**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on medical records, policy and procedures, telemetry logs and interviews it was determined that the facility failed to supervise and evaluate the nursing care for each patient with a telemetry monitor in two (#2, #4) of four patients sampled. Findings include: 1. Review of Patient #2's medical record reveals that on 01/02/2021 at 3:36 AM, A Charge Nurse was doing rounds and went in to take a closer look at Patient #2. A code blue (cardiac arrest) was called. Advanced cardiac life support (ACLS) started; Patient #2 expired at 3:49 AM. Upon further review of Patient #2's medical record, there was no evidence that the telemetry technician notified the nurse of the rhythm change from [DIAGNOSES REDACTED](Afib) with bundle branch block (BBB) to a life-threatening rhythm requiring immediate notification of change. 2. Review of Patient #4's medical record reveals that on 03/30/2021 at 4:00 AM, a nursing note (late entry) documented a change in patient cardiac rhythm from sinus rhythm (SR)/sinus tachycardia (ST) to [DIAGNOSES REDACTED](Afib) with Rapid ventricular response (RVR). Further review of the medical record reveals Patient #4 was on a telemetry monitor. Patient heart rate was 130-150 beats per minute (bpm). Patient #4 was transferred to a higher level of care. Extensive review of medical records shows no evidence that the tele technician notified the nurse of a life-threatening change in heart rhythm. Review of Policy and Procedure title, Cardiac Telemetry Monitoring Revised Date 01/27/2020 ...Interpretation of cardiac monitoring is the responsibility of the register nurse. They may delegate this task to personnel who have competed an approved basic arrhythmia interpretation class and have demonstrated competency. However, this does not relinquish the RN responsibility ...Monitoring technicians will be responsible for monitoring cardiac tele, running documentation strips, and communicating to the nurse changes in patient rhythm and when patient are off monitor ...If patient rhythm is not transmitting to the central station the monitor personnel will call for immediate resolution by calling a Telemetry Alert to the patient room and bed ...If the patient rhythm is transmitting but a suspected life threatening rhythm is detected the monitoring personnel will immediately call a code Blue ... the following arrhythmia alarm MUST be activated at all times: asystole, [DIAGNOSES REDACTED], ventricular fibrillation, severe bradycardia (HR less than 50), severe tachycardia (HR 150 or greater) ... Monitor technician will immediately call code blue of suspected life-threatening arrhythmias. The monitor technician will run continuous strips and record on the event log and await further instruction by the RN .... A change in rhythm or rate ...the monitor tech notify the RN of change in patient's rhythm and print a strip of changed rhythm ...The monitor technician will maintain a daily telemetry event log to record tele event, calls placed to the care team and alerts or codes initiated from the monitoring station ... Review of the telemetry logs shows no evidence documented of Patient #2 and Patient #4, changes in cardiac rhythm, nor notification of the Registered Nurse. The Telemetry technician failed to immediately notify the Nursing staff of a life-threatening rhythm. Interview with Risk Manager/Director of Patient Safety confirm the above findings.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on policy review, medical record reviews, and staff interview, it was determined the facility failed to provide services and honor patient rights of transfer and discharge against medical advice (AMA) for three (#1, #2, #5) of six patient medical records sampled. Findings included: A review of the policy entitled, Against Medical Advice (AMA) Discharge, no #, revised 08/06/20, showed: 1. The nursing unit staff will notify the physician of the patient's intent to leave AMA, and of actual elopement. 2. The physician must decide that the patient is: a. Alert and Oriented to time, person , and place. b. Not mentally impaired due to alcohol, drugs, or other recognizable organic factors or mental illness. c. Fully aware of provisional diagnosis. d. Aware of the risk (s) related to refusing treatment... 3. The RN must notify the physician (primary and consultations) of the discharge... 4. Check for instructions the physician may wish to give. A review of Patient #1's physician history and physical (H&P) documentation dated 09/08/20 at 7:24 AM showed the patient was admitted on [DATE] for the following: a thrombus (clot) in the abdominal aorta (as see on cat scan), sepsis, bacteremia (bloodstream infection), bilateral lower extremity weakness, influenza, low magnesium, [DIAGNOSES REDACTED] (low platelets), anemia, and hypertension. On 09/08/20 at 2:24 PM, the cardiothoracic surgeon documented Patient #1 wished to be treated at hospital X. On 09/08/20 at 6:38 PM, nursing documentation showed Patient #1 stated he would like to be transferred to hospital X. The note showed the cardiothoracic surgeon and primary care physician were aware of the patient and family's wishes to be treated at hospital X. The nursing note at 9:20 PM showed the patient left AMA and that the physicians had declined to accommodate the patient/family requests for transfer, as it was not necessary to patient care. On 09/08/20 at 4:30 PM a bilateral extremity arterial study resulted and showed severe peripheral vascular diseases (PVD) of the left leg and femoral artery, suggesting inflow stenosis, probable hemodynamically significant stenosis at the origin of the left profunda. On 09/08/20, the physician DC summary showed the patient was instructed to follow any DC instructions given, take any medications prescribed, and resume care as soon as possible with another provider. On 10/21/20 at 11:45 AM, an interview with the VP of Quality, confirmed the facility failed to honor the patient's right of transfer and the physician, after being notified by nursing, failed to write a DC order. The VP stated that the DC order provides nursing with DC instructions for the patient that includes; the patient's diagnosis, treatments, testing and information pertaining to the patient ' s current course of illness and treatment, post-discharge goals of care, and treatment preferences, at the time of discharge. The VP confirmed there was no evidence the patient was provided DC instructions to include the results of the bilateral extremity arterial study prior to leaving. A review of Patient #2's emergency department (ED) physician history and physical (H&P) documentation dated 08/01/20 at 11:30 AM, showed the patient presented to the ED with complaints of nausea, vomiting (N/V), epigastric pain, and diarrhea. The noted showed the patient had also been seen at the facility on 07/29/20 and 07/30/20, with reports of the same symptoms; nausea, vomiting and epigastric pain. The patient was admitted for further tests and treatment of abdominal pain and pancreatitis. A review of Patient #2's inpatient physician H&P documentation dated 08/01/20 at 4:47 PM, also showed a diagnosis of [DIAGNOSES REDACTED] A review of Patient #5's physician H&P dated 09/10/20 at 2:49 AM, showed a 71 year that presented to the facility with complaints of chest pain (CP). The pain was accompanied by nausea, dizziness and some shortness of breath. At 10:34 AM the physician note revealed the cat scan (CT) of the chest showed a small left side pleural effusion and echocardiogram testing was pending results. At 1:49 PM, the physician note showed the patient left AMA. On 10/21/20 at 1:30 PM, an interview with the VP of Quality, revealed Patient #2 left the facility AMA at 9:59 PM. The VP confirmed nursing failed to notify the physician that the patient left AMA and there was no physician documentation present showing the patient had been made fully aware of the provisional diagnosis and of the risk (s) related to refusing treatment. The VP confirmed there was no further nursing or physician documentation in Patient #5's medical record regarding why the patient left AMA, or whether made fully aware of the provisional diagnosis, and risk (s) related to refusing treatment.
