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Based on observation, interview, and patient record review, the facility failed to protect the rights of patients to receive care in a safe setting.

Findings:

The facility did not implement policies and procedures to ensure safety and safe patient outcomes. Refer to A 144.

Based on interview, and record review, the facility failed to ensure patient safety in a safe setting, as there was not a consistent process of communication between health team members as it related to fall precautions. Further, staff were not consistently knowledgeable of fall risk policy and procedure in the emergency department (ED). This failure resulted in the fall and subsequent death of one patient (N 406) in the radiology department waiting area and has the potential to result in other patients falling and getting hurt or injured while in the hospital setting.

Findings:

During the course of a complaint investigation, the facility failed to demonstrate it had implemented their policy and procedure on Fall Prevention and Communication Among Caregivers.

1. A review of the Emergency Department (ED) notes indicated Patient N406, a 76 year old male, was brought to the emergency department (ED) annex fast track (a part of the ED where patients are triaged) via ambulance on 2/11/15 at 2:54 p.m. Patient N406 was brought in from a skilled nursing facility (SNF) with the presenting problem of right buttock cellulitis with possible abscess (a bacterial infection in the tissues with possible pus). Patient N 406 was assessed/evaluated by a licensed nurse (LN 4) and was identified as at high risk for fall. Patient N 406 scored 65 in the fall risk assessment (facility assessment tool used to evaluate patients for fall risk). The facility's fall risk assessment tool indicated patients with a fall risk score of 55 and greater should have fall precautions initiated. LN 4 electronically documented N 406 was a high fall risk.

The facility policy and procedure entitled "Fall Prevention" dated 2/19/14, indicated, "Patients assessed as being at risk for falls are placed on "Fall Risk Precautions" and preventative safety interventions to reduce fall risk and prevent injuries...Fall Prevention Interventions for Identified AT RISK Patients: 1. Yellow Arm Band on Patient, 2. Falling Star Magnet placed on hallway doorframe, 3. Fall Prevention Sticker affixed to front of chart, 4. Bed alarm on, 5. Fall Risk, Fall Prevention addressed in nursing care plan ..." The preventive safety measures to reduce falls and prevent injuries mentioned above were not implemented for N 406.

Patient N 406, after being triaged, was transferred from the ED annex fast track to the main ED on 2/11/15 at approximately 5:00 p.m.. Patient N 406 did not have any identifiers to indicate he was a a high risk for falls. LN 5 assumed care for Patient N 406 in the main ED. The doctor ordered an ultrasound (a diagnostic imaging method). A transporter (T 1- person who brings patients from place to place in the hospital using a wheelchair or a gurney) was assigned to transport Patient N 406 from the ED to the Radiology Department.

T 1 brought Patient N 406 to the Radiology department via gurney. According to T 1, Patient N 406 was quiet, alert, and oriented. Patient N 406 did not have a yellow wrist band to indicate Patient N 406 was a fall risk and T 1 did not receive any verbal report from LN 5 that Patient N 406 was a fall risk. Upon reaching the Radiology area, T 1 parked Patient N406's gurney in the hallway and left the patient unattended with no report to the receiving staff of the fact that Patient N 406 was a high fall risk. According to interview, approximately eight to ten minutes after T 1 left, two radiology personnel who were in the radiology department office and the radiology technician who was in the radiology room heard a thud from the hallway where Patient N 406 was left unattended (the three radiology personnel were not in visual contact with Patient N-406). Patient N 406 was found on the floor. A Rapid response team was called (a team to quickly assess a patient and intervene when lifesaving care may be needed). Patient N 406 suffered a skull fracture and subdural hematoma (bleeding in the brain). Patient N 406 was on Coumadin (blood thinner) creating an increased risk factor for bleeding in the brain.
Patient N 406 subsequently expired on 2/12/15 at 9:40 p.m.. The death certificate listed the cause of death as : Complications of Intracranial Hemorrhage and Blunt Force Injury to the Head.

