CMS-HCA-Florida-West-Tampa-Hospital

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

Based on review of medical records, policy review and staff interview it was determined the facility failed to ensure the consent for surgery was completed indicating informed consent was obtained for one (#1) of thirty patient records sampled.

Findings included:

Review of the medical record for patient #1 revealed the patient (MDS) dated [DATE] after a fall.

Documents provided by the Adult Living Facility indicated patient #1 had a Health Care Surrogate (HCS) and list contact names and phone numbers.

Review of the admitting physician's History and Physical dated 04/24/17 at 4:37 a.m. revealed a history of dementia and psychiatric illness. The note stated the patient was a poor historian and had expressive aphasia. Orthopedic Surgeon consultation note dated 04/24/17 at 7:25 a.m. noted the patient's history included Dementia and psychiatric illness.

Orthopedic surgeon documentation, approximately 1 hour and 33 minutes later, dated 04/24/2017 at 8:58 a.m. stated the surgical treatment options were discussed with the patient, the patient voiced understanding and agreed to surgery. There was no documentation in the medical record that indicated the surgery was emergent.

Facility policy titled Informed Consent dated 01/24/17 indicated a signed consent will be obtained from every competent adult or person authorized to sign for a minor or incompetent adult for major and minor surgery that involves entry into the body. If the patient has not been declared incompetent, but there is serious question as to their competency, the physician must initiate measures for legal declaration of incompetence in order to proceed and that will be documented in the chart. The policy states attempts will be made to notify the family and secure a consent.

Review of the medical record included a consent for surgery form dated 04/24/17 at 6:45 a.m. The form listed the patient's name, the surgeon's name and the procedure to be performed. There was no signature from the patient or the Health Care Surrogate consenting to the surgery. On the line for the patient's signature were hand written words, unable to sign. There was no documentation on the consent form or in the medical record indicating why the patient or the patient's Health Care Surrogate did not sign the consent form. There was no documentation in the medical record an attempt was made to contact the patient's Health Care Surrogate to obtain consent for surgery or to provide the designated individual the information required to make informed decisions about the patient's care. There was no documentation in the medical record regarding the competency status for patient #1. The medical record revealed the patient had surgery on 04/24/17 at 8:58 a.m. without a signed consent form.

An interview with the Nurse Leader on 04/26/17 at 12:00 p.m. confirmed the above findings.

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Based on observation and interview it was determined the facility failed to protect patients [past and present] personal and protected health information for greater than 530 past and present patients.

Findings included:

On 04/26/2017 at 7:47 a.m. the conference room assigned by facility for surveyors to conduct the validation survey was unlocked on arrival. All documents containing patients' personal and PHI [protected health information] had been moved, rearranged and placed in different folders. The Vice President of Quality and Patient Safety was immediately notified. She stated she was not sure what happened and had heard a children's community meeting had been held in the room.

The surveyor requested the facility investigate due to the personal and PHI breach of the following information:

1. List containing current Inpatient census of fifty-four [54] patient names admitted , unit and diagnosis

2. The restraint death record log with eight [8] patient names

3. The Surgery Schedule log with two-hundred sixty-one [261] patient names, date of procedure, and procedure to be performed.

4. The list of Returns to OR [operating room] with one hundred fifty-six [156] patient names, date and procedure

5. The list of patients who received blood/blood products containing eleven [11] patient names, number of infusions and type of blood product administered and date of administration.

6. The list of surgical patients with positive wound cultures with fifteen [15] patient names

7. The facility's emergency room Transfer Out log for 2017 included ninety-five [95] patient names, reason for transfer, where they were transferred and the Transfer In log for 2017 included twenty-five [25] patient names and reason for transfer.

8. The first quarter EMTALA [emergency medical treatment and labor act] log contained patient names, time seen, reason for seeking emergency care, too numerous to count.

9. The confidential Peer Review Committee Minutes for January, February and March 2017 containing multiple patients too numerous to count.

10. The facility Grievance logs for year 2015 to 2017 containing patient names too numerous to count.

On 04/27/2017 a request for information on the breech investigation throughout the day was made. The Vice President of Quality and Patient Safety stated they were working on it. No information was received to confirm an investigation, report of breach or action plan was being conducted.

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

Based on medical record reviews and staff interviews it was determined the facility failed to ensure medical staff rules and regulations were followed for three [#3, #4, #14] of thirty sampled patient records and the policy for verbal and telephone order verification was followed for two [#11, #15] of thirty sampled patient records.

Findings included:

1. Medical Staff Rules and Regulations Page 6 of 22 [regarding discharge summary] Item #19 The patient's medical record shall be complete within thirty days following discharge, including progress notes, final diagnosis and clinical resume.

A review of patient # 3's medical record documented the patient was admitted on [DATE] and discharged home on 12/06/2016. A review of the discharge summary showed the summary was dictated on 03/09/2017 and authenticated by the physician on 03/10/2017, three months and four days after discharge.

A review of patient # 4's medical record documented the patient was admitted on [DATE] and discharged home on 03/13/17. A detailed review of the medical record on 04/27/17 for patient # 4, with the director of surgical services, showed no documentation of a discharge summary, 45 days after discharge.

A review of patient #14's medical record documented the patient was admitted on [DATE] and discharged home on 03/12/2017. A detailed review of the medical record on 04/26/2017 for patient #14, with the director of clinical care, showed no documentation of a discharge summary, 44 days after discharge.

2. Facility policy titled Verbal and Telephone Order Verification approved by the quality council and medical executive committee on 03/2017, stated on page 1 item B: Documentation of verbal and or telephone orders shall include (but not limited to) the following elements:

Date and Time of the order for treatment or medication, . . .on page 2 item C. Standard verbal and or telephone orders are to be signed by the Prescriber within forty-eight hours. Hazardous orders must be signed within twenty-four hours (for example: Chemotherapy, Investigational Drugs, DNR [do not resuscitate], CMO [comfort measures only], Restraints).

A review of patient #11's medical record documented a telephone order received on 04/19/2017 at 9:00 a.m. for hemodialysis. A detailed review on 04/26/2017 with the director of critical care confirmed the order was not verified/validated or signed by the ordering physician within the forty-eight hour time frame specified in the facility policy.

A review of patient #15's medical record documented a telephone order for restraints received on 11/24/2016 at 2:10 a.m. A detailed review of the order on 04/26/2017 with the director of critical care showed the physician evaluation, signature, date and time section was left blank.

A continued review documented a telephone order for restraints received on 11/25/2016 at 2:00 a.m. A detailed review of the order on 04/26/2017 with the director of critical care showed the physician evaluation, date and time section was left blank.

An interview with the director of critical care confirmed she was unable to determine if the order was verified/validated within twenty-four hours per policy.

A continued review of medical record documented a physician signed order for restraints on 11/26/2016. It showed the time of restraint order left blank. A detailed review of the order on 04/26/2017 with the director of critical care showed the section of the order for clinical justification was blank, time limit was blank, criteria for release was blank, physician evaluation was blank and time the order was signed by the physician was blank.

An interview with the director of critical care on 04/26/2017 at 3:00 p.m. confirmed the above findings.

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Based on review of medical records and staff interview it was determined the registered nurse failed to supervise and evaluate nursing care to ensure care was provided according to physician orders for two (#11, #27) of thirty patients sampled.

Findings included:

1. A review of patient #11's hemodialysis physician orders and dialysis treatment flow sheets documented a physician's order for Hemodialysis with a DFR (Dialysate Flow Rate) of 700. A review of the dialysis treatment flow sheet for 04/21/2017 revealed the DFR ran at 800 as set by the RN (Registered Nurse).

A detailed review of the patient's medical record with the director of critical care on 04/26/2017 confirmed the above findings and stated there was no evidence of physician order to increase DFR.

A review of patient #11's medication orders showed an order for Calcium Acetate 1334 mg [milligrams] by mouth three times a day. A review of the medication administration record documented the patient was administered the phosphate binder on the following dates and times:

04/19/2017 at 8:35 a.m. and 8:26 p.m.

04/20/2017 at 8:48 a.m.; 2:47 p.m. and 9:53 p.m.

04/21/2017 at 8:35 a.m.; 4:50 p.m. and 8:11 p.m.

04/22/2017 at 9:54 a.m.; 3:54 p.m. and 10:03 p.m.

04/23/2017 at 9:38 a.m. and 8:34 p.m.

04/24/2017 at 9:11 a.m. and 2:22 p.m.

04/25/2017 at 11:42 a.m.

04/26/2017 at 8:56 a.m. and 1:49 p.m.

A review of the medication indications and usage using the 2017 Physician's Desk Reference 71st edition: www.pdr.net/ and Epocrates Online: https://online.epocrates.com documented calcium acetate, brand name PhosLo was to be given orally with food.

An interview with the facility pharmacist on 04/26/2017 at 1:00 p.m. confirmed the medication was to be given with food to be effective.

An interview with the director of critical care noted nurses were to know the medications they were giving as part of patient safety.

An interview with the director of dietary services on 04/26/2016 at 2:00 p.m. revealed meal tray delivery to the unit the patient was on were Breakfast at 8:30 a.m.; Lunch at 12:30 p.m. and Dinner at 5:30 p.m.

On 04/26/2017 at 3:00 p.m. a detailed review of the medication administration record with the director of critical care and the facility pharmacist confirmed the medication was not administered appropriately to be effective.