Based on a review of the facility's documents, policies and procedures, medical records, and staff interview, it was determined the facility failed to protect patients' rights. The facility failed to provide a written description of the Rights of Persons to the patient and/or health care proxy in four (#5, #6, #7, #8) of eight patients sampled (Refer to A116). The facility failed to obtain consent for psychotropic medication prior to administering the drugs for one (#8) of eight patients sampled (Refer to A117). The facility failed to provide a written copy of the rights to petition for the Writ of Habeus Corpus in two (#5, #7) of eight patients sampled (Refer to A121). The facility failed to adequately document the investigation for an allegation of sexual abuse for one (#2) of eight patients sampled (A145).
Based on review of medical records and staff interview it was determined the facility failed to provide a written description of the Rights of Persons to the patient and/or the health care proxy in four (#5, #6, #7, and #8) of eight patients sampled. Findings included: Review of the form, Rights of Persons in Mental Health Facilities and Programs, revealed a section, located at the bottom of the form, which stated to check when applicable and initial/date/time when a copy is provided. The form stated a copy must be given to the person and to any authorized decision-maker for persons incompetent or incapacitated by age or disability. Review of the medical record for Patient #5 revealed that on 06/22/2020 at 1:48 AM, the patient signed the Rights of Persons in Mental Health facilities form with the bottom section not filled out to indicate if the patient received a copy. On 06/23/2020 at 8:45 AM, Patient #5 was deemed incompetent to provide express and informed consent and therefore an authorized decision-maker was required. Further review of the medical record revealed on 07/01/2020 at 6:11 AM, a guardian advocate gave telephone consent for notification of persons' rights in a mental health facility. Review of the bottom section of the form revealed no indication the guardian advocate was provided a written copy of the patient's rights. Review of the medical record for Patient #6 revealed that on 04/15/2020 at 5:35 PM, the patient was unable/refused to sign the acknowledgement that the patient's rights were explained. Review of the bottom section of the form revealed no indication if the patient received a written copy. Review of the medical record revealed on 04/16/2020 at 7:00 AM, the patient's health care proxy provided telephone consent for notification of persons' rights in a mental health facility. Review of the bottom section of the form revealed no indication the patient's health care proxy was provided a written copy of the patient's rights. A review of the medical record for Patient #7 revealed on 05/20/20 at 3:30 AM signed the Rights of Persons in Mental Health Facilities and a written copy provided to the patient. Further review of the medical record revealed the health care proxy for Patient #7 provided telephone consent for acknowledgement of the patient's rights. Review of the bottom section of the form revealed no indication the patient's health care proxy was provided a written copy of the patient's rights. A review of the medical record for Patient #8 revealed on 07/30/2020 at 7:50 PM, The Patient signed the acknowledgement of the Rights of Persons in Mental Health Facilities and documentation a written copy was provided. Further review of the medical record revealed the health care proxy for Patient #8 provided telephone consent for acknowledgement of the patient's rights. Review of the bottom section of the form revealed no indication the patient's health care proxy was provided a written copy of the patient's rights. Interview on 08/27/2020 at 2:00 PM with the Director of Patient Safety confirmed the above findings.
Based on clinical record review and staff interview it was determined the facility failed to obtain consent for psychotropic medication administration prior to administration of the drugs in one (#8) of eight patients sampled. Findings included: Review of the medical record for Patient #8 revealed on 07/30/2020 at 10:00 AM Patient #8 was deemed incompetent to provide express and informed consent by the psychiatrist. Review of the medical record for Patient #8 revealed on 07/31/2020 at 10:12 AM, the facility administered Zyprexa and Depakote (psychotropic medications) prior to obtaining consent for the psychotropic medication administration. Further review of the medical record revealed the consent for Specific Authorization for Psychotropic Medication was obtained from the patient's health care proxy after the medications had already been administered. Review of the consent form revealed the proxy provided consent for administration on 07/31/2020 at 2:52 PM. Interview on 08/27/2020 at 2:00 PM with the Director of Patient Safety confirmed the above findings.