Interviews with the staff involved in the incident indicated the patient had no yellow band to indicate he was a high risk for fall, and no verbal report was given or received relating to Patient N 406's high risk for fall. The lack of communication between facility staff from LN 4 to LN 5 to T 1 and the staff in the radiology department resulted in the fall and ultimately death of Patient N 406.

According to administrative staff, the ED should be following the policy and procedure that encompasses's the whole facility regarding fall prevention.

2. On 5/18/15, the transfer of a high fall risk patient (N 407) from the ED to the MRI (Magnetic Resonance Image) department was observed with administrative staff. N 407 had an order from the physician to undergo an MRI. The order for transport was requested from the ED through the teletracking system (orders/requests for transport are generated electronically as text messages to transporters electronic hand held device). Part of the order through teletracking are boxes that should be checked if a patient is a fall risk, in this way communicating to the transporter to observe fall precautions for those patients at risk. Orders are entered either by a unit secretary or a licensed nurse. When asked if the unit secretary would be knowledgeable of patients assessed as a high risk for fall, there was no answer from staff. N 407 was transported to MRI via gurney and was observed with a yellow wrist band and red non skid socks on. ED staff explained that a yellow wrist band and red non skid socks are what they use to identify fall risk patients. Although there was some discrepancy between staff members as to what the red sox actually indicated. All staff seemed to grasp the concept of the yellow ID band indicating fall risk, however, some staff in the ED believed all patients wear the red socks and others indicated only fall risk patients wore the red socks. The facility had no yellow socks.

A review of Patient N 407's teletracking record indicated the request from the ED for transport to the MRI did not include the information that N 407 was a fall risk patient. MRI staff were also unaware that Patient N 407 was a fall risk since it did not appear on the order form. The MRI staff member actually performing the study indicated she was aware the patient was a fall risk but only because she had read the History and Physical (H&P), she was also not the staff member responsible for communicating to the transport team. When MRI staff requested a transport through teletracking for the return trip to the ED, the hand held device of transporter (T 2) was reviewed. It did not indicate that Patient N 406 was a fall risk.

Administrative staff were present for the observation and were unclear what system (there are two electronic systems utilized, one solely for the ED and one hospital wide) was utilized to place the order. Administrative staff were also unclear as to why the fall risk score did not transfer into the electronic order (there was a fall risk score area which was blank on the order form).

There was a lack of clear communication between staff members in different departments. The facility had previous policy for yellow bands, yellow stickers, yellow room labels and had more recently added "red" socks to the mix. Staff were not consistent on interview as to which patients wore the red socks, some believing "all" patients and other only "Fall risk". The process for communication of fall risk when ordering out of ED department studies was not clear and lacked a fall risk assessment on the order and the teletracking communication to transport staff.

Based on observation, interview, and record review the facility failed to ensure competency skills checks were done for licensed nursing staff in the Intensive Care Unit (ICU), Coronary Care Unit (CCU), and Catheterization Laboratory (Cath Lab) areas of the hospital. This failure lead to licensed nursing staff choosing inappropriate equipment during an emergency situation. This failure also has the potential to lead to further incidents of inappropriate equipment being used during emergency situations.

Findings:

A review of the job description for the Director of Cardiovascular Services (DCS), indicated, "Essential duties, job Accountability and Responsibilities include the following.....Manage employee performance.....ensure high quality patient care and service excellence.....Use critical thinking to develop, evaluate, and refine processes's to improve quality."

A review of the facility's policy and procedure entitled, "Peri-Procedural Management of Patient (pre-procedure, intra-procedure, and post procedure)", dated 4/2013, indicated, Registered nurses, Cardiovascular Technicians, Radiology Technicians, and Scrub Technicians all, "Assists in Code Blue situation per ACLS protocol."

A review of the facility's policy and procedure entitled, "Code Blue", dated 5/2014, indicated, "Persons who are in a condition of respiratory arrest or cardiac arrest are provided with resuscitative measures by members of the employee staff per standards of the Emergency Cardiovascular Care Guidelines for Basic and Advanced Cardiac Life Support." The competency requirements for the "Code Blue Response Team" are Advanced Cardiac Life Support Certified (ACLS) and Pediatric Advanced Life Support Certified (PALS).

