HospitalInspections.org

Based on interview and record review, the facility failed to ensure a prompt resolution to patients' grievances. The facility failed to perform a thorough investigation so grievances could be resolved on 2 (Patient #'s 1 and 2) of 16 sampled patients.

The facility failed to ensure that staff who were listed in the grievance reports were interviewed and documentation of those interviews were included in the investigations before being finalized.

This deficient practice had the likelihood to cause harm to all patients who filed a grievance at the facility.



PATIENT #2

Review of the facility grievance log revealed a grievance noted for patient #2 on 3-4-2019. The Event ID was noted as 1245975.

Review of the grievance for Event ID #1245975 revealed the following:

The occurrence date was listed as 3-4-2019. The complaint was initiated by a telephone call, 3-28-2019. The nature of the complaint was listed as follows:

1. Communication between patient/physician
2. Communication between patient/staff
3. Staff Behavior/Attitude Listening
4. Staff Performance/Quality of care

There were referrals made to the Registration Director, Lab Director, and 3rd floor Medical Director on 3/28/2019 with a response required by 4-3-2019.

The risk manager, Staff #8 entered responses from the Lab, Patient Access, and Med-Surg director on 4-9-2019.

There was no documentation in the grievance report indicating if the complaint was substantiated or unsubstantiated. There was no documentation in the grievance report on the investigation of the allegations to include interviews with physicians, staff, and patients involved.

During an interview with Staff #8 on 5-6-2019 after 3:00 PM the following was revealed:

There was a Peer Review attached to the Grievance Report. Physician #19 completed the Peer Review form. The report was not legible. Staff #8 was asked to assist in reading the form. Staff #8 was not able to completely read the form. Staff #8 confirmed the report was not legible and said the only form of the report was handwritten. The report had not been transcribed. Staff #8 said that Physician #19 did not find any deficient practice in his review of the record. Staff #8 was asked how that determination was made. Staff #8 said a verbal review of the findings were completed with Physician #8.

Staff #8 was asked to provide the investigation reports from department directors in reference to the above listed grievance. Staff #8 said she did not receive those reports. Staff #8 said the directors would contact her verbally and report any actions taken in response to the complaint but she did not have the investigation documentation. Staff #8 was asked how she determined if the complaint allegation was substantiated. Staff #8 said she would not know that. The only documentation she was aware of would be if the investigation become a formal process with Human resources and they would have that documentation.

Interview with Staff #'s 10 & 12 confirmed that the facility did not have specific requirements for investigating a grievance. Staff #'s 10 & 12 said investigations were usually done informal with verbal interviews. The only documentation would be in Human Resources if the investigation became a formal process that required employee discipline.




10135

Review of the facility's complaint and grievance log revealed the following:


On 12/10/2018, Patient #1's family made a grievance that the 3rd floor staff were "horrible." " She indicated that the staff did not provide anything unless they were prompted. The wife says she or the family had to ask for water, ask for clean linens, ask for assistance to get the patient up, and ask to assist the patient to the bedside commode. Wife says she had to provide all the care including pulling him up in the bed as he was "hunched" over in the bed. She also indicates that the patient was in pain and moaning but the nurses didn't check on him frequently enough to know he was hurting and the family had request he be medicated. She said his water jug was never filled and never refreshed with ice. The wife was pleased with the care he has received since he's been in ICU."


Review of the report revealed no documentation of what steps the facility took to come to a resolution to the allegations.


During an interview on 05/06/2019 after 3:09 p.m., Staff #8 revealed she took the grievance. The allegations were passed on to the Director over the unit. The Director was responsible for performing the investigation, Staff #8 revealed she did not know or could not provide documentation of how the Director resolved the grievance.


During an interview on 05/07/2019 after 11:00 a.m., Staff #12 revealed he was the new Director over the unit. Staff #12 said he could not provide any evidence about the incident.



Review of the facility's policy titled, "Complaint Grievance Process" with an approval date of 2/2019 revealed the following:

" ...The department director completes any investigation, identifying the issue has been resolved or not resolved, corrective actions taken and needed notification of other personnel for follow up. The department manager then signs and dates where indicated on the form or in the ERS ..."

