Based on medical record review, staff interview, and review of facility policy and procedures it was determined the facility was not in compliance with 42 CFR 489.24. The facility failed a) to document continued ongoing monitoring according to the individual's needs until stabilized for four of twenty patients sampled (see A2407); and b) failed to document a patient who left the facility prior to a medical screening exam for one of twenty patients sampled (see A2407). Findings included: Refer to A2407.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on facility record review, policy review and staff interview, it was determined the facility failed to reassess the patient as required to stabilize the medical condition for five (#2, #4, #15, #16, and #17) of twenty sampled patients; and failed to document a patient who left the facility prior to a medical screening exam for one (#7) of twenty sampled patients. Findings included: 1. A review of facility policy titled Assessment and Reassessment, #ADMIN.II-PC-A.002, 12/2019 states, *Each patient seeking care or treatment in the Emergency department shall receive an assessment by a qualified individual so the plan of care can be developed to best meet the needs of the patient. *All patients arriving for treatment in the Emergency Department requesting to be seen by the emergency room [ER] physician are screened and assessed by an ER physician or an Advanced Practice Provider [APP][Licensed Independent Practitioner]. *All patients entering the emergency room are Triaged by a Registered Nurse [RN] and assigned a priority, based upon their presenting symptoms and severity of illness. -Level 1 Resuscitation-Require immediate lifesaving interventions - Reassessment continuously -Level 2 Emergent - High-Risk situations, confused, lethargic and disoriented or in severe pain - Reassessment every 60 minutes -Level 3 Urgent Not in high-risk but need 2 or more resources to diagnose and treat their condition - Reassessment every 60 minutes then every 4 hours after Medical Screening Exam [MSE]. -Level 4 Less Urgent Require one resource to diagnose and treat their condition - Reassessment every 60 minutes - then prior to discharge or every 4 hours after MSE. -Level 5 Non-Urgent Require no resources to diagnose and treat their condition - Reassessment every 60 minutes and prior to discharge after MSE. 2. A review of Patient #2's medical record documents the patient presented to the emergency department via law enforcement with complaints of suicidal ideation and alcohol use at on 7/10/21 at 15:25. The patient was triaged at 15:44 as emergency severity index (ESI) acuity level 2. The patient was seen by the emergency department provider. The chart demonstrated that the patient would need to be medically cleared in several hours because his alcohol was 351. The patient was placed under Baker Act and seen by the psychiatrist via telemedicine. The patient was determined to no longer be suicidal by the psychiatrist and the Baker Act was rescinded at 18:51 because the patient was intoxicated when it was placed. The psychiatric consult documented clinical sobriety, but the emergency department provider did not. Since alcohol levels were not reassessed, the stability of the patient could not be determined. The ED provider treated the patient, however did not document that the patient was clinically sober. They did document that the patient was awaiting a sober ride home. Patient #2 was discharged home on 7/10/21 at 18:49 for outpatient follow-up and substance abuse treatment. A detailed review of the medical record with the Director of Patient Safety failed to show a documented reassessment every 60 minutes by the RN and continued review failed to document any change in ESI level. The patient's chart does not have appropriate repeat vital signs nor was the patient reevaluated in the provider's notes to determine that the patient was sober and stable for discharge. The provider documents the need for a recheck of the patient's alcohol level which was not done. This caused the delay in completion of the medical screening exam and stabilizing treatment. 3. A review of Patient #4's medical record documents the patient arrived to the facility's emergency room as a walk-in on 07/22/2021 at 17:03. Patient was triaged and received a medical screening exam [MSE]. Patient was triaged at 17:18 as ESI acuity level 2. A detailed review of the medical record with the Director of Patient Safety failed to show a documented reassessment every 60 minutes by the Registered Nurse (RN) and continued review failed to document change in ESI level. Patient was transferred to a Behavioral Health hospital on [DATE] at 06:07. 4. A review of Patient # 15's medical record documents the patient arrived to the facility's emergency room as a walk-in on 03/01/2021 at 06:52. Patient # 15 was triaged and received medical screening exam [MSE]. Patient # 15 was triaged at 07:03 as ESI acuity level 2. Patient reassessed by the RN at 09:41 approximately 2.5 hours after triage. The next reassessed by the RN documented at 11:39 approximately 1.5 hours after last reassessment. Patient discharged on [DATE] at 12:18. A detailed review of the medical record with the Director of Patient Safety failed to show a documented reassessment every 60 minutes by the RN and continued review failed to document a change in ESI level. 5. A review of Patient # 16's medical record documents the patient arrived to the emergency room as a walk-in on 03/12/2021 at 14:13. Patient was triaged and received a medical screening exam [MSE]. Patient was triaged at 14:22 as ESI acuity level 2. The patient was discharged to home at 16:35. A detailed review of the medical record with the Director of Patient Safety failed to show a documented reassessment every 60 minutes by the RN and continued review failed to document a change in ESI level. 