**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.
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.
Based on record review and staff interview it was determined the facility failed to ensure safety of patients during investigation of an allegation of sexual misconduct made against a member of the facility's personnel. Findings included: A review of the facility's log of sexual abuse/misconduct revealed an allegation of sexual abuse/misconduct was reported in April 2016. A patient in the BHU [behavioral health unit] complained a staff member rubbed up against her and exposed himself to her. A review of the alleged sexual misconduct investigation revealed. The alleged incident happened on 04/20/2016. Review of facility documents revealed the staff member alleged of the sexual misconduct was moved from the BHU to the ARU [Addiction Recovery Unit] while the facility conducted an investigation. The staff member was assigned and continued to work in patient care areas providing direct patient care. Documentation revealed the staff member alleged of the sexual misconduct continued to work in patient care areas and returned to the BHU on 04/23/2016. The patient involved in the alleged incident was not discharged from the BHU until 04/29/2016. Review of an email dated 04/26/2016 from the Vice President of Quality and Patient Safety to the Executive staff stated I received a call this morning they [DCF] are closing the case with no substantiation. Interview with the Vice President of Quality and Patient Safety and the Director of Human Resources on 04/27/2017 at 9:10 a.m. revealed the above findings were confirmed. There was no explanation why the staff member remained in patient care activities while the allegation of sexual misconduct was investigated.
**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.
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.
**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.
**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.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review and staff interviews it was determined the facility failed to keep accurate medical records for three (#4, #6, #14) of thirty sampled records. Findings included: On 04/26/2016 a review of Patient # 4's medical record revealed the patient was discharged on [DATE]. A detailed review showed no evidence of a physician discharge summary. On 04/27/17 a review of Patient #6's surgical record revealed the patient had a surgical procedure performed on 02/17/17. Review of nursing documentation revealed the surgery was performed in operating room [OR] #3. Review of the anesthesia record revealed the surgery was performed in OR #2. On 04/26/2017 a review of patient #14's medical record revealed the patient was discharged on [DATE]. A detailed review showed no evidence of a physician discharge summary. On 04/27/17 at approximately 2:25 p.m. an interview conducted with the Director of Critical Care and the Director of Surgical Services confirmed the above findings.
Based on record review and staff interview it was determined the facility failed to ensure medication orders were reviewed by the pharmacist for appropriateness of the drug, dose, frequency, route and method of administration for one [#11] of thirty records. Findings included: A review of patient #11's physician order revealed an order for Calcium Acetate [Trade name: PhosLo] 1334 mg [milligrams] by mouth three times daily. A review of patient #11's medication profile revealed the medication was reviewed by a pharmacist, however the need to administer the medication with food was not entered. During an interview with the facility's Director of Pharmacy on 04/26/2017 at approximately 1:30 p.m. he confirmed the medication was a phosphate binder that needed to be given with food to be effective.
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.
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.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review, review of policy and procedure and staff interviews it was determined the facility failed to ensure a patient's right to chose a home health agency for post hospitalization care per facility policy was maintained for one (#19) of thirty records reviewed. Findings included: Review of patient #19's record with the Nurse Director of the Behavioral Health Unit (BHU) and the Nurse Manager of the BHU on 4/24/17 and 4/25/17 noted the patient was admitted on [DATE]. Review of the admission assessment and physician progress notes, nursing documentation and case management notes from the date of admission to 4/23/17 did not reveal evidence the patient was receiving home health care prior to admission. Patient interview on 4/24/17 at 2:25 p.m. revealed the patient was going home that day with home health care. The patient stated no choice of a home health agency was provided. The patient stated the physician ordered the prior home health care agency. Review of physician orders dated 4/24/17, no time, indicated to discharge home with home health agency A. Review of case management documentation dated 4/24/17 indicated home health care agency A was contacted for in home assessment. Interview with the Nurse Director of the BHU and Nurse Manager of the BHU on 4/26/17 at 2:26 p.m. revealed no documentation of a choice list for home health agencies being provided to the patient or prior information related to home health agency A could be located. Review of policy and procedure Discharge Planning issued 3/3/17, no number, under policy 2b. indicated the evaluation of the patient's post discharge needs is identified in the first stage of discharge planning. Number 13 indicated a list of home health agencies available to the patient will be presented for a patient's choice.
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.
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
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
Based on observation and staff interview, the facility failed to maintain water closet (bathroom) ventilation as required by NFPA 101 (2012), 19.5.2.1, 9.2.1, 4.5.8, and NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems. Findings included: 1. On 04/24/2017, the first day of survey, observation during the interior tour from 10:00 a.m. to 2:45 p.m. accompanied by the Facilities Manager revealed installed water closet ventilation units failed to operate upon testing by applying a piece of tissue paper to the face of the ventilation return resulting in the tissue falling from the return indicating no suction by the ventilation unit. Examples of the failed units include patient rooms 333, 363, 365, 387 and 219. The facility is required to conduct an inspection of all patient room water closet ventilation units determining the operation and if impaired to correct the deficiency and record the findings for review by the authority having jurisdiction. NFPA 101 (2012), 19.5.2.1, 9.2.1, 4.5.8 NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems
Based on observation, record review and staff interview, the facility failed to maintain electrical safety as required by NFPA 101 (2012), 9.1.2, NFPA 70 (2011SB), Article 517 Health Care, NFPA 99 (2012), 10.5.2.1.2, 10.5.2.1.1, 10.5.8, 10.2.2.1.1, 6.4.4.1, and 6.4.4.1.2.1. 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 in third floor patient rooms, electrical beds. Continuing observation when entering an empty patient room on the third floor and extracting the electric bed power cord from the duplex outlet revealed a three prong receptacle and the three prong power cord. Staff interview of the Facilities Manager, concurrent with tour, when asked whether all patient beds were three prong the response was yes. 2. On 04/25/2017 record review from 11:30 a.m. to 2:45 p.m. revealed no documentation of the testing of electrical beds with three prong power cords as required by NFPA 101 (2012), 9.1.2, NFPA 70 (2011SB), Article 517 Health Care, NFPA 99 (2012), 10.5.2.1.2, 10.5.2.1.1, 10.5.8 and 10.2.2.1.1. Staff interview of the Facilities Manager and assistant acknowledged there was no documentation of the testing of the patient beds. 3. On 04/25/2017 record review from 11:30 a.m. to 2:45 p.m. revealed no documentation of the annual inspection and periodic exercise of the main and feeder circuit breakers of the essential electrical system as required by NFPA 99 (2012) 6.4.4.1, Maintenance and Testing of Essential Electrical System and 6.4.4.1.2.1. Staff interview of the Facilities Manager and assistant confirmed there was no documentation of an annual inspection and periodic exercise of the main and feeder circuit breakers of the essential electrical system. NFPA 101 (2012), 9.1.2 NFPA 70 (2011SB), Article 517 Health Care NFPA 99 (2012), 10.5.2.1.2, 10.5.2.1.1, 10.5.8, 10.2.2.1.1, 6.4.4.1, 6.4.4.1.2.1
Based on record review, policy review, and staff interview it was determined the facility failed to provide an appropriate screening examination that included ancillary services and failed to provide an appropriate transfer to 1 (#21) of 21 sampled patients. Please refer to A2406 and A2409.
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.
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.
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. Refer to findings in tag A-2411.
**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
Based on record review and interview the facility was not in compliance with 42 CFR ?489.24., the facility failed to examine or provide a medical screening exam for one patient (#21) and failed to comply with the regulations for transfer for two (#1 and #21)patients out of 21 patients reviewed. See A2406, A2407 and A2409.
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.
Based on Record Review and Interviews it was determined that a medical screening examination was not performed on 1 out of 21 (#21) patient records reviewed. A medical record for patient # 21 did not exist at this facility as patient # 21 left the Emergency department before the Medical Screening Examination to seek health care elsewhere. Findings Include: Patient #21 arrived by ambulance at 23:17 on 2/23/2014 enroute the Ambulance Crew (R38) made Radio contact with Hospital #1 and let the hospital know the vital information on the pediatric patient they were transporting. The two year old patient had a fever of 101.3 and a (Seal like bark) cough. The Crew of R 38 brought patient #21 into the Emergency Department and were told by the greeting RN to put the patient anywhere so they took patient and mother to a room in the western cubical portion (fast track) of the Emergency Department. After waiting a period of time without being seen the mother became concerned and told the Ambulance crew she felt uncomfortable after the hostile greeting and wanted them to take patient #21 to another hospital. After contacting the Chief the ambulance crew placed patient # 21 back in the ambulance and transported mother and patient #21 to Hospital #2. 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 R38 took the patient to another hospital that this patient was never a patient of Hospital #1. The interview confirmed that patient #21 was not entered on the hospital's log and that no record for patient #21 existed at hospital #1. Patient #21 was not triaged, nor was a Medical Screening Exam done by Hospital #1 to determine if a medical emergency existed.
