HospitalInspections.org

Based on interview and record review, the facility failed to ensure the following:

1. Nursing staff to adhere to its policies and procedures on:
a.) Policy and procedure titled (P&P) titled, "Informed Consent Policy". No second personnel signature on 1 of 30 sampled patient consent form.

b.) Policy and procedure titled (P&P) titled, "Nova Stat Strip Glucose Meter Procedure". No open and discard date written on 3 of 3 Glucose Control Solution Bottle.

2. That nursing care staff personnel are adequately supervised and that their clinical activities are evaluated for one (1) of six (6) sampled licensed nursing staff (RN1).

These deficient practices had the potential to:

1. Obtain a consent for a wrong treatment without the verification of a second witness.

2. Result in inaccuracies of blood glucose (sugar found in blood) values.

3. Affect the facility's ability to assure patient safety.

Findings:

1. During a concurrent interview and record review on 8/25/22, at 10:22 a.m., with Registered Nurse 9 (RN 9), Patient 12's "Authorization for and Consent to Surgery and Other Medical/ Therapeutic Procedures" for an Extra Ventricular Drain (A temporary system that allows drainage of cerebral spinal fluid from the ventricles to an external closed system), dated 8/22/22, was reviewed. The Record indicates that a telephone consent obtained from patient's legal representative is missing a second witness signature. RN 9 stated, it is policy that when obtaining a telephone consent, (2) staff must verify consent from the patient's legal representative. The (2) staff who verifies the consent and witness must sign and date the consent form.

During a review of the facility's policy and procedure (P&P), titled "Informed Consent Policy," last revised on 04/2022, the P&P indicated, consent by telephone must have (2) hospital personnel verify that the patient's legal representative and physician have discussed the patient's condition and the recommended treatment and that the patient's representative has given consent. The hospital staff member who obtains and verifies the consent for medical treatment and the witness should both sign and date this record.

2. During a concurrent observation and interview, on 8/25/2022, at 3:30 p.m., It was observed that (3) Glucose Control Solution bottle in the 6 West Nurse Station has no written open and discard dates. The CNC (Clinical Nurse Coordinator) confirmed that the (3) Glucose Control Solution bottle has no written open and discard dates, and that it is policy that Glucose Control Solution bottle when opened, must have a written open and discard dates on the label. Discard date is 90 Days or 3 months after opening.

A review of the facility's policy and procedure (P&P), titled "Nova Stat Strip Glucose Meter Procedure," revised 4/2021, indicated "Stat Strip Glucose Control Solution are stable for 3 months from date opened or until the printed expiration date. Always write date opened and discard date on the bottle."






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3. During an interview and concurrent nursing staff personnel record review on 8/25/2022, at 2:25 p.m., Human Resources Business Partner (HR1) stated that RN1 is missing a performance evaluation on file. HR1 stated evaluations are done annually for nursing staff however HR1 was not able to find any evaluations for RN1. Upon further inquiry, HR1 later submitted a performance evaluation for 2016-2017 appraisal period for RN1; graded as 3.71, a competent plus performer. HR1 then stated there was no other performance evaluation on file for RN1.

A review of the hospital's policy and pocedure (P&P), titled "Job Description for Registered Nurse - Emergency services," {No Date], provided by HR1, indicated staff members are required to maintain departmental policies and procedures, objective, performance improvement program, safety, environmental and infection control standards. It also indicates nursing staff are expected to participate in performance improvement activities.

During an interview on 8/25/2022, at 2:25 p.m., with Director of Clinical Education (DEC 1), DEC 1 stated nursing staff are required to participate in performance improvement activities including taking online classes and clinical skills validation with a preceptor or a charge nurse. Nurses are then evaluated on their skills and signed off if rated competent.

During an interview on 8/26/2022, at 10:41 a.m., with Vice President of Human Resources (HR3), HR3 stated that nursing and auxiliary services personnel are union employees with periodic performance evaluations however the Union agreement does not specify the "period" range.

A review of the SEIU-UHW United Healthcare Workers-West Collective Bargaining Agreement with the Hospital dated April 1,2020- March 31,2023, Article 23 indicated "periodic performance evaluations reports are hospital records." And a review of SEIU Local 121RN and the hospital dated September 16,2020 -September 15, 2023, Article 17 indicated "Annual performance evaluation reports are hospital records."

During an interview on 8/26/2022, at 10:41 a.m., with HR3, upon review of document provided, HR3 explained that the facility's policy and procedure trumps the Union agreement and specifies that the performance evaluation is done annually for all nursing personnel. HR3 then clarified that RN1 is part of the nursing services personnel. Therefore, their (referring to nursing staff) performance evaluation is an annual requirement. HR3 stated that RN1's annual performance evaluation has been done for 2021-2022 appraisal period and submitted it.
A review of RN1's performance evaluation for 2021-2022 appraisal period showed RN1 is graded as 3.71, a competent plus performer.

During an interview on 8/26/2022, at 11:12 a.m., with the Director of Emergency Department (DED 1), DED1 stated a performance evaluation is done in the current year for the previous year's work. The performance evaluations are done by clinical nurse coordinators also known as charge nurses however DED1 is not sure why RN1 is missing performance evaluations for the period he was fully employed at the hospital. DED1 stated RN1 was on a leave of absence for an extended period of time, therefore, a performance evaluation was not done.

During an interview and concurrent record review on 8/26/2022, at 11:49 a.m., HR3 stated RN1 was not working therefore a performance evaluation was not obtained for appraisal periods 2019-2020 and 2020-2021. A review of RN1's "Claim Overview documents" printed on 8/26/2022 and submitted by HR3, indicated that RN1 was out of work on a continuous leave of absence from 11/10/2020 through 2/8/2021 and again from 9/21/2021 through 2/17/2022. HR3 then confirmed that a performance evaluation is only missing for 2017-2018 appraisal year.

Based on interview and record review, the facility failed to reassess a level 3 patient every 60 minutes until seen by the ED (Emergency Department) MD (Medical Doctor) as per facility's Rapid Medical Evaluation Policy No. 2737.

This deficiency resulted to a missed ongoing assessment for 1 of 30 sampled patients (Patient 1).

Findings:

On 08/24/2022, at 2:20 p.m., during an interview with DED (Director of Emergency Department). DED stated that on 05/16/22, Patient 1 was brought to the ED via ambulance. Patient 1 was stable and Awake, alert and oriented x3 (oriented to person, place, and time). Patient 1 was Triaged a Level 3 (Urgent, not life-threatening condition). Patient 1 was transferred to the waiting room by the paramedics. The Paramedics dropped Patient 1 in the waiting room and left without giving report to the Emergency Department Technician 1 (EDT 1). EDT 1 was not aware of Patient 1 being in the waiting room. Patient 1 was found not breathing 2 hours after being dropped off by the paramedics. Facility initiated CPR (Cardiopulmonary Resuscitation-a life saving procedure performed when the heart stops beating) but was unsuccessful, Patient 1 expired. DED said that staff should have assessed Patient 1 every hour. No assessment was completed for more than 2 hours. There should have been a report or hand-off between staff. DED further added that facility will be initiating a new process in which moving a patient from ambulance triage to waiting room will require approval by emergency provider or physician. Charge Nurse must give report to ED technician to continue supervision of patient.

A review of the facility's policy and procedure (P&P), titled " Rapid Medical Evaluation - Policy No. 2737", indicated that level 3 patient in the waiting area must be reassessed every 60 minutes until seen by the ED MD or discharged. Reassessments of RME (Rapid Medical Evaluation) patients are the responsibility of the RME team.