Based on observation, interview and record review, the facility failed to ensure personal privacy was provided for 2 (Patient #'s 2 and 12) of 16 sampled patients.


Findings include:

During a confidential interview on 05/06/2019 it was reported that staff were routinely leaving patient's doors open.


Patient #12

During a skin observation on 05/06/2019 after 12:22 p.m., un-identified staff members exposed Patient #12's buttock with the door open. Anyone passing by in the hallway could see him.


Patient #2

Review of a grievance resolution dated 03/14/2019 revealed Patient #2 complained about staff leaving the door to his room open.




Review of a facility's policy named "Patient Rights & Responsibilities" dated 06/2015 revealed:

"The patient regardless of age, has the right, within the law, to personal and informational privacy, as manifested by the following rights:

...To be interviewed and examined in surroundings designed to assure reasonable visual and auditory privacy.."

Based on interview and record review, the facility failed to ensure patients received care in a safe setting for 2 (Patient #'s 1 and 16) of 9 sampled patients related to incident reports. The facility failed to ensure adverse events were accurately investigated. Also, the facility failed to ensure a Root Cause Analysis was initiated per facility policy and preventative actions were implemented to prevent patient harm and medical errors.

This deficient practice had the likelihood to cause harm in all patients at the facility.

Findings:

Patient #16

Review of the History and Physical dated 2/13/2019 revealed the following:

"Patient was admitted on 2/13/2019 with suspected cholecystitis. Patient #16 had a past medical history of Hypotension, GERD, Hypothyroid, hyperlipidemia, Parkinson, A Fib, now in NSR (Normal Sinus Rhythm) not on AC (Anticoagulant's), PVD."

Review of incident/occurrence logs from 11/2018 to5/6/2019 revealed the following:

Review of the incident report #1237387 & #1235184 with an occurrence date of 2/13/2019 revealed the following:

The event type was listed as a medication variance - wrong dose. The location was listed as 3rd floor. The discovery date was noted as 2/14/2019.

During an interview with Staff #8 after 11:00 AM, on 5-7-2019 the following was revealed:

1. Staff #14 entered the incorrect dosage order for Patient #16's medication on Coreg (a beta blocker that treats high blood pressure and heart failure) and Digoxin (Antiarrhythmic that can treat heart failure and heart rhythm problems) in the Home Medication Reconciliation system in the MAR (Medication Administration Record).

2. Staff #14 entered Coreg into the electronic MAR as Coreg 6025 mg. The correct dosage was 6.25 mg.

3. Staff #14 entered Digoxin into the MAR as Digoxin 1.0 mg. The correct dosage should have been Digoxin 0.125 mg.

4. Staff #15 approved the Home Medications in the Home Medication Reconciliation of the Electronic Medical Record.


Review of the History and Physical dated 2-13-2019 revealed Staff #15 noted in the History and Physical under home medications, "see home med rec."

5. Pharmacy approved the Home medications entered into the electronic MAR.


Staff #5 provided an email from the education director that revealed the following:

The email was from Staff #8 and sent to the education department director on 2-27-2019.

The email stated, "Please assign the following nurse the Safe Medication ALC Course:

Staff #14 entered the incorrect dosage order for Coreg (6025 mg initially ordered) and Digoxin (1 mg ordered initially) on Patient #16 on 2/13/2019. The medication was not given as ordered, dosage was corrected prior to administration, no harm.

*NP (Nurse Practitioner) did verify order and pharmacy approved it also."

The email was sent with a CC to CNO, and the Medical Floor Director.

Staff #5 & #8 were asked if an RCA (Root Cause Analysis) was completed as per their policy. Staff #5 and Staff #8 confirmed a RCA was not completed. There was no documentation provided by the facility of an investigation that occurred, to include investigation of the pharmacy or the provider.


Review of the facility policy titled, "Cause Analysis Policy and Procedure" dated with an approval date of 5/2018 revealed the following:

"PURPOSE

a. The purpose of this policy is to provide structure and guidance for detection and correction of systemic and/or individual failures or weaknesses and to prevent the future occurrences of events of harm ...

SCOPE AND DEFINITIONS

l. Near Miss Safety Event: An event whereby a deviation from GAPS does not reach the patient, results in no harm and is caught by a detection barrier or by chance ...