**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.
Based on Record Review and Interview it was determined that the facility did not make appropriate transfer arrangements for two, (#1 and #21) of 21 records reviewed during this investigation. Findings Include: Patient #21 was in the Emergency Department of Hospital 1 on February 23, 2014 when the mother asked the ambulance crew, who brought the infant patient to the facility, to take them to another hospital. The Ambulance Crew agreed to do so and left the emergency department with the patient enroute to another facility. The risks benefits of this transfer were never explained to the mother. The facility did not make arrangements with another facility to care for the patient. 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 patient #21 and that no record other than her internal investigation existed of this encounter. Patient #1's record contained form called EMTALA/COBRA/Memorandum of Transfer dated 1/26/2014. This form was used by Hospital 1 to record the Risks and Benefits of a transfer to the patient from their facility to another. The form for Patient #1 was checked that the patient was stable and the reason for the transfer was to a Higher level of Care. Risks were only listed as MVA. The benefits portion of the form was blank. Patient #1 was transferred to hospital #3 for definitive medical care on . An interview with the VP of Quality/Risk management on 3/06/2014 at approximately 13:30 revealed that she had reviewed this form and was unsure why the patient was transferred. She agreed that because of this lack of understanding, that she did not know the benefits, to the patient, for the transfer.
**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.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on medical record review, staff interview, and review of policy and procedure it was determined the facility failed to ensure the nursing staff kept current the nursing care plan and reviewed it daily for one (#2) of ten patients sampled. Findings include: Review of the medical record for patient #2 revealed the patient was admitted to the facility on [DATE] with a diagnosis of Pulmonary Embolus. Review of the patient's interdisciplinary plan of care revealed nursing identified knowledge deficit, discharge planning, safety, and pain as the focus areas. Review of the plan of care revealed no evidence nursing identified airway management/gas exchange as a focus area. The patient's admitting diagnosis was pulmonary embolus and documentation revealed the patient had abnormal breath sounds, complained of a cough, and chest discomfort. Review of the medical record revealed a pulmonologist evaluated the patient on 9/19/2013 and documented the patient had symptoms of gastroesophageal reflux disease, chronic obstructive pulmonary disease, and was a heavy smoker. Review of the patient's plan of care on 9/19/2013 and 9/20/2013 revealed no further documentation. Review of the facility policy, Assessment and Reassessment, last approved 11/2012, states the patient plan of care will be reviewed at least daily by an RN. Interview with the Clinical Educator and Chief Nursing Officer on 11/26/2013 at 2:30 p.m., confirmed the findings.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on medical record review and staff interview it was determined the facility failed to ensure nursing staff administered medication according to physician orders for one (#2) of ten patients sampled. Findings include: Review of the medical record for patient #2 revealed the patient was admitted on [DATE]. Review of the physician orders revealed on 9/19/2013 at 8:24 am an order for Solumedrol 30 mg (milligrams) IV (Intravenous) every 12 hours. Review of the MAR (Medication Administration Record) revealed the first dose of Solumedrol was administered on 9/19/2013 at 11:33 pm, approximately 15 hours after the physician order was written. Review of the record revealed no evidence or documentation to explain the delay in providing the medication. Interview with the Clinical Educator on 11/26/2013 at approximately 11:15 am confirmed the findings.
Based on clinical record review, policy review and staff interview it was determined the facility failed to comply with the requirement to conduct a Medical Screening Examination and a delay in examination and treatment for 1 (#1) of 20 records reviewed. 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. The patient was very insistent on being seen, banging on the registrar's window and the triage nurse's door. The triage nurse called the police department. The patient left when the police arrived. 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, approximately fifteen minutes after arrival and prior to triage
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.
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.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on medical record review and staff interview it was determined the facility failed to ensure that care and treatment decisions were based on the patient's or patient's representative's informed consent for one (#2) of 30 patients sampled. This practice does not ensure patients or their representative rights for informed consent are maintained. Findings include: Patient #2 was admitted to the facility on [DATE]. A review of the medical record revealed a telephone consent for surgery was obtained from a family member and witnessed by two nurses on 1/13/2013 at 05:25 a.m. The consent authorized the surgeon and/or chosen associates and assistants to perform the following operation(s) and /or procedure(s), which was left blank. Interview with the nurse manager in a telephone call to the primary nurse revealed the nurse stated The surgeon was not sure exactly what procedures he would be doing so I left it blank. Interview and record reviews with the primary nurse, the nurse manager and the corporate director of clinical operations on 1/15/13 at 10:00 a.m. confirmed the findings.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, record review and interview the facility failed to ensure that nutritional needs were met for allergies for one of three (#14) active sampled patients with food allergies. This practice does not ensure patient safety. Findings include: Review of the facility's Diet Worksheet dated 01/15/13 revealed patient #14 had an order for a regular diet with listed food allergies that included tomatoes, oatmeal, corn, lemon, oranges, pecans, beans and peas. Observation on 01/15/13 at 12:10 p.m. with the Food and Nutrition Services Director of patient #14's lunch tray, which had been delivered on the food cart, revealed the lunch tray contained tomato soup, small tomatoes on the lettuce salad and green beans. Interview with the Director at this time related this was not appropriate and took the tray back to the food service department. Record review revealed patient #14 had been admitted on [DATE] on a regular diet. Review of the nursing notes dated 01/14/13 revealed the patient was stating she had food allergies. Nursing requested the patient make a list of the food allergies. Nursing inputted into the computer the list of food allergies. Observation of the food tray slip for the patient's lunch tray on 01/15/13 at 12:10 p.m. stated the list of food allergies. The facility did not ensure that nutritional needs were met for food allergies for patient #14.
**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.
**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.
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.
Based on staff interview and review of Organizational Performance Improvement and Patient Safety Plan it was determined the facility failed to develop a Quality Assessment Performance Improvement (QAPI) plan to improve patient outcomes. This practice does not ensure areas of improvement are identified and an action plan is developed and evaluated to promote patient safety and ensure goals are met. Findings include: Review of the Organizational Performance Improvement and Patient Safety Plan approved on 4/24/12 provided by the Risk Manager during the survey revealed no evidence that 1. The program included measurable improvement in indicators for which there was evidence that it will improve health outcomes. 2. Identify and reduce medical errors in high volume problem prone areas. 3. The number and scope of distinct QAPI projects conducted annually must reflects the scope and complexity of the services provided. The plan did not contain evidence of specific project or including such specialty areas as the Behavioral Health Unit or the Addiction Recovery Unit. Various interviews with the Risk Manager from 10/27-30/12 revealed the facility would not provide meeting minutes, the committee, list of what was discussed, QAPI project (other than routine project such as medication errors, fall, pressure sores, infection) or list of attendees at the meeting due to Patient Safety Work Product.
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. 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' s 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 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. 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 released since there was no evidence of malfunction. She stated she interviewed all staff involved and reviewed the chart. The interview did not reveal 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 this was not an issue. She stated the Director of Quality and the Director of Education were not involved in the RCA or the development of the plan. Interview with the attending physician (who was the Chief of Staff) for patient #8 on 10/30/12 at approximately 9:15 a.m. revealed he did a partial review of the medical record. He stated he was interviewed but not part of the whole RCA process. He indicated it is not known if the nitro drip and Lporessor were a contributing factor or not but could have been. 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. 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.
Based on staff interview and review of documentation provided by the facility administration it was determined the facility failed to ensure resources were provided to measure, assess, improve, and sustain quality of care on the medical surgical units. This practices may have caused potential harm to patient. Findings include: 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. A review of emails presented to the surveyors by the Chief Nursing Officer (CNO) revealed communication with the ex-Medical/Surgical Nurse Manager was aware of medication and assessment issues by nursing on the unit as early as 7/3/12. The CNO had requested a action plan from the nurse manager and determine what the issues were. During an interview conducted on 10/29/12 at 1:50 pm the CNO shared that after trying to work with the Nurse Manager concerning the issues for approximately (8) weeks, the Nurse Manger was finally terminated. An confidential interview was conducted on 10/30/12 at 11:12 am with the Director of Education. The Director was questioned on what his role is in RCA and training/inservicing nursing staff. He responded that unfortunately he is not involved in the RCA of incidents. But that he is involved in the nursing orientation and unit specific training. He is not involved in the orientation for Agency Nurses. Usually the Management of a particular unit will request the inservices. The Director stated he was hired in April 2012 and presented a action plan in May 2012 to the administration for review. 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 was 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.