Based on medical record review and staff interview it was determined the facility failed to provide a written copy of the rights to petition for Writ of Habeas Corpus in two (#5 and #7) of eight patients sampled. Findings included: Review of the medical record for Patient #5 revealed no evidence the patient received written notice for the Writ of Habeas Corpus (information of his/her right to file a petition to question the cause and legality of a patient's detention). Further review revealed the facility's designee signed the form on 6/23/2020 at 1:48 AM with the section left blank on the individual that the facility provided a copy of the notice. A review of the medical record for patient #7 revealed no evidence the patient received written notice for Writ of Habeas Corpus. On 05/21/2020 at 12:15 AM, the facility's designee signed the form with the section left blank on the individual that the facility provided a copy of the notice. Interview on 08/27/2020 at 2:00 PM with the Director of Patient Safety confirmed the above findings.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on facility document review, policy and procedure review, medical record review, and staff interview it was determined the facility failed to adequately document the investigation for an allegation of sexual abuse for one (#2) of eight patients sampled. Findings included: Review of the facility policy, Patient and Non-Patient Safety Event Notifications, stated the purpose was to establish the policy and outline procedures for reporting unusual and adverse or untoward patient related and non-patient related events, or potential patient safety related events, that occur within or around the hospital facility and property. The policy stated under Procedure (A) Reporting: (5) other adverse/untoward incidents that are to be reported to the Patient Safety Director/Risk Manager/designee through the Meditech QM module Risk Management section include, but are not limited to issues/concerns involving: (a) allegations of sexual abuse/rape; (6) department directors are responsible for reviewing all patient notification event reports to which they are assigned, completing a thorough investigation and documenting findings in the notification report within 15 days; (7) the Patient Safety Director/Risk Manager/designee will complete reports within 60 days; (B) Event Follow-up (3) the Patient Safety Director/Risk Manager/designee will track statistical data for analysis and process improvement purposes; (C) Event Notification Report Review and Analysis: the patient safety director/risk manager/designee is responsible: (a) for the regular and systematic review of Patient Notification event reports and (c) providing the governing body with quarterly summary reports and maintaining summary data for three years. Review of the patient notification event reporting log revealed an event, described as a grievance, was received by the Administrative Nursing Supervisor on 7/04/2018 at 3:00 pm from the mother of sampled patient #2. Documentation revealed the patient was admitted from 6/3 - 6/8/2018 on the Behavioral Health Unit (BHU). It was alleged the patient was sexually molested during her admission and she was going to report it to the police. Review of the facility documents (emails) revealed on 7/04/2018 at 3:00 pm the Nursing Supervisor reported the information to the Chief Nursing Officer (CNO) and Director of BHU. A handwritten facility document, dated 7/05/2018 at 9:00 am, by the Administrative Nursing Supervisor, stated the cameras were to be reviewed, and to check all patients and staff with the specific name reported. At 10:06 am a telephone call was placed to the patient's mother and a voicemail left. At 2:37 pm documentation revealed the patient's mother was called again and interviewed via telephone. The patient's mother stated it was an employee that molested her daughter. She provided a description of the employee and that he was assigned to watch her (the patient) on either the 6th, 7th or 8th. Review of the facility document, Employee Investigation, revealed on 7/5/2018 the CNO and Director of BHU interviewed employees in question and reviewed video tape. There was no documentation of which employees were interviewed nor any details of the interviews, and no documentation of the video tape review. The facility was unable to produce the video to view or provide a copy of the video. Review of the document, Employee Investigation, revealed on 7/6/2018 at 3:55 pm an employee identified as the potential perpetrator was interviewed by the Vice President of Operations, the Director of BHU, and Vice President of Quality. Documentation revealed the employee was interviewed but denied any wrong doing. The employee was placed on temporary suspension while the investigation was completed. At 4:09 pm the facility made a report to Department of Children & Family (DCF) and at 4:39 pm a report to the Sheriff's office was made. Documentation revealed a Sheriff's deputy (MDS) dated [DATE] at 5:00 pm and a police report was completed. Documentation stated the deputy called the patient's mother and she reported the patient received multiple text messages from the employee (specific first name used and same as the employee interviewed). The deputy was provided with the phone number from which the alleged perpetrator was texting the patient from. When compared with the phone number of the employee which was interviewed by the facility it did not match. Review of a facility document, written by the Director of BHU, revealed on 7/12/2018 the Director of BHU met with a detective conducting the investigation. The detective was provided two additional employee names as well as staffing sheets, and a copy of the video. Review of a facility document, written by the Director of BHU, revealed on 7/18/2018 at 9:40 am, the Infection Control Coordinator fielded a call from an Adult Protective Investigator. The Investigator requested additional employee information on another male employee that was working at the time of the alleged sexual assault incident. Documentation stated the VP of Human Resources provided the requested information. Documentation stated the employee was then interviewed but he denied any inappropriate behavior. The employee was suspended at that time pending completion of the investigation. Documentation stated the detective called and requested the personal contact information for the employee. On 7/20/2018 the facility received an arrest notification from AHCA for this employee. Documentation revealed the employee was terminated on 7/25/2018 due to AHCA ineligible status. Review of the facility documents, policy and procedures, and the facilities investigation revealed lack of evidence a comprehensive and thorough investigation was completed with documentation of findings; analysis of the investigation with potential for process improvements to ensure all patients were free from all forms of abuse. The VP of Quality was interviewed on 8/27/2020 at 1:50 pm and confirmed the above findings and that all documents related to the investigation and actions of the facility were provided at the time of the survey.