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Based on observation, interview and record review, the facility staff failed to ensure the patient had the right to participate in the development and implementing of his plan of care. Patient 21 was not informed of his right to be involved in the placement of a heplock (intravenous line device) for administration of intravenous medication as part of his plan of care.

Findings:

On February 9, 2010, at approximately 10:15 a.m., during the tour of the facility with Staff P, Patient 21 was observed lying in bed with a heplock in placed on his right lower foot. Upon interview, the patient stated that he did not want the heplock to be placed on his foot. He also stated that everytime the licensed nurses flushed the heplock it hurts and it stings. He added that he made the licensed nurses aware of his concern but the license nurses continued to flush the heparin lock.

A review of the clinical record revealed the patient was admitted to the facility on February 7, 2010, with a diagnosis of left upper lip laceration. The nursing admission assessment indicated that patient was alert and oriented. The medication administration record (MAR) dated February 7, 2010, documented the patient received an antibiotic via heplock and a licensed nurse flushed the heparin lock with normal saline solution after administering the antibiotic.

On the same day, at 11 a.m., in an interview with Staff S, while reviewing the clinical record, failed to show documentation that the patient was consulted prior to starting a heplock on the right lower foot.

Based on observation, interview, and record review, the facility staff failed to ensure the patient was provided personal privacy during a room transfer.

Findings:

On February 9, 2010, at approximately 4 p.m., during an observation tour, Patient 26 was observed wearing a hospital's gown. The gown was untied by the waist exposing his back and his buttocks. Staff V was walking behind the patient towards Room 8. At that time, the patient was in full view of the three (3) security guards, another staff member, and visitors passing by the hallway.

During a concurrent interview with Staff V, she stated that before they left Room 12, she made sure that she tied the back of the gown.

The admission facesheet revealed that Patient 26 was admitted to the facility on February 9, 2010, with diagnoses that included tachycardia and dehydration. The patient was assessed as alert, awake, and oriented to person, time and place, and required minimal to no assistance from staff for daily activities of living.

Based on observation, interview, and record review, the facility failed to ensure that 2 patients, in a survey sample of 37, received the care based on their needs while at the facility (Patients 27 and 29).

Findings:

1. On February 9, 2010, at approximately 3 p.m., during the observation tour, Patient 27 was noted lying in bed and was receiving a gastrostomy tube feeding at 50 cc/hr.

The patient was observed to be a mouth breather and there was foul odor coming from the mouth.

A review of the clinical record revealed the patient was admitted to the facility on February 7, 2010, with diagnoses that included gastro-intestinal bleeding and vomiting coffee ground emesis. The initial assessment/screening on admission assessed the patient as being disoriented, lethargic, unable to make needs known, and having left sided contractures secondary to cerebro-vascular accident.

On February 9, 2010, at approximately 3:30 p.m., in an interview with Staff P, she stated that she would have someone provide the oral care to the patient right away.

2. On February 12, 2010, a approximately 9:30 a.m., during the observation tour, Patient 29 was lying in bed and was connected to a ventilator.

The patient's tongue was noted to be coated with a white substance and her lips were crusted.

A review of the clinical record revealed the patient was admitted to the facility on December 3, 2009, with a diagnosis of respiratory failure. The initial assessment/screening on admission assessed the patient as being lethargic, unresponsive, having contractures to both upper and lower extremities and requiring daily care.

Based on observation and interview, the facility staff failed to ensure the privacy of patients's medical informations which had the potential to result in unauthorized viewing of confidential medical information.

Findings:

1. During an observation and tour of the unit on February 9, 2010, at approximately 11:15 a.m., there were medication administration records (MAR) of four (4) patients that were left unattended on top of the medication cart. The MAR consisted of patient names, dates of birth, diagnoses, room numbers and other personal information. The medication cart was parked on the busy hallway of the medical-surgical unit. The hallway was the main thorough fare in order to go to other areas of the hospital for visitors, staff, and other patients.

During a concurrent interview with Staff P, she stated that the patients' medical records should not be left unattended for potential for unauthorized viewing.


14041

2. On February 11, 2010, the evaluator conducted an inspection of the Norwalk Campus's dietary storage area which was located in the back of the facility. The evaluator observed a propped open door located in the back of the area. Further inspection revealed that the area was used for storage of Medical Records. The area was used for storing the patients' medical records for the Human Resources. The door was not locked or secured.

An interview was held with the Chief Executive Officer and he stated that the Medical Room should be secured for the Human Resources and for the patients' Medical Records at all times.


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3. On February 9, 2010 at 11:09 a.m., during a tour of the facility, the evaluator observed an unsecured and unlockable nightstand in disrepair in a corridor with no clinical staff present. The nightstand was located at the opposite end from the nurses station, across from room 202, readily accessible to unauthorized persons.

The facility's environmental staff opened the drawers before removing the nightstand, at that time the evaluator observed there were three 24 hour report sheets from the medical record of Patient 37 among the medical supplies in the nightstand. The reports were dated January 25, 26 and 27, 2010.

Staff BB was called to the location of the nightstand and made aware of the reports and medical supplies. At this time, Staff BB picked up the medical supplies and walked away toward the nurses station, leaving the reports face up on the nightstand.

Staff BB was called back to the location of the nightstand at which time during an interview about leaving the reports on the nightstand, she stated that the reports were not part of the patient's medical record.

The information on the reports included the patient's name, birth date, room number, code status, isolation status, consults, chief complaint, medical history, diagnosis, allergies, diet, abnormal/pertinent labs, pending labs, and medications.

4. On February 18, 2010 at 11:09 a.m., the evaluator observed two desks in the ICU activities room. The evaluator also observed a patient's Interdisciplinary Plan of Care Conference report, a patient's face sheet, and a weekly census of 31 patients were laying face up, in plain view on one of the desks. The door to the activities room was unlocked, all the drawers to the file cabinets were unlocked, and there were no staff in the room when the evaluator entered the room.

During an interview,Staff Q confirmed that the room was an activities room that was also used as the activities director's office and social services office.

The information on the documents included patients names, room numbers, complaints, physical condition, weights, medications and vent status.

The facility's policy and procedure entitled, Safeguarding PHI and Confidential Information dated February 1, 2009, indicated that all facilities shall implement reasonable and appropriate physical safeguards to protect the privacy of PHI and confidential information. The procedure indicated to restrict the view of information on paper containing PHI by turning print side of documents down on a desk or workstation when visitors are present. The procedure also indicated to lock file cabinets or record storage cabinets whenever the area is unattended.

5. On February 11, 2010 between 2:42 p.m. and 3:25 p.m., during a tour of the Norwalk Campus, the evaluator observed nineteen boxes of pathology slides stored in the electrical room located at the exterior perimeter of the building behind ICU. The evaluator also observed the boxes were dated from 1993 to 2003 (7 to 17 years ago). None of the boxes were bagged or contained, and at least one of the boxes was open exposing the slides.

During an interview, Staff CC stated the slides should have gone to infectious waste, but were overlooked.

On February 12, at 9:30 a.m., during an interview, Staff Q stated the slides came from a hospital that had closed, and that the facility had taken responsibility of the pathology slides which were part of the closed hospital's medical records.

The facility's policy and procedure entitled, Safeguarding PHI and Confidential Information dated February 1, 2009, indicated that all facilities should implement reasonable and appropriate physical safeguards to protect the privacy of PHI and confidential information. The procedure indicated that when no longer needed, and in accordance with the Documentation Retention Policy, PHI and Confidential Information contained on any media (electronic, paper, etc.) should be shredded or otherwise destroyed so as to render the information unrecognizable and unrecoverable. Interim storage of all such information, pending destruction, shall be in a secure area or locked container.