POLICY

a. An RCA will be conducted in response to serious safety events or sentinel events ...

PROCEDURE

a. The primary, 10 (ten) steps to conducting an RCA are outlined below and in Table 1 and Table 2.

1. Immediately following knowledge of a serious safety event, staff involved will stabilize the situation; address immediate patient, family, and staff needs; address any immediate additional threats impacting other patients, family and staff ...

4. Conduct the first RCA meeting (facts meetings) within 24-48 hours post event; Charter the RCA team ..."


10135

Patient #1

Review of the clinical record on Patient #1 revealed he was a 67-year- old male admitted on 12/01/2018 with diagnoses of sepsis, urinary tract infection and pneumonia.


Review of emergency department notes dated 12/01/2018 revealed Patient #1 had a history of blood clots in the lungs, multiple myeloma (blood cancer) and pulmonary hypertension.


Review of the medication administration record for 12/07/2018 revealed the following medications were administered:

At 2:14 a.m. the pain medication Morphine 2 milligrams was administered via intravenous push for pain between 6-10.

Review of nurses notes dated 12/08/2018 at 5:00 a.m., revealed there was documentation that Patient #1 had a long history of congestive heart failure. Patient #1 had a pain level of 10 /10 (indicating severe pain). Patient #1 was described as having expiratory wheezing, blood pressure of 122/77, pulse 123, respirations 24, temperature was 98 and oxygen saturation was 93 percent on oxygen. Orders were received for "2mg of Dilaudid (pain medication) x 1 dose, iv fluids NS at 50ml/hr x 1 bag, Lorazepam 1 mg x 1 dose and EKG stat."

Review of the medication administration record dated 12/08/2018 revealed the Dilaudid was administered at 5:36 a.m.. There was documentation that the Ativan was not administered.

Review of nurses notes dated 12/08/2018 at 5:40 a.m., revealed documentation that the Patient #1 was in "distress at the moment, lethargic after administered Dilaudid 2mg IV push per orders received. ETCo2 monitor in place to check for respirations and oxygen saturation. The nurse called a rapid response due to Patient #1's oxygen saturation at 66 percent and patient very lethargic. Rapid response team on scene." According to documentation Patient #1 was given Narcan IV push (agent used to counteract narcotic overdose).

At 06:00 a.m., Patient #1's oxygen saturation was at 96 percent on oxygen. Patient #1 was responsive and was currently on a bipap (positive pressure ventilator).

At 8:30 a.m., Patient #1 was sent to the Intensive care unit.


Review of the occurrence and incident logs from November 2018-May 2019 revealed no documentation of the incident on Patient #1.

During an interview on 05/10/2019 after 11:00 a.m., Staff #1 (Quality Director) revealed the incident went to peer review in February 2019. The nurse practitioner on the case was removed shortly after the incident. The physician did not find a problem with the medication just with the Sepsis protocol. Staff #1 revealed not knowing why a variance report was not put in the computer. Risk management informed her that they did not know why a variance report was not completed on the incident. Pharmacy had not provided any input in regards to the medications. Usually when it's an adverse event they usually look at it for adverse drug reactions and mortality. Staff #1 said that her and the Chief nursing officer (CNO) had looked at the chart and agreed there was a lot of documentation missing in the chart. Staff #1 confirmed they did not have a written investigation on the incident.


Review of a facility's policy named "Sentinel Event Serious Safety Event Review and Reporting" dated 05/16/2018 revealed the following:

"..All department managers/directors, and hospital staff shall report a Sentinel Event or Serious Safety to the Risk Manager and /or to a member of the hospital's administrative team. Each root cause analysis (RCA) will have an executive sponsor. The executive sponsor will be the senior leader of the area where the event occurred. The executive sponsor will report status updates of the RCA and implementation of improvement activities to the Patient Safety Committee ..."

Based on observation, interview, and record review, the facility failed to provide nursing services to adequately meet the needs of patients. The facility failed to ensure sufficient numbers of staff to provide patient care on 2 of 2 units that were observed (Medical-surgical and Step-down). The facility failed to:

A. ensure they staffed the Medical-surgical unit according to patient acuity.

B. ensure sufficient numbers of nurse's assistants to assist with activities of daily living care on both units.

C. ensure patients baths, linen changes, range of motion, turning and repositioning and/or Foley catheter care were being provided on Patient #'s 1, 2, 3, 4, 6, and 12.