Based on record review, policy review and staff interview, it was determined the nursing staff : 1. failed to appropriately conduct a skin assessment of a patient for (5) days, failed to implement immediate interventions, failed to consult the wound care nurse for (2) days following the discovery of the wounds and/or upon admission of a patient with known skin breakdown (7 days after admission), causing a delay in treatment and the possibly causing further skin damage and deterioration in the patients health. (Refer to A-395) 2. failed to document the RN initiating and verifying the PCA or assessing the patient's status prior to initiation. ( Refer to A-395 and A-405) 3. failed to appropriately monitor Intravenous sites, failed to provide a sanitary equipment to facilitate wound healing, and failed provide assessments/reassessments of the patient by an RN or provide RN supervision of patient care for several days. This has a potential for an increase in infection both from the patient's feet and IV site which could lead to deterioration of the patient's health and well- being. (Refer to A-395) 4. failed to provide of a RN assessment on admission, delayed a transfer to the Intensive Care Unit (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 (RRT) on 3 North for a patient that experienced a significant life threatening change in condition. (Refer to A-395) 5. failed to reassess; monitor or intervene for a patient who was at a critical low blood sugar of 50. There was no documentation of a RN assessment/co-signature for the LPN assessment. (Refer to A-395) 6. 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. (Refer to A-395) 7. failed to document any assessment/co-signature or interaction from the RN prior to the patient going to ICU. ( Refer to A-395) 8. 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 Respiratory Therapy (RT) responding to the request for RT. 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. (Refer to A-395) 9. The facility failed to provide adequate supervision and evaluation of 1 (#A) of one non employee licensed registered nurse. This practice does not provide for the safe delivery of nursing care and services that may have caused harm to a patient. Nurse #A failed to administer critical medications as ordered by the physician and did not follow ICU policy of checking the dose and pump setting with two ICU staff nurses to ensure accuracy. (Refer to A-395; A-398 and A-405). The cumulative effect of the failure of the Nursing Staff to appropriately assess and evaluate the needs of the patient, failure to follow physician orders, notify the registered nurse and physician of changes in condition, failure to administer medications as ordered, failure to initiate the Rapid Response Team and delays in patient treatments have resulted in the determination the facility is out of compliance with the Condition of Participation for Nursing Services.
**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 ensure enough staff was available for 2 of 2 Medical/Surgical units in the facility and to ensure the immediate availability of a registered nurse for bedside care for 8 (#1,#5, #6, #7, #8,#9, #10 & #11) of 13 sampled patients. 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 7A-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 130s. 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.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interviews and policy, procedure and clinical record reviews it was determined the Registered Nurse failed to supervise and evaluate nursing care to patients experiencing a significant change in condition requiring immediate critical nursing invention, skin care needs,assessments and adhering to policies and procedures for 8 (#1,#5, #6, #7, #8,#9, #10 & #11) of 13 sampled records. This practice may cause a prolonged hospital stay and does not ensure patient goals are met. This practice may have caused potential harm, including death, to patients. 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 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. After review of the clinical record, policy review and interviews it was determined that nursing failed to appropriately conduct a skin assessment of the patient for (5) days, failed to implement immediate interventions, failed to consult the wound care nurse for (2) days following the discovery of the wounds and/or upon admission of a patient with known skin breakdown (7 days after admission), causing a delay in treatment and the possibly causing further skin damage and deterioration in the patients health. 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 patient ' s 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) was 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 patient ' s 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. The facility staff failed to appropriately monitor Intravenous sites, failed to provide a sanitary equipment to facilitate wound healing, and failed provide assessments/reassessments of the patient by an RN or provide RN supervision of patient care for several days. This has a potential for an increase in infection both from the patient ' s feet and IV site which could lead to deterioration of the patient ' s health and well- being. 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 7A-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 130s. 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. Patient #7 was admitted status post CVA on 10/15/12 to 3N with a physicians order for telemetry. 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 130s. The monitor technician documented at 1:53 a.m. the nurse was notified of cardiac rhythm changes and a code blue was called. Review of the policy and procedure Monitoring of Telemetry Patients, # PC359 reviewed 5/13/12 revealed if the monitor technician noted an abnormal rhythm, the technician would obtain a rhythm strip. Under section Procedure #7 indicated the Monitor technician will document a rhythm strip every four hours and place on the telemetry form. Review of the clinical record with the Risk Manager, Director of Quality and the Nurse Information Technologist on 10/26/12 and 10/27/12 revealed no evidence of rhythm strips in the record. 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' s 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. It was determined that nursing did not reassess; monitor or intervene for a patient who was at a critical low blood sugar of 50. There was no documentation of a RN assessment/co-signature for the LPN assessment. 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. 6. 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.
Based on clinical record review, policy review and staff interview it was determined the facility failed to keep one (#6) of 13 patients reviewed plan of care current for skin integrity. Findings include: Patient # 6 was admitted to the Medical/Surgical Unit on 10/14/12 for wound care to both lower extremities. The patients history included coronary artery disease and dementia. A review of the Interdisplinary Plan of Care revealed the skin integrity focus was initiated on 10/15/12. The intervention is to monitor skin integrity and the desired outcomes was for the skin to remain intact. Further review of the Plan of Care; daily evaluation sections was not initialed from 10/21/12 to 10/27/12. The Director of Quality confirmed the findings on 10/27/12 at approximately 4:00 pm. A review of the facility policy, Assessment and Reassessment, policy # 200, approved 1/31/12, page 3, paragraph 7b, revealed all current problems are reviewed with the patient/family and are addressed at least daily in the patients medical record.
Based on interviews and review of policy, procedures, orientation forms and clinical records it was determined the facility did not ensure non employee licensed nurses adhered to Intensive Care Unit polices and procedure, were oriented to the unit and care provided was evaluated. The facility failed to provide adequate supervision and evaluation of 1 (#A) of one non employee licensed registered nurse. This practice does not provide for the safe delivery of nursing care and services that may have caused harm to a patient. Findings include: 1. Patient #8 presented to the Emergency Department (ED) on 10/5/12 with a chief complaint of chest pains. The history included coronary artery disease with stent placement and hypertension. ED physician orders revealed a heparin lock was placed. The patient was admitted to 3 North at 3:52 p.m. Licensed Practical Nurse (LPN) documentation at 6:40 p.m. revealed the patient complained of chest pain of 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. 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 (#A). 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 (#A)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' s 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. Staff interview and clinical record review revealed nurse #A failed to administered critical medications as ordered by the physician and did not follow ICU policy of checking the dose and pump setting with two ICU staff nurses to ensure accuracy. Review of the information file for agency ICU nurse #A revealed a copy of a current RN license, Cardiopulmonary Resuscitation and Advanced Cardiac Life Support certification. There was no evidence of a unit orientation, unit competency skills, or any evaluation of care provided. Interview with the Risk Manager on 10/30/12 at approximately 9:40 a.m. revealed the facility did not have a copy #A's orientation and could only provide a blank form since it was a Patient Safety Work Produce. She stated the facility did not have a competency form that the staffing agency maintained that information. She indicated the staffing agency does the nurses evaluation and nurse #A was last evaluated on 7/2/11. The risk manager presented a blank form Agency Nurse (RN/LPN) orientation Checklist. The form indicated the agency nurse had received two hours of orientation to the unit but had 12 hours to complete the checklist. The form noted all skills must have a return demonstration. The skills included demonstration and safety use of the IV pumps and different types of code procedures. The forms contains an area for unit specific competency to be listed. Review of policy and procedure Agency Staff HR Management, no number, reviewed 3/08 indicated the agency nurse was to report to the nursing office two hours prior to working for the first time at the hospital for orientation. The agency nurse would complete the Nursing Orientation Review Test The policy stated the agency nurse and the chare nurse/designee would sign off on the Department Orientation Form. The policy indicated at the end of the first shift a performance evaluation would be completed by the supervisor or charge nurse. Interview with the Risk Manager on 10/30/12 at approximately 9:40 a.m. revealed orientation and evaluation documentation would not be provided due to Patient Safety Work Product.
Based on staff interview and clinical record reviews it was determined the nursing staff failed to administered medications as ordered by the physician for 4 (#7, #8, #11, #13) of 13 sampled records. This practice does not ensure effective medication therapy, may prolong a hospital stay and may cause harm to patients. Findings include: 1. Patient #8 was admitted to the 3 North nursing unit for chest pain on 10/5/12 at 5:28 p.m. Licensed Practical Nurse ( LPN) documentation on 10/5/12 at 6:40 p.m. revealed the patient complained of chest pain of eight out of ten on a 0 to 10 scale. Physician verbal orders dated 10/5/12 at 6:40 p.m. ordered a Nitroglycerine (Nitro) drip at 0.25 micrograms, Lopressor 50 milligrams (mg) now and to transfer to the Intensive Care Unit (ICU). There was no route ordered for the Lopressor. There was no evidence of the nurse clarifying the route for the Lopressor. 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. The documentation noted the Lopressor was also given intravenously (IV). There was no documentation of the time the Nitro drip was initiated or the Lopressor given. Review of the physician orders revealed no evidence of a 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 patient had intravenous (IV) fluids set at a rate of at 10 milliliters per hour. There was no physician order for the IV fluids. 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. 2. Patient #7's physician order dated 10/20/12 instructed for Solumedrol 60 milligrams (mg) intravenously every 12 hours. Review of the Medication Administration Record (MAR) revealed on 10/21/12 the patient received one dose at 10:04 a.m. Interviews with the Risk Manager and Director of Quality on 10/26/12 at approximately 3:45 p.m., during the record review, confirmed the findings. 3. Patient #11's blood study results noted a critical CO2 (carbon dioxide) level of 8 (22-32). 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. Nursing documentation at 7:33 p.m. revealed the patient had arrived to the 3 North nursing unit. Nursing documentation dated 10/10/12 at 7:45 p.m. revealed Normal Saline at 100 milliliters was infusing via the IV. There was no evidence of the IV fluids being administered as ordered. Various interviews with the Chief Nursing Officer, Risk Manager, Director of Quality, Director of the ICU/ED and the Nurse Information Technologist from 10/27-10/30/12 confirmed the findings. 4. Patient #13's physician orders dated 10/22/12 at 12:01 a.m. ordered Clondine 0.1 mg three times a day. Review of the MAR revealed on 10/23/12 at 5:55 a.m., 10/24/12 at 5:12 a.m. and 10/25/12 at 5:45 a.m. the medication was held due to clinician decision. Review of the MAR and nursing documentation revealed no evidence as to why the clinician made the decision to hold the medication or that the physician was notified. Interview with the Risk Manager, Director of Quality and the Nurse Information Technologist on 10/30/12 at approximately 2:23 p.m. confirmed the findings.
