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Based on review of policies and procedures and patient handouts and staff interviews, the hospital failed to provide patients information that patient grievances could be submitted verbally.

Findings:

The hospital grievance policy and procedure recorded that grievances could be submitted either in writing or verbally.

The patients' rights handout, provided to the surveyors on 11/10/2015, recorded that grievances/complaints had to be submitted in writing.

The patient rights posted in the entrance lobby recorded that grievances/complaints had to be submitted in writing.

On 11/10/2015 at 2:55 p.m., Staff A and G stated the policy was what staff followed, but confirmed the handouts provided to patients recorded that grievances/complaints had to be submitted in writing.

Based on surveyors' observations, review of hospital documents, and interviews with hospital staff, the hospital failed to ensure each patient's physical personal privacy.

Findings:

1. Observations:

The surveyors toured the patient care areas on 11/10/2015 from 10:50 a.m. to 11:50 a.m. and 11/12/2015 from 9:25 a.m. to 10:20 a.m.

~ The 13 patient rooms, located on the locked units, had glass openings in the doors without blinds or curtains.

~ The toilets in Rooms 103 and 105 were located in the open room and not in an enclosed space/separate room. The other 11 rooms had separate/enclosed toilets.

~ Nine of the thirteen locked patient rooms were designated as semi-private rooms. There were no curtains between the beds for personal privacy from roommate.

~ Although Staff A told the surveyor that the hospital had portable screens for patient privacy, no privacy screens were observed in patient rooms or accessible for use.


2. The Patient Rights and Responsibilities handout did not contain information to inform patients they had the right to personal privacy.

On 11/10/2015 at 2:55 p.m., this finding was reviewed and verified with Staff A and G.

Based on review of hospital documents and medical records and interviews with hospital staff, the hospital failed to ensure:

a. For one (Patient #12) of two patients records reviewed of patients who were restrained -
1. Staff followed the hospital policy for restraint use;
2. The restraints were discontinued at the earliest possible time; and

b. Restraint use was monitored, reviewed and analyzed through the hospital's quality assessment and performance improvement (QAPI) program.

Findings:

1. The hospital's policy, entitled Physical and Soft Restraints with a revised date of 06/2014, recorded that a physician's order would be obtained for restraints with:
a. The type of restraint;
b. Extremity to be restrained; and
c. Amount of time restraint would be applied "not to exceed 24 hours".

2. The physician's restraint orders for Patient #12:
a. On 10/27/2015 only documented "3 point soft restraints" and did not document what extremities were to be restrained;
b. On 10/28/2015 and 10/29/2015 only recorded "2 point soft restraints" and did not document what extremities were to be restrained;
c. On 10/30/2015 at 3:00 p.m., the physician ordered the patient be placed in a Posey restraint bed. The next time the order for the restraint bed was written was 11/02/2015 at 8:40 a.m.

~ The patient was not placed in the Posey restraint bed until 10/31/2015 at 9:40 and not removed/released until 11/02/2015 at 9:46 a.m.

~ On 11/13/2015 at 3:00 p.m., Staff A stated nursing staff should obtain an order for restraints, if needed every day. She stated a Posey bed (an enclosed bed) was considered a restraint.


3. Review of Patient #12's medical record did not show the Posey bed restraint use was reviewed to ensure the restraint was discontinued as soon as possible.

~ The hospital's restraint policy recorded patients in restraints were to be monitored with documentation recorded in the medical record every two hours to ensure restraints were discontinued as soon as possible.

~ While Patient #12 was in the Posey bed from 10/31/2015 to 11/02/2015, nursing documentation did not show the patient in the restraint was monitored every two hours as required and discontinued as soon as possible.

~ On 10/31/2015 at 2039, the nurse charted the patient was calm and compliant. The patient was resting on the left side with the head of bed elevated slightly. Although further nursing notes documented the patient was still in the Posey enclosure bed, no further need for restraints were identified.


4. QAPI meeting minutes for 2015 did not reflect restraint use was monitored, reviewed and analyzed. On 11/13/2015, Staff A confirmed restraints use was not reported and monitored through QAPI.

Based on review of hospital documents and interviews with hospital staff, the hospital failed to the Quality Assessment and Performance Improvement (QAPI) program included:

a. All services/departments of the hospital; and

b. Analysis, tracking of the data and plans of action, when needed, to improve patient care/outcomes.

Findings:

1. On 11/10/2015 at 9:30 a.m., the surveyors requested and reviewed QAPI meeting minutes and current Plan. Review of the QAPI plan and meeting minutes for 2015 did not demonstrate all departments/services were included in the program. Examples include, but not limited to:
a. Restraints (See Tag A-154.);
b. Respiratory therapy;
c. Organ Procurement.