Refer to A tag 0392 for additional information.


D. ensure medications were administered according to hospital policies for 5 (Patient #'s 1, 8, 12, 13, and 15) of 16 sampled patients.

The facility failed to ensure Potassium supplements, respiratory medications, and pain medication were administered as ordered by the physician and timely.


Refer to A tag 0405 for additional information.


E. ensure 5 (Patient #'s 1,3, 4, 11, and 13) in 16 sampled patients received intravenous fluids and care per physician orders and their facility's policy.

The facility failed to ensure intravenous were administered at the rate ordered by the physician.

The facility failed to ensure intravenous site and tubing were changed out every 72 hours as their policy required.


Refer to A tag 0409 for additional information.

Based on observation, interview, and record review, the facility failed to ensure sufficient numbers of staff to provide patient care on 2 of 2 units that were observed (Medical-surgical and Step-down). The facility failed to:

A. ensure they staffed the Medical-surgical unit according to patient acuity.

B. ensure sufficient numbers of nurse's assistants to assist with activities of daily living care on both units.

C. ensure patients baths, linen changes, range of motion, turning and repositioning and/or Foley catheter care were being provided on Patient #'s 1, 2, 3, 4, 6, and 12.

This deficient practice had the likelihood to cause harm to all patients admitted to both units.


Findings:

MEDICAL -SURGICAL UNIT (TELEMETRY)

During confidential interviews the following was stated about staffing:

"The nurse to patio ratio is high. After ringing the call light, it takes a long time to get them in here. When the family is here the staff very seldom come in the room."

"The staffing is horrible. The patients are assigned by room number instead of acuity."

"Sometimes you have 5 out of 6 total care patients. They are incontinent, need turning every 2 hours, status post-surgery patients, aspiration pneumonia, needs all medications crushed, have to be fed, and. swallowing problems. Three aides on the hall are spread out, with so many patients that they cannot really help. It is hard to get the medications out on time because some of the patients have so many."


Review of assignment sheets for the timeframe of 04/22/2019-05/05/2019 revealed nurses being assigned a group of patients by room order not acuity.


Review of timesheets for the timeframe of 04/22/2019-05/05/2019 and the staffing matrix the following was revealed:

Seven (7) out of fourteen (14) days the facility did not have the minimal number of nurse's aides the matrix called for. The following was listed on some days:

On 04/27/2019 there were 2 nurse's aide on the day shift for 32 patients and 2 on the night shift for 27 patients.

On 04/28/2019 there were 2 nurse's aide on the day shift for 30 patients and 2 on the night shift for 33 patients.

On 04/30/2019 there were 2 nurse's aide on the night shift for 39 patients.

On 05/02/2019 there were 2 nurse's aide on the night shift for 30 patients.

On 05/04/2019 there were 2 nurse's aide on the night shift for 37 patients.


During an interview on 05/07/2019 after 11:20 a.m., Staff #12 confirmed the nurses. Staff #12 said he was staffing more nurses when they did not have enough nurse's aides. Staff #12 confirmed he was not staffing by acuity though.

During an interview on 05/07/2019 after 11:20 a.m., Staff #3 said that corporate had provided new guidelines for assigning patients by acuity, but they had not implemented it yet.


STEP-DOWN UNIT

During confidential interviews the following was stated about staffing:

A patient "stayed up in the chair for over 5 hours."


"The nurses usually do total care on patients. Patients supposed to get baths every day, but sometimes its pushed to the next shift. Linen changes are supposed to be done with baths." There is no place in the charts for documenting baths or linen changes."


"If there is no order for physical therapy, I do range of motion myself if I have time"


Review of assignment sheets for the timeframe of 04/23/2019-05/05/2019 revealed the unit was short nurses on 3 days/night during this time frame. There was no assistance from a tech to help with activities of daily, but one day during this timeframe.


During an interview on 05/07/2019 after 1:30 p.m., Staff #10 confirmed her staffing numbers.