Based on reviews of clinical records, policies and procedures, Medical Staff Rules and Regulations, Patient Transfer Sheet, on-call schedules, and staff interviews it was determined the facility failed to accept a transfer for an individual presenting to the emergency department with an Emergency Medical Condition that was within the facility's capability for the specialized services of a hand surgeon for one (#21 ) of twenty one records reviewed. Refer to findings in Tag A-2411.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on reviews of clinical records, policy and procedure, Medical Staff Rules and Regulations, Patient Transfer Sheet, on-call schedules, and staff interviews it was determined the facility failed to accept a transfer for an individual presenting to the emergency department with an Emergency Medical Condition that was within the facility's capability for the specialized services of a hand surgeon for one (#21 ) of twenty one records reviewed. Findings include: Review of the Emergency Department (ED) record for patient (#21) from the transferring facility revealed the patient presented to ED on 6/10/12. The patient was evaluated by the ED physician on 6/10/12 at 1:54 a.m. The ED physician documented the patient presented with right finger pain and bleeding for one day. The type of injury was listed as laceration from a piece of glass. The ED physician noted it was attempted to control the bleeding with a tourniquet and stitch but it was unsuccessful. The physician could not close the wound to help tamponage (is useful method of stopping hemorrhage) the bleeding since the injury was greater than 24 hours old. The ED physician documented the patient needed more definitive bleeding control then just a tamponage dressing. The ED physician's impression and plan was acute right 2nd digit laceration, greater than 24 hours old, acute arterial laceration to right second digit. . . The disposition was for transfer to another facility for hand surgeon services. Review of the transferring facility's ED physician notes dated 6/10/12 at 5:14 a.m. revealed the physician had discussed the case with the hand surgeon on call at the intended receiving facility. The documentation noted the intended receiving physician did not believe it was an emergency issue. The ED physician explained to him the issue was controlling the bleeding, it had been tamponed with a bandage but would require more definitive care. Review of the transferring facility's Patient Transfer Sheet for patient #21 dated 6/10/12 revealed the intended receiving facility was called at 4:31 a.m. A physician's name, phone number and comment refused was documented in outcome box. A review of the intended receiving facility's ED on call schedule for June 2012 revealed the facility did have that hand surgeon available on 6/10/12. The facility failed to accept an individual from a transferring hospital who required the specialized services of the hand surgeon on -call that was within the capability and capacity of the hospital to treat patient #21 on 6/10/2012. Review of the Medical Staff Rules and Regulations, 2011, reviewed and approved 5/2011, page 8 of 19, paragraph 3, revealed if a practitioner takes call for another practitioner he or she is obligated to see all patients needing medical or surgical attention in Emergency Services, without regard to financial reimbursement or lack of membership in any health plan. A review of the facility's policy, EMTALA- Duty to Accept, policy #RM1216, approval date 4/2/12, revealed a hospital with specialized capabilities or facilities shall accept an appropriate transfer of an individual with an emergency medical condition who requires specialized capabilities or facilities if the facility has the capacity to treat the individual. A review of page 2, paragraph 4, revealed only the emergency physician and the Hospital Chief executive officer (CEO) or his or her designee have the right to accept or refuse to accept the transfer of a patient on behalf of the hospital. An interview with the ED Medical Director was conducted on 6/21/12 at 10:10 a.m. The physician stated if a facility calls to transfer the patient the secretary notifies the Charge Nurse or the ED physician. The patient is first seen by the ED physician, who determines if the on-call physician needs to see the patient. A telephone interview was conducted on 6/21/12 at 4:40 p.m. with the Unit Secretary (US) that answered the phone call from the transferring facility on 6/10/12. The US was questioned if she recalled the conversation she had with the transferring facility. She stated yes. She stated the facility voiced they had a patient who needed a hand surgeon and did they have one on-call. She told them yes and proceeded to give them the on call hand surgeon's name and phone number. She instructed the facility to call the physician directly. A telephone interview was conducted on 6/21/12 at 5:00 p.m. with the hand surgeon that was on-call 6/10/12. The physician stated he did recall the transferring facility calling him. The case was discussed. The physician stated he told the ED physician he did not feel this was an emergency and instructed him to put a pressure dressing on it and send the patient to his office. A review of the patient #21's ED record from the receiving facility dated 6/10/12 revealed the patient presented to the ED at 6:47 a.m. per ambulance transfer. The chief complaint was transferred from receiving facility with pulsating arterial bleed to the right index finger, lateral artery to proximal, involving joint capsule, cut on glass 36 hours ago. The ED physician's impression was the finger has some swelling development; concern for [DIAGNOSES REDACTED] (that leads to a disrupted function of it), will start antibiotics to cover for staph aureous(Staphylococcus aureus is a bacteria frequently part of the skin flora found in the nose and on the skin). The patient was seen by the hand surgeon at 9:05 a.m. The patient was admitted on [DATE] at 11:14 a.m., for definitive care. Interview with the Chief Nursing Officer on 6/21/12 at approximately 3:00 p.m. revealed the facility did not have a protocol, policy, or procedure for how to accept a patient in transfer. The facility failed to follow its policy and procedure for declining the acceptance of a transfer by not involving the ED physician or CEO or the designee.
Based on record and policy review it was determined the facility failed to ensure that appropriate physician orders are obtained and authenticated for the use of patient restraints for one (#3) of 12 records reviewed. This practice does not ensure safe use of restraints. Findings include: Patient #3's physician orders, reviewed on 4/5/12 at approximately 11:10 a.m., revealed a telephone order for soft wrist restraints to be applied on 3/30/12 was written by the Registered Nurse (RN). The order was not timed. The physician giving the order had not yet authenticated it at the time of the review. A second telephone order for soft wrist restraints was taken by the RN on 3/31/12 and again had not been authenticated by the physician. This order was also not timed. Review of the facility's policy Restraint and Seclusion, #PC 336, revised 12/10 required that telephone orders for restraints be authenticated within 24 hours. It further required that if restraints are to be continued after 24 hours, the physician must assessment the patient and write the order for continuation. Telephone orders are not acceptable for restraint continuation.
Based on record review, policy review and staff interview it was determine the facility failed to ensure verbal orders were authenticated per facility policy for 2 (#3 and #12) of 12 sampled patients. This practice does not ensure safe delivery of medical care. Findings include: The facility's policy Physician Orders-Use Of # 1103, required that telephone orders be authenticated within 24 hours. 1. Review patient #3's medical record on 4/5/12 at approximately 11:10 a.m. revealed a telephone order taken by a Registered Nurse on 3/29/12 at 4:43 p.m. for Procardia XL. Another telephone order for bed rest, Lexis stress test and nothing by mouth after midnight was taken by the nurse on 4/2/12. The orders had not been authenticated by the physician. The Director of Quality who was present during the review confirmed the findings. 2. Patient #12's medical record revealed a telephone physician order was taken by the nurse on 2/27/12 at 3:20 p.m. and 5:45 p.m. The orders were not authenticated until 3/14/11. The discharge order was taken as a telephone order on 3/1/12 at 1:25 p.m. The order was not authenticated by the physician until 3/14/12. An order sheet entitled Admission Orders Gastrointestinal Bleed was documented as a telephone order with no date or time and was not authenticated until 3/11/12. The medication reconciliation admission form that indicated which medications were to be continued in the hospital was documented as a telephone order with no time indicated and was not authenticated until 3/14/12. The Nursing Director who was present during the record review on 4/5/12 at approximately 12:45 confirmed the findings.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record and policy review it was determined the facility failed to ensure an appropriate History and Physical was in place prior to an endoscopic procedure for 1 (#11) of 12 patients. This practice does not ensure up to date patient information is available. Findings include: Patient #11 was admitted to the facility on [DATE] for an outpatient endoscopic procedure. Review of the medical record revealed a History and Physical that had been dictated in the physician's office. There was no documentation of the date the examination was performed. Review of the facility's policy a History and Physical Documentation in the Medical Record # 224, reviewed 12/11 required that the History and Physical be no more than 30 days before admission. There was no way to determine how old the History and Physical was.