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on review of the facility policy and procedures, documents, medical records, and staff interview it was determined the facility failed to ensure an adverse patient event was analyzed, and preventive actions were implemented for one (#2) of eight patients sampled; and failed to ensure the governing body, medical staff, and administrative officials were responsible and accountable for ensuring clear expectations for safety were established. Findings included: Review of the facility policy, Patient and Non-Patient Safety Event Notifications, stated the purpose was to establish the policy and outline procedures for reporting unusual and adverse or untoward patient related and non-patient related events, or potential patient safety related events, that occur within or around the hospital facility and property. The policy stated under Procedure (A) Reporting: (5) other adverse/untoward incidents that are to be reported to the Patient Safety Director/Risk Manager/designee through the Meditech QM module Risk Management section include, but are not limited to issues/concerns involving: (a) allegations of sexual abuse/rape; (6) department directors are responsible for reviewing all patient notification event reports to which they are assigned, completing a thorough investigation and documenting findings in the notification report within 15 days; (7) the Patient Safety Director/Risk Manager/designee will complete reports within 60 days; (B) Event Follow-up (3) the Patient Safety Director/Risk Manager/designee will track statistical data for analysis and process improvement purposes; (C) Event Notification Report Review and Analysis: the patient safety director/risk manager/designee is responsible: (a) for the regular and systematic review of Patient Notification event reports and (c) providing the governing body with quarterly summary reports and maintaining summary data for three years. On 8/24/2020 at approximately 9:15 am a list of requested documents was provided to facility administrative staff which included a list of alleged abuse or neglect with facility documentation of investigation and actions implemented. The facility reported no allegations of abuse or neglect. On 8/26/2020 at 9:15 am the VP of Patient Safety stated upon further investigation the facility had a grievance on 7/4/2018 which alleged sexual misconduct against an employee on the Behavioral Health Unit (BHU). Review of the patient notification event reporting log revealed an event, described as a grievance, was received by the Administrative Nursing Supervisor on 7/04/2018 at 3:00 pm from the mother of sampled patient #2. Documentation revealed the patient was admitted from 6/3 - 6/8/2018 on the BHU. It was alleged the patient was sexually molested during her admission and she was going to report it to the police. Interview with Vice President of Quality on 8/27/2020 at 1:50 pm confirmed the event reporting system had a category for abuse and confirmed the employee entered the event received on 7/04/2018 at 3:00 pm as a grievance. Review of the facility documents (emails) revealed on 7/04/2018 at 3:00 pm the Nursing Supervisor reported the information to the Chief Nursing Officer (CNO) and Director of BHU. A handwritten facility document, dated 7/05/2018 at 9:00 am, by the Administrative Nursing Supervisor, stated the cameras were to be reviewed, and to check all patients and staff with the specific name reported. At 10:06 am a telephone call was placed to the patient's mother and a voicemail left. At 2:37 pm documentation revealed the patient's mother was called again and interviewed via telephone. The patient's mother stated it was an employee that molested her daughter. She provided a description of the employee and that he was assigned to watch her (the patient) on either the 6th, 7th or 8th. Review of the facility document, Employee Investigation, revealed on 7/5/2018 the CNO and Director of BHU interviewed employees in question and reviewed video tape. There was no documentation of which employees were interviewed nor any details of the interviews, and no documentation of the video tape review. The facility was unable to produce the video to view or provide a copy of the video. Review of the document, Employee Investigation, revealed on 7/6/2018 at 3:55 pm an employee identified as the potential perpetrator was interviewed by the Vice President of Operations, the Director of BHU, and Vice President of Quality. Documentation revealed the employee was interviewed but denied any wrong doing. The employee was placed on temporary suspension while the investigation was completed. At 4:09 pm the facility made a report to Department of Children & Family (DCF) and at 4:39 pm a report to the Sheriff's office was made. Documentation revealed a Sheriff's deputy (MDS) dated [DATE] at 5:00 pm and a police report was completed. Documentation stated the deputy called the patient's mother and she reported the patient received multiple text messages from the employee (specific first name used and same as the employee interviewed). The deputy was provided with the phone number from which the alleged perpetrator was texting the patient from. When compared with the phone number of the employee which was interviewed by the facility it did not match. Review of a facility document, written by the Director of BHU, revealed on 7/12/2018 the Director of BHU met with a detective conducting the investigation. The detective was provided two additional employee names as well as staffing sheets, and a copy of the video. Review of a facility document, written by the Director of BHU, revealed on 7/18/2018 at 9:40 am, the Infection Control Coordinator fielded a call from an Adult Protective Investigator. The Investigator requested additional employee information on another male employee that was working at the time of the alleged sexual assault incident. Documentation stated the VP of Human Resources provided the requested information. Documentation stated the employee was then interviewed but he denied any inappropriate behavior. The employee was suspended at that time pending completion of the investigation. Documentation stated the detective called and requested the personal contact information for the employee. On 7/20/2018 the facility received an arrest notification from AHCA for this employee. Documentation revealed the employee was terminated on 7/25/2018 due to AHCA ineligible status. Review of the facility documents, policy and procedures, and the facility investigation revealed lack of evidence a comprehensive and thorough investigation was completed with documentation of findings; analysis of the investigation with potential for process improvements and preventative actions and mechanisms to ensure all patients were free from all forms of abuse. The VP of Quality was interviewed on 8/27/2020 at 1:50 pm and confirmed the above findings and that all documents related to the investigation and actions of the facility were provided at the time of the survey.
Based on medical record review, policy review and staff interview it was determined the registered nurse failed to evaluate nursing intervention, patient response and status on discharge for one (#2) of ten records reviewed related to intravenous therapy. Findings include: Patient #2's physician orders dated 5/6/2015, the day of discharge, indicated to discontinue the Peripherally Inserted Central Catheter (PICC) line. Review of nursing documentation for 5/6/2015 revealed no documentation the PICC line was discontinued. Review of the policy and procedure titled Intravenous Therapy last revised 3/2015, stated on page 2, #1 Intravenous therapy ...and/or maintain venous access, according to physician (or LP) orders. The findings were confirmed by the Risk Manager on 5/19/2015 at approximately 2:30 p.m.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on medical record review and staff interview it was determined the facility failed to ensure nursing reviewed the patient's plan of care daily and kept the care plan current for three (#3, 4, 5) of twelve records reviewed. Findings include: 1. Review of the medical record for patient #3 revealed the patient was admitted on [DATE] and was a current inpatient. Review of the patient's plan of care revealed nursing initiated the plan on 3/9/2014. Review of nursing documentation revealed no evidence the patient's plan of care was reviewed from 3/14/2014 through 3/17/2014. Interview with the Director of 3 Medical on 3/18/2014 at approximately 10:30 am stated the patient's plan of care is to reviewed by an RN daily. The Director confirmed the patient's plan of care was not reviewed daily. 