2. Review of the medical record for patient #27 revealed an order for hemodialysis three times per week on Monday, Wednesday, Friday. Review of the hemodialysis orders dated 4/10/2017 at 11:00 a.m. revealed no ordered rate for the DFR. Review of the hemodialysis treatment flowsheets revealed the RN ran the DFR at the following rates:

4/10/2017 DFR 800

4/12/2017 DFR 600

4/13/2017 DFR 700

4/15/2017 DFR 700

4/17/2017 DFR 700

4/19/2017 DFR 800

4/21/2017 DFR 700

4/24/2017 DFR 600

Interview and review of the record with the Director of Critical Care on 4/27/17 at 3:30 p.m. confirmed the above findings.

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

Based on review of medical records and policy and staff interview it was determined the nursing staff failed to develop and keep current an individualized care plan for two (#1, #2) of thirty patients sampled.

Findings included:

1. Review of the medical record for patient #1 revealed the patient was admitted on [DATE] with a right femoral neck fracture.

Review of the Pain Assessment completed in the Emergency Department on 04/23/17 at 4:48 p.m. revealed a pain score of five out of ten (zero was no pain and a ten was the worst possible pain).

Review of the History and Physical dated 04/23/17 at 4:59 by the Emergency Department physician revealed the patient complained of right hip pain. The history indicated the patient was cognitively impaired and had impaired communication.

The admitting physician's History and Physical dated on 04/24/17 at 04:37 a.m. revealed patient #1 had pain in the right hip at the time of the assessment. On 4/23/17 an order was initiated for Morphine Sulfate, 2 milligrams (mg) intravenously every two hours as needed for pain.

Review of the document Patient's Plan of Care created on 04/23/17 revealed the identified problems were Impaired Musculoskeletal Function, Impaired Physical Function and Impaired Neurological Function. There was no plan of care developed to address pain prior to or after surgery.

2. Review of the triage record for patient #2 revealed the patient (MDS) dated [DATE] at 6:27 a.m. for perforated appendicitis. At the time of triage, Patient #2 reported a pain score of ten out of ten (Zero was no pain and a ten was the worst possible pain).

According to the Nursing Admission assessment dated [DATE] at 11:23 a.m. patient #2 complained of left lower quadrant abdominal pain.

Review of the pain assessment documentation revealed Patient #2 continued to experience intermittent pain from the time of admission until 04/26/17 at 12:00 p.m.

Review of the document Patient's Plan of Care created on 04/17/17 revealed the problems identified were Impaired Gastrointestinal Function, Impaired Skin Integrity and Knowledge Deficit. There was no plan of care developed to address pain from 04/17/17 to 04/26/17.

Review of the facility policy titled Assessment-Reassessment dated 01/24/17 revealed the Registered Nurse will determine and set priorities on the patient's nursing care needs during the initial assessment phase. Upon completion of the initial assessment, an individualized, prioritized plan of care shall be developed in consultation with the patient/significant other. Any change in the patient's condition shall require an immediate reassessment with changes in the plan of care reflecting the change in condition. The plan of care shall be reviewed regularly in consultation with the patient/significant other and revised as patient's condition or diagnosis changes.

An interview with the Nurse Leader on 04/26/17 at 12:00 p.m. confirmed the above findings.

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

Based on review of medical records, staff interview and review of policy and procedures it was determined the facility failed to ensure medications were timely administered and administered in accordance with orders for two (#27, #28 ) of thirty sampled patients.

Findings included:

Review of policy and procedure Medication Administration, effective date 5/24/16, under section, Procedure III Standard Medication Administration Times indicated timed medications ordered more than once a day will be given no more than one hour before or one hour after the scheduled time.

1. Patient #28 was admitted on [DATE] to the Intensive Care Unit with sepsis. Review of physician admission orders dated 4/8/17 at 8:00 p.m. included orders for Zosyn 2.75 grams every eight hour. Physician order dated 4/8/17 at 9:50 p.m. ordered Bactroban twice a day.

Review of the Electronic Medication Administration Record noted the Zosyn was given on 4/8/17 at 10:32 p.m. and on 4/9/17 at 4:43 a.m. The medication was due at 6:00 a.m., approximately one hour and fifteen minutes later. There was no documentation as to why the medication was given earlier than one hour. Review of the Electronic Medication Administration Record revealed no evidence the Bactroban was administered.

Interview with the Director of Critical Care during the record review on 4/27/17 indicated Bactroban had been faxed to the pharmacy but not placed on Electronic Medication Administration Record. The Director of Critical Care stated medications that are timed are given one hour before or one hour after the due time.

Record review and interview with the Director of Critical Care on 4/27/17 at approximately 3:00 p.m. confirmed the above findings.

2. Review of the medical record for patient #27 revealed a physician order for Epogen 4000 units with each hemodialysis treatment. Review of the medical record revealed the patient received hemodialysis on 4/10/2017 beginning at 2:21 p.m. Review of the MAR (Medication Administration Record) dated 4/10/2017 revealed no evidence the Epogen was administered as ordered.

Review of the medical record revealed the patient received hemodialysis on 4/12/2017 beginning at 11:45 a.m. Review of the physician orders revealed an order on 4/11/2017 to change the Epogen to 8000 units with each hemodialysis treatment. Review of the MAR dated 4/12/2017 revealed Epogen 8000 units was administered at 12:14 p.m. At 12:15 p.m. Epogen 4000 units was administered. Review of the MAR revealed the Epogen was administered once by the primary care nurse and also administered by the hemodialysis nurse.

Review of a physician order indicated Zemplar 2 mcg (micrograms) was to be given with each hemodialysis treatment. Review of the medical record revealed the patient received hemodialysis on 4/10/2017 at 2:21 p.m. Review of the MAR dated 4/10/2017 revealed no evidence the Zemplar was administered as ordered.

Review of the medical record revealed the patient received hemodialysis on 4/12/2017 beginning at 11:45 a.m. Review of the MAR dated 4/12/2017 revealed Zemplar was administered at 12:13 p.m. and at 12:15 p.m. Review of the MAR revealed the Zemplar was administered once by the primary care nurse and also administered by the hemodialysis nurse.

Review of the MAR revealed on 4/15/2017 at 10:45 a.m. Albumin was administered to the patient by the hemodialysis nurse. Review of the physician orders revealed no evidence of an order to administer Albumin. On 4/21/2017 at 9:45 a.m. and 11:30 a.m. Albumin was administered to the patient by the hemodialysis nurse. Review of the physician orders revealed no evidence of an order to administer Albumin.

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Based on observation and staff interview it was determined the facility failed to ensure routine and preventive maintenance, inspections, testing and repair activities were performed.

Findings included:

On 04/24/2017 at approximately 10:00 a.m. accompanied by the Life Safety Code surveyor and the Maintenance Director a tour of the facility was conducted on the 3rd Floor. It was noted:

1. Observation of 3-prong electrical beds with no documentation of preventative maintenance or electrical safety tests.

2. Observation and inspection of the 3rd floor revealed patient restrooms in rooms 333, 335, 363, 365, 361 and 387 revealed all exhaust vents not working and clogged with fuzzy lint.

3. Patient nutrition room's ice dispenser drain and tray covered in brown slimy substance.

Observation of the 2nd floor revealed a locked Behavioral Health Unit [BHU] and an Adult Rehabilitation Unit [ARU]. It revealed:

1. Observation of the BHU revealed a clogged sink drain in the staff lounge with approximately 2 inches of greenish brown liquid confirmed by the Maintenance Director

2. Observation of the BHU showed fire extinguishers stored within locked cabinets. Interview of staff member [A] during the tour stated she did not have a key. An interview with the BHU charge nurse on 04/24/2017 stated all staff should have a key to the fire extinguishers.

3. Observation of patient room 219 revealed restroom exhaust vent not working and with fuzzy lint on grate covering.

4. Observation of the air conditioning unit in patient room 219 with copious amounts of brown sticky substance and fuzzy lint. Per the maintenance director, housekeeping did not have a key to the unit cabinet and stated maintenance checks, cleans and changes filters once per month and this one is due.

5. Observation of the BHU and ARU patient laundry rooms revealed dryer with copious amount of lint in the dryer vent behind the cleaning screen.

Observation of the 1st floor revealed the Intensive Care Unit, Emergency Department, Laboratory Department, Pharmacy, Radiology and Dietary. It revealed:

1. Observation during tour of the Intensive Care Unit (ICU) on 4/27/17 at 12:30 p.m. with the Director of Critical Care revealed in the nourishment room next to the refrigerator a grape fruit size area of paint peeling down to the wood work. Interview with the Director of Critical Care during the observation indicated she had no knowledge of how it occurred or when it occurred.

An interview with the maintenance director during the tours confirmed the above findings.

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Based on review of facility policy, observation and staff interview it was determined the facility failed to follow the infection control policies related artificial nails, nail polish and nail length.

Findings included:

On 04/25/17 at 9:00 a.m. review of the facility surgical services policy titled OR-Scrub Technique, revised 02/14/17 revealed the following: keep fingernails trimmed neatly and short ...fingernail polish should not be worn ...no artificial nails of any type allowed.

Review of a human resources policy titled Professional Dress Standards revealed artificial nails may not be worn by employees providing direct patient care, in food services, environmental services or sterile processing.

Review of an infection control policy titled Hand Hygiene, effective 01/16/16 revealed a house wide clinical policy indicating no artificial nails are allowed.

Review of an infection control policy titled OSHA Bloodborne Pathogen Exposure Control Plan effective 01/11/16 revealed a house wide policy requiring nails to be short enough to allow thorough cleaning under nails and to avoid damage to gloves ...artificial nails or tips on employees providing direct patient care is not permitted since these can become colonized with microorganisms that cannot be removed by routine hand washing.

