervision and evaluation of the clinical activities of a non-employee licensed nurse.
Based on staff interview and review of policy and procedures it was determined the facility failed to ensure nursing staff supervised the administration of medication. This practice does not ensure medications are administered according to physician orders. Findings include: On 3/30/11 at 2:40 p.m. the risk manager was interviewed. The risk manager was interviewed regarding a patient concern that medications were left by nursing at the patient's bedside. The risk manager stated nursing will leave a medication in a medication cup at the patient's bedside if the patient requests to take the medication with a meal. Review of the facility's policy, Medication Administration, General Guidelines, last revised 2/2011, states medications are not to be left in patient rooms. Pyxis medications are to be returned to Pyxis when not administered.
Based on staff interviews, review of clinical records, and observations it was determined the facility failed to provide documentation the infection control officer maintained a log of incidents related to infections and communicable diseases (refer to A750). The facility failed to ensure the chief executive officer, the medical staff, and the chief nursing officer addressed problems identified by the infection control officer and implemented the problems identified into the hospital wide quality assurance program and training programs. The facility failed to ensure the chief executive officer, the medical staff, and the chief nursing officer were responsible for the implementation of successful corrective action plans in affected problem areas (refer to A756). Lack of documentation provided by the facility failed to ensure the facility maintained an infection control program for the prevention, control, and investigations of infections and communicable diseases. This does not ensure the provision of quality health care in a safe environment.
Based on staff interview and requested infection control log it was determined the facility failed to maintain a log of incidents related to infections and communicable diseases, including healthcare associated infections and infections identified through employee health services. Findings include: On 3/30/11 during the entrance conference the infection control log was requested. The administrative staff stated the facility is a PSO (Patient Safety Organization) and upon advice from legal counsel the facility could not provide the infection control log stating the log was patient safety work product. In reference to 73 FR , November 21, 2008: Information is not patient safety work product if it is collected to comply with external reporting, such as ..... certification or licensing records for compliance with health oversight agency requirements .....compliance with required disclosures by particular providers or suppliers pursuant to Medicare ' s Condition of Participation or Conditions of Coverage ..... In reference to 73 FR , November 21, 2008 Providers have the flexibility to protect this information as patient safety work product within their patient safety evaluation system while they consider whether the information is needed to meet external reporting obligations. Information can be removed from the patient safety evaluation system before it is reported to a PSO to fulfill external reporting obligations. An interview was conducted with the IC (Infection Control) Officer on 3/31/11 at 1:15 p.m. The log of incidents related to infections and communicable diseases was requested. The IC Officer denied access to the information. She stated she was informed by administration this was protected information. Furthermore, she stated she maintains a log, monitors the program and reports finding to corporate and to hospital administration. She stated the reports are taken to the infection control committee, quality committee, and then to the Board. Infection control meeting minutes were requested but the facility refused to provide them. It could not be determined if the facility was in compliance with the Condition of Participation for Infection Control based on the lack of documentation.
Based on staff interviews and review of clinical records, policy and procedures it was determined that the Registered Nurse (RN) failed to supervise and evaluate the nursing care for one (#7) of eight patients sampled. This practice does not ensure patient safety and goals are maintained. Findings include: Review of patient #7's medical record revealed on 3/20/11 at 7:00 p.m. a LPN (Licensed Practical Nurse) was assigned to the care of the patient. Documentation revealed on 3/20/11 at 9:30 p.m. the LPN performed a nursing assessment of the patient. There was no evidence the RN supervised or evaluated the nursing care of the patient. On 3/21/11 at 7:00 a.m. the care of the patient was transferred to another LPN. Documentation revealed on 3/21/11 at 8:00 a.m. the LPN performed a nursing assessment of the patient. There was no evidence the RN supervised or evaluated the nursing care of the patient. On 3/21/11 at 7:00 p.m. the care of the patient was transferred to another LPN. On 3/21/11 at 7:20 p.m. the LPN performed a nursing assessment of the patient. There was no evidence an RN supervised or evaluated the nursing care of the patient. On 3/22/11 at 7:00 a.m. the care of the patient was transferred to another LPN. On 3/22/11 at 8:00 a.m. the LPN performed a nursing assessment of the patient. There was no evidence that the RN supervised or evaluated the nursing care of the patient. On 3/22/11 at 7:00 p.m. the care of the patient was transferred to an RN. Review of the documentation revealed an RN did not supervise or evaluate the nursing care of the patient for 48 hours. Review of the facility's policy, Assessment of Patients, last reviewed 6/2010, stated the patient will be reassessed at least every 8 hours with an RN performing the assessment at least once in each 24 hour period. On 4/01/11 at 1:30 p.m. the risk manager confirmed the findings. Interview with the Chief Nursing Officer (CNO) revealed LPN and RN's should rotate each shift so that the patient is assessed by an RN at least once in each 24 hour period.