During an interview with a Cath Lab staff member (CLS1), on 5/19/15 at 9:15 a.m., the CLS1 stated, "No we don't have any education for code blue. We don't do mock codes or any skills check offs. Our annul competency is basically a self assessment tool which is reviewed with the manager of the department."
When asked how the facility would know it the staff member was actually competent or not, the CLS1 response was, "That's a good question." When asked if the department manager actually observed the CLS1 physically perform skills, the CLS1's response was, "No, my manager does not watch me do specific skills." CLS1 has worked in the department for 16 years.

During an interview with a Cath Lab staff member, (CLS2), on 5/19/15, at 11:00 a.m., CLS2 stated, "No we don't do any skills training or updates unless it is a new piece of equipment." CLS2 indicated the other facility he came from always did skills updates for their Cath lab staff, but since he had been here he had not had any skills updates. CLS2 has worked in the department for over a year.

During an interview with a Cath Lab staff member, (CLS3), on 5/19/15 at 12:00, CLS3 indicated when he worked in a different department there were always skills updates going on, but that since he began working in the Cath Lab area he had not had any skills updates done. CLS3 also indicated the only time skills updates were done was when a new piece of equipment was entered into use in the department. CLS3 indicated he had been an employee of the department for the past 4 years.

During an interview with the DCS, on 5/20/15 at 10:00 a.m., the DCS stated, we don't do any mock codes or any skills updates unless there is a new piece of equipment being introduced into the department. Our process is the staff do a self assessment worksheet of their skills and then I meet with them annually to review the self assessment."








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A review of the facility's critical care unit (CCU) policy and procedure entitled: Competency of Staff, last revised 11/04/2013, indicated CCU license nurses (LN) competencies are reviewed at least annually, and revised in response to changing patient care needs and/or population. Furthermore policy states annual competency validation is completed through training modules, post- tests, skills labs, demonstration, documentation and direct observation.
During a tour of the CCU on 5/19/15 at 9:30 a.m., the CCU manager (CCUM) was questioned related to the CCU LN's competency education and how LNs competency was validated to assure LNs are providing safe care in a high risk, fast paced environment, considering the CCU is a specialized unit that requires highly specially trained nurses.
CCUM provided year 2013 excel spreadsheet of all CCU LNs and relevant competency skills (e.g. Heart & Balloon pump trained, Hypothermia, Swan-ganzs, Arterial lines, NIHSS-stroke, etc.). This list indicates which LN is considered "competent" for the above skills.
The CCUM and CCU clinical educator (CCUE) were questioned regarding the 2013 skills competency spreadsheet accuracy. Both of them were not sure on the accuracy of the competency spreadsheet. They both agreed that once a LN is competent on a skill LNs are not checked off again because they are already considered "competent" on that skill and the time frame when LN's were checked off did not matter (can be 2-10 years).
According to both the CCUM and CCUE, LNs are checked off (validated) on their CCU skills upon hiring and once they are considered competent then they don't have to be validated again.
During an interview with CCUE on 5/20/15 at 12:05 p.m., CCUE was asked on the methodology used to validate CCU LNs skill competency. CCUE stated "myself, the CCU manager, and charge nurse know which nurses are competent on certain skills e.g. open-heart & balloon pump trained, hypothermia, swan-ganzs, arterial lines, stroke etc. This is a small unit and we keep a close eye on them." CCUE was asked regarding the 2013 skills competency spreadsheet accuracy again. CCUE stated "I don't know, I did not know this competency spreadsheet existed, I did not do this." According to CCUE, the CCU LNs education files are with her. She stated "I have my own education files.'
During another interview with CCUE on 5/21/15 at 8:45 a.m., she was asked to provide LNs education files to review their CCU competency skills validation. We went into CCUE's office where she supposedly had staff education files. LNs names were chosen randomly to review CCU skills competency education files. CCUE was not able to provide any LNs CCU skills competency education files.
CCUE appeared fluster opening various drawers of her office in attempt to locate education files for LNs. She opened various folders consisting of in-service rosters for various hospital-wide education topics but unable to provide with requested CCU skills competency education files.
On 5/21/15 at 9:00 a.m., an interview with quality director (QD) was held who stated "Hospital wide, the hospital does not have an education department. The unit's clinical educators are responsible for the LNs specific education needs and competencies."
During an interview with the CCU director (CCUD) on 5/21/15 at 9:05 a.m., the CCUD stated the hospital has an education committee where current education needs for the entire hospital are determined but each department educator is responsible for unit specific LNs education needs.
During another interview with CCUM on 5/21/15 at 9:10 a.m., she stated "the hospital has an education tracker system and maybe the CCU education competency skills documentation or certificates are there. This system is for the education taken in the facility, for mandatory education such as advanced cardiac life support (ACLS), basic life support (BLS), Fire cards etc. The system tracks education courses for LNs if they want to bring their continue education units (CEU) certificates but is up to the LNs."
Four LNs education tracker summary reports were provided, 4 out of 4 competency skills from spreadsheet did not match education on summary reports.
During concurrent interviews at facility on 5/21/15 at 9:45 a.m., the CCUM, CCUD and CCUE were asked to provide documentation of LNs critical care training (in-house or outside training) before LNs being hired into the CCU at this facility.
CCU LNs competency and specialty training documentation to validate competency was not provided during the validation survey.