The Association of peri-Operative Registered Nurses (AORN) recommended the following: Fingernail tips should be no longer than 2 mm (millimeters) (0.08 inch). Studies found fingernails at a length shorter than 2 mm were less likely to harbor bacteria when compared to nails longer than 2 mm. (Guideline for hand hygiene. In: Guidelines for Preoperative Practice. Denver, CO: AORN, Inc.)

On 04/25/17 at approximately 9:55 a.m. a tour was conducted, accompanied by the Director or Surgical Services, of the Sterile Processing and Peri-operative Departments. During the tour of the Operating Room the RN Supervisor was observed wearing finger nail polish with an approximate length of 5 mm.

An interview conducted with the RN supervisor revealed she performed direct patient care. The nails were not artificial. Additionally, the RN supervisor stated scrub techs cannot wear artificial nails, but the Registered Nurses (RNs) can.

At approximately 11:00 a.m. a tour was conducted of the Sterile Processing Department (SPD) where the sole Sterile Processing Technician was observed wearing artificial nails with an approximate length of 10 mm. The SPD technician stated she performed all of the functions related to the sterile processing of surgical instruments for the facility. Additionally, the SPD technician stated she was aware the policy for her position did not allow wearing of artificial nails.

On 04/25/7 at approximately 11:07 a.m. the Director of Surgical Services confirmed the above findings with the OR RN Supervisor and Sterile Processing Technician nails.

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Based on review of facility policy, review of documents and staff interview it was determined the facility failed to follow the policy related to terminal cleaning and disinfection of the surgical department operating rooms for 18 of 90 days reviewed.

Findings included:

On 04/25/17 at approximately 11:10 a.m. review of the facility surgical services policy titled Cleaning Sanitation Surgical Procedure Areas, revised 02/02/17, revealed the objective of the policy was to re-establish a clean safe environment after each surgical procedure ...cleaning procedures done within the Surgical Suite will be according to the Association Of periOperative Registered Nurses (AORN) recommend guidelines. Further review of the policy revealed terminal cleaning will be performed at the conclusion of the day's schedule, operating rooms, scrub/utility areas, corridors, furnishings and equipment should be terminally cleaned ...mechanical friction and a hospital-approved disinfectant/detergent are used to clean equipment and areas that should include:

1) Surgical lights and tracks,

2) Fixed and ceiling mounted equipment

3) All furniture, including wheels and casters

4) Handles of cabinets and push plates

5) Face plated of vents

6) Horizontal surfaces (e.g. tops of counters & fixed shelving)

7) Entire floor

8) Kick buckets

9) Scrub sinks

On 04/25/17 at approximately 10:30 a.m. review of the facility documents for the months of February, March, and April 2017 titled with the following: Team Member: By initialing the following spaces, you are indicating that the suite has been terminally cleaned and disinfected to AORN and Joint Commission Standards ...Manager/Supervisor: By providing your signature, you are indicating cleaning has been in compliance. Further review of the document revealed multiple days in this three month period that did not have staff or Manager/Supervisor initials indicating the OR suite had been terminally cleaned.

On the following dates the facility performed surgical procedures and terminal cleaning was not performed:

02/20/17-Review of the surgical log revealed surgical procedures were performed in OR #2 and #6. Review of the terminal cleaning log revealed no terminal cleaning was performed at the conclusion of the day's schedule in OR #2 and #6.

02/22/17-Review of the surgical log revealed surgical procedures were performed in OR #3. Review of the terminal cleaning log revealed no terminal cleaning was performed at the conclusion of the day's schedule in OR #3.

02/26/17-Review of the surgical log revealed surgical procedures were performed in OR #4. Review of the terminal cleaning log revealed no terminal cleaning was performed at the conclusion of the day's schedule in OR #4.

03/03/17-Review of the surgical log revealed surgical procedures were performed in OR #1. Review of the terminal cleaning log revealed no terminal cleaning was performed at the conclusion of the day's schedule in OR #1.

03/07/17-Review of the surgical log revealed surgical procedures were performed in OR #3. Review of the terminal cleaning log revealed no terminal cleaning was performed at the conclusion of the day's schedule in OR #3.

03/19/17-Review of the surgical log revealed surgical procedures were performed in OR #1 and #4. Review of the terminal cleaning log revealed no terminal cleaning was performed at the conclusion of the day's schedule in OR #1 and #4.

03/20/17 - Review of the surgical log revealed surgical procedures were performed in OR #6 and #7. Review of the terminal cleaning log revealed no terminal cleaning was performed at the conclusion of the day's schedule in OR #6 and #7.

03/24/17-Review of the surgical log revealed surgical procedures were performed in OR #3 and #4. Review of the terminal cleaning log revealed no terminal cleaning was performed at the conclusion of the day's schedule in OR #3 and #4.

03/25/17-Review of the surgical log revealed surgical procedures were performed in OR #6. Review of the terminal cleaning log revealed no terminal cleaning was performed at the conclusion of the day's schedule in OR #6.

03/29/17-Review of the surgical log revealed surgical procedures were performed in OR #3. Review of the terminal cleaning log revealed no terminal cleaning was performed at the conclusion of the day's schedule in OR #3.

04/02/17-Review of the surgical log revealed surgical procedures were performed in OR #2. Review of the terminal cleaning log revealed no terminal cleaning was performed at the conclusion of the day's schedule in OR #2.

04/04/17-Review of the surgical log revealed surgical procedures were performed in OR #6. Review of the terminal cleaning log revealed no terminal cleaning was performed at the conclusion of the day's schedule in OR #6.

04/08/17-Review of the surgical log revealed surgical procedures were performed in OR #1 and #4. Review of the terminal cleaning log revealed no terminal cleaning was performed at the conclusion of the day's schedule in OR #1 and #4.

04/09/17 - Review of the surgical log revealed surgical procedures were performed in OR #1. Review of the terminal cleaning log revealed no terminal cleaning was performed at the conclusion of the day's schedule in OR #1.

04/13/17-Review of the surgical log revealed surgical procedures were performed in OR #1. Review of the terminal cleaning log revealed no terminal cleaning was performed at the conclusion of the day's schedule in OR #1.

04/15/17-Review of the surgical log revealed surgical procedures were performed in OR #4. Review of the terminal cleaning log revealed no terminal cleaning was performed at the conclusion of the day's schedule in OR #4.

04/16/17-Review of the surgical log revealed surgical procedures were performed in OR #1. Review of the terminal cleaning log revealed no terminal cleaning was performed at the conclusion of the day's schedule in OR #1.

04/21/17-Review of the surgical log revealed surgical procedures were performed in OR #1, #2 and #3. Review of the terminal cleaning log revealed no terminal cleaning was performed at the conclusion of the day's schedule in OR #1, #2 and #3.

On 04/25/17 at 10:25 a.m. an interview conducted with the Director of Surgical Services and the Director of Environmental Services confirmed the above findings.

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Based on observation, record review and staff interview, the facility failed to fully sprinkler the MRI (Magnetic Resonance Imaging) Building an existing health care occupancy as required by NFPA 101, (2012), 19,3.5.3, 9.7.1.1 (1), NFPA 13 (2010), with the additional requirement provided in the CMS (Centers for Medicare and Medicaid Services) S&C (Survey and Certification) letter 11-05 LSC Revised 02.18.2011.

Findings included:

1. On 04/25/2017, the second day of survey, observation from 9:00 a.m. to 11:30 a.m. accompanied by the Facilities Manager revealed a MRI Building physically attached to the main hospital by a covered walkway. Continuing observation upon entering the building revealed smoke detectors and available egress through front and rear exits. There were no sprinkler heads observed. Staff interview of the Facilities Manager concurrent with tour confirmed the MRI building was protected by the hospital fire alarm system, however, the building was not sprinklered.

On 04/25/2017 staff interview of the Imaging Department Manager revealed some inpatients did receive MRI procedures in the MRI Building. A request was made for a listing of all inpatients billed for MRI procedures for the months of January and February, 2017.

On 04/25/2017 record review of the listings provided by the Imaging Department Manager of inpatients receiving MRI procedures revealed 29 inpatients in January, 2017 and 37 inpatients in February, 2017.

On 04/25/2017 record review of NFPA 101 (2012) 19.1.3.1 Multiple occupancies revealed in section (1) They are not intended to provide services simultaneously for four or more inpatients for purposes of housing, treatment, or customary access by inpatients incapable of self preservation. Record review of S&C-11-05-LSC REVISED 02.18.2011, revealed CMS does not consider the number of patients in determining if a provider is a hospital or a CAH; therefore, a CMS-certified hospital or CAH does not need to have four or more inpatients at all times in order to be classified as a Health Care Occupancy. Occupancy classification must be determined regardless of the number of patients served at a hospital's or CAH's component facility. Therefore, the facility does provide MRI procedures to hospital inpatients in the MRI Building and the MRI Building is a Health Care Occupancy and must meet existing health care requirements of NFPA 101, (2012), Chapter 19,3.5.3, 9.7.1.1 (1), as well as NFPA 13 (2010).

NFPA 101, (2012), 19,3.5.3, 9.7.1.1 (1)

NFPA 13 (2010)

S&C-11-05-LSC REVISED 02.18.2011

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Based on observation and staff interview, the facility failed to maintain smoke barriers as required by NFPA (2012), 8.5.2.1, 8.5.2.2, 8.5.4.1, 8.4.4, and 4.6.12.5.