6. A review of Patient # 17's medical record documents the patient arrived to the emergency room as walk-in on 03/20/2021 at 11:33. Patient was triaged and received medical screening exam [MSE]. Patient was triaged at 11:37 as ESI acuity level 2. The patient was discharged to home at 13:00. A detailed review of the medical record with the Director of Patient Safety failed to show a documented reassessment every 60 minutes by the RN and continued review failed to document a change in ESI level. On 08/09/2021 at 1630 an interview with the Director of Patient Safety and Nursing Director of Emergency Services confirmed the above findings stating the RN should document reassessments per policy. 7. A review of facility policy titled EMTALA Definitions and General Guidelines, #ADMIN.LD.011, effective 11/2019 stated, on page 10 of 16, (C) When the Individual Leaves Before the EMTALA Obligation is Met, (1) (c) if the individual leaves the facility prior to triage but the individual is not seen when he/she leaves, document the number and time of attempts to locate the individual for screening. A review of facility policy titled EMTALA - Florida Medical Screening Examination and Stabilization, #ADMIN.LD.009, effective 10/2019 stated, on page 11 of 15, (d) Documentation of Unannounced Leave, if an individual leaves the facility without notifying facility personnel, this must be documented upon discovery. The documentation must reflect that the individual had been at the facility and the time the individual was discovered to have left the premises. If the individual leaves prior to an MSE (Medical Screening Examination), the information should be documented on the individual's medical record. 8. Review of the medical record for Patient #7 revealed the patient was recepted on 6/14/2021 at 1:16 am. The patient's stated complaint was productive cough times one week even after prescribed medication. The patient's vital signs, height and weight were assessed, no time documented. Review of the record revealed at 1:54 am the patient was removed from the tracker. Review of the record revealed no further documentation of when the patient was discovered to have left the premises, if the patient notified facility personnel of the intent to leave, nor documentation of attempts to locate the patient. On 08/09/2021 at 4:40 pm an interview with the Director of Patient Safety and Nursing Director of Emergency Services confirmed the above findings.
Based on policy review, medical record review, and staff interview, it was determined the facility failed to follow the discharge plan and provide a safe discharge for one (#3) of five patient records sampled. Findings included: A review of the policy entitled, Discharge of Patient to Another Facility, #BH.10.07, reviewed 08/18, showed that to assure the transfer of a patient to another level of care, treatment or services, the method of transportation is based on patient's assessed needs and hospital capabilities. A review of the policy entitled, Discharging Planning and Continuing Care Overview, #BH.10.01, reviewed 08/18, showed discharge planning begins upon admission, and when specific placement is ordered by the Attending Physician, the Discharge Planner arranges the placement via appropriate transportation. A review of the Emergency Department (ED) physician's history & physical (H&P) documentation, dated 12/30/18 at 3:33 PM, revealed Patient #3 was brought in by law enforcement (LEO) under a Baker Act for aggressive behavior. The documentation showed the patient had a history of Alzheimer's dementia. Patient was noted to be stable and was medically cleared at 8:46 PM and sent to Medical Center of Trinity West Pasco Behavioral Health Unit (BHU). The subject patient's husband was listed as the patient's representative, authorized decision maker, and listed a skilled nursing facility as the patient's residence. A review of the psychiatric physician's discharge summary dated 01/02/19 at 11:13 AM showed the patient was to be discharged to, a skilled nursing facility (SNF). The note showed the patient had stabilized and was appropriate for discharge (DC). A review of the Case Management (CM) note, dated 01/02/19 at 1:40 PM showed the patient was discharged via stretcher and transported by medical transport. An interview with Patiennt #3's DC planner revealed that she thought the patient had been transferred via stretcher to the skilled nursing facility. The DC planner was unware the patient had been DC'd in a taxicab. On 01/24/19 at 11:30 AM, an interview with the Director of the BHU revealed Patient #3's discharge was not appropriate and he stated that approximately three weeks ago he was contacted by the Administrator of the skilled nursing facility. The Administrator had reached out to the Director to make him aware that a confused patient arrived via a taxicab and the cab driver walked her up to the door to ensure her safety. On 01/24/19 at 12:11 PM, an interview was performed with the subject patient's RN. The RN stated the facility utilizes a Pink Sheet of paper that shows what the DC Planner had arranged for transport. The subject patient was to go via stretcher to the skilled nursing facility via medical transport. The RN stated transport was ordered as a will call. The RN stated she called the transfer center at 2:30 PM and was told there was still was no transportation available. The RN called the transport center at 5:30 PM and was told they would arrive in about 30 min. The RN stated the next thing that occurred was a cab showed up for the patient. The RN did not think that was right and called transport to let them know the patient needed a stretcher and not a cab. The transporter told the RN that a cab was all they had available. The RN said she sent the patient to the facility in a cab. The RN stated this was the first time this had ever happened to her and she was not comfortable with sending this patient via a taxi and reported this to her supervisor. On 01/24/19 at 12:18 PM, an interview with the Director of Case Management confirmed the above findings and indicated all Medicaid patients are only allowed to use medical transport. According to the Director, they have been problematic and have rerouted patient transports to another service, such as a cab. She stated, They will find whoever they can.
