HospitalInspections.org

Based on document review and staff interview, the facility failed to monitor 5 of 7 contracted services through its quality assurance/performance improvement program (QAPI) to assure the services were provided in a safe and effective manner.

Findings:

1.) On March 10, 2011 at 10am, review of the quality program documents indicated lack of inclusion of the following contracted services in the quality program: biohazardous waste, lab, dietary, maintenance and mobile services.

Based on policy and procedure review, employee personnel file review and staff interview, the facility failed to ensure annual and semi annual safety training, as per policy, for 7 of 11 staff files reviewed (P2, P4, P5, P6, P9, P10 and P11).

Findings:
1. At 9:30 AM on 3/10/11, review of the policy and procedure, "NR 401", "Staff Development/In-Service Program" indicated in the "Policy" section:
a. "...3) Staff is expected to attend all mandatory in-services in addition to their yearly education day (CPR and CPI renewals)..."
b. "4) Staff Development/In-Service programs will be offered on an ongoing basis and as need arises. In addition, each staff person will have a mandatory education day each year consisting of re-certifying in CPI (Crisis Prevention Intervention), seclusion/restraint competencies....."
c. "6) Life Safety education is done through Human Resources and renewed annually through Essential Learning." (computer based learning process)

2. At 9:30 AM on 3/10/11, review of the policy and procedure, "NR 646", "CPI: Non-Violent Crisis Behavior Training/Retraining", indicated in the "Policy" area: "...All nurses and MHT (mental health technicians) are to complete the mandatory refresher session Crisis Prevention Training after initial training on a semi-annual basis..."

4. Review of personnel files at 11:30 AM on 3/9/11 indicated:
a. staff member P2, a MHT:
I. had CPI training on 5/10, but was lacking the second (semi-annual) training in CPI for 2010

b. staff member P4, a MHT:
I. had CPI training on 5/10, but was lacking the second (semi-annual) training in CPI for 2010
II. last had life safety education documented on 9/09 and lacked documentation of such training for 9/10

c. staff member P10, an ESC employee had:
I. had CPI training on 8/09, but was lacking both of the trainings (semi annual) in CPI for 2010
II. last had life safety education documented on 9/09 and lacked documentation of such training for 9/10

5. Interview with staff members NC and NF at 12:00 PM on 3/8/11 indicated:
a. annual life safety education for all staff is September of each year
b. staff members P4 and P10 missed the 9/10 annual education day
c. there is no process in place to track those who miss the annual education day and assist the employee in making up this policy required annual education/training
d. staff members P9 and P10 help in emergency safety interventions on the intensive in-patient unit
e. staff member P10 should not be responding to emergency safety events/situations since CPI training has not occurred since 8/09 (missed both CPI trainings in 2010)

Based on document review and interview, the facility failed to assure that 17 (P2, P4-6, P9-11, MD#1-9, AH#1) members of staff had certification in the use of cardiopulmonary resuscitation, including required periodic recertification.

Findings:

1. At 9:30 AM on 3/10/11, review of the policy and procedure, "HR 346", "CPR - Cardio-Pulmonary Resuscitation Training", indicated in the "Policy" section: "It is the policy of Oaklawn that CPR training is mandatory for all inpatient, residential and outpatient staff providing direct client care services" and "...A CPR review will be provided on an annual basis to demonstrate continued competency for the intensive services program personnel..."

2. Review of personnel files at 11:30 AM on 3/9/11 indicated:
a. staff member P2, a MHT:
I. last had CPR on 12/09 and was lacking the annual CPR training on 12/10
b. staff member P4, a MHT:
I. last had CPR on 9/09 and was lacking the annual CPR training on 9/10
c. staff member P5, a RN, had CPR dated 7/09 and was lacking annual CPR review documentation for 7/10
d. staff member P6, a RN, had CPR dated 4/09 and was lacking annual CPR review documentation for 4/10
e. staff member P9, an ESC (emergency safety counselor), had CPR dated 5/09 and was lacking annual CPR review documentation for 5/10
f. staff member P10, an ESC employee had:
I. last had CPR on 5/09 and was lacking the annual CPR training on 5/10
g. staff member P11, a student nurse extern working on the adult intensive psych unit, had CPR on 8/09, but was lacking the annual CPR documentation for 8/10

3. On March 10, 2011, review of credentialing files indicated MD#1-9 and AH#1 lacked documentation of CPR training.

4. Interview with staff members NC and NF at 12:00 PM on 3/8/11 indicated it was thought that CPR was only due every two years, however, facility policy indicates this is an annual requirement.

Based on policy and procedure review, patient medical record review and interview, the nursing administrator failed to ensure that nursing staff followed facility policies and physician orders for 10 of 15 records reviewed (pts. N1, N2, N4, N5, N9, N11, N12, N13, N14 and N15).