2. Review of the medical record for patient #4 revealed the patient was admitted on [DATE] and was a current inpatient. Review of the patient's plan of care revealed nursing initiated the plan on 3/15/2014. Review of nursing documentation revealed no evidence the patient's plan of care was reviewed on 3/16/2014. The Director of 3 Medical confirmed the above findings. 3. Review of the medical record for patient #5 revealed the patient was admitted on [DATE] and was a current inpatient. Review of the patient's plan of care revealed nursing initiated the plan on 3/15/2014. Review of the patient's record revealed a culture was positive for MRSA and nursing was notified on 3/17/2014. Review of the patient's plan of care revealed no evidence the care plan reflected the newly identified problem of MRSA and the intervention of contact isolation. The Director of 3 Medical confirmed the patient's plan of care was not updated and current.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on review of medical records and staff interview it was determined the facility failed to ensure administration of medication was administered according to the physician's orders and administered in a timely manner for five (#1, 3, 5, 8, 12) of twelve records reviewed. Findings include: 1. Review of the medical record for patient #1 revealed the patient was admitted to the facility on [DATE]. Review of the patient's record revealed on 2/01/2014 the physician ordered Penicillin G 4 million units to be administered IV (Intravenously) every 4 hours. Review of the patient's MAR (Medication Administration Record) revealed on 2/02/2014 the scheduled 8:00 pm dose of Penicillin G was not administered until 10:11 pm. On 2/03/2014 the scheduled 8:00 am dose of Penicillin G was not administered until 10:00 am. On 2/03/2014 the scheduled 8:00 pm dose was not administered until 10:42 pm. Review of the MAR revealed on 2/04/2014 the 12:00 am scheduled dose of Penicillin G was not administered. Nursing documentation revealed the dose was not administered due to the previous dose being given late. Review of the record revealed the nurse did not notify the ordering physician of the missed dose of antibiotic. Interview with the Director of 2 West on 3/18/2014 at approximately 2:00 pm confirmed medication should be administered within one hour of the scheduled dose. The Director confirmed the above findings. 2. Review of the medical record for patient #3 revealed te patient was admitted to the facility on [DATE] and was currently an inpatient. Review of the physician orders revealed on 3/09/2014 the physician ordered Zosyn 3.375 grams IV every 6 hours. Review of the MAR revealed on 3/10/2014 the scheduled 12:00 pm dose and 6:00 pm dose were not administered. Review of the record revealed no evidence for not administering the medications. The finding was confirmed with the Director of 3 Medical on 3/18/2014 at approximately 10:30 am. Review of the physician orders for patient #3 revealed on 3/16/2014 at 7:15 pm an order for a 250 ml (milliliter) Normal Saline IV bolus stat was ordered. Review of the MAR and nursing documentation revealed no evidence the IV bolus was administered as ordered. The finding was confirmed with the Director of 3 Medical on 3/18/2014 at approximately 10:30 am. 3. Review of the medical record for patient #5 revealed the patient was admitted to the facility on [DATE] and was currently an inpatient. Review of the physician orders, dated 3/15/2014 at 12:50 pm, stated to give Vancomycin 1 gram IV every 12 hours with pharmacy to dose. Documentation in the record revealed pharmacy dosed the Vancomycin stating Vancomycin 1 gram IV every 12 hours to begin at 1:00 am. Review of the MAR revealed the Vancomycin was not administered at 1:00 am. Nursing documentation on at 3:00 am stated the medication was not available. Review of the MAR revealed the Vancomycin was given at 11:50 am, more than 10 hours after it was ordered. The finding was confirmed with the Director of 3 Medical on 3/18/2014 at approximately 11:30 am. 4. Review of the medical record for patient #8 revealed the patient was admitted to the facility on [DATE] and was a current inpatient. Review of the physician orders revealed Tramadol 50 mg (milligrams) by mouth twice a day and at bedtime was ordered on [DATE] at 1853. Review of the MAR revealed on 3/17/2014 a scheduled dose of Tramadol 50 mg at 9:00 pm was not administered. Review of the nursing documentation revealed no evidence why the medication was not administered. Review of the physician orders revealed Quetiapine 200 mg by mouth at bedtime was ordered on [DATE] at 1836. Review of the MAR revealed the schedule 9:00 pm dose on 3/17/2014 was not administered. Review of the nursing documentation revealed no evidence why the medication was not administered. Interview with the Director of 2 West at the time of the above findings on 3/18/2014 at approximately 10:15 am confirmed the findings. 5. Review of the medical record for patient #12 revealed the patient was admitted to the facility on [DATE]. Review of the physician orders revealed on 1/31/2014 Daptomycin 400 mg IV every 48 hours. Review of the MAR revealed the scheduled dose on 2/2/2014 at 11:00 am was not administered. Review of the nursing documentation revealed on 2/2/2014 at 5:16 pm the nurse documented the medication has not been available for administration. There was no evidence the nurse notified the pharmacy of the unavailability of the medication and no evidence the physician was notified that the medication was not administered. Review of the MAR revealed the Daptomycin was not administered until 2/4/2014 at 12:19 am. The Director of 2 West called and spoke with the pharmacist at the time of the finding to verify Daptomycin was available on 2/2/2014. The pharmacist confirmed the medication was available on 2/2/2014. Interview with the Director of 2 West on 3/18/2014 at approximately 3:10 pm confirmed the medication was not administered as ordered.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, record review and staff interview the facility failed to provide two (#10, #13) of six of the fourteen patients sampled with the Important Message from Medicare Letter upon admission or discharge. Findings include: Record reviews conducted on 2/10/13 at approximately 2:00 p.m. revealed the facility did not include the Important Message Letter from Medicare (IM) as part of the patient medical record for patients #10 and #13. 1. Staff member (A) along with surveyor #2 conducted an electronic medical review for patient #10 on 2/10/13. The patient was admitted on [DATE] at 4:31 p.m. from a skilled nursing facility. Further record review revealed the patient was discharged back to the skilled nursing facility on 9/28/13. The patient first received an IM on 9/9/13 at 4:58 p.m. in the Emergency Department. It was noted the patient was unable to sign. The second IM dated 9/10/13 at 12:15 a.m. appeared to be signed by the patient. The patient was discharged from the hospital on [DATE]. The electronic medical record did not reveal the required second IM letter upon discharge on 9/28/13. 