1. Based on medical record review, review of facility policy and procedures, transfer agreement review and staff interviews it was determined the facility failed to ensure that an appropriate medical screening examination was provided and failed to document ongoing monitoring according to individual's needs until stabilized and prior to transfer for 1 of 20 sampled patients. Refer to findings in Tag A-2406. 2. Based on medical record review, staff interview, and review of facility policy and procedure it was determined the facility failed to offer an individual further medical examination and treatment, and failed to inform an individual of the risks and benefits of the examination or treatment or both for 1 (#14) of 20 sampled patients. Refer to findings in Tag A-2407. 3. Based on review of the medical record, transfer center calls review, review of facility's policy and procedure, and staff interview it was determined the facility failed to ensure medical treatment was provided, within its capacity, to minimize risk to an individual's health prior to transfer to another medical facility for one (#3) of twenty-one patients sampled. Refer to findings in Tag A- 2409.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on medical record review, review of facility policy and procedures, transfer agreement review and staff interviews it was determined the facility failed to ensure that an appropriate medical screening examination was provided and failed to document ongoing monitoring according to individual's needs until stabilized and prior to transfer for 1 of 20 sampled patients. Findings included: 1. Medical Record Reviews Review of the medical record for patient #3 revealed the patient presented to the facility ED (Emergency Department) on 02/15/2018 at 7:46 PM. Documentation stated the patient was a walk-in and the stated medical complaint was hit in head with baseball while playing as pitcher rating pain as 7 out of 10 on a scale of 0 to 10 with 10 being worst pain ever. Review of nursing triage documentation on 02/15/2018 at 7:58 PM documented vital signs of oral temperature 98.9 degrees Fahrenheit, heart rate of 98, blood pressure of 137/87 and respiratory rate of 18 with oxygen saturation of 98 percent of room air. Medical Screening Exam [MSE] initiated at 7:48 PM. Computerized Tomography [CT] scan completed at 8:03 PM CT Neuro Alert documents a depressed skull fracture with subdural hematoma with parenchymal contusion involving the left frontal lobe, and the results called to physician at 8:20 PM. CT scan Orbits completed 8:14 PM documents multiple comminuted fractures and hemorrhagic contusions. At 8:20 PM patient rates pain as 10 out of 10 and given Morphine 4 milligrams intravenously [IV] for pain and Zofran 4 milligrams IV for nausea. At 9:00 PM blood pressure recorded as 139/72 and heart rate 52. (Normal Pulse rate 60-100). At 9:11 PM the facility contacted the call center to initiate a transfer. Review of the facility's transfer form dated 2/15/2018 at 2246 revealed that patient #3 had an identified emergency medical condition, Depressed (L) skull fracture with small subdural . patient #3's condition was listed as unstable and that the transfer was medical necessary. The risks and benefits of the transfer, were: Medical Benefits: checked was to obtain level of care/service unavailable at this facility and the medical benefits outweighed the risks. Further review of the transfer form revealed the transfer was accepted by another local acute care facility at 9:16 PM. No documentation signifying emergency medical services [ground ambulance] was informed that this was an urgent transfer. At 10:03 p.m., blood pressure was 144/84 and heart rate was 40. At approximately 10:08 PM, the patient was intubated by the physician. A repeat CT scan at 2242 revealed in part, Impression: Interval worsening of the left frontal Intraparenchymal hematoma now with approximately 10 mm of left-to- right midline shift and effacement to the left lateral ventricle. These findings are new since the prior study. Further review revealed that the Critical findings of the repeat CT scan was discussed with ED in the ED at 2245 on 2/15/2018. The subdural bleed had significantly increased. No documentation of Neuro checks, no documentation of Glasgow coma scale (a neurological scale that aims to give a reliable, objective way of recording the conscious state of a person) and no documentation of ongoing assessments were available in the medical record. The facility failed to ensure that an appropriate medical screening examination was provided for patient #3 on 2/15/2018. The medical record from the receiving facility dated 2/15/2018 for patient #3 was reviewed. Documentation revealed that patient #3 was initially seen at Trinity Hospital where his neurologic function declined and he was subsequently intubated. He was later transferred to the (name of acute care facility where patient #3 was transferred to) and went for an emergent craniotomy by (name of Doctor) neurosurgeon. 2. Transfer Agreement Review A review of the facility's Transfer agreement revealed the hospital offers Neurosurgery services through transfer agreement only. 3. Policies and Procedures A review of the facility policy entitled, Provision of Care, Treatment and Services, Plan, #ADMIN-11-PC-P.011, published 10/2017, showed the following: Assessment/ Reassessment depends on patient's diagnosis, and setting emergency department (ED), and as appropriate, each patient will have needs assessed by an RN. Reassessment after initiation of the medical screening examination (MSE) is performed by RN's according to policy. Level 3 / Urgent will be performed and documented every 2-4 hours as condition dictates. Reassessments should be done anytime there is the following: 1. Change in patient's status 2. Change in vital signs (VS's) 3. Change in patient's condition A review of the policy entitled, EMTALA Definitions and General Guidelines, #ADMIN.LD.011, effective 10/2012, showed the following: Definition of an emergency medical condition (EMC) is a medical condition manifesting itself by acute signs and symptoms (S/S) of sufficient severity (including pain) such that the absence of immediate medical attention could reasonably expect to result in placing the patient at jeopardy. MSE is the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether or not an EMC exists. Screening is to be conducted to the extent necessary by a qualified medical provider (QMP). Stabilized, with respect to an EMC, means that no material deterioration of the condition is likely within reasonable medical probability to result from or occur during the transfer of the individual from the facility. A review of the policy entitled, Assessment / Reassessment Patient Care Acuity Levels, ED-A.003, reviewed on 11/13 showed the following: The purpose is to provide assessment/ reassessment guidelines for [DIAGNOSES REDACTED]il evaluation, continued monitor and /or changes in patient status or condition. To ensure that each patient's physical and social status is assessed to determine the patient's care needs and to ensure the patient's changing needs are reassessed in response to treatment and care. 4. Interviews: Interview with the Medical Director of Emergency Department on 03/16/2018 at 10:00 am stated he would assume the nurses are doing Neuro checks and performing assessments frequently. Interview with the Assistant Chief Nursing Officer on 3/16/2018 at 1:45 PM confirmed the above findings.