Based on staff interview, review of personnel files, and review of policy and procedures it was determined the Chief Nursing Officer (CNO) failed to provide for adequate supervision and evaluation of the clinical activities for one non employee licensed nurse. This practice does not ensure the competency and safety of nursing care being provided. Findings include: 1. A tour of the Intensive Care Unit (ICU) was conducted on 3/31/11 at 2:40 p.m. An agency nurse currently working on the unit was interviewed. The nurse stated he had been working in the facility for approximately 3 months. He was asked about the orientation he received at the facility. He stated on his first shift he was to be oriented with the charge nurse. The interview revealed the charge nurse walked off the unit so he did not receive an orientation. He stated that he just started caring for the patients. The CNO interrupted the agency nurse to tell him this was a surveyor and was here on a complaint. She stated the surveyor was not here about the other situation. The agency nurse then stated that he received about four hours of orientation on his first shift. Review of the facility's policy, Agency Personnel, Orientation, last reviewed 11/2009, states each agency nurse will receive one shift of orientation on an appropriate unit. The policy also stated the agency nurse will work with a facility employee on a one-to-one basis for the shift to become familiar with the facility's routines and policy and procedures. On 4/01/11 the personnel file for the agency nurse interviewed was requested and reviewed. Review of the file revealed a completed orientation form dated 3/31/11. The form stated the above individual has oriented with me and has demonstrated the behavior, competency and understanding of the above . The form was signed by the agency nurse and the Chief Nursing Officer and dated 3/31/11. The Chief Nursing Officer was interviewed on 4/01/11 at 1:00 p.m. The CNO confirmed the form was completed and signed on 3/31/11. The CNO was questioned if she oriented and observed the agency nurse's competencies. She denied she oriented or observed the nurse's competencies. Review of the facility's policy, Agency Personnel Evaluation, last reviewed 6/2010, stated an evaluation form will be completed at the end of the orientation shift, first shift and whenever deemed necessary.
Based on staff interview and review of policy and procedures it was determined the facility failed to ensure nursing staff supervised the administration of medication. This practice does not ensure medications are administered according to physician orders. Findings include: On 3/30/11 at 2:40 p.m. the risk manager was interviewed regarding a patient concern that medications were left by nursing at the patient's bedside. The risk manager stated nursing will leave a medication in a medication cup at the patient's bedside if the patient requests to take the medication with a meal. Review of the facility's policy, Medication Administration, General Guidelines, last revised 2/2011, stated medications are not to be left in patient rooms. Pyxis medications are to be returned to Pyxis when not administered.
Based on staff interview the facility failed to demonstrate if the facility was in compliance with the Condition of Participation for Infection Control based on the lack of documentation. This does not ensure the provision of quality health care in a safe environment. 1. The facility failed to provide documentation that the infection control officer maintained a log of incidents related to infections and communicable diseases (refer to A750). 2. The facility failed to ensure the chief executive officer, the medical staff, and the chief nursing officer addressed problems identified by the infection control officer and implemented the problems identified into the hospital wide quality assurance program and training programs. The facility failed to ensure the chief executive officer, the medical staff, and the chief nursing officer were responsible for the implementation of successful corrective action plans in affected problem areas (refer to A756). Lack of documentation provided by the facility failed to ensure the facility maintained an infection control program for the prevention, control, and investigations of infections and communicable diseases.
Based on staff interview and requested infection control log it was determined the facility failed to maintain a log of incidents related to infections and communicable diseases, including healthcare associated infections and infections identified through employee health services. This practice does not ensure a successful infection control program Findings include: On 3/30/11 during the entrance conference the infection control log was requested. The administrative staff stated the facility was a PSO (Patient Safety Organization) and upon advice from legal counsel the facility could not provide the infection control log stating log was a patient safety work product. In reference to 73 FR , November 21, 2008: Information is not patient safety work product if it is collected to comply with external reporting, such as ..... certification or licensing records for compliance with health oversight agency requirements .....compliance with required disclosures by particular providers or suppliers pursuant to Medicare's Condition of Participation or Conditions of Coverage ..... In reference to 73 FR , November 21, 2008 Providers have the flexibility to protect this information as patient safety work product within their patient safety evaluation system while they consider whether the information is needed to meet external reporting obligations. Information can be removed from the patient safety evaluation system before it is reported to a PSO to fulfill external reporting obligations. An interview was conducted with the IC (Infection Control) Officer on 3/31/11 at 1:15 p.m. The log of incidents related to infections and communicable diseases was requested. The IC Officer denied access to the information stating it was protected information as she was informed by administration. The IC Officer stated she maintains a log, monitors the program and reports finding to corporate and to hospital administration. She stated the reports are taken to the infection control committee, quality committee, and then to the Board. Infection control meeting minutes were requested but the facility refused to provide any type of meeting minutes. It could not be determined if the facility was in compliance with the Condition of Participation for Infection Control based on the lack of documentation.
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