The facility's policy and procedure entitled, Disposal of Materials: Pathology, dated June 2001, indicated that the facility's disposal of slides is based on the following regulations:

LACH 10 years
CALIF. 5 years (Cytology)
CLIA `88 10 years (5 yr. Cytology)

Based on record review and interview, the facility staff failed to ensure that the use of restraint for Patient 28 was in accordance with the written patient's plan of care.

Findings:

On February 10, 2010, at approximately 11:30 a.m., during a review of the clinical record revealed Patient 28 was admitted to the facility on December 31, 2009, with diagnoses that included altered level of consciousness, history of fall, and diabetes mellitus.

On January 1, 2010, the physician ordered initially for a soft wrist restraint as a fall precaution for patient safety. The clinical record also indicated the patient was pulling out and biting the intravenous tubing and was trying to get out of bed.

Further review of the clinical record revealed the patient was placed on soft wrist restraint on different dates on January 5, 6, 11 and 18, 2010 and February 2, 2010.

During an interview with Staff U on February 10, 2010, at approximately 12 noon, while reviewing the clinical record, she concurred the patient was placed on a soft wrist restraint. However, there was no documentation to indicate that a care plan was developed to address the use of restraint.

Based on record review and staff interview, the facility staff failed to ensure that the use of restraint for Patient 28 was in accordance with the order of a physician or other licensed independent practitioner.

Findings:

On February 10, 2010, at approximately 11:30 a.m., during a review of the clinical record revealed Patient 28 was admitted to the facility on December 31, 2009, with diagnoses that included altered level of consciousness, history of fall, and diabetes mellitus.

On January 1, 2010, the physician ordered initially a soft wrist restraint as a fall precaution for patient safety. The clinical record also indicated the patient was pulling out and biting the intravenous tubing and was trying to get out of bed.

Further review of the clinical record revealed there were restraint orders on the following days January 5, 6, 11 and 18, 2010 and February 2, 2010, however, they were not signed by the physician.

During an interview with Staff U on February 10, 2010, at approximately 12 noon, while reviewing the clinical record, she concurred that the soft wrist restraint orders were not signed by the physician.

A review of the protocol for restraint management stipulated the restraints are to be applied only after obtaining a physician's order.

Based on staff interview, record review, and review of facility reports, the hospital's pharmacy failed to develop, implement, and maintain an effective, data-driven quality assessment and performance improvement program for the pharmacy's eight clinical indicators, including assessment of areas of pharmacy services such as the automated drug delivery cabinets. In addition, the facility failed to develop, implement and
maintain an effective ongoing, hospital-wide,data driven quality assessment and
performance improvement (QAPI) program reflecting the complexity of the hospital's
organization and services, involving all hospital departments and services, that
focused on indicators related to improved health outcomes and the reduction of medical
errors.

1. The pharmacy failed to provide documented evidence that the pharmacy's eight quality indicators showed measurable improvement and improved health outcomes.
(See CFR 482.21(a)(1), A 265)

2. The pharmacy failed to provide documented evidence that the pharmacy's eight quality indicators identified and reduced medical errors.
(See CFR 482.21(a) (1), A 266)

3a. The pharmacy failed to provide documented evidence that the data collected monitored the effectiveness and safety of service and quality of care, since the data was voluntarily reported with no actual established baseline for the data, and no assurance of how accurate the reported data was or whether it represented the patient population of the facility.
(See CFR 482.21(b)(2) (i), A 275)

3b. The facility failed to show evidence of the use of datat it had collected to monitor the effectiveness and safety of services and quality of care. (Refer to A 275)

4. On 2/10/10 the PIC failed to provide documented evidence that demonstrated that the data collected from the eight pharmacy clinical indicators identified opportunities for improvement and changes that would lead to improvement.
(See CFR 482.21(b)(2)(ii), A 276)

5a. The pharmacy failed to provide documented evidence that demonstrated that the pharmacy had set priorities for its performance improvement activities that; (i) focused on high risk, high volume, or problem prone areas, (ii) considered the incidence, prevalence and severity of those areas, and (3) affected health outcomes and quality of care.
(See CFR 482.21 (c) (1) (i)(ii)(iii) #1, A 285)

5b. The pharmacy failed to demonstrate that quality assurance or performance improvement activities were done on the override reports.
(See CFR 482.21 (c) (1)(i)(ii)(iii) #2, A 285)

6a. The pharmacy failed to demonstrate medical errors related to the pharmacy had their causes analyzed. (See CFR 482.21(c)(2), A 288)

6b. The pharmacy failed to provide documented evidence that the pharmacy's performance improvement activities for medication errors had implemented preventative actions and mechanisms that include feedback and learning throughout the hospital in the calendar year of 2010 and 2009. (See CFR 482.21(c)(2), A 288)

7. The pharmacy failed to provide documented evidence the pharmacy's performance improvement projects were proportional to the scope and complexity of the hospital's services and operations. (See CFR 482.21(d)(1), A 298)




25049


8. The facility failed to have in place a QAPI program that measured, analyzed, and tracked quality indicators, including adverse patient events and other aspects of performance, that assessed processes of care, hospital service and operations ( Refer to A 267)

9. The facility failed to reveal performance activities that tracked medication errors and adverse patient events, and analyzing their causes. (Refer to A 287)

10. The facility failed to reveal evidence of taking actions aimed at performance improvement, and after implementing those actions, measuring its success, and tracked performance to ensure that improvements were sustained. (Refer to A 291)

11. The facility failed to provide evidence of the existence of an information technology system designed explicitly to improve patient safety and quality of care. (Refer to A 299)

12. The facility failed to provide documentation of reasons for the quality improvement projects being conducted and measurable progress achieved on these projects. (Refer to A 302)

The cumulative effects of these systemic practices and issues resulted in the failure of the hospital to deliver statutorily mandated compliance with the Condition of Participations for Quality Assurance and Performance Improvement.

Based on staff interview and review of the pharmacy's quality assessment and performance improvement programs, the pharmacy failed to include an on-going program that showed measurable improvement in indicators for which there was evidence that would improve health outcomes.

Findings:

1. On 02/10/10 at 2:00 P.M., the PIC (Pharmacist in Charge) was interviewed on eight clinical indicators:
(a) Medication Errors
(b) Number of Pharmacy Interventions
(c) Adverse Drug Reactions
(d) Controlled Substance Documentation
(e) Patient Demographic Information
(f) Orders for Scheduled Medication are Administered to the Patient
(g) Renal function /creatinine clearance based dose monitoring for Levaquin 500mg
(h) Renal function/ creatinine clearance based dose monitoring for Levaquin 250mg

On 2/10/10 the PIC was asked to explain and demonstrate the following:
(a) how any of the eight clinical indicators improved health outcomes,
(b) Why only two indicators (controlled substance documentation and Number of pharmacy interventions) of the eight indicators met or exceeded their benchmark for four straight quarters, while other indicators such as Renal function/Creatinine Clearance based Dose Monitoring of Levaquin 500mg and 250mg, Medication Errors Reports, failed to reach of their respective benchmark's for four straight quarters.

On 2/10/10 the PIC failed to provide documented evidence that the pharmacy's eight quality indicators showed measurable improvement and improved health outcomes.