Based on observation, interview, and record review the facility failed to ensure nursing staff were communicating effectively regarding patient care and implementing a plan of care for fall risk patients. Further facility staff failed to implement facility policy and procedure related to fall precautions. This failure resulted in patient (N 406) falling from a gurney while left unattended and suffering a fatal head injury. Four patients on the fourth floor who were identified as high risk for falls did not have a yellow wrist band and red socks as per facility policy to identify these patients as high risk fall patients. This failure had the potential to result in these four patients falling and injuring themselves.

Findings:

A record review of patient (N 406's) chart, on 5/18/15, indicated patient (N 406) was brought via ambulance to the emergency department (ED) annex fast track and was assessed by licensed nurse (LN 4). According to LN4's assessment, under fall risk, patient (N 406) had a history of fall and the fall risk score assigned to Patient 406 per LN 4 was 65. Facility policy indicated a score greater than 55 or equal to 55 is a "High risk for fall". LN 4 charted, "Patient is at high risk for fall. Initiate falls precautions for high risk score greater than 55."

Patient (N 406) was transferred over to the main ED. Licensed nurse (LN 5) assumed care for Patient N 406. Although Patient (N 406) was initially identified as a high fall risk, no yellow wrist band and red socks were put on the patient per facility policy. LN 5 was unaware that patient (N 406) was at high risk for fall.

Patient N 406 had an order to go to the radiology department for an ultrasound study. Patient (N 406) was transported via gurney to the radiology department. There was no indication and no report given by the licensed nurse that Patient N 406 was a high risk for fall, consequently, Patient N 406 was left unattended on a gurney, in the hallway of the radiology department waiting for an ultrasound study. Patient N 406 fell from the gurney resulting in a head injury and bleeding in the brain and subsequently expired due to the head trauma.

During a record review and observation on 5/18/15, at 2:50 p.m., on the fourth floor, a list (which the facility referred to as a "hot list") was provided to this surveyor. The list had all the names of patients who were at high risk for falls on the fourth floor. During a tour of the floor, four of the patients on the list did not have a yellow wrist band to indicate fall risk per facility policy.

During an interview with the licensed nurse (LN 1), on 5/18/15, at 2:50 p.m., LN 6 agreed the four patients should have yellow wrist bands to identify them as high risk fall patients.