Findings:
1. Review of policy and procedures at 9:30 AM on 3/10/11 indicated:
a. policy number "NR 136", "Notation of Orders-Therapeutic and Diagnostic", indicated:
under procedures, in section "5) Vital Sign Orders": "a) Oral temperatures, pulse, respiration, and blood pressure are to be taken on ALL ADMISSIONS according to physician orders, and then taken according to unit guidelines. See policy NR 844."
b. policy number "NR 136", "Notation of Orders-Therapeutic and Diagnostic", indicated:
under procedures, in section "6) Height and Weight Orders": "a) Height and weight orders are taken on ALL ADMISSIONS...ii) Adult psych and senior inpatient: Weight weekly before breakfast."
c. policy number "NR 844", "Unit Vital Signs Protocols", indicated under "Procedures": "Adult Psych Inpatient Vitals signs are taken on admission and b.i.d. for three days and then daily, unless ordered otherwise by the physician. Adult Senior Inpatient Vital signs are taken on admission and b.i.d., unless ordered otherwise by the physician..."

2. Review of patient medical records through out the survey process of 3/8/11 to 3/10/11 indicated:
a. pt. N1 had:
I. an order for "Daily am weight and VS (vital signs)..." ordered on 1/19/11 with a daily weight missing on 1/24/11
II. an order for "Accuchecks ac (before meals) & HS (bedtime)..." written on 1/19/11 with the noon accucheck not performed on 1/25/11 due to "no glucometer" as noted by nursing

b. pt. N2 was lacking a weekly weight on Thursday, 2/24/11

c. pt. N4 had orders on 1/8/11 for "...4. Routine Vitals: b.i.d. X 3 days, then daily if within normal range..." with a second set of vital signs missing on 1/9/11

d. pt. N5 was lacking a weekly weight on Thursday, 12/9/10

e. pt. N9 had orders written on 1/14/11 for "daily am blood pressure checks" with blood pressure checks documented in the afternoon (not AM) as follows: 1/15/11 at 4:45 PM, 1/17/11 at 4:46 PM, 1/19/11 at 4:30 PM and 1/24/11 at 5:22 PM

f. pt. N11 had orders on 2/12/11 for "...4. Routine Vitals: b.i.d. X 3 days..." and was lacking documentation of a second set of vitals on 2/13/11

g. pt. N12 had:
I. admission orders on 1/5/11/ for "...4. Routine vitals: b.i.d. X 3 days, then daily if within normal range..." that were lacking a second set of vital signs on 1/5/11, 1/6/11 and 1/7/11
II. no documentation of a weekly weight on 2/10/11 and 2/24/11

h. pt. N13 had orders on 2/18/11 for "...4. Routine Vitals: b.i.d. X 3 days..." and was lacking documentation of a second set of vitals on: 2/20/11

i. pt. N14 had orders on 2/22/11 for "...4. Routine Vitals: b.i.d. X 3 days..." and was lacking documentation of a second set of vitals on: 2/23/11

j. pt. N15 had orders on 1/14/11 for "...4. Routine Vitals: b.i.d. X 3 days..." and was lacking documentation of a second set of vitals on: 1/15/11 and 1/16/11

3. Interview with staff member ND at 12:30 PM on 3/10/11 indicated staff is not following facility policy and physician orders for glucometer checks, vital signs and weight documentation

Based on medical record review, policy and procedure review and interview, the medical staff failed to follow facility policy, related to authentication of verbal/telephone orders within 48 hours, for 7 of 15 records reviewed (pts. N2, N3, N5, N6, N8, N9 and N12).

Findings:
1. at 9:30 AM on 3/10/11, review of the policy and procedure "NR871", "Verbal/Telephone Orders", indicated:
a. under "Procedure", in section 4., it reads: "The physician/advanced practice nurse must sign and date the T.O./V.O. order within 48 hours..."

2. review of patient medical records through out the survey process indicated:
a. pt. N2 had:
I. admission telephone orders written on 2/17/11 at 1320 hours were not yet authenticated by the ordering practitioner
II. telephone orders written 2/19/11 at 1320 hours that were authenticated "3/ / " (day and year were blank, but the month was "3" or March
III. Verbal orders written 2/23/11 at 1433 hours that were authenticated 3/2/11

b. pt. N3 had:
I. a telephone order written on 1/5/11 at 1408 hours that was authenticated on 1/11/11
II. Verbal orders on 12/8/10 at 1010 hours that were authenticated on 12/11/11

c. pt. N5 had:
I. a telephone order written 12/16/10 at 2156 hours that was authenticated on 12/20/10
II. a telephone order written on 12/17/10 at 1345 hours that was authenticated on 12/20/10

d. pt. N6 had telephone orders written on 2/14/11 at 2145 hours that was not yet authenticated

e. pt. N8 had admission telephone orders written 1/28/11 at 1110 hours that were authenticated on 1/31/11

f. pt. N9 had:
I. telephone orders written on 1/14/11 at 1835 hours that were not yet authenticated
II. three different telephone orders written on 1/22/11 that were not yet authenticated

g. pt. N12 had:
I. telephone orders written on 2/3/11 at 1045 hours that were authenticated on 2/7/11
II. standing orders of 2/4/11 signed 3/2/11

3. interview with staff member ND at 12:30 PM on 3/10/11 indicated:
a. facility policy and procedure requires practitioner authentication of telephone and verbal orders within 48 hours of the order
b. patient orders, as stated in 2. above, were not authenticated as per policy requirements