~ On 11/10/2015, at 10:00 a.m., the surveyors asked to speak with the staff responsible for QAPI. Staff C stated that each department head is responsible for their QAPI measures; no one person was designated to oversee the QAPI program.

2. QAPI meeting minutes did not contain evidence of analysis, corrective actions and/or plans for improvement with follow-up to ensure correction and improvement. Examples include, but not limited to:

a. Chart review:
~The meeting minutes recorded medical records, death charts, were reviewed, but the minutes did not contain evidence the medical records were analyzed to determine if:
i. care followed established standards of practice;
ii. changes needed to occur to improve patient care or outcomes;

~Meeting minutes for QAPI, Medical Staff and Governing Body did not demonstrate peer review was being conducted.

b. Medication usage:

~ The hospital policy, "QUALITY ASSURANCE" effective 10/2013, stated, "...Medication errors and discrepancy reports presented to the Drug Room for the month shall be summarized and included with the QA report ...When problems are identified, a plan of action will be developed and implemented to correct the action causing the problem."

~ Meeting minutes, QAPI, Medical Staff and Governing Body, did not demonstrate medication errors/adverse drug reactions were being reviewed and analyzed with corrective action taken to reduce occurrences and follow-up to ensure the corrective actions were effective. (See Tag A-508 for details.)

Based on review of hospital documents and staff interviews, the hospital failed to ensure credentialing:
a. occurred within the time specified by the Medical Staff By-laws and Rules and Regulations, and
b. files contained current data for three (Staff L, R and Q) of four medical staff whose credential files reviewed.

Findings:

1. The Medical Staff By-laws and Rules and Regulations required reappointments to occur every two years.

~ According to Staff Q's credential file, the most current reappointment by the Governing Body was 09/23/2013.

~ On 11/13/2015 at 1:10 p.m., Staff G stated the reappointment in Staff Q's file was the most current.

~ Medical Staff and Governing Body meeting minutes for 2015 did not contain evidence Staff Q's credentialing file had been presented for reappointment.

2. The credential files for L, R, and Q did not contain current certifications, licenses and registrations. According to the data contained in the credential files,

~ Staff L's Oklahoma Board of Narcotics and Dangerous Drugs (OBNDD) license registration expired 10/31/2015.

~Staff Q's physician's assistant certification expired in 2012; the OBNDD expired 10/31/2014; Drug Enforcement Administration registration expired 05/31/2015 and the certificates for Advanced Life Support, Pediatric Advanced Life Support and Basic Life Support expired 10/2014.

~ Staff R's medical license expired 07/31/2015 and the OBNDD expired 10/31/2015.

~ The findings were confirmed with Staff G on 11/13/2015 at 1:10 p.m.

Based on surveyor's review of hospital documents and interviews with hospital staff, the hospital failed to ensure medication errors and adverse drug reactions were reported to the hospital's Quality Assessment and Performance Improvement (QAPI) program.

1. The surveyors reviewed the monthly pharmacist reports, from January 2015 to present, compiled by Staff E.

~Review of monthly reports did not contain any evidence or analysis of medication errors or adverse drug reactions. Staff E was asked for documentation of where medication errors and adverse drug reactions were analyzed. None was provided.

~Surveyors reviewed a hospital policy with the subject; "REPORTING AND RECORDING MEDICATION ERRORS" revised 10/2013. This policy outlined a six level Error Rating System, with Level 0 - no error actually occurred, through Level 6 - occurrence resulted in patient's death. Staff E stated the hospital analyzed medication errors at Level 3 and above (Levels 3 through 6).

2. Surveyors reviewed the hospital's Pharmacy and Therapeutics (P and T) Meeting Minutes from October 2014 to present.

~The P and T meeting minutes dated October 16, 2014 documented, "...Members discussed what should be done when a discrepancy occurs between medications removed from MGD automated system and what is charted in CPSI [electronic medical record] if they are unable to be fixed for any reason. It was decided that an incident report and proper documentation will be filled out explaining error and why it cannot be fixed and what has been done in regard to the error."

~Staff E was interviewed during the tour on 11/10/2015 between 10:50 a.m. and 11:50 a.m., and again on the afternoon of 11/13/2015. Staff E was asked if incident reports were completed for each medication error and/or adverse drug reactions. Staff E stated, "No."


3. Surveyors requested and reviewed QAPI meeting minutes from January 2015 to present. The meeting minutes did not show medication errors and/or adverse drug reactions were reviewed and analyzed with plans of action to decrease events and/or improve patient care/outcomes. This finding was reviewed with Staff A on 11/13/2015.

Based on review of hospital documents and staff interviews, the hospital failed to ensure that controlled substance inventory was properly tracked.