Based on medical record review, staff interview, and review of facility policy and procedure it was determined the facility failed to offer an individual further medical examination and treatment, and failed to inform an individual of the risks and benefits of the examination or treatment or both for 1 (#14) of 20 sampled patients. Findings included: 1. Medical Record Review Review of the medical record for patient #14 revealed the patient presented to the facility ED (Emergency Department) on 3/13/2018 at 10:06 PM. Documentation stated the patient was a walk-in and the stated medical complaint was a nosebleed for 2 hours. Review of nursing documentation on 3/13/2018 at 10:45 PM revealed the RN (Registered Nurse) documented the patient notified the staff of departure and the patient was alert at the time. Review of the medical record revealed no evidence the staff provided the patient with the risks and benefits associated with leaving prior to receiving an MSE. Review of the medical record revealed no evidence the patient was asked to sign the Refusal of MSE and/or Consent to Treatment form. There was no evidence staff documented the patient refused to sign the form. 2. Policy and Procedure Review Review of the facility policy, EMTALA Definitions and General Guidelines, states on page 12 of 14, (B) when the individual leaves before the EMTALA obligation is met, (1) Leaving DED (Dedicated Emergency Department) Prior to Triage LPT: if an individual presents to the DED and requests services for a medical condition, but the individual desires to leave prior to triage, the facility must request that the individual complete the Sign-In sheet; (b) Logistics (iii) if the individual indicates that he is leaving prior to triage or it is noticed that the individual is leaving prior to triage, the risks and benefits associated with leaving prior to receiving an MSE (Medical Screening Exam) must be discussed with the individual, (iv) if the individual still desires to leave, the individual should be asked to sign the Refusal of MSE and/or Consent to Treatment form. If the individual does not sign the form, the individual refusal should be documented, with the individual completing the form signing and documenting the form as to the date and time of refusal. 3. Interview Interview with the Assistant Chief Nursing Officer on 3/16/2018 at 1:45 PM confirmed the above findings. The hospital failed to ensure that their policy and procedure was followed as evidenced by failing to obtain a written informed refusal of the risks and benefits of the examination or treatment or both for patient #14 on 3/13/2018 prior to leaving the hospital.
Based on review of the medical record, transfer center calls review, review of facility's policy and procedure, and staff interview it was determined the facility failed to ensure medical treatment was provided, within its capacity, to minimize risk to an individual's health prior to transfer to another medical facility for one (#3) of twenty-one patients sampled. Findings included: 1. Medical Record Review Review of the medical record for patient #3 revealed the patient presented to the facility ED (Emergency Department) on 2/15/2018. Review of the physician's medical screening exam and radiological tests completed revealed the patient had a left depressed skull fracture with subdural hematoma (collection of blood between the covering of the brain (dura) and surface of the brain), multiple comminuted fractures and hemorrhagic contusions which required neurosurgical services. Review of nursing assessments revealed no evidence neurological checks or increased frequency of monitoring of the patient was conducted. Review of nursing documentation and physician treatments revealed the patient's condition deteriorated and the patient required intubation (insertion of a flexible tube into the trachea to maintain an open airway and facilitate ventilation of the lungs) at 10:08 pm. Review of radiological tests revealed a repeated CT scan of the brain was performed which revealed the subdural hematoma had significantly increased. Review of the Memorandum of Transfer form revealed box (d) marked on transfer of patient, Stable for Transfer was crossed out and the box labeled Unstable was then marked. Review of the form revealed no evidence who made the change of the patient from stable to unstable or when the change was made. 2. Interview Interview with the Assistant Chief Nursing Officer and Risk Manager on 3/16/2018 at 1:45 PM confirmed the above findings. 3. Transfer Center Call review Review of the transfer center calls between the transferring facility and receiving facility revealed on 2/15/2018 at 9:16 pm the transferring facility ED physician provided report to the receiving facility accepting physician. The transferring ED physician stated the patient was stable for ground transport. Review of the transfer center calls revealed ground transport with ALS (Advanced Life Support) was arranged at 9:18 pm with a stated estimated time of arrival at the transferring facility at 9:54 pm Review of the transfer center calls revealed the transferring facility called to request urgent transport of the patient via helicopter. Due to weather conditions transport via helicopter was declined. Review of the transfer center calls revealed the transferring facility ED physician called the receiving facility physician to provide an update on the patient's deteriorated condition. Review of the physician to physician call revealed the accepting facility physician stated, its been over two hours why is he (patient #3) still there (at transferring facility), he is bleeding, and the only thing that is going to save him is when he is in the hands of a neurosurgeon in the OR (Operating Room). The transferring facility ED physician stated he did not know why the patient's transfer was delayed. 