RANGE OF MOTION AND TURNING AND REPOSITIONING


Patient #12

Review of the clinical record of Patient #12 revealed he was admitted on 04/29/2019 with diagnoses of sepsis, urinary tract infection and pneumonia.

Review of a physician progress notes dated 04/30/2019 revealed Patient #12 had left hemiplegia, contractures of the left side and had a history of peripheral vascular disease.

Review of a physician's order dated 04/30/2019 revealed Patient #12 was to be turned every 3 hours while awake.

During an observation on 05/06/2019 after 12:20 p.m., Patient #12 was observed to be totally dependent on staff for care. Patient #12 was unable to turn or feed himself and had a right above the knee amputation, left foot with toes amputated. Patient #12 had a protective dressing to the buttock to prevent skin breakdown.

During a confidential interview it was revealed that Patient #12 was not receiving any range of motion and he had a history of forming clots. When nursing staff were asking if they could give him range of motion they said it was physical therapy's job. They don't do that.

Review of the clinical record revealed no documentation of orders for physical therapy or nursing performing range of motion.

Review of turning and repositioning dated 05/06/2019 revealed documentation of a 4-hour timeframe where Patient #12 was not turned.

During an interview on 05/06/2019 after 12:00 p.m., Staff #2 confirmed Patient #12 was not receiving range of motion and the lack of turning.


Review of the facility's policy named "Nurse Practice Guidelines: Integumentary" dated 10/2017 revealed the following:

"Reposition patients q 2 hours and PRN to prevent pressure.
" Passive range of motion (ROM) will be done on immobile patient every 12 hours and PRN."



Patient #1


Review of the clinical record on Patient #1 revealed he was a 67-year-old male admitted on 12/01/2018 with diagnoses of sepsis, urinary tract infection and pneumonia.

Review of physician orders dated 12/02/2019 revealed Patient #1 was on bedrest.

Review of nurses notes and patient care logs while on the Medical- Surgical unit from 12/01-08/2018 revealed no documentation of turning and repositioning while in bed.

During an interview on 05/07/2019 after 10:00 a.m., Staff #12 and 20 confirmed the documentation.

Review of the facility's policy named "Nurse Practice Guidelines: Integumentary" dated 10/2017 revealed the following:

"Reposition patient's q 2 hours and PRN to prevent pressure.


FOLEY CATHETER CARE


Review of the clinical record of Patient #12 revealed he was admitted on 04/29/2019 with diagnoses of sepsis, urinary tract infection and pneumonia.

During an observation on 05/06/2019 after 12:20 p.m., Patient #12 was observed to have an indwelling Foley catheter.

Review of nursing shift reports dated on 05/05/2019 revealed the Foley catheter was placed in 04/24/2019 (11 days ago and prior to admission).

Review of physician's progress notes dated 05/06/2019 revealed Patient #12 was ". Status post sepsis, Pseudomonas urinary tract infection in a patient, who has indwelling catheter." ..." Change the Foley catheter today and monitor clinical progress."

There was no documentation of Foley catheter care in the chart.

Review of the facility's policy named "Nurse Practice Guidelines: Integumentary" dated 10/2017 says that "Foley care will be done every 24 hour."



39801

Review of medical records on 5-6-2019 after 11:00 AM revealed the following:


FOLEY CARE CARE

Patient # 6

Patient #6's Foley catheter was inserted on 5/3/2019. There was documentation for Foley care on 5/3/2019 and 5/5/2019. There was no documentation in the medical record for Foley care on 5-4-2019.

Staff #17 confirmed the above findings.

Review of the policy named "Nurse Practice Guidelines: Integumentary" dated 10/2017 revealed the following:

"Foley care will be done every 24 hours."


BATH & LINEN CHANGES

Patient # 2
The patient was admitted on 3/4/2019. There was no documentation for baths or linen changes in the record for the admission of 3-4-2019 to 3-7-2019.

Patient #3
The patient was admitted on 5-2-2019. As of 5-6-2019 there was no documentation in the chart for baths or linen changes.

Patient # 4
The patient was admitted on 5/1/2019. There was documentation in the chart on 5-1-2019 that the patient was self-care and had bath care on 5-1-2019. There was no other documentation as of 5-6-2019 in chart for baths or linen changes.