Findings included:

1. On 04/24/2017 observation during the interior tour from 10:00 a.m. to 2:45 p.m. accompanied by the Facilities Manager revealed penetration of smoke barriers (corridor walls above the suspended ceiling) and opening protectives (doors in means of egress of fire/smoke barriers). Examples of observed penetrations included:

2nd floor, Behavioral Health Unit, the means of egress corridor walls above the suspended ceiling penetrated by cables; means of egress corridor walls above the suspended ceiling at the IT (Information Technology) room with penetration by a cable; multiple penetrations through the suspended ceiling in the computer equipment room in which it was not possible, due to the fragility of the equipment, to determine whether the exterior walls to the compartment have been penetrated.

Continuing observation revealed opening protectives (means of egress corridor doors) in which new door hardware had been installed and either the type of locking device or the wrong locking device had been installed resulting in 1/2 inch hole penetrations of the 1 1/2 inch substantial doors. Examples of observed penetrations included:

the Nursing Station dictation room with 2 penetrations at the latching device and the third floor Wound Care Office 2 penetrations, 1/2 inch holes, at the latching device. Staff interview of the Facilities Manager concurrent with the tour acknowledged the penetrations above the suspended ceiling, in the IT room and in corridor doors. The facility is required to conduct an inspection of means of egress corridor walls above the suspended ceiling as well as opening protectives, means of egress corridor doors, identifying penetrations and the correction of the deficiencies by qualified personnel and maintaining documentation of the findings and outcomes for the authority having jurisdiction.

NFPA (2012), 8.5.2.1, 8.5.2.2, 8.5.4.1, 8.4.4, 4.6.12.5

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Based on record review, policy review and staff interview it was determined the facility failed to provide an appropriate screening examination to one (#21) of 21 sampled records.

Findings included:

The Emergency Provider Report dated 11/17/16 at 1:54 p.m. and signed by the Emergency physician included Patient #21 was 27 weeks pregnant and had been experiencing pain in her upper abdomen for the previous 2 days. The Physical Exam included the patient ' s vital signs were normal according the ambulance staff (EMS). The patient was not in acute distress. EMS reported no abnormal heart rhythm. The abdomen was described as gravid.

There was no evidence of the physician's evaluation of the intensity of the patient's abdominal pain at the time she arrived nor at the time she departed.

The record contained no evidence Patient #21 was offered diagnostic testing nor any treatment to relieve her pain before continuing in the same ambulance to the next hospital.

The facility policy titled EMTALA-Screening and Stabilization, no policy number, effective 5/24/16 was reviewed on 11/28/16. The policy included documentation indicating the facility is required to provide an appropriate medical screening examination within the capability of the hospital's emergency services, including ancillary services routinely available to determine whether or not an Emergency Medical Condition (EMC) exists to any individual who requests services or presents in such a manner as a reasonable person would conclude an examination is necessary.

An interview was conducted with the Vice President of Quality on 11/28/16 at approximately 10:00 a.m. She indicated she was present on 11/17/16 when the Director of Emergency Services called to say the department secretary observed a physician going out to examine a patient who was still in the ambulance. The Vice President of Quality and the Director of Emergency services determined from their interview with the ED physician that he had examined Patient #21 in the ambulance without bringing the patient into the facility and instructed the ambulance crew to take the patient to another hospital. She confirmed the above findings.

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Based on record review, policy review, and staff interview it was determined the facility failed to ensure one (#21) of 21 sampled patients was provided an appropriate transfer from the Emergency Department to another hospital.

Findings included:

The Emergency Provider Report dated 11/17/16 at 1:54 p.m. and signed by the Emergency physician included Patient #21 was 27 weeks pregnant and had been experiencing pain in her upper abdomen for the previous 2 days. The Physical Exam included the patient's vital signs were normal according the ambulance staff (EMS). The patient was not in acute distress. EMS reported no abnormal heart rhythm. The abdomen was described as gravid.

The Emergency Provider Report included, Patient seen and examined in the ambulance bay and found to be medically cleared and stable to transfer to [another hospital]. Patient not in active labor but having abdominal pain for one day. My clinical reasoning is that this 3rd trimester patient with abdominal pain is not in labor but may start labor, so she should be at a facility with obstetrical and gynecologic services...

There was no evidence the ED physician contacted the receiving facility at any time to ensure the receiving facility had the capability and capacity to accept the transfer of Patient #21.

There was no evidence copies of the Provider Report, the only clinical information in the medical record, were sent to the receiving facility.

The record did not include a Certificate of Transfer indicating the ED physician had provided Patient #21 with the information required for her to make an informed decision regarding her transfer, nor was there evidence the physician discussed the potential risks of transferring versus receiving treatment at this facility.

The facility policy titled EMTALA-Transfer Policy, no policy number, effective 5/24/16 was reviewed on 11/28/16. The policy included documentation any transfer of an individual with an Emergency Medical Condition (EMC) must be initiated either by a written request for transfer or by a physician order with the appropriate physician certification as required under EMTALA. The policy required the physician to sign a certification that based upon the information available at the time of transfer the medical benefits of transfer outweighed the increased risks of the transfer, and the patient has been informed of the potential risks prior to making a decision. The policy indicated a transfer will be appropriate if the transferring hospital provided medical treatment within its capacity, the receiving hospital has available space and qualified personnel to provide appropriate treatment, and the transferring hospital sends the receiving hospital copies of all medical records related to the EMC.

An interview was conducted with the Vice President of Quality on 11/28/16 at approximately 10:00 a.m. She indicated she was present on 11/17/16 when the Director of Emergency Services called to say the department secretary observed a physician going out to examine a patient who was still in the ambulance. The Vice President of Quality and the Director of Emergency services determined from their interview with the ED physician that he had examined Patient #21 in the ambulance without bringing the patient into the facility and instructed the ambulance crew to take the patient to another hospital. She confirmed the above findings.

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

Based on medical record review, staff interview and review of on call coverage schedules, facility policy and procedures and transfer logs it was determined the facility failed to accept incoming appropriate transfers that were within the receiving facility's capabilities and capacity for two of (#22, #23) twenty-three patients sampled.

Findings include:

An interview was conducted with the VP Quality/Patient Safety from Tampa Community Hospital (the receiving facility -Facility A) on 12/17/2014 at 12:28 p.m. She stated on 11/29/2014 an ER (emergency room ) physician refused to accept transfers for two patients (#22, #23) from a transferring facility (Facility B- an acute care hospital). He stated had consulted with the GI (gastroenterologist) specialty physician on call. The GI physician stated facility B had GI coverage. Patient #22 was accepted at another facility. Patient #23 was accepted and transferred to another facility. The patients were refused for acceptance by the ER physician of facility A.

Review of the medical record from Facility B for patient #22 revealed the patient presented to facility's B ED (Emergency Department) on 11/29/2014 for complaints of abdominal pain with nausea and vomiting for 6 days. This was the 3rd visit to the ED for the same symptoms. The patient had ongoing emesis despite medication and a plan to admit for intractable emesis. The physician documented no GI (gastroenterology) services were available with a transfer needed. Review of the form EMTALA/Memorandum of Transfer revealed the patient required care unavailable at facility A.

Review of the medical record from Facility B for patient #23 revealed the patient presented to facility's B ED on 11/29/2014 for complaints of bloody sputum (hemoptysis) since 3:00 a.m. that day. Review of the ED physician documentation revealed the patient had a history of [DIAGNOSES REDACTED]. The patient would require admission for further evaluation. The ED physician documented they did not have GI on call and the hospitalist felt GI evaluation was needed. Review of the form EMTALA/Memorandum of Transfer revealed the patient required care unavailable at facility B.

On 12/17/2014 at 12:28 p.m. an interview with the VP Quality/Safety and review of the call center log revealed on 11/29/2014 an ER (emergency room ) physician refused to accept a transfer for two patients (#22, #23) from facility B. He stated he had consulted with the GI specialty physician on call that stated facility B had GI coverage. Both patients were refused acceptance by facility A who had capacity and capability. The VP of Quality/Safety revealed only the AON (administrator on duty) had the authority to refuse a transfer per facility's A transfer policy and duty to accept.

Review of the transfer logs for facility A revealed no evidence of patient #22 or #23 being accepted for transfer on 11/29/2014. Interview with the Nursing Director of Emergency Services on 12/17/2014 at 9:00 a.m. confirmed the patients (#22 and #23) were not on the transfer log dated 11/29/2014 due to the patients not being accepted for transfer.

Review of the medical records for patient #22 and #23 and interviews with the VP Quality/Safety and the Nursing Director Emergency Services revealed both patients met the criteria for an individual with an Emergency Medical Condition that required specialized care for transfer by the ER physician of the Facility B to facility A. Review of Facility A's on call physician specialists Medicine Department On-Call Coverage Schedule for November 2014 revealed a Gastroenterologist was on call on 11/29/2014, the date of requested transfer but refused to accept patient #22 and #23.

Review of the EMTALA - Transfer Policy dated 2/2014 with a purpose to establish guidelines for either accepting an appropriate transfer from another facility or providing an appropriate transfer to another facility of an individual with an emergency medical condition (EMC), who requests or requires a transfer for further medical care and follow-up to a receiving as required by the Emergency Medical Treatment and Labor Act (EMTALA). The policy states that a hospital with specialized capabilities or facilities shall accept from a transferring facility an appropriate transfer of an individual with an EMC who requires specialized capabilities if the receiving hospital has the capacity to treat the individual. Under Section 3 - Authorization to Accept a Transfer, the policy states that, The Emergency Physician and the Hospital CEO or designee, such as the Administrator on Call (AOC) or the House Supervisor, are the ONLY individuals authorized to accept or refuse the transfer of an individual from another facility on behalf of the receiving hospital. Section 5 - Transfer Center Use, states that At the Emergency Physician's request, the Transfer Center must facilitate a discussion between the Emergency Physician and the on-call physician of the receiving facility. The on-call physician does not have the authority to refuse an appropriate transfer on behalf of the facility

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Based on Record Review and Interviews it was determined that the facility did not keep an accurate central log of individuals who come to the Emergency Department seeking emergency medical care for 1 out of 21 records reviewed #21.