4. Policy and Procedure Review The facility's policy and procedure titled, EMTALA Definitions and General Guidelines, policy #ADMIN. LD.011, Effective 12/12, Replaces Policy dated 11/2011 was reviewed. The policy revealed in part, page 3 of 14, Procedure: Definitions: Appropriate Transfer occurs when: (i) The transferring hospital provides medical treatment within it capacity that minimizes the risks to the individuals' health.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on review of medical records, facility policy and procedures, and staff interview, the facility failed to ensure a registered nurse supervised and evaluated nursing care for two (#1, #10) of 10 sampled patients. The facility failed to provide medication administration for elevated blood pressure in accordance with physician orders for Patient #1 and failed to provide treatment in accordance with policies and procedures for the insertion of a Dobhoff feeding tube for Patient #10. Findings included: 1. Review of the physician history & physical (H&P) dated 10/27/2017 at 9:27 AM showed the patient was admitted to the facility for an acute skin rash, opiate withdrawal, and hypertension (HTN). Review of the physician plan on the H&P revealed the patient would be admitted for management of symptoms related to opiate withdrawal, which included medication to control his blood pressure. Review of the physician orders dated 10/27/17 at 2:25 PM showed the medication Clonidine 0.2 mg was ordered every 3 hours as needed to keep systolic blood pressure (SBP) less than 170. The SBP is the first number also referred to as the top number in a blood pressure (BP) reading. Review of the admission vital signs (VS) on 10/27/17 at 9:28 AM, revealed a BP of 218/141. Normal blood pressure is between 120/80 - 140/90. The American Heart Association (AHA) considers a blood pressure reading above 180/110 a hypertensive crisis and emergency treatment should be sought. Review of nursing documentation from admission on 10/27/17, at 9:28 AM through 10/29/17 at 8:30 PM, showed the following VS: 10/27/17 at 9:28 AM - 218/141 10/27/17 at 11:08 AM - 206/120 10/27/17 at 12:17 PM - 192/122 10/27/17 at 12:37 PM - 196/120 10/27/17 at 1:37 PM - 220/134 10/27/17 at 2:01 PM - 201/122 10/27/17 at 2:33 PM - 204/104 10/27/17 at 3:38 PM - 199/117 (clonidine given at 4:52 PM) 10/28/17 at 6:57 AM - 171/110 10/28/17 at 8:06 AM - 190/120 (clonidine given at 8:12 AM) 10/28/17 at 10:24 AM - 174/109 10/28/17 at 11:25 AM 184/104 (clonidine given at 11:36 AM) 10/29/17 at 4:32 AM 171/123 (clonidine given at 4:36 AM) 10/29/17 at 2:23 PM 188/122 10/29/17 at 5:29 PM 210/111 10/29/17 at 6:38 PM 199/115 10/29/17 at 7:37 PM 198/122 10/29/17 at 8:30 PM 200/115 10/29/17 at 10:14 PM 198/125 10/29/17 at 11:45 PM 183/110 10/30/17 at 1:35 AM 181/109 - No further readings were taken on this day. 10/31/17 at 8:52 AM 201/116 - Patient's medical record shows a discharge on 10/30/17 at 2:20 AM Review of the nursing medication administration record (MAR) showed the blood pressure medication Clonidine was only administered 4 of the 22 times the SBP was greater than 170. Clonidine 0.2 mg was administered as follows: 10/27/17 at 4:52 PM 10/28/17 at 8:12 AM 10/28/17 at 11:36 AM 10/29/17 at 4:36 AM Review of nursing documentation from the time the physician ordered the clonidine on 10/27/17 at 2:25 PM, until the patient left against medical advice (AMA) on 10/30/17 at 2:20 AM, no documentation or evidence could be found to indicate that the physician was notified of Patient #1's critically high blood pressure readings over the course of the patient's four day hospital stay. On 12/07/17 at 2:15 PM, an interview conducted with the Risk Management Coordinator confirmed the above findings in the medical record of Patient #1. 2. Review of the physician history & physical (H&P) for Patient #10 revealed the patient was admitted on [DATE] for cardiac surgery. Review of the H&P documentation dated 09/07/17 showed the patient was admitted to the cardiovascular intensive care unit (CVICU) post surgery. An interview conducted with the Director of Patient Safety on 12/07/17 at approximately 9:35 AM, revealed that on 09/15/17 Patient #10's physician ordered a Dobhoff feeding tube to be placed by nursing staff for nutritional purposes. RN #A attempted to place the feeding tube, however, two Registered Nurses (RN's) could not verify placement via auscultation with a stethoscope and therefore removed the feeding tube. RN #A attempted to insert another Dobhoff tube, and once again, placement could not be verified. An x-ray of the chest and abdomen was obtained. The Advanced Nurse Practitioner (ARNP) read the x-ray and told RN #A to advance the tube. A second x-ray was obtained after the RN advanced the Dobhoff feeding tube and the ARNP read the x-ray and told RN #A the tube was okay to be used for tube feedings. The Dobhoff tube feedings were not started on the day shift by RN #A, however, when the night shift RN #B came on, the day shift nurse told RN #B that the feeding tube was in place and the feedings could be started. RN #B gave the patient a bolus tube feeding of 150 cc's and the patient subsequently developed significant abdominal pain and had to be given pain medication (Dilaudid) for the pain by RN #B. Definition of Dobhoff feeding tube- a small-lumen feeding tube that can be advanced into the duodenum (https://medical-dictionary.thefreedictionary.com) On 09/16/17 at 3:33 AM a CAT (CT) scan was obtained that showed the Dobhoff feeding tube was seen through the trachea, the left main stem bronchus and into the lingual division of the left upper lobe. Additional findings included; a small left apical pneumothorax, bilateral pleural effussioins with comprehensive atelectic changes, and a small mediastinal and extensive subcutaneous emphysematous changes in the left anterior chest. On 09/16/17, at 6:01 AM a chest x-ray showed the Dobhoff tube had been removed. There was a small (15%) left pneumothorax, a moderate to large left pleural fluid collection, and a left hemothorax that could not be excluded. Review of the physician progress noted dated 09/17/17 at 9:16 AM showed the patient