The facility policy and procedure entitled "Fall Prevention" dated 2/19/14, indicated, "Patients being assessed as being at risk for fall are placed on "Fall Risk Precautions" and preventive safety interventions to reduce fall risk and prevent injuries...Fall Prevention Interventions for Identified AT Risk Patients Yellow Arm Band Placed on Patient."

Based on interview and record review the facility failed to ensure prn (as needed) medication orders for one of seven patients (Patient N-206) covered specific instructions for use. Orders for three prn medications indicated for pain with one having a pain scale level and with no pain scale level for the other two. There was no documentation that indicated the facility attempted to clarify a pain scale level to use with the physician.

Findings:

The facility policy and procedure entitled "Physician's Orders-Including Telephone or Verbal Order;Questioning or Clarifying Order; Transcribing & Shift Check Process" dated 4/12/13, indicated...Order-Clarifying or Questioning: When content of an order is not legible, unclear or in question as to appropriateness considering the patient's condition, it requires clarification in a timely manner. The physician should be contacted immediately...This may be done by by an individual authorized by law to do so, within their scope of practice and limitations of their licensure or certification (i.e. RN, LVN...)..."

The facility policy and procedure entitled " Pain Management Adult, Pediatric and Neonate" dated 2/20/14, indicated the " Purpose: To establish pain assessment/management for adults...3. The patient will be educated to use the pain scale (if possible) to report level of pain and to establish his/her comfort...1. 0-10 numeric pain intensity scale...This scale is used by simply asking your patient for a verbal response i.e. " On a scale of 0 to 10, with 0 being no pain , and 10 as the worst possible pain, how would you rate your pain?... E. Intervention: 1. Interpretation of Physician Orders Mild-Score Corresponds to Pain Scale Range 1 to 3 Moderate- Score Corresponds to Pain Scale Range 4 to 5 Severe-Score corresponds to Pain Scale Range 6 to 10..."

Review of Patient 206's record reflected physician's orders dated 5/18/15 for Norco ( a combination pain medication- hydrocodone-an opioid and acetaminophen) 1 tab every 4 hours as needed for level 3 to 5 and an order for acetaminophen (mild to moderate pain reliever and fever reducer) 325 mg. (milligram) oral every 4 hours PRN pain or fever > (greater than) 100.5. Another physician's order dated 5/20/15 indicated tramadol ( a synthetic opioid agonist for moderate to moderately severe pain) 50 mg. oral every 4 hours PRN pain.

During a concurrent interview and order review with licensed nurse 1 (LN 1) on 5/21/15 at 9:40 a.m., she stated she would ask the patient the pain level and if more than five she would call the doctor and get something stronger. She also said that she would have clarified the Tylenol order when she received it because there was no pain scale.

During a concurrent interview and order review with LN 2 on 5/21/15 at 9:45 a.m., she stated she would call to clarify the order with the doctor for a pain parameter for the Tylenol and check with the doctor for an order for a parameter for the Tramadol for a higher level of pain.

Based on interview, record review, and policy review the facility failed to ensure telephone orders for patients N 202 and N 407 were authenticated within 48 hours as indicated by hospital policy.

Findings:

Review of the facility's policy titled " PHYSICIAN'S ORDERS-Including, telephone or Verbal Order; Questioning or Clarifying Order; Transcribing & Shift Check Process" dated 4/12/13, indicated...To define and standardize the process of physician orders;including telephone or verbal orders...This is utilized throughout the CMHS health system to maintain an accurate and legible electronic record... Telephone orders must be authenticated by physician within 48 hours according to Medical Staff Policy..."

The clinical record of patient N 202 was reviewed on 5/18/15 at 3:20 p.m. A Doctor's Order sheet dated 5/7/15 indicated a telephone order (TO) to continue patient's meds from home. There were six medications listed on the order. Review of "order audit trail " forms for each of the six medications reflected the orders were "Esigned by the ordering physician on 5/14/15, seven days after the the order was written. Further review of Patient 202's record indicated an order for IV fluids dated 5/10/15. An "order audit trail" form reflected no Esignature nor was there a signature on the handwritten TO at the time of the record review.