Patient #6
The patient was admitted on 5/2/2019. There was documentation on 5/3/2019 for bath and linen changes. There was no other documentation in the chart as of 5-6-2019 for baths or linen changes.


Review of the CNA/NURSE TECH SKILLS for February 26&28, 2019 revealed the following subjects were covered for all CNA/Nurse tech's:

DOCUMENTATION- CNA CHARTING
Tech Charting documentation...

CHG BATHS

CHG HIBICLENS - Daily Hibicleans Bathing with Hibicleans

BEDSIDE SHIFT REPORT involves the patient in the report of their care.


Interview with the Education director on 5-7-2019 after 2 PM confirmed the above education was required for all nurse techs/CNA'S.


Patient Interviews conducted on 5-6-2019 after 1030 AM revealed the following:

Patient #3

Patient #3 said she was a paraplegic. Patient #3 said she had been in hospital since Thursday, referring to May 2, 2019. Patient #3 said her sheets had been changed one time since admission. Patient #3 said had not been offered help with baths since admission. Staff #3 said her linens had not been changed since admission but she was going to ask for them to be changed today.


Patient #4

Patient # 4 said he had been in hospital since 5-1-2019. Patient #3 said he had not been offered help with bathing or any ADL's (Assistance with Daily Living) since he was admitted. Patient #4 said his linens had not been changed since admission.


During confidential interviews with staff on 5-6-2019 after 11:00 AM the following was stated about staffing:

"There is not enough techs on the floor to handle the patient load."

"The nurses routinely have 6 patients each on the floor. It is hard to get all the care done. The techs are overwhelmed and cannot help nurses much."

"The staffing is low and the nurses are overwhelmed."

"I feel like the patient care is compromised. I cannot be compassionate to the patient because I have to stay strict to the schedule: document assessments, give meds, call physicians, etc. I feel disconnected from the patients. I want to have same passion for taking care of patients as I did as a new nurse but it's hard. Morale is down. There is a high percentage of travel nurses. The long term nurses don't feel like they are being heard. Administration doesn't care about longevity or long term employees."

"Patient assignments are based on numbers not acuity. If you are assigned four total care patients without help, it's hard to get all care done. There is not always a tech available to help."

Based on observation, interview, and record review, the facility failed to ensure medications were administered according to hospital policies for 5 (Patient #'s 1, 8, 12, 13, and 15) of 16 sampled patients

The facility failed to ensure Potassium supplements, respiratory medications, and pain medication were administered as ordered by the physician and timely.

This deficient practice had the likelihood to cause harm in all patients receiving intravenous therapy.


Findings:


Patient #15

Review of the clinical record of Patient #15 revealed she was a 62-year-old admitted on 05/05/2019 with an new onset of atrial fibrillation (irregular rapid heart rate).

Review of lab results dated 05/06/2019, collected at 4:20 a.m. and received at 5:13 a.m. revealed the following:

A low Potassium level of 3.4 with reference ranges being 3.6-5.2.


Review of physician's orders on Patient #15 revealed a Potassium protocol. According to the protocol the following was documented:

"PO POTASSIUM PROTOCOL~IF SERUM POTASSIUM is between 3.3 and 3.4 mEq per Liter, THEN total potassium replacement is 20 mEq KCL orally or enterally, every 2 hours times 3 doses. Action Required - Recheck serum potassium 4 hour after last dose administered"


During an interview on 05/06/2019 after 4:10 p.m., Staff #18 said, the lab on Patient #15 was received that morning at 5:13 a.m. The protocol was not started because Patient #15 was NPO (nothing by mouth) for a possible surgery. They found out at noon that Patient #15 was not going to surgery. Staff #18 said, she talked to the physician around 12:00 p.m. and was told to give the medication orally, as soon as possible. Staff #18 said, she was going to give the medication when Patient #15 woke up. Staff #18 said, she did not want to give the medication to Patient #15 because she was afraid she would aspirate. Staff #18 confirmed there was no order written to initiate the protocol or no documentation to indicate the physician had been talked to about the potassium.

During an observation on 05/06/2019 after 4:20 pm., Patient #15 was noted to have IV fluids infusing.