had a chest tube in the pleural space that was draining cream-colored drainage. Continued review of physician progress notes revealed the patient's respiratory status continued to deteriorate and the patient required ventilator assistance. Review of the facility policy entitled. Enteral Nutrition Therapy/Tube Feeding, #FNS-800.11/C5, revised 01/15, showed that before initiation of feeding, NG Feeding Tubes require a chest x-ray for placement verification; Post-pyloric tube placements require a KUB. Tube feedings can be initiated after receiving placement verification from the Radiologist. Review of the policy entitled, Feeding Tube Insertion, Small Bore, #ADMIN II.PC-F.004, reviewed 09/2015, showed Scope: Critical Care RN with competency. Policy: This procedure is only performed with a specific physician order by Critical Care RNs trained in small bore feeding tube placement. Training includes review of policy and procedures and placement of one tube under supervision of a Critical Care RN already trained in this procedure. Step 12 in the procedure states leave guidewire in place and obtain KUB to verify proper placement. On 12/14/17 at approximately 12:22 PM, Quality Management (QM) staff confirmed RN #A did not have a competency for insertion of a Dobhoff feeding tube. An interview conducted on 12/07/17 at approximately 10:00 AM with the VP of QM/Risk Management and the Director of Patient Safety, confirmed the above findings in the medical record of Patient #10.
Based on clinical record and policy review and staff interview it was determined that the facility failed to perform Pre-Admission Screening and Resident Review for six (#1, #3, #4, #5, #6, #9) of six patients transferred to a Skilled Nursing Facility. This practice does not ensure patients are appropriately screened for placement. Findings include: 42 CFR 483.100 requires that the facility transferring a patient to a Skilled Nursing Facility (SNF) ensures that a Pre-Admission Screening and Resident Review (PASRR) be completed prior to the patient's being transferred to the SNF to ensure appropriate placement. 1. Review of the clinical records for patients #1, #3, #4, #5, #6, and #9 revealed they were transferred to a SNF for continuing care. The records had no evidence the PASRR was completed prior to the transfer. 2. A interview was conducted on 4/20/11 at 12:42 p.m. with the second floor Case Manager. When questioned if she completes the PASRR for patients that are being transferred to a SNF, she stated that she did not. Interview on 4/20/11 at 11:40 a.m. with the Director of Case Management revealed the facility had no policy on completing the PASRR. She stated it was done by the receiving SNF.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on medical record review and interview with nursing and dietary staff, the facility failed to ensure that documentation of fluid intake and protein supplement intake reflected following physician's orders for two (#12, 28) of thirty sampled patients, putting those patients at risk for negative outcomes when either fluid or protein intake wasn't monitored. Findings include: 1. Patient # 12 was admitted to the facility on [DATE] with Hepatic [DIAGNOSES REDACTED] per the admitting notes located in the patient's medical record. A physician's order, dated 02/25/11 with the time at 1530 (3:30 p.m.), was noted for 1 liter day po (by mouth) fluid restriction. Review of the Vital Signs and I & O (Intake & Output) Worksheet for 02/25/11 revealed entries documenting the Oral/PO input which had been totaled for the first twelve hours equaling 375 (mls). The next twelve hours intake, not totaled per the Worksheet directions Please total every 4 hours, but documented a total of 1135 mls. The 24 hour total for 02/25/11 was 1510 cc, 510 cc more than the physician's order for 1000 mls. Review of the same worksheet for 02/26/11 revealed the patient had a total intake of 870 mls. Review of the same worksheet for 02/27/11 revealed the patient had a total intake of 1320 mls, 320 mls more than the physician's order for 1000 mls. Interview with the patient's nurse, on 02/28/11 at 1:30 p.m. confirmed that the physician's order for one liter a day had not been followed. 2. Patient #28 had been admitted on [DATE] with multiple decubitus ulcers, per the Emergency Department admitting documents located in the patient's medical record. Review of the History and Physical, dated 02/17/11 , revealed discussion of the multiple decubitus and an albumin at 1.9 mg ( normal = 3.5 - 5.0 mg). The plan included enhance protein in the diet. A physician's order was noted, dated 02/18/11, for promod powder BID (protein powder twice a day). Interview with the Registered Dietitian(RD), on 03/02/11 beginning at 1:30 p.m. revealed that orders for protein powder supplements were filled by the dietary department. The RD reported that the powder would be mixed into a food, such as applesauce, and delivered to the patient on the meal tray. The patient's intake of the supplement would be documented by the nurse. Review of the documentation of the percentage of meals eaten revealed three columns - breakfast, lunch, dinner, and snack. Only a number was documented in the columns and there was no specific listing of the physician's ordered protein powder. The RD reported during the interview and while looking at the document, that the intake of the protein powder was probably the number listed in the snack column, even though the order for the protein powder was for twice daily. Documentation for the period from 02/19/11 through 02/28/11 revealed only 24 entries out of the 40 opportunities to document percentage eaten of three meals and a snack had occurred. The 'snack' column, identified as the documentation of the protein powder contained four entries for the 10 day period. Review of the Medication Administration Record did not reveal a listing for the physician ordered protein powder allowing documentation by the nurse that the patient had taken the protein supplement.