25049


2. On February 10, 2010 at 2:00 p.m., a
review of hospital policies and procedures,
quality assessment and improvement
documents, while interviewing the
Quality Assurance/Risk Management
Coordinator, revealed a collection
of clinical indicators that were being
monitored and evaluated. There was no evidence
substantiating measurable improvement
in health outcomes existed. The
indicators were reflected was percentages
of those patient who had received
instruction concerning their medical
conditions. Included were patients
admitted with congestive heart failure who
were provided education at the time of their
discharge, for avoiding its recurrence.
While 96% of patients that were discharged with an
admitting diagnosis of congestive failure,
no data was tracked showing measurable
improvement in health outcomes as the
result of this or to what degree this
measured the numbers of patient
returning with the same diagnosis.

Cigarette smokers were provided with
instruction and regimens to reduce their
cigarette use. As with those having been
admitted for and the 96% having been
provided with dietary education
concerning their diagnosis of congestive
heart failure, only the percentage of patients
receiving the education was in evidence.
As with congestive heart failure, the efforts
to reduce cigarette use was collected and
expressed in the percent of individuals
who had received efforts to intervene in
the course of their clinical disease, but
without evidence of improved health
outcome.

Based on staff interview and review of facility reports, the pharmacy's ongoing program of clinical indicators failed to identify and reduce medical errors.

Findings:

On 2/10/10 at 2:10 P.M., the PIC was asked to provide evidence that the eight quality indicators for pharmacy identified and reduced medical errors.

On 2/10/10, the PIC failed to provide documented evidence that the eight quality indicators identified and reduced medical errors.

Based on interview and document review,
the facility failed to have in place a QAPI
program that measured, analyzed, and
tracked quality indicators, including
adverse patient events and other aspects of
performance, that assessed processes of
care, hospital service and operations.

Findings:

A review of quality assessment and
improvement documents on February 10,
2010, at 2:30 p.m., while interviewing the
Quality Assurance/Risk Management
Coordinator, revealed a collection
of primarily clinical indicators that were
being monitored and evaluated.

There was no evidence was revealed, describing
the hospital's measuring, analyzing, tracking,
and tracking quality indicators including
adverse patient events was provided. There was
no aspects of performance assessing processes
of care, hospital service and operation was
in evidence. The indicator data regarding
educating patients in the prevention of
recurrences of congestive heart failure and
to reduce their use of cigarettes, measured
the numbers and percentage of patients
receiving these interventions, but without
evidence of their being tracked or other
aspects of performance assessing processes
of care, hospital service and operations.

Based on staff interview, and review of facility reports, the pharmacy's ongoing program of clinical indicator data failed to monitor for the effectiveness and safety of service and quality of care. In addition, the facility failed to show evidence of the use of data that it had collected to monitor the effectiveness and safety of services and quality of care.

Findings:

1. On 2/10/10 at 2:15 P.M., the PIC was asked to demonstrate how the data collected monitored the effectiveness and safety of service including quality of care, when
(a) the clinical indicator data for Medication Errors, Number of Pharmacist Interventions and Adverse Drug Reactions were from voluntary self -reports with no determination whether the data reported was accurate and represented the patient population,
(b) the data had no established baseline rather an arbitrary number that was set as a benchmark.

On 2/10/10 the PIC failed to provide documented evidence that the data collected had monitored the effectiveness and safety of service and quality of care, when the data was voluntarily reported with no actual established baseline for the data, and no assurance of how accurate the reported data was or whether it represented the patient population of the facility.



25049

2. On February 10, 2010 at 3:00 p.m., a review
of the hospital policies and procedures as well as
quality assessment and performance
improvement documents, while interviewing,
the Quality Assurance/Risk
Management Coordinator, revealed a
collection of primarily clinical indicators
being monitored and evaluated. There was no
evidence existed demonstrating that
data being collected, used to monitor the
effectiveness and safety of services and
quality of care beyond the monitoring of
patients discharge with congestive heart
failure, cigarette usage or those with
tracheotomies as related to the
pre-emptive changing of their
tracheotomy tubes every 24 hours to
avoid their becoming obstructed or
causing infection. There was no specific
comparative data was forthcoming from
this.

Based on staff interview and facility reports, the pharmacy failed to use data collected to identify opportunities for improvement and changes that would lead to improvement.

Findings:

1. On 2/10/10 at 2:30 P.M., the PIC was asked to provide evidence that the data collected for the eight pharmacy clinical indicators identified opportunities for improvement and changes that would lead to improvement for current calendar year of 2010 and for 2009.

On 2/10/10, the PIC failed to provide documented evidence that demonstrated that the data collected from the eight pharmacy clinical indicators identified opportunities for improvement and changes that would lead to improvement.

Based on staff interview and review of facility reports the hospital's pharmacy failed to set priorities for its performance improvement activities that (i) focused on high risk, high volume, or problem prone areas, (ii) considered the incidence, prevalence and severity of those areas, (iii) affected health outcomes, and quality of care.

Findings:

1. On 2/10/10 at 2:35 P.M., the PIC was asked to demonstrate that the pharmacy's performance improvement activities focused on high-risk, high volume, or problem areas, considered the incidence, prevalence, and severity of problems in those areas, and affected the health outcomes and quality of care,

On 2/10/10, the PIC failed to provide documented evidence that demonstrated that the pharmacy had set priorities for its performance improvement activities that (i) focused on high risk, high volume, or problem prone areas, (ii) considered the incidence, and (ii) prevalence and severity of those areas.

2. On 2/11/10 at 8:30 A.M., the PIC and Pharmacist 1 were interviewed on the automated drug delivery cabinets (ADC) override reports for the profile and non-profiled unit.

(a) In the non-profiled unit (drug can be removed without the supervision or review by the pharmacist) located in the emergency department there were 772 transactions or 803 items removed since the ADC was installed (12/09). There was no quality assurance or performance improvement activities that assessed or monitored whether drugs were being removed appropriately based on the patients clinical condition, physician order or lab values.

(b) The ADC's profiled override reports were reviewed for whether the drug removed matches the physician order and the medication administration record. Otherwise, there were no quality assurance or performance improvement activities done on the profiled override reports.

Based on staff interview and review of facility reports, the hospital's pharmacy performance improvement activities for medical errors failed to have their causes analyzed. In addition,
the facility failed to reveal performance activities that tracked medical errors and
adverse patient events, and analyzing their causes.

Findings:

1. On 2/10/10 at 2:35 P.M., a medication error report was reviewed. The report was initiated due to a physician order written as:
'Vicodin ES (pain medication) 7.5 mg by mouth every 4 hours prn (as needed)'.

The rational was that the "prn" (if needed) had no with no indication for its use.

The PIC was asked if there were any facility policy and procedures that stated having an indication for a 'prn' physician order was a medication error. The PIC stated there were none.

The following issue is that the physician order was marked as a medication error since there was no indication for a prn but there was no facility policy and procedure that would make it a medication error.

2. On 2/10/10 at 2:35 P.M., the PIC failed to to provide documented evidence that demonstrated an analysis of the medication error reports were done in order to find issues to improve health outcomes.


25049

3. On February 10, 2010 at 3:30 p.m., a review
of the hospital policies and procedures as well as
quality assessment and performance
improvement documents, together with an
interview, the Quality Assurance/
Risk Management Coordinator, failed to show
evidence of performance improvement
activities, tracking medical errors and adverse
patient events and an analysis of their causes.

Based on staff interview and review of facility reports the hospital's pharmacy performance improvement activities for medication errors failed to implement preventative actions and mechanisms that include feedback and learning throughout the hospital.

Findings:

On 2/10/10 at 3:00 P.M., the PIC was asked to demonstrate that the hospital's pharmacy performance improvement activities for medication errors had implemented preventative actions and mechanisms that include feedback and learning throughout the hospital in the calendar year of 2010 and 2009.