During concurrent record review and record review with LN 3 on 5/18/15 at 3:20 p.m., LN 3 agreed that one order was Esigned by the physician seven days after the TO was written and there was no written or Esignature on the order for IV fluids.






32661

The clinical record for resident (N 407) was reviewed on 5/20/15, at 11:30 a.m.. The doctor order sheet dated 5/16/15, at 9:10 a.m. indicated a telephone order from doctor (MD 1) to administer Dilaudid (pain medication) 1 mg (milligram) now. MD 1 had not authenticated the telephone order as of 5/20/15.

The facility "Medical Staff General Rules and Regulations" dated 11/18/14, indicated, "Verbal Orders...Within 48 hours such orders shall be authenticated with signature, date and time by the ordering practitioner, or by a covering practitioner if the ordering practitioner is unavailable."

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

1. Antibiotics being used had an indication for use.
2. Opened medications were not kept beyond 28 days.
3. Multi use medications entering into patient environments were used for only one patient.
4. Analgesia medication drip order transcribe incorrectly.


These failures had the potential to cause unwanted organisms to spread and grow, thus increasing the chance of infection for all patient's in the affected areas and the potential for unnecessary antibiotics to be utilized, and the potential to render medications ineffective, or make them unavailable during a procedure, and potential for patients to be over medicated and resulting in serious injury to patient.

Findings:

A review of the facilities policy and procedure titled, "Antibiotic Stewardship Program", dated 1/2014, indicates, "Drug therapy order shall include indication for use and anticipated duration."

According to the Centers for Disease Control (CDC), "Multi-dose vials should be dedicated to a single patient whenever possible. If multi-dose vials must be used for more than one patient, they should not be kept or accessed in the immediate patient treatment area. This is to prevent inadvertent contamination of the vial through direct or indirect contact with potentially contaminated surfaces or equipment that could then lead to infections in subsequent patients. If a multi-dose vial enters the immediate patient treatment area, it should be dedicated to that patient only and discarded after use." and, "If a multi-dose has been opened or accessed (e.g., needle-punctured) the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial."

1. During medical records review it was revealed that antibiotic orders in the Neonatal Intensive care areas (NICU), Labor and delivery, and post-partum areas were being administered without a clear indication for their use.

A review of N101's medical record revealed there was an order for antibiotics written on 5/17/15 without a clear indication for use.

A review of N'102's medical record revealed there was an order for antibiotics written on 5/18/15 with no clear indication for use.

A review of N103's medical record revealed there was an order for antibiotics written on 5/10/15 without a clear indication for use.

During an interview two assistant directors of pharmacy (ADP's), on 5/19/15 at 2 p.m., both ADP's indicated they reviewed the patient's medical records to be sure the antibiotic was appropriate for use. Both ADP's stated they looked at many different areas of the patient's medical records to be sure it was okay to use the antibiotic that was ordered. Neither ADP could show where there was a clear indicator within the medical records for the use of the antibiotics. Both ADP's acknowledged their policy and procedure was not being followed by the ordering physicians.