Based on clinical record review, review of facility policy and staff interview it was determined the facility failed to obtain a properly executed informed surgical consent for 1 (#29) of 30 sampled patients, prior to the patient receiving surgery. Findings include: A review of the clinical record for patient #29 revealed a surgical consent for Bilateral total knee replacement was signed and witnessed on 12/21/10. A review of the Physician's admission orders dated for 2/8/11 at 2:30 p.m. revealed an order to obtain an Operative permit for Bilateral total Knee Replacement. Further review of the Physician's orders revealed the date of admission listed as 3/1/11 and the date of surgery was listed for 3/1/11. A review of the electronic surgical checklist revealed the surgical consent was written, signed and completed. A telephone interview was conducted with the surgical director 3/2/11 at approximately 1:30 p.m. to verify when the surgery consent is obtained. The Director responded that surgery usually gets the consent signed the day of surgery and sometimes the patients will sign consent at the Physicians office prior to arrival. An interview was conducted with the Director of the Surgery Intensive Care Unit (SICU) on 3/2/11. After she reviewed the clinical record, she confirmed the findings. A review of the facility policy, Informed Consent Policy, policy # ADMIN.09/RI-7, approved 4/28/09 revealed on page 8 of 9, section VII. (A.) Informed consent should be discussed sufficiently prior to proposed treatment of procedure to provide the patient with adequate time to deliberate, but not more than 30 days. (D) A new consent is required in all circumstances in which the consent is more than 30 days old. On page 9 of 9, section VIIII, (B) Nursing Personnel- Prior to the beginning of any procedure where written informed consent is required, the nurse must verify that the consent form has been appropriately completed, signed and witnessed.
Based on observation, review of facility policies, and interview with Dietary staff, the facility failed to ensure that facility policies were followed, putting patients at risk for possible food borne illness, physical contamination , and potentially receiving the wrong meal tray. Findings include: 1. During the tour of the main kitchen, beginning on 02/28/11 at 10:00 a.m., the following concerns were noted: a-Dishwashing /Warewashing Machine Temperature Logs, one for each meal, were posted on the outside wall of the dish machine room. There were no temperatures documented for the dish machine on 02/28/11, even though dishes from breakfast were being washed. The log for documenting temperatures for washing the lunch dishes, documented throughout February at 1:00 p.m., had as the last entry on the log the pre wash temperature on 02/27/11. The other two temperatures that were to be logged were the wash and final rinse temperature which had not been logged on 02/27/11. The log for documenting temperatures for washing the dinner dishes had as the last entry temperatures logged on 02/25/11. There had been no temperatures logged at 6:00 p.m. for the 26th or the 27th of February. Review of the policy entitled, Dishmachine Temperature Checks (Policy # 800.11/F-20 effective 1/11), revealed the statement: Dishmachine temperature is monitored to assure that dishes are cleaned and sanitized. The procedure included: Temperature checks on the dishmachine are completed twice daily - A.M. and P.M. - and documented on log by supervisor on duty. The temperature log attached to the policy indicated areas for three documentation times - Breakfast, Lunch, and Dinner - which was a different log than the one that was currently in use and did not represent the procedure outlined in the policy. Interview with the Dietary Director on 02/28/11 beginning at 10:15 a.m. confirmed that temperatures were to be logged prior to running the dish machine after each meal. b- Observation of the shelving racks inside the reach in refrigerator located in the cold preparation area , on 02/28/11 at 10:15 a.m., revealed the plastic coating had worn off of the edges of the racks, potentially allowing plastic bits to break off into food items. Without the plastic coating, the rack edges presented with a surface that was difficult to keep clean and provided a rusty surface, also a potential contaminant. The shelving in the walk in produce refrigerator, observed on 02/28/11 at 10:25 a.m., was observed to be soiled with a wet, black substance on the edges of the racks, which was easily wiped away. Both refrigerator shelving racks were observed with the Department Director. c-A dietary aide was observed, on 02/28/11 beginning at 10:15 a.m., finishing the task of cutting and plating slices of cheesecake in the nourishment/catering area. This aide had on plastic gloves (with a knife glove under the plastic glove on the right hand) and was observed placing a knife into a pitcher filled with water. This aide was then observed to walk away from her station and within a few minutes returned to the area, still with gloves on, go into the produce cooler, exit with a plastic container of strawberries, obtain a metal sieve from a rack of clean equipment, and go to the sink to rinse the strawberries. This aide was questioned about what she was doing and when it would be appropriate to change her gloves. She reported that she was going to change her gloves after she rinsed the strawberries. The Department Director, at that same time, asked the aide to remove the gloves and wash her hands. The Director then reported that dietary staff are trained to change gloves after finishing a task and when they leave their preparation area to obtain other food items or equipment. 