On 2/10/10, the PIC failed to provide documented evidence that the hospital's pharmacy performance improvement activities for medication errors implemented preventative actions and mechanisms that include feedback and learning throughout the hospital in the calendar year of 2010 and 2009.

Based on interview and document review,
the facility failed to reveal evidence of taking
actions aimed at performance improvement,
and after implementing those actions,
measuring its success, and tracked
performance to ensure that improvements
are sustained.

Findings:

A review of quality assessment and
improvement documents on February 10,
2010, at 4:00 p.m., while interviewing the
Quality Assurance/Risk Management
Coordinator, failed to provide
evidence of activities undertaken aimed
at performance improvement, which after
being implemented yielded measures of
success, followed by further efforts to
ensure that improvement was sustained.

A project aimed at reducing C. difficile
infection by following clinical guidelines
with the use of bleach when cleaning in
the hospital was instituted. No figures of
success were provided nor evidence
tracking performance to ensure
improvement achieved, being sustained.
In addition, the education of medical staff.
as regards antibiotic use and acquired
nosocomial infection was undertaken.
Anecdotally, the rate of hospital acquired
infection was described as being down,
however, no improvement success data was
provided, not evidence of activities to
sustain what improvement did occur.

The hospital had attempted to evaluate the
use of registry nurses with that of staff nurses,
to determine higher hospital infections rates
associated with registry personnel. No
performance data concerning improvement
outcome from this analysis was provided, nor
tracking to analyze and ensure improvement
was sustained.

Based on staff interview and review of facility's pharmacy failed to demonstrate that the number and scope of distinct improvement projects that were conducted annually were proportional to the scope and the complexity of the hospital's services and operations.

Findings:

On 2/10/10 at 3:00 P.M., the PIC was asked to demonstrate that the pharmacy's performance improvement projects were proportional to the scope and complexity of the hospital's services and operations.

The PIC failed to provide documented evidence the pharmacy's performance improvement projects were proportional to the scope and complexity of the hospital's services and operations since:
(a) The PIC stated that the hospital has a lot of geriatric patients and uses a lot of antibiotics but performance improvement projects for the pharmacy did not review the geriatric population and reviewed only one antibiotic for renal clearance with no data to support why that one antibiotic was assessed and why other antibiotics that required renal clearance was not assessed too.
(b) The PIC could not provide data that demonstrated any of the quality indicators for pharmacy were proportional to the scope and complexity of the hospital's services.

Based on interview and document review,
the facility failed to provide evidence of
the existence of an information technology
system designed explicitly to improve patient
safety and quality of care.

Findings:

On February 10, 2010 at 4:15 p.m., a review
of the hospital policies and procedures as well as
quality assessment and performance
improvement documents, together with an
interview with the Quality Assurance/
Risk Management Coordinator, revealed the
hospital failed to provide evidence of the
existence of a dedicated information technology
designed explicitly for quality assessment and or
performance improvement activities, being
in existence of planned to be available in the
foreseeable future.

Based on interview and document review,
the facility failed to provide documentation
of reasons for the quality improvement projects
being conducted and measurable progress
achieved on these projects.

Findings:

On February 10, 2010 at 4:30 p.m., a review
of the hospital policies and procedures as well as
quality assessment and performance
improvement documents, together with an
interview with the Quality Assurance/
Risk Management Coordinator, failed to reveal
the reasons for the quality improvement projects
being conducted and measurable progress that
had been achieved here to date.

Based on observation, interview, and record review, it was determined that the facility did not meet the Condition of Participation (CoP) for Nursing Services by failing to:

1. Supervise and evaluate nursing care of patients requiring telemetry, review patients' Initial Assessment/Screening by a licensed vocational nurse (LVN). (Refer to A 0395)

2. Ensure the nursing staff developed and kept a current nursing care plan based on assessments of the patient's nursing care needs with appropriate nursing care interventions. (Refer to A 0396)

3. Ensure the pediatric staff were competent in emergency care, emergency procedures and needs of pediatric patients in the facility. Three (3) of three (3) registered nurses in the pediatric unit failed to demonstrate and verbalize knowledge of defibrillation, suction set up and suctioning of pediatric patients. (Refer to A 0397)

The cumulative effects of these systemic problems resulted in the facility's inability to ensure the they had an organized nursing services.

Based on observation, interview, and record review, the facility failed to maintain the licensed nurse-to-patient ratio in the pediatric unit at 1:4 or fewer at all times in accordance with the State regulation on nurse-to-patient ratio requirement California Title 22 section 70217(a)(6) that states, "The nurse-to-patient ratio in a pediatric service unit shall be 1:4 or fewer at all times." In addition, the facility failed to ensure adequate staffing when the medical/surgical care patients were combined with patients on telemetry in accordance with the acuity of patient care classification system.

Findings:

1. On February 12, 2010 at 8:45 a.m., a tour of the pediatric unit was conducted.

Concurrent interviews with the licensed nurses was conducted in the nurses' station. Staff M stated the charge nurse was on break and the census was twenty (20) patients. Staff M stated she was assigned to five (5) patients. Staff M stated that while the other staff was on break, the remaining staff were covering for the patients close to their assigned patients. Staff M acknowledged they have more than 5 patients assigned to them during break time. Staff D stated she was from the medical/surgical floor and was assigned to work in pediatrics this shift. Staff D stated she had received orientation in the pediatric unit. Staff D stated she was assigned to five (5) patients and she was responsible for the intravenous fluids and intravenous piggy back (IV/IVPB) for two (2) patients who were assigned to the LVN.

A review of the pediatric unit assignment sheet dated February 12, 2010, indicated there were three (3) registered nurses and one (1) licensed vocational nurse for twenty patients, and each licensed nurse was assigned to five (5) patients.

2. On February 9, 2010, at 2 p.m., Staff A stated the patients on telemetry were in the medical/ surgical unit.

A review of the assignment sheet dated February 9, 2010, revealed there were twenty (20) patients in Unit I at the start of the shift with three (3) registered nurses and one (1) licensed vocational nurse, and each licensed nurse was assigned to five (5) patients. The assignment sheet did not address or indicate which patient was on telemetry.

During an interview with Staff A on February 16, 2010 at 2:45 p.m., she stated Unit I was licensed as a medical/surgical unit and was staffed as medical/surgical unit. Staff A stated the patients on telemetry have a higher acuity level. Staff A unit acknowledged the assignment sheet did not identify which patients were on telemetry.

The facility policy and procedure titled, "Acuity of Patient care Classification System" dated as last reviewed in May 2003, indicated, "Each patient is assessed on the basis of care provided and nursing time required to provide the service...influenced by the intensity of the patient's condition and/or medical therapy."

Based on observation, interviews with facility staff, review of patient medical records, and review of facility documents, the facility failed to supervise and evaluate the nursing care for 9 patients in a survey sample of 37 (Patients 5, 6, 7, 9, 10, 11, 21, 22, and 28).

For Patient 9 and Patient 10, requiring telemetry, the facility staff failed to ensure the patients' cardiac telemetry were continuously monitored. There was no telemetry signal, thereby no visible cardiac rhythm to identify abnormal heart rhythm. In addition, there were no rhythm strips posted and no rhythm interpretation in accordance with the Telemetry policy and procedure. For Patient 6 and Patient 7, the initial assessment/screenings were not evaluated by a registered nurse. For Patient 11, a posted rhythm strip indicated, "Alarms suspended, Resp Lead Off" followed by "All ARRH Alarms Off."