As of 4:20 p.m. (over 11 hours after the lab results), the protocol had not been initiated. There was no documentation on the chart that staff talked to the physician about an alternate route of administering the medication.


Patient #13

Review of a clinical profile on Patient #13 revealed he was a 61-year-old male who was admitted on 04/29/2019 for weakness and falling.

Review of the home medication reconciliation sheet and MAR dated 04/30/2019 revealed Patient #13 was on the respiratory medication Breo one puff every day for chronic obstructive pulmonary disease.


During an interview on 05/06/2019 after 11:00 a.m., Staff #16 confirmed she was Patient #13's nurse. Staff #16 looked through the medication administration record (MAR) and confirmed Patient #13 was supposed to receive the home medication Breo every morning at 9:00 a.m. Staff #16 said the family had taken it home on yesterday. Staff #16 said the morning dose of the medication today had not been given. Staff #16 checked the MAR and it showed the medication had not been administered at all.


Patient #12

Review of the clinical record of Patient #12 revealed he was admitted on 04/29/2019 with diagnoses of sepsis, urinary tract infection and pneumonia.

Review of physician orders dated 04/30/2019 revealed Patient #12 had an order for the respiratory medication Ipratropium-Albuterol 0.5-2.5 milligrams/milliliter every 4 hours.

Review of the medication administration record revealed that on 05/01/2019 Patient #12 missed a dose and there was no documentation as to why. Patient #12 went over 7.5 hours without a treatment.


Patient #1

RESPIRATORY MEDICATION

Review of the clinical record on Patient #1 revealed he was a 67-year-old male admitted on 12/01/2018 with diagnoses of sepsis, urinary tract infection and pneumonia.

Review of physician orders dated 12/01/2018 revealed an order for the respiratory medication Duoneb every 6 hours.


Review of medication administration records revealed the following:

On 12/05/2018 a treatment was given at 10:00 a.m. and another was given over 9 hours later at 7:00 p.m. After the 7:00 p.m. treatment, another one was given over 12 hours later on 12/06/2018 at 7:00 a.m.

On 12/07/2018 a treatment was given at 1:00 a.m. and another was given over 10 hours later at 11:44 a.m.


PAIN MEDICATION

Review of physician orders dated 12/02/2018 revealed an order for Norco 5-325 milligrams, orally every four hours if needed for pain 4-6 on scale.


Review of the medication administration records and patient care notes dated 12/06/2018 revealed "Hydrocodone given for cough, per patients request." There was no documentation of Patient #1 having pain at this time.


The staff failed to follow the physician's order.


During an interview on 05/07/2019 after 10:00 a.m., Staff #12 and 20 confirmed the documentation in the charts.



39801

Patient #8

Review of Patient #8's medical record revealed the following:

5-1-2019 - Ipratropium-Albuterol 0.5/2.5 - 3 MG/3ML was ordered to be given every 4 hours-INT. The order was active for 5-1-2019 to 5-2-2019. There was no documentation in the respiratory tab that medication Ipratropium-Albuterol was given on 5-1-2019. There was no documentation in the medical record for the omittance/missed medication.

5-2-2019 - Ipratropium-Albuterol 0.5/2.5 - 3 MG/3ML was ordered to be given every 4 hours. The order was active for 5-2-2019 to 5-5-2019.

There was no documentation in the respiratory tab that the medication Ipratropium-Albuterol was given on 5-2-2019. There was no documentation in the medical record for the omittance/missed medication.

There was a missed dose documented on 5-3-2019 at 4 AM. There was no reason documented in the record for the missed dose.

There was a missed dose documented on 5-5-2019 at 4 AM. There was no reason documented in the record for the missed dose.

Staff #12 Confirmed the above findings.


Review of the facility's policy named "Medication Administration Times" dated 12/2017 revealed the following:

E. Time-critical scheduled medications are those which an early or late administration of greater than thirty minutes (+/- 30 minutes) might cause harm or have significant, negative impact on the intended therapeutic or pharmacological effect.

..Time critical - Medications scheduled every 4 hours or more frequently.."