Findings Include:

A review of the run report for the Hillsborough County Fire Rescue Service reveled that on on 2/23/2014 an Ambulance crew (R 38) responded to a private residence. They found a 2 year old infant in medical distress with a fever of 101.3 and a (Seal like bark) cough. They made arrangements to transport the resident and the mother wanted to go to the nearest Hospital. Patient was transported to Hospital #1. Upon arrival at the hospital the greeting ER nurse scolded the team of R 38, in front of the mother, and told them in a loud voice that Hospital #1 did not have an inpatient pediatric unit and asked why they brought the child to that facility. The crew of R38 were not told what bed to put the patient in only to pick an empty one by this RN. After waiting about 10 minutes in the room the mother became concerned that her child was not going to be seen and doubting the facilities desire to provide care for her child asked R 38 to transport the patient to another Hospital.

During the tour of the emergency department on the morning of March 05, 2014 accompanied by an emergency department (ED) nurse and the VP of Quality Services and Risk management, an interview revealed that the normal practice for an Ambulance bring a patient to the ED was for a radio contact to be made between the two and the ED given the vital information on the patient being transported. If radio contact was not possible then the crews used a cell phone for contact.

A review of the Run Report dated 2/23/2014 revealed that during the initial contact between the crew of R 38 and the RN that evening one of the crew members asked why they were not told not to bring the child to the ED when the Radio Call was made.

A record review of patient #21 from Hospital #2 reveled that the patient did arrive at their facility at 23:55 and that patient #21 was provided a Medical Screening exam and that stabilizing medical care was provided. Pediatric patient was discharge to Home in the care of it's mother.

The central log for the dates in question were reviewed and there was no entry for Resident # 21 on the central log. An Interview with the Interim Risk Manager on March 5, 2014 at approximately 11:30 a.m. revealed that the facility was aware of the incident but did not know the name of the patient and felt that since the crew of R 38 took the patient to another hospital that this patient was never a patient of Hospital # 1.

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

Based on Record Review and Interview it was determined that the facility did not provide emergency medial examination and treatment for 1 out of 21 records reviewed #21. Patient #21 arrived at the facility on 2/23/2014 at 22:55 and left the facility on 2/23/2024 at approximately 23:18, without being examined or treated by hospital staff.

Findings Include:

1. Based on review of the ambulance run report, # 69, signed 2/23/2014, it was determined that

patient #21 was brought to the facility on [DATE] the patient was placed in a room in the fast track area and never examined by hospital personnel. After waiting some time in the room the pediatric patient's mother asked the ambulance crew to take the sick child to another hospital, which they did.

2. In an interview with the Risk Manager on 3/05/2014 at approximately 10:00 it was learned that the facility had done an internal investigation related to Patient #21 and the facility had self reported the incident to the Agency for Health Care Administration on February 27, 2014. It was also discovered based on this interview that the facility did not have any patient documentation on the resident and there was not an entry on the central log or a medical record of this visit available. The interview confirmed that patient #21 was not examined or treated while in the Emergency Department.

3. A review of investigation done by the interim Risk Manager revealed that it consisted of An interview with the nurse who spoke to the Ambulance Crew, an interview of the unit secretary, and interview of 3 other department staff. The investigation did not obtain the Ambulance Run Report or a medical record from the treating facility. The Interim Risk Manager confirmed that they did not even know the name for this patient.

4. Stabilizing medical treatment was not provided by hospital #1. Medical Records obtained from hospital #2 confirmed that hospital #2 did provide a medical screening examination and treatment for patient #21 later that evening.

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

Based on medical record review, policy and procedure review, and staff interview it was determined the facility failed to ensure nursing staff provided interventions for a patient identified with pain for one (#2) of ten patients sampled; failed to assess the patient's pain level prior to providing pain medication and following administration of pain medication for one (#4) of ten patients sampled; and failed to ensure two (2) physician ordered consultations were completed for one (#2) of ten patients sampled.

Findings include:

1. Review of the medical record for patient #2 revealed the patient was admitted to the facility on [DATE]. Review of nursing documentation revealed on 9/19/2013 at 3:12 p.m., the patient complained of back pain of 8 out of 10 with 10 being the worst possible pain. Review of the nursing documentation and MAR (Medication Administration Record) revealed the patient was medicated for pain at 7:01 p.m., approximately four (4) hours after complaining of pain. Review of the nursing documentation revealed no alternative interventions were offered or provided during those four hours. Interview with the Clinical Educator and Chief Nursing Officer on 11/26/2013 at approximately 2:30 p.m., confirmed the findings.

2. Review of the medical record for patient #4 revealed the patient was admitted to the facility on [DATE] status post a fall at home. Documentation revealed the patient sustained a fractured ankle requiring surgical repair. Review of the MAR revealed on 9/21/2013 at 9:57 p.m. Morphine 4 mg (milligrams) was administered IV (Intravenously). Review of the nursing documentation revealed no evidence the patient's pain level was assessed prior to administration of the Morphine. Review of the nursing documentation revealed no evidence the patient's pain level was assessed post administration of the Morphine. There was no documentation to reveal if the pain medication was effective.

On 9/22/2013 at 3:38 a.m. Morphine 4 mg IV was administered. Review of the nursing documentation revealed no evidence of a pre or post pain level assessment. There was no documentation to reveal if the pain medication was effective for the patient's pain.

Review of the facility, Pain Management, #PC 350, last approved 6/2012, states (II) Intervention, (D) re-evaluation occurs within 30 minutes to 1 hour following intervention, with documentation of the time; pain score, level of sedation, descriptors and/or non-verbal signs. Interview on 11/26/2013 at 11:30 am with the Clinical Educator confirmed the above findings.

3. Review of the medical record for patient #2 revealed the patient was admitted to the facility on [DATE]. Review of the physician orders revealed on 9/19/2013 at 6:15 am a pain management consultation was ordered. Review of nursing documentation on 9/19/2013 at 5:32 p.m., stated pain consultation not placed earlier, consult called by secretary. Review of the record revealed the consultation was not completed as ordered. The patient was discharged on [DATE].

Review of the physician orders revealed on 9/18/2013 at 7:00 p.m., a pulmonologist radiologist consultation was ordered. Review of the medical record revealed no evidence the consultation was completed. Interview with the Chief Nursing Officer on 11/26/2013 at approximately 2:30 p.m., confirmed the findings.

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Based on clinical record review, policy review and staff interview it was determined the facility failed to provide a medical screening examination that was within the capability and capacity of the Emergency Department for 1 (#1) of 20 sampled patients presenting to the Emergency Department to determine if an emergency medical condition existed.

Findings include:

A review of the facility's policy Triage Policy #ER 101, reviewed 4/12, section II, revealed triage data will be obtained at the bedside, if a bed is available, as soon as the patient arrives. This subjective and objective information will be utilized to accurately sort patients according to their acuity and resource needs.

A review of the facility's policy Assessment and Reassessment policy #200, approved 11/8/12, page 6, revealed for the Emergency Department, patients receive primary assessment survey upon arrival to the hospital and triaged as soon as possible by a registered nurse .

A review of the facility's policy, EMTALA- Medical Screening policy #RM 1211, approved 4/2/12, page 10, section D revealed (1) hospitals are obligated to perform the Medical Screening Examination to determine if an emergency medical condition exists. It is not appropriate to merely log in a patient and not provide a medical Screening examination.

Patient #1 presented to the Emergency Department (ED) on 4/19/13 at 12:50 a.m. Review of the ED patient information document revealed the reason for the visit was that the patient had anxiety medication and antibiotics last night and that night had a bottle of a highly alcoholic, low-price fortified wine.

Review of the triage record dated 4/19/13 at 12:56 a.m. revealed a chief complaint of vomiting. The past medical history included anxiety. Further review of the documentation revealed there was no triage assessment and/or vital signs completed on the patient.

An interview was conducted on 5/3/13 at 2:40 p.m. with the registrar involved with patient #1. The registrar stated the patient was very insistent and aggressive, banging on her window and the triage nurse's door. She said she was very afraid of him and told the nurse about him. The triage nurse called the police department, the patient left when the police arrived. The facility failed to ensure that their Triage policy and procedure was followed on April 19, 2013 for patient #1 as evidenced by failing to sort out this patient ' s needs to determine his acuity and resource needs when he presented to the emergency department with complaints of possible drug overdose after taking many medications and drinking alcohol.

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Based on clinical record review, policy review, credit card receipt, and staff interview it was determined the facility delayed providing an appropriate medical screening examination for 1 (#1) of 20 sample patients by accepting the patients co-pay before being assessed for an emergency medical condition.

Findings include:

Patient #1 presented to the Emergency Department (ED) on 4/19/13 at 12:50 a.m. Review of the reason for the visit was that the patient had taken the anti-anxiety medication, Lexapro and an antibiotic last night and that night he had a bottle of a highly alcoholic, low-price fortified wine. The form is provided to registration after the patient fills it out.

Review of the triage record dated 4/19/13 at 12:56 a.m. revealed the chief complaint was vomiting. The past medical history included anxiety. Further review of the documentation revealed there was no triage assessment or vital signs completed on the patient.

A review of a copy of the patient's credit card receipt in the record revealed the patient had paid $200 on 4/19/13 at 1:03 a.m. to the ED registrar.