For Patient 21, there was no pain assessment and reassessment after medication administration. For Patient 22 and Patient 28, the initial assessment/screenings were not evaluated by a registered nurse. For Patient 5, the initial assessment/screening and the pain assessment were not evaluated by a registered nurse and an occurrence report was not done during Patient 5's elopement.

Findings:

1. On February 10, 2010 at 1:45 p.m., during the tour of the East Wing with Staff G, Patient 9 was observed in bed, with a telemetry box number 3.

During a concurrent interview, Staff G stated the patient had acute cerebral vascular accident, and was transferred to the East Wing from the Intensive Care Unit (ICU) yesterday.

On February 10, 2010, the patient's medical record was reviewed. The physician transfer order dated February 9, 2010 at 11:20 a.m., indicated to transfer the patient to Telemetry unit. A review of the medical record revealed no rhythm strips for Patient 9.

During an interview with Staff H on February 10, 2010 at 2:40 p.m., he stated the rhythm strips would be in ICU.

At 2:45 p.m., the same day, in the ICU nurses' station, the central monitor for the telemetry patients showed no signal from telemetry box number 3 on Patient 9.

A review of the Telemetry Log for Patient 9 revealed a rhythm strip dated dated February 9, 2010 at 4:37 p.m. There were no other rhythm strips posted.

During a concurrent interview with Staff E, she stated there was no signal to show cardiac rhythm in order to identify abnormal heart rhythm since the start of the shift and she had notified the telemetry staff about the loss signal. Staff E acknowledged there had been no rhythm strips from the night shift. Staff E stated the practice was to post rhythm strips every 4 hours on the telemetry record. When asked to demonstrate a patient's stored event history (cardiac rhythm) from the central station monitor, Staff E was not able to do so and stated the central monitor was not capable.

At 3:05 p.m., the same day, during an interview with Staff A, she stated the staff was supposed to let her know when the telemetry was not working.

The Telemetry Log Book was reviewed on February 10, 2010, and revealed the following:

a. There were five other patients on telemetry and there was no rhythm strips posted after February 7, 2010 at 3:37 a.m., for Patient 10.

b. On December 25, 2009, the documentation indicated "Do not release Telemetry #8, 9, 11, 12. The receivers are not working and will not show up on the monitor. They will fix the problem on Monday 12/28/09. If the problem arises again, the monitor need to be replaced with newer one already. On 12/25/09, tele-monitor went completely blank. The "bad" receivers (8, 9, 11, 12) messed up the monitor and shut down."

c. On January 21, 2010, the documentation indicated "As of today only 8 telemetry are working. Nursing Supervisor aware. Engineering aware." The documentation also indicated the Director of Plant Operation, Quality Improvement and Director of Nursing were aware.

During an interview with Staff H on February 10, 2010 at 3:35 p.m., he stated the facility had problems with the telemetry boxes. Staff H stated there were issues with the transmitters, and the staff kept trying to test the boxes to check which boxes would work in which unit.

At 4:05 p.m., the same day, during an interview, Staff Q stated he was not aware of the problem with the telemetry. Staff Q stated there were no work orders filled out by the nurses.

During an interview with Staff A on February 10, 2010 at 4:10 p.m., she stated the telemetry was very important for cardiac monitoring. Staff A stated the patients could die and the heart could beat too fast or too slow.

On February 11, 2010 at 8:35 a.m., during an interview with Staff E, she stated the tele-monitor was replaced when it shut down in December 2009. Staff E stated there are two tele-monitor and pointed to two of three central station monitors located in the ICU nurses' station.

The facility policy and procedure titled, "Telemetry, Use Of" indicated, "The primary purpose of the telemetry unit is: To ensure continuous visualization of electrical activity of the heart, thereby allowing identification of cardiac dysrhythmias.... Provide consistent monitoring of patient's cardiac status when CCU or ICU care is not needed." The policy and procedure stipulated "Every 4 hour posting of monitor strips on the daily nurses notes of the patient's medical record, but every 2 hour documentation of rhythm interpretation."

2. The physician orders for Patient 10 was reviewed on February 10, 2010. The physician order dated February 2, 2010 at 4:45 p.m., disclosed, "Telemetry." The physician order indicated the following diagnoses: congestive heart failure, shortness of breath and renal insufficiency. There was no documented physician order to discontinue the telemetry.

A review of the Telemetry Log Book on February 10, 2010, revealed no rhythm strips posted after February 7, 2010 at 3:37 a.m., for Patient 10.

On February 11, 2010 at 8:15 a.m., during an interview, Staff A stated the patient had been discharged.

3. On February 9, 2010 at 9:45 a.m., Patient 6 was observed in bed with a tracheostomy tube connected to a ventilator (Esprit).

A review of the patient's medical record revealed an Initial Assessment/ Screening form dated January 25, 2010 at 8:30 p.m., and signed as completed by a licensed vocational nurse (LVN).

During an interview with Staff A on February 9, 2010 at 11:15 a.m., she stated the LVN may collect information and the registered nurse (RN) must review the data then sign the Initial Assessment/Screening form.

4. On February 9, 2010 at 2:35 p.m., Patient 7 was observed in bed with a sign at the head of the bed indicating nothing by mouth.

A review of the patient's admission sheet indicated the patient was admitted to the facility on February 5, 2010 at 1:40 a.m., with abdominal pain, rule out pancreatitis.

A review of the Initial Assessment/Screening form dated February 5, 2010 at 3:30 a.m., revealed the initial assessment/ screening was signed as completed by a licensed vocational nurse (LVN).

During an interview with Staff D on February 9, 2010 at 3:50 p.m., she stated the practice was for the RN to review the Initial Assessment /Screening form completed by the LVN then sign.

The policy and procedure titled, "Assessment/ Reassessment of Patient" indicated, "Analysis of the admission data collected and the nursing physical assessment is the responsibility of the registered nurse." The policy and procedure stipulated that the registered nurse "Must confirm the data and information collected by other nursing staff members."

5. Patient 11's closed medical record was reviewed on February 18, 2010. The admission sheet indicated the patient was admitted to the facility on January 15, 2010, with generalized weakness and difficulty swallowing, was placed as do not resuscitate (DNR) on January 20, 2010, and expired on January 26, 2010.

A review of the Arrhythmia Sheet disclosed several rhythm strips. The posted rhythm strips contained data indicating the patient's name, bed number, date, time, heart rate, cardiac rhythm and respiration. Further review of the posted rhythm strips indicated "Some ECG Alarms Off" for strips dated January 19, 2010 at 11:15 p.m., and January 23, 2010 at 6:31 a.m. The posted rhythm strip dated January 18, 2010 at 11:58 p.m., indicated, "Alarms suspended, Resp Lead Off" followed by "All ARRH Alarms Off."

During an interview with Staff B on February 18, 2010 at 11:20 a.m., he stated the rhythm strips were to be posted every 4 hours. Staff B stated the staff do not turn off the alarm and was not able to explain why the posted rhythm strip for Patient 11 indicated the all the arrhthymias alarms were off. Staff B demonstrated in the nurse's station central station monitor. The central monitor alarm was set up for lethal arrhythmias like ventricular tachycardia, ventricular fibrillation and the heart rate was set for high limit of 160 and low limit of 45.


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6. On February 9, 2010, at approximately 10:15 a.m., during the tour of the facility with Staff P, Patient 21 was observed lying in bed. There was a laceration on the upper left lip with dried blood on the open area. A nasal cannula was lying on the bed and the oxygen flowmeter indicated one (1) liter. Upon interview, the patient stated he uses oxygen daily and had pain in his lower back and shoulder that required medication.