2. Staff member (A) along with the surveyor #2 conducted an electronic medical review for patient #13 on 2/10/13. It revealed the patient was admitted on [DATE] and discharged on [DATE]. The IM was signed and dated 12/18/13 at 4:06 p.m. Further record review revealed the patient did not have IM within the correct timeframe of admission or one upon discharge. An interview with the Risk Manager was conducted on 2/10/14 at approximately 2:45 p.m. She was informed of the missing documentation. A review of the facility's policy BO.010A with an origination date of 4/1/13 titled Important Message from Medicare was provided by Risk Management. Under the heading policy bullet point (C) it read: Hospitals will issue the IM within two calendar days of the day of admission and obtain the signature of the beneficiary or his representative to indicate that she or he understood the notice. (E) Hospitals may deliver the initial copy of notice if the beneficiary is seen during a preadmission visit, but not more than 7 calendar days in advance of admission, and (F) The IM or a copy of the IM, must also be provided to each beneficiary within 2 calendar days of the day of discharge.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review, policy review and staff interview it was determined the facility failed to ensure the registered nurse supervised and evaluated nursing care related to skin care assessments for 2 (#1, # ) of 30 sampled patients. This practice does not ensure nursing goals are met and may lead to an increased hospitalization . Finding include: 1. Patient #1 was admitted on [DATE]. Review of the initial nursing skin assessment dated [DATE] at 11:15 a.m. revealed a pressure ulcer to the coccyx area. The documentation noted skin abnormality to the coccyx and right buttocks. There was no description or size of the abnormalities or pressure ulcer documented. Nursing documentation dated 12/13/12 at 11:50 p.m., 12/14/12 at 10.58 a.m. and 9:37 p.m., 2/15/12 at 8:01 a.m. and 8:25 p.m. revealed the same information. There was no description or size of the abnormalities or pressure ulcer documented. Nursing documentation dated 12/16/12 at 2:34 p.m. revealed an open area on the coccyx, Duoderm had been applied on 12/14/12 and pictures were obtained. The documentation noted a pressure ulcer on the coccyx and abnormalities of the right buttock and coccyx. There was no description or size of the abnormalities or pressure ulcer documented. Nursing documentation dated 12/16/12 at 9:55 p.m. showed a pressure ulcer on the coccyx and skin abnormalities on the right buttocks and coccyx. There was no description or size of the abnormalities or pressure ulcer documented. Nursing documentation dated 12/17/12 at 1:33 p.m. revealed the old wound site appeared to be opened. The documentation noted pressure ulcer on the coccyx and skin abnormalities on the right buttocks and coccyx. There was no description or size of the abnormalities or pressure ulcer documented. Review of Wound Care Nurse (WCN) documentation dated 12/18/12, no time, revealed a 1x1x0.2 centimeters wound. The WCN indicated to use Duoderm and to change every three days. The WCN stated to refer to the wound care center upon discharge Interview with the Licensed Practical Nurse caring for the patient on 12/17/12 at approximately 11:20 a.m. revealed on 12/14/12 the coccyx area was red and Duoderm was applied. On 12/16/12 the area was noted to be opened and on the mid back was a two shade bruised like area. She stated the physician was notified and a wound care nurse consult was ordered. The LPN stated the area remained open to air. Review of policy and procedure Skin Integrity Protocol and Prevention Guidelines #N3-07 last revised 3/12 revealed to assess, measure and document all wounds on admission and identification. The policy indicated for patients at risk, the patient should be turned every two hours, there should be a position turn clock at the head of the bed, and to use positioning devices. Patient observation on 12/17/12 at approximately 10:40 a.m. revealed the patient was on the back and no evidence of a position turn clock or positioning devices. Interview and record review with the Director of the Medical Surgical Unit on 12/17/12 confirmed the findings. 2. A review of patient #27 ' s clinical record revealed the patient was admitted to the facility on [DATE] with a diagnosis of syncope. The patients past medical history were diabetes, hypertension, cardiac disease, pacemaker and high cholesterol. Further review of the patient ' s clinical record nursing assessments revealed an assessment was completed on 12/18/12 at 10:21. There were no further assessments documented at the time of the chart review on 12/19/12 at 9:30 am. An interview with the Nursing Units Nurse Manager conducted on 12/19/12 at approximately 10:00 am, confirmed there were no other assessments documented in the record. When questioned on how often assessments are completed, the nurse manager stated depending on the patient condition if stable than every shift (every 12 hours).
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review and staff interview it was determined the facility failed to administer medications in accordance with physician orders for one (#13) of thirty patients sampled. This practice does ensure safe and effective medication therapy. Findings include: 1. Patient #13's physician order dated 12/6/12 at 6:28 p.m. instructed for Vancomycin 1 gram intravenously (IV) every twelve hours. At 9:00 p.m. the Vancomycin was changed to 1 gram every eight hours. The order indicated for a trough level to be obtained on 12/8/12 at 5:30 a.m. and the pharmacist was to dose. Review of the Medication Administration Record (MAR) dated 12/6/12 noted the medication was administered at 7:20 p.m. Interview with the Director of the Medical Surgical Unit on 12/18/12 during the electronic record review revealed revealed the pharmacy timed the medication to be administered at 6:00 a.m., 2:00 p.m. and 10:00 p.m. Review of the MAR noted on 12/7/12 the Vancomycin was administered at 5:02 a.m. and midnight. Review of the nursing documentation revealed no evidence of why the 6:00 p.m. dose was not administered or why the 10:00 p.m. dose was given late. Review of the MAR dated 12/8/12 revealed the Vancomycin was administered at 2:54 p.m. and 9:35 p.m. There was no documentation as to why the morning dose was not administered. Review of the ordered trough level showed a level of 7. It could not be determine if the level was accurate since the medication had not been administered as ordered on [DATE] or 12/8/12. Review of pharmacy/physician order dated 12/8/12 at 3:00 p.m. revealed the level indicated it was not a trough, for the Vancomycin to be administered as ordered and to repeat the level on 12/9/12 at 1:30 p.m. Review of laboratory results revealed the trough was 13.4. Review of pharmacy/physician orders dated 12/9/12 at 3:20 p.m. revealed to increase the dose to 1.25 gram every eight hours. Interview with the Director of the Medical Surgical Unit on 12/18/12 during the electronic record reviewed confirmed the above findings. 2. Patient #13's physician orders dated 12/6/12 instructed for Lisinopril/HCTZ (blood pressure medication) to be administered daily. Review of the MAR dated 12/7/12 revealed the medication was scheduled for 9:00 a.m. The MAR noted the medication was held at 6:13 p.m. Review of nursing documentation revealed the medication was held at 6:13 p.m. due to a low blood pressure. There was no evidence of what the blood pressure was or why it was not given at 9:00 a.m. There was no evidence of the physician being notified. There was no evidence of parameters given by the physician to hold the medication. Review of the MAR dated 12/9/12 revealed the medication was held for a low pressure. There was no evidence of what the blood pressure was or if the physician was notified. Interview with the Director of the Medical Surgical Unit on 12/18/12 during the electronic record reviewed confirmed the above findings.