Based on observation, interview, and record review, the facility failed to ensure 5 (Patient #'s 1,3, 4, 11, and 13) in 16 sampled patients received intravenous fluids and care per physician orders and their facility's policy. The facility failed to:

A. ensure intravenous fluids were administered at the rate ordered by the physician.

B. ensure intravenous site and tubing were changed out every 72 hours as their policy required.


This deficient practice had the likelihood to cause harm in all patients receiving intravenous therapy.


Findings:


Patient #13

Review of a clinical profile on Patient #13 revealed, he was a 61-year-old male who was admitted on 04/29/2019 for weakness and falling.


Review of a medication administration record (MAR) dated 04/30/2019 revealed, Patient #13 had a diagnoses of chronic obstructive pulmonary disease.


Review of "Shift Assessment" notes revealed the following:

Patient #13 had a 22 gauge intravenous in the left forearm which was inserted on 05/02/2019 and there was a tubing change.

On 05/03/2019, 05/04/2019 and 05/05/2019 there was documentation of Patient #13 having the same IV site.


During an observation on 05/06/2019 after 11:00 a.m. (4 days later after 05/02/2019), Patient #13 was observed with a 1000cc bag of normal saline infusing intravenously (500 cc was left). Patient #13's intravenous (IV) site was edematous, slightly red, and was not dated. The IV tubing was also not dated.

Review of physician orders revealed no current order on the chart for the fluids to be infusing on Patient #13.


Staff #2 confirmed the IV site, the fluid hanging and no identifications on the site and tubing.

Staff #16 confirmed, the information in the chart and that the IV was changed on 05/02/2019. Staff #16 reported that she only knows when the IV was changed out from report sheet. Staff #16 reported, they normally put stickers on the sites and tubing to indicate when they were changed. Staff #16 confirmed, there not being an order for the normal saline to be infusing.


Patient #11

Review of the clinical record on Patient #11 revealed, she was a 92-year-old female who was admitted on 05/01/2019 with a diagnosis of pneumonia.

During an observation on 05/06/2019 at 12:13 p.m., Patient #15 had a 1000 cc bag of intravenous fluid of 5 percent Dextrose and Lactated Ringers infusing at 75 cc per hour (approximately 300c was left in the bag). There was no date on the IV site nor the IV tubing.

Review of physician orders revealed 5 percent Dextrose and Lactated Ringers was to be infusing at 100cc per hour.

Review of the last "Shift Assessment" notes dated 05/05/2019 revealed Patient #11's IV was inserted on 05/01/2019.

According to the same notes on 05/03/2019, 05/04/2019 and 05/05/2019 there was documentation of Patient #13 having the same IV site.

Staff #2 confirmed the IV site, the fluid hanging and no identifications on the site and tubing. Staff #2 said the site and tubing were supposed to changed every 72 hours.


Patient #1

Review of the clinical record on Patient #1 revealed, he was a 67-year-old male admitted on 12/01/2018 with diagnoses of sepsis, urinary tract infection and pneumonia.

Review of a physician's order dated 12/02/2018 revealed, Patient #1 had an order for intravenous fluids of Normal saline infusing at 100 cc per hour. On 12/04/2018 the rate was changed to 75cc per hour.

Review of nursing "date of service notes" from 12/01-07/2018 (7days) revealed Patient #1 had an 18-gauge IV in the right antecubital that was inserted on 12/01/2018


During an interview on 05/07/2019 after 10:00 a.m., Staff #2 confirmed the IV site had not been changed.


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Patient #3

The initial insertion date of the IV catheter was noted as 5-2-2019 at 2138. The IV was noted as changed to left FA on 5-6-2019. The IV tubing was changed on 5-6-2019. The change was over 4 days from previous insertion date (96 hours).


Patient #4

The initial insertion date of the IV catheter was noted on 4-30-2019 in the ED (Emergency department). The IV and IV tubing was noted as changed on 5-5-2019; over 5 days later (120 hours) from previous insertion date.


Review of the facility policy titled, "IV Primary and Secondary Administration Set" with an approval date of 8/2017 revealed the following:

"POLICY
1. Primary Tubing is to be changed every 72 hours"


Review of the facility policy titled, "Intravenous IV Insertion and Care" with an approval date of 9/2018 revealed the following:

"POLICY
10. IV sites must be changed every 72 hours. If unable to access a new site, notify physician for order to retain present site and document in nurses notes if no contraindications."