A review of the clinical record revealed the patient was admitted to the facility on February 7, 2010, with diagnoses that included laceration on the left upper lip. Further review of the clinical record specifically the licensed nurses notes failed to show documentation to indicate the laceration was being assessed and cleaned and the patient was medicated with pain medication since admission.

Further review of the clinical record specifically the MAR dated February 7, 2010, did not have documentation to indicate the patient was assessed for the presence or absence of pain. On February 8, 2010, at approximately 9:45 a.m. and 10:40 p.m., the patient was administered Tylenol 650 mg as ordered. On February 9, 2010, at approximately 10 a.m., the patient was administered Morphine 4 mg intravenously. However, on both occasions, there was no documentation to indicate a reassessment of the patient's pain level was conducted after medication administration.

On February 9, 2010, at approximately 11 a.m., during an interview with Staff P while reviewing the clinical record failed to show documentation of an assessment conducted on the upper lip laceration as well as reassessment of the level of pain after medication administration.

7. A review of the medical record revealed Patient 22 was admitted to the facility on February 4, 2010, with diagnoses that included cellulitis of the buttocks and lower extremities.

A review of the Patient History/Data Base (initial assessment/screening) on admission indicated the form was signed as completed by a licensed vocational nurse (LVN).

During an interview with Staff P on February 9, 2010 at 4:20 p.m., she stated the initial assessment/screening for Patient 22 could be done by a licensed vocational nurse, however, a registered nurse was supposed to sign off on the assessment.

A review of the facility's policy and procedure on Assessment / Reassessment of Patient stipulated the analysis of the admission data collected and the nursing physical assessment were the responsibility of the registered nurse and at the time of admission, each patient would have their needs assessed by a registered nurse. The policy and procedure also stipulated the registered nurse must confirm the data and information collected by other nursing staff members.

8. A review of the medical record revealed Patient 28 was admitted to the facility on December 31, 2009, with diagnoses that included altered level of consciousness, dementia , old cerebro-vascular accident, colon cancer and diabetes mellitus.

A review of the Initial Assessment/Screening on admission indicated a signature of an LVN to indicate the LVN completed the assessment.

A review of the facility's policy and procedure on Assessment/ Reassessment of Patient stipulated the analysis of the admission data collected and the nursing physical assessment were the responsibility of the registered nurse and at the time of admission, each patient would have their needs assessed by a registered nurse. The policy and procedure also stipulated the registered nurse must confirm the data and information collected by other nursing staff members.


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9. The medical record was reviewed on February 9, 2010. The face sheet indicated Patient 5 was admitted to the facility on February 6, 2010, with diagnoses of sickle cell crises.

A review of the initial assessment/screening form dated February 7, 2010, indicated a signature of a LVN to indicated the LVN completed the assessment.

During an interview Staff EE on February 9, 2010 at 4:20 p.m., she stated she completed the initial assessment/screening for Patient 5, however, a registered nurse was supposed to sign off on the assessment. Staff EE further stated the pain assessment form for Patient 5 was incomplete because the nurse did not sign at the bottom of the form and she did not date it.

A review of the facility's policy and procedure titled, Assessment/ Reassessment of Patient indicated the analysis of the admission data collected and the nursing physical assessment was the responsibility of the registered nurse and at the time of admission, each patient would have their needs assessed by a registered nurse. The policy and procedure also indicated the registered nurse must confirm the data and information collected by other nursing staff members.

A review of the progress notes dated February 8, 2010 indicated Patient 5 was notified not to attempt to elope from facility.

During an interview with Staff EE on February 9, 2010 at 4:25 p.m., she stated Patient 5 left the facility yesterday, without notifying a hospital personnel. Staff EE stated Patient 5 was outside the facility for over 30 minutes and the staff had to search for the patient. Staff EE further stated she notified the family, however, she did not document it. She stated she told the charge nurse, however, no incident/ occurrence report was done.

During an interview with Staff D on February 9, 2010 at 4:30 p.m., she stated she was not informed of Patient 5's elopement.

A review of the facility's policy and procedure titled, Against Medical Advice and Elopements dated March 2009 indicated when elopement has been determined, the elopement is documented in the nurse's notes regarding the date, time and when first discovered the patient was missing, and to include name/position of staff in search of patient. The policy and procedure indicated to inform the nursing supervisor of the incident and generate an occurrence report, to call the patient's home and notify family or significant other and to document the condition of the patient including emotional state and last time patient was seen.

Based on observation, interview, and record review, the facility staff failed to ensure the nursing staff developed and kept current, a nursing care plan based on assessments of the patient's nursing care needs with appropriate nursing care interventions for 3 patients, in a survey sample of 37 (Patients 5, 21, and 28). Patient 21's record revealed no care plans to address the care of the patient's lip laceration, a heplock to his right foot, and oxygen. Patient 28's record revealed no care plans developed to address care of the gastrostomy tube feeding and indwelling catheter. For Patient 5, the licensed nurse indicated Patient 5 was non-compliant by disconnecting the intravenous tubing, however, there was no care plan regarding the non-compliance.

Findings:

1. On February 9, 2010, at approximately 10:15 a.m., during the tour of the facility with Staff P, Patient 21 was observed lying in bed. There was a laceration on the upper left lip with dried blood on the open area. The patient had a heplock in place to his right lower foot. The patient was receiving a liter of oxygen via nasal cannula.

On February 9, 2010, at approximately 10:30 a.m., during an interview with Staff P, while reviewing the patient's clinical record, failed to show documentation that the care plans were developed to address concerns such as laceration on the upper left lip, heplock on the right lower foot, and the current use of oxygen.

2. On February 10, 2010, at approximately 11:10 a.m., during the tour with Staff U, Patient 28 was observed lying on a special bed because of a stage III pressure ulcer on the sacral area. The patient was on gastrostomy tube (G-tube) feeding of Diabetic Source running at 50 cc/hour which was hang at 4 a.m., on February 10, 2010. The patient's indwelling catheter was observed draining 700 cc of cloudy, amber urine.

On February 10, 2010, at approximately 1:30 p.m., during an interview with Staff U, while reviewing the patient's clinical record, failed to show documentation that the care plans were developed to address concerns such as G-tube feeding and indwelling catheter.


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3. The medical record was reviewed on February 9, 2010. The face sheet indicated Patient 5 was admitted to the facility on February 6, 2010, with diagnoses which included sickle cell crises.

During the initial tour observation with Staff EE on February 9, 2010 at 2:45 p.m., Patient 5 was not in the room. There was an intravenous (IV) antibiotic hanging on the IV pole, the tubing was disconnected and was found inside the patient's drawer. Staff EE stated Patient 5 sometimes removed/disconnected the IV tubing by herself to go out on the patio.

During an interview with Staff EE on February 9, 2010 at 4:05 p.m., she stated Patient 5 was back from the patio and tried to reconnect the IV by herself. Staff EE also stated that only the nurse should disconnect and reconnect the IV tubing and that she told this to Patient 5, but she was non-compliant. When Staff EE was asked if Patient 5 had a care plan regarding the non-compliance, she searched the medical record, then stated she would make a care plan for the patient.

A review of the facility's policy and procedure titled, Assessment and Reassessment of Patient indicated to facilitate communication of data assessment and plan of treatment among disciplines. The policy and procedure also indicated all assessments would include data analyzed to create the information necessary to develop a plan to meet the patient's care of treatment needs.