Findings:

1. Surveyors requested and reviewed the hospital's narcotic records from January 2015 to present.

~ Hospital records provided did not show medication wastage. Examples included, but not limited to:
a. 10/30/2015: Physician Ordered: Dilaudid 2 mg:
Staff W documented administering: Dilaudid 1 mg:
Amount Wasted: None recorded.

b. 10/30/2015: Physician Ordered: Oxytrust 1 ml;
Staff P documented administering: Oxytrust 0.5 ml;
Amount Wasted: None recorded.

c. 09/29/2015: Physician Ordered: Dilaudid 2 mg;
Staff X documented administering: Dilaudid 1 mg;
Amount Wasted: None recorded.

d. 09/29/2015: Physician Ordered: Dilaudid 2 mg
Staff Y documented administering: Dilaudid 1 mg
Amount Wasted: None recorded

~ Staff E told the surveyors there was a problem with the MGD [automated medication dispensing system] and the "scanner" recording wastage.


2. Surveyors reviewed the hospital's Pharmacy and Therapeutics (P and T) Meeting Minutes from October 2014 to present.

~The P and T meeting minutes dated October 16, 2014 documented, "...Members discussed what should be done when a discrepancy occurs between medications removed from MGD automated system and what is charted in CPSI [electronic medical record] if they are unable to be fixed for any reason. It was decided that an incident report and proper documentation will be filled out explaining error and why it cannot be fixed and what has been done in regard to the error."

Based on surveyors' observations, review of hospital documents, and interviews with hospital staff, the hospital failed to maintain the overall hospital environment to ensure the safety and well-being of patients by placing two patient in a single occupancy patient room.

Findings:

1. On 11/10/2015, between 10:50 a.m. and 11:50 a.m. surveyors toured the hospital.

2. On 11/10/2015, at 10:40 a.m., Director of Nursing (DON) stated the hospital had 22 Department of Correction (DOC) beds (Rooms 101-113) and four civilian beds (Rooms 114-116).

~The DON stated on the DOC side, Rooms 101, 103, 105, and 113 were single occupancy rooms; the remaining beds were double occupancy rooms.
~The DON stated on the civilian side, Rooms 115 and 116 were single occupancy rooms; Room 114 was a double occupancy room.
~This was confirmed by the surveyors during the tour.

3. On 11/10/2015, at 11:05 a.m., surveyors asked DON and Chief Executive Officer (CEO) what the procedure was when DOC census was greater than 22 patients. DON stated they would place a second patient in Rooms 101, 103, and 105. This was also confirmed by the medical director.

4. On 11/10/2015, at 12:00 p.m., surveyors reviewed the hospital census books from January 2015 to present.

~Hospital census books documented the following :
January 14 - Two patients in Room 103
February 4 - Two patients in Room 103
February 12-17- Three patients in Room 102
March 25 and 26 - Two patients in Room 101
June 12-14 - Two patients in Room 105
June 16- Two patients in Room 105
October 27 - Two patients in Room 101
October 28 - Two patients in Room 101 and two patients in Room 105
November 7 - Two patients in Room 103
November 8 - Three patients in Room 106

5. On November 13, 2015, surveyors requested and reviewed medical records.

~Review of the medical records for Patients #3, 4 and 5 documented all three patients were in Room 102 on the following dates: February 12 through February 16, 2015.
~Review of the medical records for Patients #1 and 2 documented both patients were in Room 101 on the following dates: March 25 and March 26, 2015.
~Documentation in the medical records, such as but not limited to order sheets, patient identifier stickers, billing statements and progress notes, supported these findings.

Based on surveyors' observations and hospital staff interviews, the hospital failed to maintain an appropriate area for disinfecting and storing respiratory therapy equipment.

Findings:

1. On 11/10/2015 at 10:55 a.m., the surveyors observed respiratory therapy (RT) equipment., covered with plastic, stored in the physical therapy (PT) room/area.

~ At the time of the observation, Staff C stated the RT storage area, which was located adjacent to the PT room, did not have space to keep the equipment.


2. On 11/10/2015 at 11:00, the surveyors asked about cleaning of the RT equipment. Staff C stated she thought it was cleaned in the PT area.

~ On 11/13/2015 at 11:30, Staff I stated most of the RT equipment/supplies were disposable.

~ Staff I stated RT staff tried to clean the reusable equipment in the patient's room if the patient had been discharged.

~ Staff I stated that if the equipment was discontinued before the patient was discharged, the equipment would be taken to the PT area and disinfected there.

~ Staff I stated RT did not have a dirty equipment room to clean reusable RT supplies/equipment. Staff I stated, "The only dirty place is the hallway."

Based on review of personnel files and interviews with hospital staff, the hospital failed to maintain verification of current licensure for one (Staff F) of two respiratory staff, whose license verifications were reviewed. On the morning of 11/13/2015, Staff G stated no more information could be obtained.