**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 a registered nurse assessed and reassessed patients for pain and changes in condition for two (#5, #6) of eight patients sampled. The Registered Nurse failed to follow the physician ordered plan of care for two (#5, #7) of eight patients sampled. This practice does not ensure patient goals are maintained and may lead to a prolonged hospital stay. Findings include: 1. Review of the medical record for patient #5 revealed the patient was admitted to the facility on [DATE] with a diagnosis of [DIAGNOSES REDACTED]. Review of nursing documentation revealed the patient was on room air at 12:00 p.m., 4:30 p.m. and 7:45 p.m. Review of physician order on 3/10/2012 at 10:00 p.m. revealed an order that stated to keep the patient on oxygen at 2 liters, humidified, via nasal cannula. Nursing documentation at on 3/10/12 at 10:00 p.m. revealed the oxygen was applied. Review of nursing documentation on 3/11/2012 at 8:00 a.m. revealed the patient was on room air and remained on room air until 7:30 p.m. on 3/11/2012. At that time the patient was noted to be on oxygen at 2 liters via nasal cannula. On 3/11/2012 at 11:30 p.m. nursing documentation revealed the patient had oxygen at 0.5 liters via nasal cannula. On 3/12/2012 at 8:00 a.m. documentation revealed the patient had oxygen at 2 liters via nasal cannula. Interview with the CNO (Chief Nursing Officer) on 3/12/2012 at 12:10 p.m. confirmed the oxygen was not administered as ordered by the physician. 2. Patient #5's physician's orders dated 3/10/2012 at 3:00 p.m. revealed an order for Dilaudid 2 mg (milligrams) IV (Intravenous) every 3 hours as needed for pain. Review of the MAR (Medication Administration Record) dated 3/10/2012 revealed Dilaudid 2 mg was given at 3:50 p.m. Review of the nursing documentation revealed on 3/10/2012 there was no pain assessment or reassessment of the patient's pain level before and after the pain medication. Review of the MAR (Medication Administration Record) revealed the patient was administered Dilaudid 2 mg IV on 3/11/2012 at 9:53 a.m., 4:36 p.m., and on 3/12/2012 at 12:08 a.m. Review of the nursing documentation on 3/11/2012 and 3/12/2012 revealed no pain assessment or reassessment of the patient's pain level. Review of the facility's policy, Pain Management, effective 1/2001, stated the patient's intensity of pain is scored from 0 to 10 on a pain score tool. Re-evaluation occurs within 1/2 to 1 hour following intervention, with documentation of the time; pain score, level of sedation, descriptors and non-verbal signs. Interview with the CNO on 3/12/2012 at 12:10 p.m. confirmed the findings. 3. Review of the medical record for patient #7 revealed the patient was admitted to the facility on [DATE]. Review of the physician orders dated 3/10/2012 at 3:15 a.m. revealed an order for SCD (Sequential Compression Device) while in bed. Review of the medical record and nursing documentation revealed no indication the SCDs had been initiated and applied as ordered. Observation of the patient in his room on 3/12/2012 at 2:10 p.m. revealed the patient lying in bed. The SCDs were sitting on a chair located in the patient's room. On 3/12/2012 at 2:15 p.m. the nurse in charge of the patient was interviewed. The nurse stated the night shift nurse reported the patient was confused and would not leave the SCDs on. When questioned the nurse stated she did not attempt to place the SCDs on the patient. At 2:25 p.m. the charge nurse stated she placed the SCDs on the patient. An interview with the CNO on 3/12/2012 at 2:10 p.m. confirmed the above findings. 4. Patient #6's physician's H&P (History & Physical) revealed the patient had a history of alcoholism and alcoholic liver disease. Review of the physician orders on 3/09/2012 at 9:00 a.m. revealed an order for Ativan Withdrawal Protocol. Review of the protocol stated to evaluate the patient using the CIWA (Clinical Institute Withdrawal Assessment) upon admission. If CIWA was less than 8, reassessment should be done every 4 hours. If the score remains less than 8 for 24 hours, then the patient can be assessed per unit routine. Review of the nursing assessments for 3/09/2012 and 3/10/2012 revealed no evidence the CIWA assessment was completed as required by the facility's protocol and physician order. Interview with the CNO on 3/12/2012 at 2:45 p.m. confirmed the findings.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on medical record review and staff interview it was determined the facility failed to ensure the nursing staff kept current the nursing care plan for one (#4) of eight patients sampled. This does not ensure the appropriate nursing interventions are provided based on the patients needs. Findings include: Review of the medical record for patient #4 revealed the patient was admitted to the facility on [DATE] for altered mental status and alcoholic liver disease. The patient's plan of care was initiated on 3/10/2012. Review of the plan of care revealed the plan of care was not reviewed by the nursing staff on 3/11/2012. The plan of care was not reviewed or revised on 3/11/2012 in order to respond to the changes in the patient's health status and movement toward the achievement of the patient's health care goals. Interview on 3/12/2012 at 11:15 a.m. with the CNO confirmed the patient's plan of care should be reviewed daily and revised as indicated by the nursing assessments and the patient's response to interventions. The CNO confirmed the above findings.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on medical record review, staff interview and review of policy and procedures it was determined the facility failed to ensure medications were administered according to physician orders for two (#4, #8) of eight patients sampled. This practice does not provide for safe and effective medication therapy. Findings include: 1. Review of the medical record for patient #4 revealed the patient was admitted to the facility on [DATE] for altered mental status and alcoholic liver disease. Review of the physician orders revealed an order on 3/10/2012 for Ativan Withdrawal Protocol. Review of the protocol stated to evaluate the patient using the CIWA (Clinical Institute Withdrawal Assessment) upon admission. If CIWA was less than 8, reassessment should be done every 4 hours. If the score was less than 8, no medication was to be administered. Review of the MAR (Medication Administration Record) revealed on 3/11/2012 at 8:54 p.m. the patient received Ativan 2 mg (milligrams) by mouth. Review of the patient's CIWA assessment on 3/11/2012 at 8:00 p.m. revealed a score of 1. Based on the facility's protocol the patient did not meet the criteria for administration of the Ativan. The protocol stated Ativan 2 mg for CIWA score of 8 to 15 and reassess in 2 hours. The patient's CIWA score on 3/11/2012 at 10:00 p.m. was 1 as documented by nursing. Nursing failed to follow the medication administration protocol as ordered by the physician. An interview with the Chief Nursing Officer (CNO) on 3/12/2012 at 11:15 a.m. confirmed the above findings. 2. Review of the medical record for patient #8 revealed the patient was admitted to the facility on [DATE] for orthopedic surgery. Review of the physician orders on 3/06/2012 at 2:20 p.m. revealed an order for accuchecks AC/HS (before meals and at the hour of sleep) with low dose insulin sliding scale protocol. Review of the accucheck results and MAR revealed on 3/06/12 at 8:44 p.m. the patient's accucheck result was 270 mg/dL, She was administered 4 units of insulin. Review of the low dose insulin sliding scale protocol revealed the patient should have received 6 units of insulin. On 3/07/12 at 7:14 a.m. the patient's accucheck result was 213 mg/dL. She was administered 2 units of insulin. Review of the low dose insulin sliding scale protocol revealed the patient should have received 4 units of insulin. On 3/07 at 11:58 a.m. the patient's accucheck result was 232 mg/dL. She was not administer any insulin. Review of the low dose insulin sliding scale protocol revealed the patient should have received 4 units of insulin. Documentation on the MAR stated to see nursing notes. Review of the nursing notes revealed no indication why the insulin was not administered as required by the physician ordered protocol. On 3/07 at 4:49 a.m. the patient's accucheck result was 223 mg/dL. The patient was administered 2 units of insulin. Review of the low dose insulin sliding scale protocol revealed the patient should have received 4 units of insulin. An interview with the CNO on 3/12/2012 at 3:45 p.m. confirmed the above findings.