An interview was conducted on 5/3/13 at 2:40 p.m. with the registrar involved with the patient. The patient gave the registrar his credit card for a $200 payment. She had told him that it was not protocol but he insisted she take it anyway. After she received the payment, the patient was insisted on being seen. The registrar informed the triage nurse who called the police department. When the police arrived, the patient left before being seen by the triage nurse or his vital signs taken.

A review of the facility's policy, EMTALA-Medical Screening policy #RM 1211, approved 4/2/12, page 11, section E, (1) there shall be no delay in providing a medical screening examination or stabilizing treatment for an emergency medical condition in order to inquire about a patient's method of payment or insurance status. (3) Individuals who inquire about financial responsibility for emergency care should receive a response by a staff member who is well trained to provide information regarding potential financial liability. Patients should be encouraged to delay such discussions until after the completion of the medical screening examination and any necessary stabilizing treatment.

The facility failed to ensure that their policy and procedure was followed on 4/19/2013 related to accepting a method of payment before a medical screening examination was completed on Patient #1.

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

Based on clinical record review, staff interview and policy review it was determined the facility failed to honor the patients rights for 1 (#4) of 13 sampled patients related to obtaining an informed consent from the patient or health care representative.

Findings include:

Patient #4 (MDS) dated [DATE] for a gastrointestinal bleed and sepsis. The patient has a history of cerebral vascular accident (CVA), right hemiparesis, and expressive aphasia. A blood consent was dated 10/20/12 at 9:00 pm that documented Medical Doctor (MD) in emergency room (ER) request. The consent was not signed by patient or representative but was signed by a witness. On 10/21/12 at 8:25 am the physician ordered a transfusion of 4 units of packed red blood cells (PBRC's). The patient received all 4 units of blood. On 10/22/12 a 5th unit of PRBC's was administered at 8:25 am.

A peripherally inserted central catheter (PICC) was inserted on 10/23/12 at 12:22 pm. A review of the PICC placement consent dated 10/21/12 revealed a Physician had signed the consent and wrote medically necessary above his name.

A review of the facility's policy, Informed Consent-Consents and Authorization for treatment Plan for patients, policy # RM101, approved 4/2/12, page 2, General Information, paragraph 6. revealed if the patient is adjudicated incapacitated, found to be incompetent or incapable to consent to treatment, express and informed consent to treatment shall be sought instead from the patient's guardian,guardian advocate or legal representative. Further review of the policy revealed in the event that informed consent cannot be obtained either from the patient or legal representative and the patient is experiencing a life threatening /emergent situation, (2) physicians familiar with the patients care may make the determination to proceed with the proposed procedure in the absence of the informed consent. Documentation regarding the same will be entered into the patients medical record.

A interview with the case manager was conducted on 10/29/12 at 1:00 pm after review of the clinical record, confirmed there was no documentation of the family being notified to give consent for either the blood transfusion and/or the PICC placement.

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

Based on clinical record review, policy review and staff interviews it was determined the facility failed to honor the patients rights to receive care in a safe setting, for 8 (#1,#5, #6, #7, #8,#9, #10 & #11) of 13 sampled patients by not ensuring enough qualified staff was available to ensure the immediate availability of a registered nurse for bedside care of any patient located on the Medical/Surgical Unit. The continued use of this practice does not ensure safe patient care as demonstrated in sample records.

Findings include:

1. Patient #1 presented to the Emergency department(ED) on 8/12/12. The patient was evaluated by the ED physician at 7:10 pm with a chief complaint of weakness. The ED Physicians impression was urosepsis and septic encepholopathy. The ED Physician noted that present on admission was a vascular/urinary catheter associated infection and bed sores (decubiti).

A review of patient #1's nursing documentation, revealed from 8/13/12 to 8/17/12 nursing documented the skin assessment as within normal limits (WNL). On 8/17/12 at 7:30 am a nursing assessment revealed the patient had (2) pressure ulcers on his sacral and coccyx areas. He also had ecchymotic areas to both heels, left knee and bilateral buttocks and the perineal area was excoriated. The wound care nurse was consulted on 8/19/12 at 1:20 pm (2 days later) and assessed the patient the same day at 3:45 pm.

Further review of patient #1's clinical record revealed the patient was assessed by an Licensed Practical Nurse on 8/17/12 on both 7:00 am to 7:00 pm and 7:00 pm to 7:00 am shifts. There is no documentation of a RN completing an assessment or co-signing the LPN assessments for either shifts.

A review of the assessment and reassessment policy, policy # 200, approved 1/31/12, revealed under scope: the assessment process will be a continuous, collaborative effort with all the health care members functioning as a team. the registered nurse, initially assesses the patients needs for care in all settings where patient care is provide. On page 3, section #5c. Skin integrity- all patients are assessed on admission for pressure ulcer risk using the skin integrity scale . Page 4, section 8c., Reassessments: at least one assessment/reassessment should be conducted by a Registered Nurse per calendar day.

Interviews were conducted on 10/24/12 from 10:30 am to 12:00 pm with the Nursing staff of the Medical/Surgical units. During the interviews the staff was questioned on the skin assessments, identifying pressure ulcers, and the process/procedures for treating the patient with skin breakdown. The staff responded that patients are assessed on admission and every shift for skin breakdown. That if a patient has any skin breakdown or potential for skin breakdown than the wound care nurse is consulted immediately. The wound care nurse evaluates the patient within 24 hours and makes recommendations for treatment. If a patient is felt to be a potential candidate for skin breakdown than the nursing staff initiates frequent every 2 hour turning schedule for the patient.

2. Patient #5 was admitted to the Medical/Surgical unit on 10/23/12 after a total knee Arthroscopy surgery. A review of the Anesthesiology Patient Control Analgesia (PCA) orders dated 10/23/12 at 11:30 am revealed a PCA for Morphine Sulfate was ordered for the patient. At the top of the order form is written 319, indicating the patient was on 3 north room 319.

A review of the Medication Administration Record (MAR) revealed the PCA had been initiated on 10/23/12 at 12:33 pm. Further review of the Nursing documentation on 10/23/12 revealed a Licensed Practical Nurse had initiated the PCA Morphine pump at approximately 12:20 pm.

A review of the facility's policy, Medication Administration Patient Controlled Analgesia (PCA), policy # MM 430, reviewed/revised on 9/11, revealed under scope of responsibility;

1. A registered nurse (RN) must program the PCA settings

2. Any licensed nurse may double check the setting

3. any licensed nurse may monitor the PCA device and patient status.

Further review of patient #5's clinical record, medication administration records and nursing documentation did not reveal any RN documentation of initiating and verifying the PCA or assessing the patients status prior to initiation.

Interviews were conducted on 10/24/12 from 10:30 am to 12:00 pm with the Nursing staff of the Medical/Surgical units. The Medical/Surgical Nursing staff (consisting of both LPN's and RN's) were questioned concerning the initiation of the PCA pumps. They responded that the RN reviews the physician orders, assesses the patient, sets up and initiates the PCA pump with a RN or LPN verifying the settings.

3. Patient #6 was admitted to the Medical/Surgical unit on 10/14/12 for wound care to both lower extremities. A review of the patient's clinical record, nursing assessments revealed the LPN completed the patients assessments on 10/20 to 10/22 and 10/24 to 10/27/12. There was no documentation the RN co-signed and/or supervised the LPN's assessments of the patient for these dates. An observation of patient #6 was made on 10/25/12 at approximately 11:00 am. During the observation it was noted the protective boots used to float the patients heels were soiled with yellow drainage and the patients intravenous left forearm (IV) site insertion date was 10/21/12 (outdated per policy), the intravenous site on the right forearm was not marked with an insertion date. The Medical/Surgical manager and the patients nurse were both at the bedside during this observation and confirmed these with the surveyor.

4. Patient #7's History and Physical revealed the patient was admitted with post [DIAGNOSES REDACTED] CVA on 10/15/12 to 3N after being transferred from another acute care facility. The documentation noted the patient was non-verbal, unable to make his needs know and had peg tube for nutrition.

Review of the nursing flow sheet dated 10/20/12 for the 7 A-7P shift noted a LPN completed the nursing assessment as well as for the 10/20/12 7P-7A. On 10/21/12 on the 7A-7P shift a LPN complete the assessment.

Interview on 10/29/12 with the Chief Nursing Officer, Director of Quality and the Risk Manager revealed on 10/20/12 one LPN was now a RN but a computer issue showed her as a LPN.

On 10/23/12 at 9:16 a.m. a RN assessment was completed that revealed the patient's breath sounds remained decreased and coarse. On the 7P-7A shift on 10/23/12 a LPN was assigned to the patient. The LPN did not complete an assessment. Review of the vital signs dated 10/24/12 at 12:09 a.m. revealed a heart rate of 92, respiratory rate of 24, blood pressure 138/72 and an oxygen saturation of 96%.

Review of the nursing flow sheet revealed on 10/24/12 at 12:59 a.m. the monitor technician notified the nurse of an increased heart rate in the 130's. The documentation did not reveal if the LPN caring for the patient was notified or another nurse was notified of the findings. There was no evidence of the LPN assigned to the patient or a RN assessing the patient for the increased heart rate. The Patient Care Technician (PCT) documented at 1:00 a.m. routine patient safety care. The monitor technician documented at 1:53 a.m. that the nurse was notified of cardiac rhythm changes and a code blue was called.

Review of the code blue report revealed the code was called at 1:50 a.m. and the patient was pronounced at 2:07 a.m.