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3. During an observation of the ED environment on 5/18/15 at 10:30 a.m., there was a procedure cart in the nurses' station which had a multi-dose vial of Lidocaine and Sodium Bicarbonate injectable inside of one of the drawers. The vials had been uncapped and used before and left in the cart for future use.
Concurrently during an interview with license nurse (LN 7) she acknowledged lidocaine medication had a date of 5/17/15 (possibly open date), no time and no second date (discard date). Sodium bicarbonate multi-dose vial had no dates or times at all.
During an interview with the Director of Emergency Services (DES) on 5/18/15 at 10:35 a.m., the DES acknowledged the vials should not have been left in the cart for future use. The DES stated "The vials should have been discarded after they were used. My doctors left them there."
During an interview with the assistant director of pharmacy (ADP 2) on 5/20/15 at 9:20 a.m., ADP 2 stated "All our multi-dose vials are treated as single dose. They are to be used one time only and then the vial is discarded."
A review of the facility's policy and procedure entitled, "Medication Administration", revised 02/03/2015, indicated "All partially used multi-dose vials will be discarded by the end of the shift or end of the business day."
4. During the record review of N303 on 5/19/15 at 10:00 a.m., the medical record revealed there was an order for Fentanyl Citrate drip to be given for pain control in the intensive care unit (ICU). The electronic physician's order was Fentanyl Citrate drip to start at 25mcg (micrograms)/hour titrate up to maximum dose of 300 mcg/hour.
Upon review of patient's E-mar (electronic medication record) on 5/19/15 at 10:00 a.m., the Fentanyl citrate drip was started at 50mcg/hour on 5/18/15 at 11:16 p.m. by license nurse (LN 8) and continued until the morning of 5/19/15. The E-mar Fentanyl citrate protocol indicated "Start rate 25mcg/hour, titrate 25mcg/hour, maximum dose 300mg(milligrams)/hour".
During an interview with the assistant director of pharmacy (ADP 1) on 5/20/15 at 9:00 a.m., ADP 1 indicated that in this case the pharmacist typed in the wrong maximum dose of Fentanyl citrate in the protocol. According to ADP 1 in this facility the pharmacist has to manually type in the Fentanyl medication protocol dose. ADP stated "The pharmacist typed in Fentanyl citrate 300 mg/hour, instead of 300 mcg/hour as the maximum dose, this is an incorrect maximum dose of Fentanyl citrate."
According to ADP 1 the medication process is as follows:
1. Pharmacist gets the Fentanyl citrate physician order.
2. Pharmacist enters the order and titrating protocol parameters manually into Medi-tech (electronic medication system).
3. The LN compares the physician order for Fentanyl citrate with the E-mar and if there are any discrepancies the pharmacist is notified by the LN in order for the pharmacist to correct discrepancies.
4. Intensive care unit (ICU) LN acknowledges the Fentanyl medication order before administering the medication.
ADP 1 acknowledged neither of the healthcare personnel (LN or pharmacist) had recognized the Fentanyl citrate incorrect maximum dose and that there was a potential for fentanyl medication to be titrated to the maximum dose of 300 mg/hour instead of 300 mcg/hour. High dose of Fentanyl medication can cause patient to be over medicated with the potential for serious injury.
A review of the facility's policy and procedure entitled, "Medication Administration", revised on 2/3/2015, indicated "Medication will appear on patient's E-mar when pharmacy has completed transcription process correctly, LN has compared medication with doctor's order and acknowledged order before first dose of medication is given and that the medication shift check process has been completed correctly."

Based on interview with facility staff and review of documents the facility failed to ensure that the infection control officer implemented policies and procedures, based as much as possible on national guidelines that required adherence to nationally recognized infection prevention and control precautions, such as current Centers for Disease Control and Prevention (CDC) guidelines and recommendations, for infections/communicable diseases when not all physicians were required to provide documentation of screening for tuberculosis (TB).
Findings:
During an interview on 5/18/15 at 3:30 p.m., the nurse epidemiologist stated members of the medical staff were allowed to provide an attestation that they were free from infectious tuberculosis instead of the documentation required by hospital policies for tuberculosis screening of hospital personnel and outside contractors. The nurse epidemiologist stated the hospital followed Centers for Disease Control and Prevention guidelines for the screening of healthcare workers (HCWs). According to the Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings HCWs refer to all paid and unpaid persons working in health-care settings who have the potential for exposure to Mycobacterium tuberculosis through air space shared with persons with infectious TB disease. Part time, temporary, contract, and full-time HCWs should be included in TB screening programs. All HCWs who have duties that involve face-to-face contact with patients with suspected or confirmed TB disease (including transport staff) should be included in a TB screening program.

Based on observation and interview, the facility failed to ensure their infection control program was observed and practiced by staff. This failure had the potential to result in infections and complications of already compromised patients receiving intravenous medications and the possible transmission of infectious pathogens between patients, to staff, and the visitors in the hospital.