Based on observation, staff interview, and record review, the infection control officer failed to identify, report, and investigate infection control activity to ensure a sanitary kitchen environment and proper food handling practices to prevent potential foodborne illness. Findings Include: 1. The hospital's dishwashing machine was not working properly to ensure dishes were properly washed and sanitized. During a tour of the kitchen on 06/09/11 at 9:55 a.m., the dishwasher was in use. The dishwasher was equipped with 3 temperatures gauges for the wash, rinse and final rinse temperatures. During the dishwashing cycle, the wash temperature was 138 ?F, the rinse temperature was 144 ?F, and the final rinse was 192 ?F. The data plate on the dishwasher indicated that the minimum wash, rinse and final rinse temperatures were 140 ?F, 164 ?F, and 180 ?F, respectively. The dishwasher was run again and the temperatures for the wash, rinse and final rinse were 142 ?F, 150 ?F, and 182 ?F. The water flow pressure gauge was 2 PSI, rather than a minimum of 20 PSI, according to the machine specifications. The food service director was informed of this at the time and stated that he was not aware that the machine water flow pressure was regulated. He used heat sensitive labels or paper thermometers to check the sanitizing temperature and the labels did not change color for 160 ?F. Then he used a maximum registering thermometer which he ran through the dishwasher twice and this measured the maximum temperature at 158 ?F and 160 ?F. Several plates that were being washed in the dishwasher were observed to have food particles on the food contact surface after being washed. The dishwasher temperature log was reviewed for the month of June 2011. The log had only the final rinse temperatures recorded three times daily, which were all 180 ?F . There was no monitoring of the wash temperature for the dishwasher. The food service director stated he would call the service technician to check the machine. He was asked what actions should be taken when the dish machine was not working properly. He directed the employee operating the dishwasher to use disposables. At 11:25 a.m. on 06/08/11 the service technician informed the food service director and the surveyor that the water flow pressure gauge was broken and the spray jets were clogged. He stated that he needed to get a part to fix the dishwasher. 2. Food service equipment was not properly cleaned. During a tour of the kitchen on 06/08/11 at 9:45 a.m., there were multiple metal sheet pans throughout the kitchen that were encrusted with food residue and/or had excessive carbon/grease build-up. In the overnight reach-in refrigerator unit, there several cans of sodas, cartons of soy milk and a container with individual margarine packets stored on a metal sheet pan with encrusted food residue. The exterior of the bulk flour and sugar bins had food spillage and residue. A large inverted clear plastic rectangular food container, which was clean and stored on a shelf with other clean equipment, was observed with brown colored dried liquid food spill around the rim. Additionally, there was clean cylinder-shaped clear plastic container with a degraded adhesive label on the the exterior and a clean rectangular-shaped black food container that had a degraded adhesive label on the exterior surface. At 10:18 a.m., there were 3 spatulas hanging above a cook's prep table. The food contact surface of these 3 spatulas was very stained with an amber color (the original color was white). There was a metal suspension cart on which food was stored that had dried food residue it. One of the manual can opener had a nick in the blade with scant metal shavings around the gear. The top of the slotted knife holder had an accumulation of food residue. At 10:55 a.m., the dome lid storage dollie had an accumulation of dried food particles in the bottom of it. The sandwich press had an accumulation of carbon/grease build up on the exterior. At 10:07 a.m., the sprayer nozzle for the three compartment sink was encrusted with food soil. 3. A kitchen worker did not handle dishes properly to prevent cross contamination. On 06/08/11 at 10:07 a.m., a kitchen worker was observed to load soiled dishes in the dishwasher and then went to unload clean dishes. He was wearing gloves and did not change gloves between handling the soiled and clean dishes. The food service director was informed of this at the time. At 10:18 a.m., the same kitchen worker removed an empty container of dishwasher spot rinse from the dispenser and replaced this with a full container, loaded soiled dishes and did not change gloves after these tasks before preceding to touch clean trays. The food service director intervened at that point and told the kitchen worker to change his gloves.
Based on clinical record reviews, staff interview, and review of policy and procedures, it was determined the Registered Nurse failed to evaluate and supervise the nursing care for 4 (#16, #17, #19, #25) of 34 patients sampled. This practice does not ensure patient's goals are met and may cause a delay in discharge. Findings include: 1. Review of patient #16's physician order dated 6/3/2011 at 5:05 a.m. revealed the blood glucose to be monitored before meals and at bedtime and to administer insulin according to a low dose sliding scale. Review of the documentation revealed the blood glucose on 6/3/11 at 11:51 a.m. was 184. According to the sliding scale insulin order, the patient should have received two units of insulin. Documentation by the nurse indicated the patient was not eating well and she would recheck the blood glucose. There was no further documentation of the blood glucose results until 4:29 p.m., the regularly scheduled time for blood glucose to be checked. There was no documentation the nurse communicated with the physician regarding not giving the ordered insulin Blood glucose results on 6/6/11 at 11:50 p.m. revealed the patient's blood glucose was 159. According to sliding scale insulin order, the patient should have received two units of insulin. The nurse documented the patient was not eating and she was going to hold the insulin as a clinical judgment. There was no documentation that the nurse communicated with the physician regarding not giving ordered insulin. 2. A review of the medical record for patient #17 revealed a physician order for a heparin lock dated 6/4/11 at 5:15 p.m. A review of the nursing documentation revealed intravenous (IV) access was initiated on 6/4/11 at 4:00 p.m. The facility's policy Peripheral Intravenous Therapy #PC 344, last reviewed 3/11 required that IV sites are to be monitored with documentation of the condition of the site every two hours. Documentation of the IV site monitoring was reviewed on 6/6/11 at 11:00 a.m. There had been no documentation of the IV site monitoring since 4:00 a.m. on 6/6/11. The clinical nurse manager who was present during the record review on 6/6/11 at approximately 11:00 confirmed the finding. 3. Review of physician orders for patient #19 revealed an order for blood glucose monitoring before meals and at night dated 6/3/11 at 9:33 p.m. The physician indicated that insulin was to be administered according to standard dose sliding scale. A review of nursing documentation revealed the blood glucose was 237 at 8:57 a.m. A review of the sliding scale revealed the patient should have received 20 units of insulin. Review of the Medication Administration Record revealed no medication was administered. The Clinical nurse manager was present during the record review on 6/6/11 at approximately 1:00 p.m. and confirmed the above finding. 4. Review of physician orders for patient #25 revealed an order dated 6/3/11 at 8:45 a.m. for a Patient Controlled Analgesic (PCA) infusion pump with Dilaudid 0.2 milligram (mg). The demand dose was 0.2 mg, initial lockout interval 6 minutes, and 1 hour maximum dose 2 mg. The order indicated to call anesthesia for a systolic blood pressure below 90, pulse below 60, and a respiratory rate below 10. The documentation of vital signs on 6/4/11 at 4:00 a.m. revealed the patient's blood pressure was 88/49. There was no further documentation by the nurse that indicated the physician had been notified and no further patient assessment was found.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review and staff interview it was determined that the facility failed to ensure medications were administered according to physician orders for three (#17, #18, #20) of 34 sampled patients. This practice does not ensure safe and effective medication therapy. Findings include: 1. Patient #17 physician's order dated 6/4/11 at 5:15 p.m. instructed for Lovenox 40 milligrams to be administered subcutaneously daily. Review of the Medication Administration Record (MAR) revealed the medication was not administered as ordered on [DATE] and 6/5/11. The clinical nurse manager who was present during the record review on 6/6/11 at approximately 11:00 a.m. confirmed the findings. 2. Patient #18's physician order dated 6/1/11 at 6:00 p.m. indicated solumedrol 40 milligrams was to be administered intravenously (IV) every 8 hours. On 6/3/11 at 1:00 p.m. the order was changed to solumedrol 40 milligrams IV every 12 hours. Review of the MAR revealed the patient received 40 milligrams at 1:13 p.m. on 6/3/11. The next dose was administered at 9:50 p.m., which was 8.5 hours later, 3.5 hours too early. On 6/2/11 at 8:25 a.m. the physician wrote an order for Levaquin 250 milligrams IV every morning. Review of the MAR revealed no Levaquin was administered on 6/3/11. The clinical nurse manger who was present during the record review on 6/6/11 at approximately 12:00 p.m. confirmed the above findings. 3. Patient #20 was admitted to the facility on [DATE]. Review of the medication reconciliation order form, which was signed by the physician, revealed the patient was to received 8 milligrams of perphenazine three times daily. Review of the MAR revealed the medication was not added to the MAR and was not administered. The unit director who was present during the record review on 6/7/11 at approximately 9:00 a.m. confirmed the finding. The physician wrote an order for Ciprofloxacin 400 milligrams IV every 12 hours on 6/5/11 at 10:00 p.m. The first dose was administered at 12:52 a.m. on 6/6/11. The next dose was administered 9 hours later at 10:00 a.m. The next dose was administered at 8:00 p.m., which was 10 hours later. The unit director also confirmed the above finding.
Based on record review, policy review and staff interview it was determined the facility failed to ensure appropriate orders were received prior to administration of medications for 2 (#19, #20) of 34 sampled patients. This practice does not ensure safe medication administration. Findings include: The facility's policy Medication Ordering and Transcribing #RXDNV MM. 4 SR- 1, SR-2, SR - 3, SR-4, last reviewed 6/1/10 required that physician orders are to include the medication name, strength and dosage form and directions for use. It required the signature of the prescriber. It also required that orders that are incomplete are to be clarified with the prescriber prior to administration of the order. In addition it required that titrate orders are to include the minimum and maximum dose, parameters to be used, dosage and time increment used to titrate and the titration medication chart is to be referenced. 1. Review of the medical record for patient #19 revealed that the preprinted sliding scale for administration of Humalog insulin was included with the physician orders. The order sheet was not signed by the physician. The clinical nurse manger who was present during the record review at 1:00 p.m. on 6/6/11 confirmed that the form was to be signed by the physician. 2. Review of the medical record of patient #20 revealed the physician had ordered Propofol 1000 milligrams per 100 milliliters on the preprinted ventilator order set. The required elements for a titrating medication order were present on the form, but were not selected by the physician. The nurse failed to clarify the order with the physician. The unit director confirmed the above findings during record review on 6/7/11 at approximately 9:00 a.m.