Review of LPN documentation dated 10/24/12 at 8:41 a.m. revealed at 1:15 a.m. he was informed by Respiratory Therapy (RT) the patient's breath sounds were wet and moist and he went to assess the patient. The documentation noted a call was placed to the physician and while waiting for the physician to call back the PCT went to obtain vital signs. The documentation revealed the PCT noted the patient was unresponsive, did not look right and a code blue was called. The documentation did not contain evidence of the nurse's assessment after being notified by the RT of the change in the patient's condition.

Interview with the LPN caring for the patient that night on 10/29/12 at approximately 10:08 a.m. revealed the RN was notified of the change in condition by the LPN. Review of the nursing documentation did not reveal evidence of an assessment by the RN.

Staff interview and clinical record review revealed that nursing failed to provide an assessment of patient on 10/23/12 for the 7P-7A shift. The RN failed to assess the patient with a change of condition related to an increased heart rate and later in the shift related to breath sounds. There was a delay in providing nursing care by not assessing the patient at the time of the changes in condition for a patient that experienced a significant life threatening change in condition.

Various interviews with the Chief Nursing Officer, Risk Manager, Director of Quality, Director of the ICU/ED and the Nurse Information Technologist from 10/26-10/30/12 confirmed the findings.

5. Patient #8 presented to the Emergency Department (ED) on 10/5/12 with a chief complaint of chest pains since the night prior. The history included coronary artery disease with stent placement, diabetes and hypertension. The patient was triaged on 10/5/12 at 12:57 p.m. The vital signs included blood pressure 120/52, heart rate 73. respiratory rate 16, an oxygen saturation of 99% on room air and a pain level of 0 on a scale 0 to 10. Triage documentation noted the patient was alert and oriented. The ED physician examined the patient at 12:50 p.m. The ED physician's impression was chest pain with a history of stents and the patient was stable. ED physician orders revealed a heparin lock was placed. A cardiologist consult was ordered. The plan was to admit the patient. The patient was admitted to 3 North at 3:52 p.m.

The cardiology consult dated 10/5/12 revealed the patient was a symptomatic and had a possible myocardial infarction. The plan was for anticoagulation therapy and if intractable pain was present then a cardiac catheterization.

Review of physician admission orders dated 10/5/12 at 2:20 p.m. revealed to admit to telemetry with medications and laboratory and EKG testing.

Review of nursing documentation revealed the admission assessment was completed on 10/5/12 at 5:28 p.m. by a Licensed Practical Nurse (LPN). Vital signs at 6:05 p.m. were heart rate 72, respiratory rate 22, blood pressure 141/81 and an oxygen saturation level of 89% on room air. There was no evidence of a Registered Nurse (RN) assessment or the LPN reporting the findings, including the oxygen saturation of 89% to the RN. LPN documentation at 6:40 p.m. revealed the patient complained of chest pain of eight out of ten, the physician was called and orders were received for a Nitro (Nitroglycerine) drip and a transfer to the Intensive Care Unit (ICU) STAT. The documentation revealed the house supervisor was notified of a STAT transfer at 6:45 p.m.. The LPN documented at 6:50 p.m. revealed no one in the ICU would take report after three attempts. The patient was wheeled down to ICU and bedside report was given due to the patient's condition not being stable. There was no evidence the RN was advised of the patient's condition or the patient being assessed.

Physician verbal orders dated 10/5/12 at 6:40 p.m. ordered a Nitroglycerine drip at 0.25 micrograms, Lopressor 50 milligrams (mg) now and to transfer to the ICU. There was no route ordered for the Lopressor.

Review of the nursing flow sheet for transfer/discharge date d 10/5/12 at 7:00 p.m. revealed the patient was transferred to the Intensive Care Unit (ICU) accompanied by the LPN, monitor and IV equipment. The documentation noted report was given at the bedside to the agency ICU nurse. The ICU agency nurse documented at 7:10 p.m. the patient was transferred to ICU due to severe chest pain at an eight out of ten and possible pulmonary edema.

The vital signs at 7:10 p.m. were heart rate 153, respiratory rate 28, blood pressure 230/110 and an oxygen saturation of 87% on 2 liters of oxygen. At 7:18 p.m. the vital signs were heart rate 156, blood pressure 212/100 and an oxygen saturation of 88% At 7:19 p.m. the ICU agency nurse initiated a code blue due to the patient being unresponsive and with respiratory distress.

Review of the Code Blue record revealed the patient coded at 7:30 p.m. and expired at 7:57 p.m.

Review of ICU agency nurse documentation dated 10/5/12 at 9:00 p.m. revealed the patient was admitted to the ICU in transfer at 7:50 p.m. with chest pain, respiratory distress, mottled and hypertensive. The documentation noted the Nitro drip was started at 33 micrograms and increased to 100 micrograms due to chest pain and increased blood pressure. The documentation noted the Lopressor was also given intravenously (IV). The documentation noted a code blue was called at 7:19 p.m. The ICU agency nurse documented the Nitro drip was turned off at 7:23 p.m. There was no actual time the Nitro drip was initiated or the Lopressor given. Review of the physician orders and nursing documentation revealed there was no titration order for the Nitro drip or to initiate the drip at 33 micrograms or give the Lopressor IV. The ICU agency nurse's documentation at 9:00 p.m. contain conflicting times of care.

Confidential staff interviews on 10/26/12 and 10/27/12 revealed the intravenous (IV) pump was set at a rate of 100 milliliter per hour for the Nitro drip. The IV fluid pump was set at 10 milliliters per hour. The interviews revealed the agency nurse may have reversed the setting on the pump. The interviews revealed that is what the staff RN saw when the staff RN walked over to the patient' bedside to assist when the patient deteriorated.

Interview with two staff ICU RNs on 10/28/12 at approximately 3:45 p.m. and 4:50 p.m. revealed it is the their policy to have two nurses check the dose and pump setting for all drips. There was no evidence this occurred for patient #8.

Review of policy and procedure Rapid Response Team Code Purple #PC 800 reviewed 1/10 revealed a purpose that indicated the Rapid Response Team (RRT) had been shown to reduce morbidity and mortality rates in hospitals. The RRT help improve the staff nurse's critical thinking. Under the section for Procedures the policy indicated staff members and patient, families or visitors concerned about a patient's status may call the RRT line. It stated the RRT has orders that have been approved by the medical staff that may be initiated including Nitroglycerine IV fluids.

Staff interview and clinical record review revealed that nursing failed to provide of a RN assessment on admission, delayed a transfer to ICU with implementation of critical care medications such as the Nitro drip and Lopressor, did not administered critical medications as ordered by the physician, did not follow ICU policy of checking the dose and pump setting with two ICU staff nurses to ensure accuracy, and did not use the services if the RRT on 3 North for a patient that experienced a significant life threatening change in condition.

Various interviews with the Chief Nursing Officer, Risk Manager, Director of Quality, Director of the ICU/ED and the Nurse Information Technologist from 10/26-10/30/12 confirmed the findings.

6. Patient #9 was admitted to the Medical/Surgical (3S) unit on 10/25/12 for persistent nausea and vomiting. The admitting physicians initial impression was end-stage renal disease, massive upper gastrointestinal bleeding, hypertension, ascites and hypotension. On 10/25/12 at 2:00 pm the physician ordered the patient's blood sugar levels to be monitored every 4 hours. A review of the clinical record for 10/25/12 at 4:41 pm revealed the patients blood sugar was 50 documented by the LPN. The next blood sugar was obtained by the RN at 9:18 pm ( almost 5 hours later and was documented as 35. There was no documentation of any interventions for the blood sugar of 50 and no further monitoring of the blood sugar for almost 5 hours. There is also no evidence that a RN co-signed or assessed the patient during the time the patient was taking care of the patient. Further review of patient #9's clinical record revealed the RN from the 7:00 pm to 7:00 am shift documented her assessments and interventions after her shift was completed at 10:46 am.

7. Patient #10 presented to the emergency department (ED) on 10/23/12 at 7:38 pm. The patient was assessed by the ED Physician at 7:53 pm for cough, congestion with a thick sputum. The physicians diagnosis was Dyspnea with productive cough , [DIAGNOSES REDACTED]and hypertension. The patient was admitted to the Medical/Surgical unit on 10/24/12 at 3:06 am. A review of the nursing documentation revealed a LPN assessed the patient on 10/24/12 at 11:32 am; the patient was transferred to the intensive care unit (ICU) at 2:33 pm. There is no documentation of any assessment/co-signature or interaction from the RN prior to the patient going to ICU.

8. Patient #11 (MDS) dated [DATE] with a chief complaint of fecal impaction for 5 days. The triage vital signs were heart rate 71, respiratory rate 16, blood pressure 126/58, and an oxygen saturation of 99% on room air. Review of the ED physician documentation dated 10/10/12 revealed the patient had been constipated for 5 days with abdominal pain and nausea. The documentation noted a history of Alzheimer and dementia. Review of the abdominal CT scan revealed a fecal impaction and moderate gas. Review of blood study results noted a critical CO2 (carbon dioxide) level of 8 (22-32). Review of the critical value report revealed the critical value was called at 2:01 p.m. to the staff. The ED physician's impression was fecal impaction, metabolic acidosis and renal insufficiency. The plan was to admit to telemetry. The patient left the ED to 3N on 10/10/12 at 6:23 p.m. The vital signs at 6:23 were heart rate 95, respiratory rate 23, blood pressure 105/65 and an oxygen saturation of 91% on two liters of oxygen.

Review of verbal admission physician orders dated 10/10/12 at 5:19 p.m. included IV fluids of ? Normal Saline with one amp of Sodium Bicarbonate at 70 milliliters (ml) per hour and a tap water enema upon arrival to floor.