Findings:

During an observation on 5/18/15, at 2:50 p.m., on the fourth floor, an intravenous (IV) stand was observed beside the patient bed. The IV stand had three different IV solution bags. Each of these three IV solution bags had individual IV tubing. The first IV bag had no date on the IV tubing thereby giving no indication as to when it was first used and when it should be replaced. The second IV bag had a start date of 5/10/15 and a replacement/change date of 5/14/15 . The third IV bag had a start date of 5/13/15 and a replacement/change date of 5/17/15.

During an interview with licensed nurse (LN 1), on 5/18/15 at 2:55 p.m., LN 1 stated, "The first date indicates the day the IV tubing was first used. The second date indicates the date the IV tubing should be disposed. All IV tubing should be dated."

The facility policy and procedure entitled "Intravenous Therapy Management" dated 4/22/13, indicated "Tubing Change A. Change all peripheral IV, saline/heparin lock and secondary tubing sets, including the extension set as follows: 1. Every 96 hours."

Based on record review and interview the facility failed to ensure the anesthesia record was complete and accurate for one patient (N105). This failure led to N105's medical record being incomplete and an inaccurate reflection of the care and services that were provided to N105 during a critical emergency situation.

Findings:

A review of the Facility's policy and procedure entitled, "Amended and Restated Medical Staff General Rules and Regulations Of.......", dated 11/2014, indicated, "The attending practitioner shall be responsible for the preparation of a complete and legible medical record for each patient. It's contents shall be pertinent and current."

"A review of the facility's policy and procedure entitled, "Documentation for the Patient in the Cardiovascular/EP/IR Departments", dated 4/2012, indicated, "CVL/EP/IR personnel will accurately document the provision of care for the patient undergoing procedures in the department. Documentation will reflect the assessment of the patient, plan of care, procedure protocol to include medications delivered and treatment rendered.....IV site and fluids being administered.....Medications given/effect.....urinary output.....", and "Competency: Competency for documentation will be evaluated annually during performance reviews."

A review of N105's medical record revealed N105 was admitted with diagnoses including cardiac arrest, stroke, hypertension, and renal failure. N105 went to the cath lab on 3/6/15 for two medical procedures. The date on the anesthesia record was documented as 2/25/15. During the procedure N105 suffered a cardiac arrest and cardiopulmonary resuscitation (CPR) was initiated. The anesthesia record was incomplete as it was missing documentation of two doses of Epinephrine (a medication sometimes used to increase heart rate during a medical procedure) and it was also missing fluid intake and output amounts that occurred during the procedure.

During an interview with the anesthesiologist, on 5/19/15 at 3:07 p.m., the anesthesiologist stated, "I just forgot to write it down."

Based on observation and interview, the facility failed to ensure respiratory care services followed policy and procedure regarding changing of respiratory equipments in patient care areas. This failure had the potential to cause respiratory infection and complications to patients with respiratory problems.

Findings:

During an observation on 5/18/15, at 2:55 p.m., on the fourth floor, a transparent plastic bag was observed hanging by the head of the bed. The transparent plastic bag contained respiratory equipments for nebulizer treatments (device used for producing a fine spray of liquid medication used for inhalation treatments to improve breathing). The equipment consisted of a corrugated tubing, face mask, and an oxygen tubing with a medication chamber. There was no date written on any of the respiratory equipment. The lack of a date written on the respiratory equipments does not give an indication as to when the respiratory equipments should be replaced.

During an interview with licensed nurse (LN 1), on 5/21/15, LN 1 stated, "I agree. There should be a date. We have no way of knowing when RT supplies should be changed."

The facility policy and procedure entitled, "Equipment, Disposable (Care and Storage)" dated 5/3/12, indicated."Disposable items are single patient use only and are discarded in the appropriate container. Disposable supplies are replaced as follows: Every 72 hours (Tuesdays and Fridays) or p.r.n. 1. All nebulizers, IPPB circuits, and oxygen delivery devices. Entire set up is to be changed including equipment bags."