Based on observation, interview, and review of facility documents, the facility failed to ensure the pediatric staff were competent in emergency care, emergency procedures, and needs of pediatric patients in the facility. Three (3) of three (3) registered nurses in the pediatric unit failed to demonstrate and verbalize the knowledge of defibrillation, suction set up and suctioning of pediatric patients. A situation of Immediate Jeopardy was declared on February 12, 2010 at 2:30 p.m., with Staff A and Staff P and was lifted on February 12, 2010 at 5:30 p.m., during the survey based on acceptable corrective action plan implemented by the facility.

Findings:

On February 12, 2010 at 9:30 a.m., a crash cart was observed in the hallway of the pediatric unit. When asked to set up the portable suction machine, Staff L took out a suction tubing, connected it to the short tubing with filter already attached to the suction cannister, and without checking the amount of pressure, Staff L turned on the suction. The fluid (saline) collected in the suction filter, not the suction canister. Staff L stated the suction machine was working.

At 9:40 a.m., Staff D was asked to demonstrate how to use the suction machine, Staff D set up the suction machine exactly the same way as Staff L, then turned on the suction without checking the amount of pressure. The fluid (saline) collected in the filter and not in the suction canister.

Both Staff D and Staff L were then asked to demonstrate how to use the defibrillator. Staff D turned the selector switch to the designated energy level (joules) to test the defibrillator and tested the defibrillator both plugged and unplugged to the wall outlet. When asked to demonstrate how to defibrillate a pediatric patient with the defibrillator on the crash cart, Staff L checked and double checked the crash cart, picked up an electrode then put it down. When asked to use the paddles, both staff were not able to remove the paddles from their holders.

At 10 a.m., Staff M was asked to assist Staff D and Staff L and demonstrate how to defibrillate a pediatric patient. Like Staff D, Staff M proceeded to turn the selector switch to the designated energy (joules) for testing the defibrillator. Staff was asked again to demonstrate how to defibrillate a pediatric patient not to test the defibrillator, Staff M checked the crash cart, picked up an electrode then put it back on the crash cart. Staff M was asked to use the defibrillator paddles. After three attempts Staff M was able to remove the defibrillator paddles from their holders, however, she was not able to slide the adult paddles to expose and access the pediatric paddles that lie directly under the adult paddles.

At 10:30 a.m., the same day, inspection of the crash cart revealed there was no pediatric defibrillator electrode with connector and cable.

During an interview with Staff L on February 12, 2010 at 10:40 a.m., she stated the facility has a code team. Staff L stated the code team included the emergency room physician, intensive care unit nurse, respiratory therapist, nursing supervisor and pharmacist.

During an interview with Staff A at 11:50 a.m., she stated the code team for pediatric patient included emergency room physician, two pediatric nurses with PALS (pediatric advance life support for example Staff L and Staff M), respiratory therapist, nursing supervisor and pharmacist.

At 12:05 p.m., a mock code in the pediatric unit was observed. The charge nurse discovered the patient and summoned for help. The crash cart was brought in the room. The nurse supervisor, respiratory therapists, emergency room physician then the pharmacists arrived at the scene. The scene was disorganized with several people in the hallway observing the mock code. There was no Breslow tape, no PALS dozing guidelines used and two pharmacist were observing and not participating or assisting the nurse when medications were called. One staff holding the pediatric Ambu bag continued bagging when the physician stated to stop CPR.

On February 12, 2010 at 2:30 p.m., Staff A and Staff P were notified of "Immediate Jeopardy (IJ)" situation for facility's failure to ensure the pediatric staff were knowledgeable with emergency situations to provide safety for the pediatric patients. Three (3) of three (3) registered nurses in the pediatric unit failed to demonstrate and verbalize knowledge of defibrillation, suction set up and suctioning of pediatric patients. On February 12, 2010 at 5:30 p.m., Staff A and Staff B presented a plan of corrective action to the survey team and the team abated the IJ.

The team accepted the written plan of action for the immediate jeopardy situation on February 12, 2010 at 5:30 p.m. The facility implemented the plan of action as follows: The facility immediately provided defibrillation and suctioning of pediatric patient in-service with demonstration and return demonstration to the pediatric staff, emergency staff and nursing supervisors on duty. The facility reviewed cardiopulmonary resuscitation, pediatric "code white" policies and procedure with the on duty staff. In addition, the facility set up additional in-service for the in-coming staff.

Based on record review and interview, the facility staff failed to ensure that two qualified licensed nurses checked both the patient and donor identification appearing on the unit blood prior to administering blood product to Patient 28.

Findings:

On February 10, 2010, at approximately 11:10 a.m., Patient 28's medical record was reviewed. There was a physician's order dated February 4, 2010, at 3 p.m., to transfuse two (2) units of packed red blood cell. The patient's laboratory result dated February 3, 2010 revealed hemoglobin was 9 (normal values 14-18) and hematocrit was 26.5 ( normal values 42-50). The transfusion record dated February 4, 2010, documented that the blood transfusion was started at 4:15 p.m., and completed at 7:15 p.m. The transfusion record revealed one (1) signature of a licensed nurse who verified the transfusion and there was blank on the section for the person who started the transfusion. The transfusion record noted that at the end of the transfusion, the patient's temperature was 100.1 degree Fahrenheit and there was no documentation to show that the physician was notified.

During an interview with Staff U on the same day at 1:30 p.m., while reviewing the clinical record, she concurred that there was no second signature required in the transfusion record, the length of time for the transfusion was not part of the physician's order and there was no documentation to indicate the physician was notified of patient's temperature.

The facility's policy on Blood and Blood Components stipulated two Licensed Nurses, one of which is an Registered Nurse (RN), must establish correct patient identification prior to administering the blood. It also stipulated that the physician's order should include the specific length of time for the transfusion.

Based on record review and interview, the facility failed to ensure the physician authenticated all prescribed verbal orders within 48 hours for 2 patients in a survey sample of 37 Patients 6 and 21.

Findings:

1. On February 9, 2010 at 11 a.m., in the Intensive Care Unit, Patient 6 medical record was reviewed.

The Physician Order Sheet dated January 31, 2010 at 3 p.m., revealed a physician medication orders for Zosyn 3.375 grams (antibiotic) to be admistered by intravenous piggy back every 8 hours and stop Cefepine (antibiotic). However, there was no documented evidence that a physician or licensed practitioner had authenticated the verbal/telephone order.

During an interview with Staff C on February 9, 2010 at 11:15 a.m., she stated the physician must have missed the order. Staff C stated the telephone orders are signed by the physician within 24 hours.


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2. According to the clinical record, Patient 21 was admitted to the facility on February 7, 2010, with a diagnosis of upper left lip laceration.

On admission, there was a physician's order for Morphine 4 mg intravenously (IV) and Tylenol 650 mg every six (6) hours for pain.

On February 9, 2010, a review of the physician's telephone/verbal medication orders indicated a physician had authenticated the orders.

During an interview with Staff P on February 9, 2010 at 11 a.m., she stated the telephone orders were signed by the physician within 24 hours.

Based on record review and interview, the facility failed to ensure a medical history and physical examination was completed and documented no more than 30 days before or 24 hours after admission and placed in the medical record for 1 patient, in a survey sample of 37.

Findings:

A review of Patient 19's History and Physical (H & P) for admission date of June 18, 2008, revealed the patient was admitted to the facility with back pain, chest pain and shortness of breath. The H & P however, was dictated and transcribed on June 20, 2008.

A review of Patient 20's Admission Sheet revealed the patient was admitted to the facility on February 20, 2009, with pneumonia.

A review of the H & P for the admission date of February 20, 2009, disclosed the H& P was dictated and transcribed on April 21, 2009, sixty (60) days after admission.