Based on record review, policy review and staff interview it was determined the facility failed to reassess a patient's discharge plan when dressing changes were ordered on discharge for 1 (#14) of 30 sampled patients. This practice does not ensure a safe discharge and may lead to an unnecessary readmission. Findings include: 1. Patient #14 was admitted for an abdominal procedure on 10/8/12. Review of physician orders dated 10/12/12 at 12:25 p.m. instructed for wet to dry dressings every 12 hours to the midline abdominal wound. Nursing documentation noted the dressing was changed on 10/12/12 at 8:53 p.m. Nursing documentation dated 10/13/12 at 8:45 a.m. revealed a wet to dry dressing with packing was performed. Review of the Patient Discharge Summary revealed the patient was discharged home on 10/13/12 at 12:30 p.m. There was no evidence of the wound care to be continued at home, if the patient was able to perform the wound care, or if the patient was assessed for post discharge wound care needs.
Based on policy, medical record and facility document review and staff interview it was determined the facility failed to maintain and demonstrate evidence of the Quality Assessment and Performance Improvement (QAPI) program. 1. Patient #3 was found unresponsive, pulseless and without respirations 06/24/12 at 1:40 p.m. The patient was on telemetry monitoring. On 6/24/12 at 5:37 a.m. a telemetry strip was printed that showed the patient was in sinus tachycardia(ST) with premature atrial contractions (PACS) and a heart rate of 110 beats per minute. At 10:12 a.m. a telemetry strip was printed that indicated the patient was in ST with PACS and a heart rate of 122 beats per minute. At 1:39 p.m. a telemetry strip was printed and the rhythm was not distinguishable nor was the heart rate able to be determined. There was no documentation of a telemetry strip or notification to the nurse caring for the patient by the telemetry technician regarding a change in cardiac rhythm. There was no documentation on the telemetry monitoring shift report and patient log of any change in the patient's rhythm or notification to the nurse caring for the patient. On 6/24/12 at 1:40 p.m. a code blue was called and the patient was pronounced on 6/24/12 at 1:50 p.m. Refer to A0285. 2. Review of current patient #5's medical record revealed the patient was admitted to the telemetry unit 10/2/12. There was no documented telemetry strip for admission or on 10/3/12 in the medical record according to facility policy. 3. On 10/5/12 at 1:45 p.m. an interview was conducted with the Director of Quality Control and meeting minutes were requested for the last 3 quarters and evidence of tracking and trending for pressure wounds, medication errors, falls, infection control and other facility chosen projects . The Director of Quality Control was unable to provide the requested documents. She indicated they were protected by the Patient Safety Work Product. She said the last meeting was conducted in January 2012. The Quality Assessment Performance Improvement (QAPI) program could not be reviewed to determine that there was a hospital-wide QAPI program in place and if identified adverse events had been addressed. 4. On 10/5/12 at approximately 4:00 p.m. an interview with the Risk Manager was conducted. She indicated a Root Cause Analysis (RCA) was completed by the risk manager for patient #3. The RCA was initiated on 6/25/12 with an end date of 7/3/12. The investigation included identification of the problem/cause, which was lack of observation by the monitor technician of all the telemetry monitors. The RCA failed to determine if the alarms were on at the time of the incident. The documentation noted the monitor tech stated he was overwhelmed and unable to watch all the monitors. The Risk Manager could not produce any evidence of these areas being investigated. She could not produce evidence of the action plan to educate staff was implemented. There was no evidence of monitoring to ensure a reoccurrence of the event did not occur. 5. There was no evidence of tracking and trending of infection control, pressure wounds, medication errors or other quality indicators chosen by the facility for the QAPI processes to promote patient safety and The cumulative effect of the facility's failure to maintained and provide evidence that a QAPI program was in effect and an adverse incident was fully investigated, correction action implemented and monitoring resulted in the determination that the Condition of Participation for Quality Assessment Performance Improvement 42 CFR 482.21 is not in compliance.