Based on record review and staff interview it was determined the facility failed to ensure all parts of the medical record were accessible for 1 (#20) of 34 sampled patients. This practice does not ensure all information is available to the interdisciplinary team caring for the patient. Findings include: Review of the medical record for patient #20 revealed that he had been in wrist restraints to prevent pulling on tubes from midnight on 6/6/11 until 2:00 p.m. An order written at 8:00 a.m. on 6/6/11 was present in the record. No order for the restraint initiated at midnight could be found. The Director of he Intensive Care Unit was interviewed on 6/7/11 at approximately 9:00 a.m. She stated she had presented the order to the physician to authenticate the order on 6/6/11. She stated she had completed the daily quality review of the restraint and had documented on the data gathering form that an order had been taken from the physician via phone call at midnight. She could not explain what had happened to the order.
Based on interview and record review the hospital failed to ensure that the food service director was granted authority and delegated responsibility by the hospital's governing body and medical staff for the operation of the dietary services. The facility failed to maintain the food service director's documentation of education and experience when hired. This practice does not ensure safe management of the dietary department. Findings include: Review of the food service director's personnel file with a hospital human resources staff on 06/08/11 at appropriately 3:45 p.m. revealed that there was no documentation that the hospital's governing body and medical staff granted authority and delegated responsibility to the food service director for the operation of dietary services. Additionally, the human resources staff person could not find any documentation of the food service director's culinary arts degree in the file. The human resources staff person asked if this documentation should be in the file. The food service director was hired by the hospital about 8 years ago. The food service director recently earned the credential of a certified dietary manager on 05/31/11.
Based on observation, interviews and record reviews it was determined the facility failed to ensure the therapeutic diet manual was available to all medical, nursing and food service personnel. This practice does not ensure dietary information is accessible. Findings include: On 06/08/11 at 11:15 a.m., the food service director, Registered Dietitian (RD) and diet clerk were interviewed about the hospital diet manual. There was a print version of the 2002 Florida Dietetic Association Diet Manual observed on a shelf in the dietary office. The RD stated that there was a current 2011 on-line version of the Manual of Medical Nutrition Therapy by the Florida Dietetic Association. The diet clerk was asked to demonstrate how she would access the on-line diet manual on the computer and she said could not and added that she uses the print diet manual. The Food Service Director also stated at that time that he did not have access to the current on-line diet manual. The RD said that she could access it but need the pass code to do this. At 12:45 p.m. on 06/08/11, a mental health technician on the second floor Behavioral Health Unit was asked to demonstrate how she would access the on-line diet manual. She was unable to do this. She did not know how to access a diet manual in the hospital. At approximately 4:00 p.m., the food service director provided instructions with a pass code to access the online diet manual. He stated there were 2 printed 2009 Manuals of Medical Nutrition Therapy by the Florida Dietetic Association on the third floor and not in the Behavioral Health Unit or critical care units. Only designated staff had access to the on-line version of the current diet manual and was not available to all medical, nursing and food service personnel.
Based on observation and staff interview, the hospital failed to maintain enough non-perishable food supply for emergency and/or disaster situations according to State law. This practice does not ensure patient safety. Finding include: The hospital's policy included a disaster menu for 5 days, instead of one week. There was not enough non-perishable food supply for one week on hand during the survey. During a tour of the hospital kitchen and dry food storage area on 06/08/11 at 10:35 a.m., there did not appear to be a one week supply of non-perishable food on hand to serve the hospital's current census of 86 patients. There was very little non-perishable foods representing the milk group. The food service director stated at that time that he thought he only need food available for 96 hours. The hospital's Food and Nutrition Services written policy, titled Disaster Preparedness Menu, effective September 2003 was reviewed. This policy included a disaster menu for 5 days and to maintain a supply for 5 days rather than a week.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review and staff interview the facility failed to conduct a case manager's admission review for 4 (#12, #14, #15, #17) of 34 medical records reviewed according to the facility's guidelines. This practice may lead to a prolonged hospital stay. Findings include: The electronic record reviews were conducted with the Director of Case Management that revealed the following: 1. Patient #12 was admitted to the facility on [DATE]. The patient did not have an admission review conducted by case management within 24 hours of admission with documentation. 2. Patient #14 was admitted to the facility on [DATE]. The patient did not have an admission review conducted by case management within 24 hours of admission with documentation. 3. Patient #15 was admitted on [DATE]. The medical record revealed that the patient did not have an admission review conducted by case management within 24 hours of admission with documentation. 4. Patient #17 was admitted to the facility on [DATE] with the diagnosis of abdominal pain. Review of the medical record revealed that the initial social services evaluation was not performed until 6/6/11. The Director of Case Management ( CM) was interviewed at approximately 11:00 a.m. on 6/6/11 and confirmed that as per the facility's Utilization Management Plan (UM), the case managers will follow the hospital UM plan and perform an admission review within twenty-four hours of admission, with documentation in the CM Decision Point system. A review of the facility's Utilization Management Plan 2011 revealed on page 11: The Initial Case Management Assessment and discharge plan will be initiated within twenty-four hours of admission. A job description for case manager's position was provided by the Risk Manager on 6/6/11 at approximately 9:30 a.m. Under the heading, Utilization Management it read: Performs admission review within twenty-four hours of admission, with documentation in the CM Decision Point System.
Based on document review and staff interview it was determined the facility failed to provide evidence that patients received written notice of decision regarding their grievance. This practice does not ensure patients' right to grievance resolution is maintained. Findings include: Review of the facility's policy Customer Grievance/Complaint Procedure #RM1204, last reviewed 12/10, revealed the requirement that a written response regarding the results of the facility's investigation of patient's grievance be provided. The Risk Manager was asked to provide the grievance log for the prior two months. She provided a redacted log that failed to provide enough information to substantiate the facility was in compliance with federal regulations and their own policy. She indicated this was the only information she was permitted to provide.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review and staff interview it was determined that the facility failed to comply with the patient's advance directive regarding discharge planning for one (#10) of 12 sampled patients. This practice does not protect patient rights. Findings include: Patient #10 was admitted to the facility on [DATE] with diagnoses that included altered mental status, insulin dependent diabetes and history of alcohol abuse. Review of case management notes revealed that the case manager spoke with a case worker from an adult protective agency on 2/8/11. The case worker told the case manager that the patient was living with a neighbor and expressed concerns about the living conditions. The case worker also provided the facility's case manager with the name and phone number of a stepson who had Power of Attorney (POA). The advance directive was contained in the medical record. The facility's case manager noted on 2/10./11 that she had spoken with the stepson (POA). There was no documentation that the discharge plan was discussed with the stepson. There was no other documentation regarding contact with the POA until 2/15/11, the day of discharge. The medical record revealed the patient was discharged to return to the neighbor's home without evidence the plan had been discussed with the POA. \ During interview on 3/28/11 at approximately 3:00 p.m., the Director of Case Management confirmed the findings.
Based on record review, policy review and staff interview it was determined that the facility failed to ensure appropriate physician orders were obtained for three (#10, #11, #12) of 12 sampled patients. This practice does not ensure appropriate physician involvement with restraint usage. Findings include: The facility's policy Restraint and Seclusion #PC 336 required that verbal and phone orders be authenticated within 24 hours. 1. Patient #10's medical record revealed that the patient had been in restraints. Review of the physician orders revealed a verbal order for soft restraints had been written on 2/8/11 at 5:30 p.m. The order had not been authenticated at the time of the record review on 3/28/11. 2. Review of patient #11's medical record on 3/28/11 revealed a verbal order written on 3/12/11 had not been authenticated. The order for the restraint was written on 3/22/11 at 8:00 a.m. The order indicated the order was valid for 24 hours. The order was not renewed until 1:30 p.m. on 3/23/11. Review of the nursing documentation on restraint revealed the patient was restrained from 8:00 a.m. on 3/22/11 to 1:30 on 3/23/11. 3. Observation of patient #12 showed the patient was restrained on 3/28/11 at approximately 1:00 p.m. . Review of physician orders revealed a verbal order to restrain the patient on 3/26/11 at 8:00 a.m. The order was renewed on 3/27/11 at 6:00 a.m. The verbal order had not been authenticated as of 3/28/11 at approximately 1:00 p.m. Review of the progress notes written on 3/27/11 and on 3/28/11 revealed no documentation by the physician regarding the need for continued restraint. The Nurse Manager from the Intensive Care Unit was present during the record reviews of the three patients and confirmed the findings.