2- Observation of the nonperishable food supply adequate for seven days, with the Department Director and Clinical Nutrition Manager on 03/02/11 beginning at 11:10 a.m., revealed the supply was based on the average hospital census. The average census was reported to be 220, which would indicate 21 cases of #10 cans of protein foods should be available. There were 12.5 cases of #10 cans, plus one case of tuna, two cases of pc (personal consumption) peanut butter and 5 cases of dried beans available as nonperishable protein sources, which would not equal the 21 cases required. Review of the planned menu did not reveal several items included on the menu that were available in the dry storage area. Fruits and vegetables required for the seven day non perishable food supply were calculated at 42 cases of #10 cans for the average census. Approximately 20 cases were observed in the nonperishable food supply. The only dairy products in the nonperishable food supply were cases of thickened milk. Review of the department's policy for service during emergency listed the state requirement to maintain a 7-day supply of nonperishable foods. 3- Observation of the procedure of passing meal trays, on the Oncology unit, on 03/01/11 beginning at 11:30 a.m., revealed out of the five meal trays passed by a dietary aide to five patients, neither of the two identifiers (patient's name and date of birth) were requested from the patient prior to the presentation of the meal tray. Review of the policy for passing meal trays (Tray Distribution and Retrieval, policy # 800.11/B-9, effective 1/11) revealed point # 4 The aide delivering the tray should hold it so the entrTe side will face the patient, and assure the patient's name is the same as that on the menu card. The second identifier check patients date of birth. Interview with the aide passing the meal trays, on 03/01/11 at approximately 12:00 p.m., confirmed that the aide was aware of the procedure to ask for the two identifiers, said that she knew the patients, and confirmed that she had forgotten to ask the birth dates.
Based on clinical record review, facility document review and staff interviews, it was determined the facility failed to obtain a properly executed informed consent form prior to the operation of 1 (#29) of 30 sampled patients reviewed. Evidenced by: A review of the clinical record for patient #29 revealed a surgical consent for Bilateral total knee replacement was signed and witnessed on 12/21/10. A review of the Physician's admission orders dated for 2/8/11 at 2:30 p.m. revealed an order to obtain an Operative permit for Bilateral total Knee Replacement. Further review of the Physician's orders revealed the date of admission listed as 3/1/11 and the date of surgery was listed for 3/1/11. A review of the electronic surgical checklist revealed the surgical consent was written, signed and completed. A telephone interview was conducted with the surgical director 3/2/11 at approximately 1:30 p.m. to verify when the surgery consent is obtained. The Director responded that surgery usually gets the consent signed the day of surgery and sometimes the patients will sign consent at the Physicians office prior to arrival. An interview was conducted with the Director of the Surgery Intensive Care Unit (SICU) on 3/2/11. After she reviewed the clinical record, she confirmed the findings. A review of the facility policy, Informed Consent Policy, policy # ADMIN.09/RI-7, approved 4/28/09 revealed on page 8 of 9, section VII. (A.) Informed consent should be discussed sufficiently prior to proposed treatment of procedure to provide the patient with adequate time to deliberate, but not more than 30 days. (D) A new consent is required in all circumstances in which the consent is more than 30 days old. On page 9 of 9, section VIIII, (B) Nursing Personnel- Prior to the beginning of any procedure where written informed consent is required, the nurse must verify that the consent form has been appropriately completed, signed and witnessed.
Based on observations and staff interview it was determined the facility did not have the minimum required equipment (Cardiac defibrillators with synchronization capability) in each of the facility's operating room suites. Findings include: A tour was conducted on 3/1/11 at 10:30 a.m. of the Surgical Areas, accompanied by the Director of Surgery. During the Tour of the (7) Operating Room (OR) suites it was observed there were no Cardiac Defibrillators kept in the OR suites. When the Director of Surgery was asked where the Code Carts were kept at, she pointed out the (3) Code carts kept on the unit. This surveyor questioned the Director how the defibrillators are obtained when the patient codes in the OR. The Director responded the staff would have to retrieve it from the hall or just call out to have it brought into the room.
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Based on record review and staff interview it was determined that the facility failed to ensure the nursing staff complied with the plan of care for one (#3) of five patients selected for review. Findings include: Patient #3 was admitted to the facility on [DATE] with the chief complaint of severe back pain. The physician noted, in the History and Physical, that the patient had thoracic spinal fractures with neuralgia. Review of the physician's orders revealed that nursing staff were to perform neurological assessments twice every shift at the time of admission. Review of the medical record on 2/15/11 revealed that the neurological assessments were performed once per shift. Interview with a staff nurse on 2/15/11 at approximately 10:00 a.m. confirmed the assessments were being performed only once each shift.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review and staff interview, it was determined that the facility failed to administer medication as ordered for one (#5) of five sampled patients. This practice may result in failure to achieve therapeutic goals. Findings include: Patient #5 was admitted to the facility on [DATE] with the chief complaint of chest pain and shortness of breath. The physician documented, in the History and Physical, the patient had a history of hypertension and [DIAGNOSES REDACTED]. Review of the physician orders revealed the physician wrote an order for Coreg 3.125 twice daily on 11/11/10. Review of the Medication Administration Record revealed no evidence that the medication had been administered and no explanation as to why. During an interview on 2/15/11 at approximately 9:30 a.m., the Director of Nursing confirmed there was no evidence that the medication had been administered.
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