Based on record and document review and staff interview is was determined the hospital failed to investigate, analyze, monitor and track quality indicators for an adverse event that resulted in a patient's death. operations. This practice does not ensure or promote patient safety. Findings include: Review of the facility's policy Telemetry-Initiating, Monitoring and Discontinuing Policy No. N3-C-18 revised 4/12 revealed a rhythm strip is obtained by the monitor tech and placed in the patient's medical record on admission. The monitor tech is to run a strip and print/interpret strips upon initiation of telemetry, rhythm changes, interruption and reapplication of telemetry and every 6 hours on a 12-6-12-6 schedule and upon termination of telemetry. The monitor tech will notify the primary nurse for rhythm changes and notification will be documented on the telemetry strip. The monitor tech is to keep the floor charge nurse and charge Intensive Care Unit (ICU) nurse aware of any significant telemetry changes. Current telemetry strips will be available to physicians in the ICU nursing station at the monitor tech area. Previous 24-hour rhythm strips will be delivered to appropriate nursing units by 6:00 a.m. Patient #3 was admitted to the telemetry unit 6/16/12 at 8:52 am. On 6/16/12 there was no evidence of a telemetry strip being printed and placed in the medical record on admission or at 6:00 p.m. On 6/19/12 there was no evidence of a telemetry strip being printed and placed in the medical record at 6:00 p.m. On 6/20/12 there was no evidence of a telemetry strip being printed and placed in the medical record at 12:00 p.m. On 6/24/12 at 5:37 a.m. a telemetry strip was printed that showed the patient was in sinus tachycardia(ST) with premature atrial contractions (PACS) and a heart rate of 110 beats per minute. At 10:12 a.m. a telemetry strip was printed that indicated the patient was in ST with PACS and a heart rate of 122 beats per minute. At 1:39 p.m. a telemetry strip was printed and the rhythm was not distinguishable nor was the heart rate able to be determined. There was no documentation on the telemetry monitoring shift report or patient log indicating the nurse had been notified of the change in rhythm by the telemetry technician. On 6/24/12 at 1:40 p.m. a code blue was called and cardiopulmonary resuscitation (CPR) was started. The code was terminated at 1:50 p.m. and the patient was pronounced. On 10/5/12 at 4:00 p.m. the Risk Manager confirmed the above findings. An interview was conducted 10/5/12 at 2:00 p.m. with Director of the Intensive Care Unit. She was asked if she checks the monitor alarms and how often. She could not supply documentation to show information about checking the monitors. She presented a piece of paper with no dates, just months with check marks. It did not specify what was being monitored on what dates. On 10/5/12 at 1:4 Quality Control meeting minutes were requested from the Director of Quality. She was not able to provide the requested documentation. The Director of Quality was asked how the adverse incident was being monitored and what trends had they found. She could not provide any documentation. She said she was not allowed to show the surveyor any of the requested information. An interview with Director of Quality Control and the Risk Manager was conducted 10/5/12 at 4:00 p.m. confirmed the findings.
Based on policy and record review and staff interview it was determined the registered nurse failed to supervise and evaluate nursing care related to telemetry monitoring for two (#3, #5) of five sampled patients. This practice does not ensure safe delivery of nursing care and that patient goals are met. Findings include: Review of the facility's policy Telemetry-Initiating, Monitoring and Discontinuing Policy No. N3-C-18 revised 4/12 revealed a rhythm strip is obtained by the monitor tech and placed in the patient's medical record on admission. The monitor tech is to run a strip and print/interpret strips upon initiation of telemetry, rhythm changes, interruption and reapplication of telemetry and every 6 hours on a 12-6-12-6 schedule and upon termination of telemetry. The monitor tech will notify the primary nurse for rhythm changes and notification will be documented on the telemetry strip. The monitor tech is to keep the floor charge nurse and charge Intensive Care Unit (ICU) nurse aware of any significant telemetry changes. Current telemetry strips will be available to physicians in the ICU nursing station at the monitor tech area. Previous 24-hour rhythm strips will be delivered to appropriate nursing units by 6:00 a.m. 1. Patient #3 was admitted to the telemetry unit 6/16/12 at 8:52 am. On 6/16/12 there was no evidence of a telemetry strip being printed and placed in the medical record on admission or at 6:00 p.m. On 6/19/12 there was no evidence of a telemetry strip being printed and placed in the medical record at 6:00 p.m. On 6/20/12 there was no evidence of a telemetry strip being printed and placed in the medical record at 12:00 p.m. On 6/24/12 at 5:37 a.m. a telemetry strip was printed that showed the patient was in sinus tachycardia(ST) with premature atrial contractions (PACS) and a heart rate of 110 beats per minute. At 10:12 a.m. a telemetry strip was printed that indicated the patient was in ST with PACS and a heart rate of 122 beats per minute. At 1:39 p.m. a telemetry strip was printed and the rhythm was not distinguishable nor was the heart rate able to be determined. There was no documentation on the telemetry monitoring shift report or patient log indicating the nurse had been notified of the change in rhythm by the telemetry technician. On 6/24/12 at 1:40 p.m. a code blue was called and cardiopulmonary resuscitation (CPR) was started. The code was terminated at 1:50 p.m. and the patient was pronounced. On 10/5/12 at 4:00 p.m. the Risk Manager confirmed the above findings. 2. Patient #5 was admitted to the telemetry unit 10/2/12. A verbal physician's order dated 10/2/12 at 6:00 p.m. instructed for the patient to be placed on telemetry. There was no evidence of a telemetry strip being printed and placed in the medical record on admission. On 10/3/12 there were no documented telemetry strips in the medical record. An interview was conducted 10/5/12 at 2:15 p.m. with a monitor technician. She was at the nurses' station in front of a large amount of monitors. She indicated she was monitoring 35 patients at the time of the interview. When asked about what she did if one of the monitors showed a change in rhythm, she replied she printed a strip, called the nurse and documented the nurse's name and time they were called. She said if there was no response from the nurse and the rhythm did not change, she call the charge nurse of the unit and the supervisor if necessary. She indicated she was not able to change the volume of the alarms. Each different rhythm had different alarm sounds. On 10/5/12 at 4:00 p.m. an interview with the Director of the Medical Surgical Unit was conducted. She confirmed the above findings. She stated an admission telemetry strip should be printed and placed in the medical record, the monitor tech should notify the nurse assigned to the patient of changes and it is the responsibility of the monitor tech to print strips and place strips in the medical record before the night shift tech leaves in the morning.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on policy and record review and staff interview it was determined the nursing staff failed to develop and kept current a nursing care plan for one (#5) of five telemetry patients. This practice does not ensure patients needs and goals are met. Findings include: Patient #5 was admitted on [DATE] at 6:00 p.m. On 10/2/12 a verbal physician's order instructed the patient was to be placed on telemetry. There was no evidence a care plan had been initiated for the patient for Altered Cardiac Output during the initial admission assessment on 10/2/12. Review of the facility's policy, Assessment & Reassessment #A2-03 reviewed 7/11 revealed the information gathered in the admission assessment is analyzed and patient needs or problems are identified and prioritized according to the physiological and cognitive areas. A Plan of Care will be selected that addresses the patient's prioritized needs. On 10/5/12 at 4:00 p.m. the Director of Medical Surgical Unit confirmed a patient on telemetry monitoring should have a Altered Cardiac Output care plan.
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