Based on record review, policy review and staff interview it was determined that the facility failed to ensure appropriate monitoring of patients in restraints for three (#10, #11, #12) of twelve sampled patients. This practice does not ensure patient safety. Findings include: The facility's policy Restraint and Seclusion #PC 336 required that the nursing staff monitor the patient every two hours and document circulation, range of motion, nutrition needs, hydration needs, elimination needs, level of distress/agitation, psychological status, cognitive functioning, comfort, readiness for discontinuation and skin integrity. 1. Review of the nursing documentation regarding monitoring of patient #10 while in restraints revealed no documentation of the required monitoring on 2/5/11 from 6:10 a.m. until 8:00 p.m., on 2/7/11 from 6:00 p.m. until 11:00 p.m., on 2/8/11 from 5:30 p.m. until 8:10 p.m., and on 2/14/11 from 7:30 p.m. until 11:30 p.m. 2. Review of the nursing documentation for restraints for patient #11 revealed no documentation of the required monitoring on 3/8/11 at 10:00 p.m. to midnight, on 3/21/11 from 4:00 a.m. until 8:36 a.m., from 11:59 a.m. until 2:41 p.m. and from 2:41 p.m. until 6:17 p.m., on 3/23/11 from 2:00 a.m. until 5:44 a.m. and from 5:20 p.m. until 8:15 p.m. On 3/24/11 the last documented monitoring was noted at 8:33 a.m. There was no documentation of discontinuation of the restraint or that the patient was assessed as readiness for restraint release. 3. Review of the nursing documentation for patient #12 revealed no documentation of the required monitoring while in restraints on 3/27/11 from 5:30 a.m. until 8:00 a.m. and on 3/28/11 from 5:30 a.m. until 8:00 a.m. The monitoring documentation on 3/28/11 at 9:00 a.m. and again at 10:00 a.m. did not include all required information. The manager of the Intensive Care Unit was present during the record reviews on 3/28/11 and confirmed the findings.
Based on record review, policy review and staff interview it was determined that the facility failed to monitor and ensure a safe, effective. and appropriate discharge plan was provided. 1. The facility failed to ensure a complete discharge plan for seven (#3, #5, #6, #7, #8, #9, #10) of twelve sampled patients that included the safety of a discharge plan, physician orders for transfer, and providing PASRR screening for discharges to a Skilled Nursing Facility (Refer to A817). 2. The facility failed to initiate a discharge plan for one (#9) of twelve patients (Refer to A820) 3. The facility failed to ensure appropriate preparation for discharge for one (#10) of twelve patients (Refer to A822). 4. The facility failed to ensure patient's right to choice regarding post hospital placement for five (#5, #6, #7, #8, #9) of 12 patients (Refer to A828). 5. The facility failed to provide ongoing assessment and reassessment of the discharge planning process (Refer to A843). Due to the cumulative effect of these systemic problems, it was determined that the Condition of Participation for Discharge Planning was out of compliance.
Based on record review and staff interview it was determined that the facility failed to ensure a complete discharge plan for seven (#3, #5, #6, #7, #8, #9, #10) of twelve sampled patients. This practice does not ensure appropriate post hospital placement. Findings include: 1. Review of the medical record revealed that patient #10 was admitted with altered mental status, insulin dependent diabetes and history of alcohol abuse. Review of case management notes revealed that the case worker for an adult protective agency spoke with the facility's case manager on 2/8/11. The documentation noted the agency case worker reported that the patient was residing with a neighbor and that living conditions were poor & marginal at best. The case worker reported the patient had a change in mental status and now was oriented only to person. She also provided the name and number of a stepson who had been designated as the patient's Power of Attorney (POA). On 2/8/11 the patient's physician noted the patient lacked capacity to make decisions. On 2/10/11 there was a case management note that the case manager was working on finding placement at a Skilled Nursing Facility (SNF). On 2/10/11 the case manager noted she had spoken with the stepson (POA) who agreed to continue to function as the POA and that he would contact the neighbor who was acting as a caregiver about finances. There was no documentation that the discharge plan was discussed with the POA. There was no documentation that the agency case worker's concerns regarding the living conditions were discussed with the POA. The physician ordered to transfer the patient to a SNF on 2/14/11 at 8:50 a.m. A case management note on 2/14/11 at 10:00 a.m. indicated that referrals were being made to a SNF for placement. The physician ordered to cancel the discharge on 2/14/11. On 2/14/11 a case management note at 12:15 p.m. indicated that the case manager placed a call to the caregiver/neighbor and that the caregiver wanted the patient to return to her home. The physician wrote an order at 9:00 a.m. on 2/15/11 to discharge the patient home with the caregiver and home health for therapy. Review of the discharge instructions revealed the patient was now to be on a mechanical soft diet with nectar thick liquids. Review of the patient/family education revealed that the diet was explained to the patient on 2/15/11 before discharge. The patient was assessed to be oriented to person only at 8:00 a.m. that morning. There was no documentation that education was provided regarding the diet to the caregiver who would be caring for the patient post discharge. The patient was released to the caregiver/neighbor on 2/15/11 at approximately 1:30 p.m. There was no documentation that the stepson/POA and the agency case worker were notified of the plan to send the patient back to the prior living situation before the patient was discharged . A case management note indicated that the POA was notified on 2/15/11 of the patient's discharge at 3:00 p.m., which was after the patient had already been discharged . There was no documentation that the case manager attempted to verify the safety of the home to which the patient was discharged . The Director of Case Management was interviewed on 3/28/11 at approximately 3:00 p.m. She confirmed that the POA had not been consulted regarding the discharge plan and had no additional information regarding the agency case worker's concerns. 2. Review of the medical record for patient #3 revealed the patient was transferred to an acute psychiatric facility on 3/22/11. No physician order for the transfer could be found. 3. 42 CFR 483.100 requires that the facility transferring a patient to a Skilled Nursing Facility (SNF) ensures that a Pre-Admission Screening and Resident Review (PASRR) be completed prior to the patient's being transferred to the SNF to ensure appropriate placement. During interview with the Director of Case Management on 3/28/11 at approximately 2:00 p.m., the Director stated that the facility has no policy on completing the PASRR. She stated it was done by the receiving SNF. She also confirmed there was no policy regarding the facility's responsibility to ensure the PASRR screen was performed before the patient was transferred, 4. Review of the medical records of patients #5, #6, #7, #8, #9 revealed each was transferred to a SNF for continuing care. None of the records had evidence the PASRR was completed prior to the transfer.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review and staff interview the facility failed to arrange for the initial implementation of the discharge plan for one (#9) of 12 sampled patients. This practice does not ensure a timely discharge. Findings include: Patient #9 was admitted to the facility on [DATE] and discharged on [DATE] at approximately 3:12 p.m.. The patient had been assessed by nursing upon admission and was referred to case management for a consult for discharge planning. Record review revealed that no consultation from case management had been performed. The findings were confirmed by the Director of Case Management on 3/28/11 at approximately 3:00 p.m.
Based on record review and staff interview it was determined that the facility failed to provide appropriate education regarding post discharge care for one (#10) of 12 sampled patients. This practice does not ensure patient safety after discharge. Findings include: Review of the discharge instructions revealed patient #10 was to be on a mechanical soft diet with nectar thick liquids. Review of the medical record revealed that Speech therapy had performed a swallow study and determined that the patient required the special diet. Review of the patient/family education revealed that the diet was explained to the patient on 2/15/11 before discharge. The patient was assessed to be oriented to person only at 8:00 a.m. that morning. There was no documentation that education was provided regarding the diet to the caregiver who would be caring for the patient post discharge. The Manager of the Intensive Care Unit confirmed the findings during the record review on 3/28/11 at approximately 3:00 p.m.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record and policy review and staff interview it was determined that the facility failed to inform five (#5, #6, #7, #8, #9) of 12 sampled records of the option in selecting a provider of their choice for post discharge skilled nursing care. Findings include: On 3/28/11 record review was conducted with the Director of Case Management. 1. Patient #5 was discharged on [DATE] to a Skilled Nursing Facility (SNF) and had not been provided with the option of selecting a facility. The patient was discharged to the provider's own SNF. 2. Patient#6 was discharged on [DATE], patient #7 was discharged on [DATE], patient #8 was discharged on [DATE] and patient #9 was discharged on [DATE]. Patient #6, #7, #8, and #9 were not provided with a choice of SNF's. The findings were confirmed by the Director of Case Management who verified that all patients were to be informed of their options as to their post discharge choice in selecting a SNF provider. A review of the facilities policy Patient Choice/Discharge Options from the Department Case Management (CM #421 last revised 4/10) revealed the Case Management department will ensure that patients are informed of their options and have a free choice in selecting their post discharge provider/agency, and have been informed of any financial interest that the hospital has with the extended care provider agencies. Patients will be informed of their options and have the ultimate choice in selecting the Provider/Service.
Based on staff interview it was determined that the facility failed to ensure the discharge planning process was assessed for effectiveness. This practice does not ensure that patients' discharge needs are being met. Findings include: During interview on 3/28/11 at approximately 5:00 p.m. the Risk Manager stated that the Case Management department does not do any monitoring of discharge planning. She stated that as part of the Utilization Review monitoring, returns to the hospital were tracked. She could not provide any evidence that the discharge process was being evaluated on an ongoing basis.
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