Documentation at 7:33 p.m. revealed the vital signs obtained by the PCT were heart rate 76, respiratory rate 16, blood pressure 98/72 and an oxygen saturation level of 65% on 3 liters of oxygen. Nursing assessment dated [DATE] at 7:45 p.m. revealed it was performed by the RN. The assessment noted the patient responded to deep pain and was non-verbal. The respirations were shallow and the patient was pale. The documentation revealed Normal Saline at 100 milliliters was infusing via the IV.

RN nursing documentation dated 10/11/12 at 2:30 a.m. revealed the RN request RT at the bedside at 7:45 p.m. Review of the Code Blue form revealed a code was called on 10/10/12 at 8:07 p.m. and the patient expired at 8:27 p.m.

Staff interview and clinical record review revealed that nursing failed to provide nursing care in response of a critical low oxygen saturation level of 65% in a timely manner. There was no evidence of RT responding to the request. The nursing staff failed to ensure the physician ordered IV fluid and Sodium Bicarbonate was initiated on arrival to 3 North in a patient with metabolic acidosis.

Various interviews with the Chief Nursing Officer, Risk Manager, Director of Quality, Director of the ICU/ED and the Nurse Information Technologist from 10/26-10/30/12 confirmed the findings.

A review of the facility's policy, Staff Assignments, policy # ADM 606, reviewed 1/10, revealed under Policy: There will be a sufficient number of qualified Registered Nurses on duty at all times to meet the needs of the patients. Nursing Personnel staffing is sufficient to assure prompt recognition of any untoward change in a patient's condition and to facilitate appropriate interventions. A registered nurse plans, supervises and evaluates the nursing care plan. A registered nurse makes a patient assessment before delegating any aspects of nursing care.

Interviews were conducted on 10/24/12 from 10:30 am to 12:00 pm with the Nursing staff of the Medical/Surgical units. The Medical/Surgical Nursing staff (consisting of both LPN's and RN's) were questioned concerning staffing issues, acuity levels and RN/LPN assessments. The staff responded that some were frustrated with the work load. The RN's are assigned 6 to 7 patients and are assigned to cover a LPN. Which to them in essence is 12 to 14 patients to be assessed during a 12 hour shift. The RN responsibility to the LPN' patients is to do the admission assessment, every 24 hour assessment, any change in condition, push IV medications, etc. The RN's that were interviewed shared they attempt to see everyone of the LPN's patients but with the acuity of the patients most of the time they can't see everyone. When questioned concerning the co-signing of the assessments, both RN and LPN's responded that sometimes they only have time to sign off the assessments. One LPN shared that since she is IV certified she usually just does her own assessments, IV push medications and setting up the PCA pumps.

Show Text of Violation

Based on clinical record review, staff interviews and review of facility documents it was determined the facility failed to develop, implement and maintain an effective, on-going, hospital-wide, data driven quality assessment and performance improvement program for all patients. The continued use of this practice does not ensure the deliverance of safe patient care, the integration of resources to ensure appropriate staff training and the continued monitoring of patient care.

1. The facility failed to analyze adverse patient events and other aspects of performance by the nursing staff related to administration of critical medications, assessments, implementing emergency measures, administering medications as ordered by the physician and nurses working outside their scope of practice. This practice may have caused harm to patients.

(Refer to A0264)

2. Patient #8 presented to the Emergency Department (ED) on 10/5/12 with a chief complaint of chest pains. The patient was admitted to 3 North at 3:52 p.m. An admission assessment was completed by a Licensed Practical Nurse (LPN). At 6:50 p.m. the patient was complaining of chest pain eight out of ten. Physician verbal orders dated 10/5/12 at 6:40 p.m. ordered a Nitroglycerine drip at 0.25 micrograms, Lopressor 50 milligrams (mg) now and to transfer to the ICU. There was no route ordered for the Lopressor.

The LPN documentation at 6:50 p.m. revealed no one in the ICU would take report after three attempts. The patient was wheeled down to ICU and bedside report was given due to the patient's condition not being stable.

The vital signs at 7:10 p.m. were heart rate 153, respiratory rate 28, blood pressure 230/110 and an oxygen saturation of 87% on 2 liters of oxygen. At 7:18 p.m. the vital signs were heart rate 156, blood pressure 212/100 and an oxygen saturation of 88%. The ICU agency nurse initiated a code blue due to the patient being unresponsive and with respiratory distress. Review of the Code Blue record revealed the patient coded at 7:30 p.m. and expired at 7:57 p.m.

Review of ICU agency nurse documentation dated 10/5/12 at 9:00 p.m. revealed the Nitro drip was started at 33 micrograms and increased to 100 micrograms due to chest pain and increased blood pressure. The documentation noted the Lopressor was also given intravenously (IV). There was no actual time the Nitro drip was initiated or the Lopressor given. Review of the physician orders and nursing documentation revealed there was no titration order for the Nitro drip or to initiate the drip at 33 micrograms or give the Lopressor IV.

Confidential staff interviews on 10/26/12 and 10/27/12 revealed the intravenous (IV) pump was set at a rate of 100 milliliter per hour for the Nitro drip. The IV fluid pump was set at 10 milliliters per hour. The interviews revealed the agency nurse may have reversed the setting on the pump. The interviews revealed this is what the staff RN saw when the staff RN walked over to the patient' s bedside to assist when the patient deteriorated.

Staff interview and clinical record review revealed that nursing failed to provide a RN assessment on admission, delayed a transfer to ICU with implementation of critical care medications such as the Nitro drip and Lopressor, did not administered critical medications as ordered by the physician, did not follow ICU policy of checking the dose and pump setting with two ICU staff nurses to ensure accuracy, and did not use the services if the Rapid Response Team on 3 North for a patient that experienced a significant life threatening change in condition.

Interview with the Risk Manager on 10/28/12 at approximately 4:10 p.m. revealed a Root Cause Analysis (RCA) was conducted, the ICU agency nurse was made a Do Not Use and a plan to provide education on RRT and verification of drips was to be done. She stated no other measure were implemented or planned. The Risk Manager would not provide the RCA or action plan or any other documentation since it was a Patient Safety Work Product.

Interview with the Risk Manager on 10/27/12 at approximately 5:00 p.m. revealed she was informed in the morning of the event. The pump was sequester and releases since there was no evidence of malfunction. She stated she interviewed all staff involved and reviewed the chart. The interview did not revel evidence of the possibility of the staff identifying the use of two pumps. She stated the chart indicated no evidence of IV fluids being administered only the Nitro drip. The Risk Manager stated the patient was laughing and talking with family on the way down to the ICU. Review of the clinical record revealed no evidence of this. The LPN documentation revealed the patient was experiencing a pain level of 8 out of 10. She stated the physician felt there this was not an issue. She stated the Director of Quality and the Director of Education were no involved in the RCA or the development of the plan.

There was no evidence of a comprehensive route cause analysis of an adverse event involving the medical/surgical unit and the Intensive Care Unit that may have contributed to a patients's death being integrated with the Quality Department. ( Refer to A0288)

3. Review of a mostly redacted 3rd Floor Observation document, no date, provided by the Risk Manager during the survey revealed that vitals were not being done/documented, assessments not being completed, lack of required documentation for skin assessments and nurses clicking through the system without actually doing the assessment.

The document did not include an action plan. Interview with the Risk Manager on 10/30/12 at approximately 9:40 a.m. revealed no other information regarding the document or development of an action plan would be provided due to Patient Safety Work Product.

The surveyor requested a copy of the Action plan for education from both the Director of Quality and Director of Education on 10/30/12 at approximately 11:45 am.

The surveyors were provided a copy of the Action Plan dated 6/24/12, on 10/30/12 at 3:00 pm. Attached to the Action Plan was the proposed (3) day nursing orientation (no date) and the Areas of focus for Nursing/Education, dated 5/10/12. a review of the Areas of Focus for Nursing/Education, revealed several areas of concerns identified by the Director of Education and the solutions.

Some of the concerns are as follows:

1. 3rd floor ( North & South) and ICU

a. not completing assessments

b. lack of required documentation for skin assessments,turns, rounding, etc.

c. failure to completed forms, i.e. pre-op order sheets

d. Nurses clicking through system, without actually doing the assessment

e. Scanning of medications, cheating by cutting off barcodes

f. Not scanning billable items when in a rush

There was no evidence action had been taken by the facility to develop and implement an action plan to improve and provide safe nursing care. (Refer to A0315)

Based upon the above findings the facility was found to be out of compliance with the Condition of Participation for Quality Assessment Performance Improvement Program.

Show Text of Violation

Based on staff interview and review of the Organizational Performance Improvement and Patient Safety Plan it was determined the facility failed to analyze adverse patient events and other aspects of performance by the nursing staff related to administration of critical medications, assessments, implementing emergency measures, administering medications as ordered by the physician and nurses working outside their scope of practice. This practice may have caused harm to patients.

Findings include:

1. Patient #8 presented to the Emergency Department (ED) on 10/5/12 with a chief complaint of chest pains since the night prior. The history included coronary artery disease with stent placement, diabetes and hypertension. The patient was triaged on 10/5/12 at 12:57 p.m. The vital signs included blood pressure 120/52, heart rate 73. respiratory rate 16, an oxygen saturation of 99% on room air and a pain level of 0 on a scale 0 to 10. Triage documentation noted the patient was alert and oriented. The ED physician examined the patient at 12:50 p.m. The ED physician ' s impression was chest pain with a history of stents and the patient was stable. ED physician orders revealed a heparin lock was placed. A cardiologist consult was ordered. The plan was to admit the patient. The patient was admitted to 3 North at 3:52 p.m.