During an interview with Staff P on March 11, 2010 at 4:45 p.m., she reviewed the medical record and acknowledged the date of admission (February 20, 2009) and date of the H & P was dictated (April 21, 2009). Staff P was not able to explain the reason for the discrepancy. Staff P stated it was probably due to filing.

Based on medical record review, interview, and review of facility documents, it was determined that the facility's pharmacy service did not meet the Condition of Participation (CoP) for Pharmaceutical Services by failing to:

1. Ensure that the medications were properly labeled and administered as ordered for three (3) pediatric patients. (Refer to A 500)

2. Ensure that all drugs and biologicals were kept in a secure area and the medication cart was locked at all times. (Refer to A 502)

3. Ensure the medications that were ordered were entered, verified, calculated and dispensed accurately by the pharmacy services. In addition, the facility failed to report the medication errors to Quality Assurance program to proactively identify causative factors and implement corrective actions to reduce or prevent reoccurrence. (Refer to A 508)

The cumulative effect of these systemic practices resulted in the facility's inability to ensure the pharmaceutical services meet the needs of the patients by promoting a safe medication use process.

Based on observation, interview and record review, the hospital pharmacy failed to ensure that the medications were properly labeled and administered as ordered for three (3 ) pediatric patients. In addition, the facility failed to provide for patient safety, drugs were not controlled and distributed in accordance with applicable standards of practice, consistent with Federal and State law.

Findings:

On February 12, 2010, at approximately 9 :25 a.m., during the observation tour of the unit, in room 208, there were three (3) overflow pediatric patients receiving IV solutions and medications via pumps that had no labels to ascertain the medications were received or being received.

1. Patient 30 had an intravenous (IV) solution of 5% Dextrose with 0.20% Sodium Chloride in a 500 milliliter (ml) bag running at 30 cubic centiliter per hour (cc/hr) via a pump in a microdrip chamber. There was another IV bag that had no label which according to Staff P, the piggy back IV was Rocephin medication.

According to the clinical record, on February 11, 2010, the physician ordered D5 1/4 at 30 cc/hr and Rocephin 175 milligram (mg) IVPB every 12 hours.

2. Patient 31 had an IV solution of 5% Dextrose with 0.20% Sodium Chloride in a 500 ml bag running at 10 cc/hr via a pump in a micro drip chamber. The other IV bag had no label which according to Staff P was the piggy back IV for Claforan medication.

According to the clinical record, on February 11, 2010, the physician ordered D5 1/2 NS at 10 cc/hr and Claforan 400 mg every eight (8) hours.

3. Patient 32 had an IV bag that had no label which according to Staff P, the IV was for Rocephin medication.

According to the clinical record, on February 11, 2010, the physician ordered Rocephin 150 mg IVPB every twelve (12) hours.

During an interview with Staff P on the same day, at approximately 3 p.m., she stated that the IV solutions and bags should be labeled prior to administering to the patients. She added that medications should be administered as ordered by the physician.



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4. On 2/10/10 at 9:25 A.M., the record for Patient 300 was reviewed.

On 2/2/10 at 8:00 P.M., the form entitled: "Preadmission Medication List Verification and Order Form" had the following physician order ("continue on admission") for Patient 30:
"Risperdal 25 mg (used for mental disorder) IM (intramuscular) every 2 weeks on Monday".

On 2/3/10 at 11:44 A.M., Pharmacist 2 rewrote the physician order as:
"Risperdal 25mg IM is non formulary. RN please use pt's own meds."

On 2/10/10 at 9:25 A.M., Pharmacist 2 was interviewed. Pharmacist 2 was asked whether Pharmacist 2 interviewed Patient 30 to determine when Patient 30 was last administered his/her Risperdal dose to ensure appropriate administration, and if Patient 30 did have the Risperdal IM. Pharmacist 2 indicated neither was done.

On 2/10/10, Pharmacist 2 was asked how did (s)he ensure Patient 30 was administered the Risperdal correctly when Pharmacist 3 never checked to see if Patient 30 had his/her own Risperdal IM injection and never checked to see when Patient 30 last received Risperdal. Pharmacist 2 stated "it was up to nursing".

5. On 2/11/10 at 8:35 A.M., the PIC was asked that when nurses remove drugs for
after-hours dispensing/administration, how does the pharmacy ensure that the nurses are at a minimum educated and competent on dispensing and administration of medications since the pharmacist is no longer present. The nurses that remove the medications for dispensing and administration are in effect acting as a pharmacist. How does the pharmacy ensure that the appropriate dispensing functions which is delegated to the pharmacist when they are on duty, such as ensuring appropriate drugs selection based on the patient's clinical condition, lab values and determining pharmacological and pharmacokinetic compatibility are met when a nurse removes drugs after hours.

On 2/11/10, the PIC failed to provide documented evidence that ensured that nurses who dispense medications have a minimum education and competence for ensuring appropriate drug selection based on the patient's clinical condition, lab values and determining pharmacological and pharmacokinetic compatibility during after-hours (when the pharmacist is no longer working) dispensing.

6. On 02/11/10, Physician 4 was interviewed on pediatric codes. Physician 4 was asked what dosing guideline for drugs are used when (s)he attends a pediatric code. Physician 4 stated that the PAL (pediatric advance life support) guidelines are reviewed.

On 02/11/10at 10:20 A.M., inspection of the pediatric crash cart revealed that the Broselow tape was in the pediatric crash cart.

The following issues were:

(a) The facility had two different dosing guidelines for a pediatric code. The Physician used the PALs guidelines while the pediatric cart had a Broselow tape.

The physician uses the PALs guidelines which has dosing for eight medications.
The pediatric crash cart contains 24 medications. There are at least 16 medications without any dosing guidelines immediately available during a pediatric code.

7. On 02/11/10 at 10:30 AM, the PIC was asked what standard concentrations would there be for drugs in the pediatric crash cart that would require dilution to ensure the consistent and accurate dosing and administration of drugs. The PIC stated it was up to the physician on the code.

On 2/11/10 at 10:30 A.M., the Physician 4 (the physician that would attend codes) was asked what standard concentrations were there for drugs that required dilution during a pediatric code? Physician 4 stated that when the pharmacist was there (s) he would ask the pharmacist and if not, (s) he would consult the other physicians and nurses.

Based on observation and interview, the facility staff failed to ensure that all drugs and biologicals were kept in a secure area and the medication cart was locked at all times.

Findings:

1. On February 9, 2010, at approximately 11:05 a.m., during an observation tour of the unit with Staff P, the medication cart was observed unattended and unlocked in the hallway. The facility staff, patients and visitors were observed walking the busy hallway.

During a concurrent interview with Staff P, she stated that medication cart should always be locked to prevent unauthorized access to the patients' medications by visitor, patients, and unlicensed personnel.




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2. On February 9, 2010 at 11:09 a.m., during a tour of the facility, the evaluator observed an unsecured and unlockable nightstand in disrepair in a corridor with no clinical staff monitoring the nightstand and it's contents. The nightstand was located at the opposite end from the nurses station, across from room 202, readily accessible to unauthorized persons.

The facility's environmental staff opened the drawers before removing the nightstand. At that time, the evaluator observed that there was a carton of PROTONIX I.V. 40 mg. (pantoprazole) stored among medical supplies in the nightstand.

The Medical Surgery RN was called to the location of the nightstand and made aware of the carton of PROTONIX I.V. 40 mg. During an interview, the Medical Surgery RN stated the PROTONIX I.V. 40 mg. should have been stored in the medication cart.

The facility's policy and procedure entitled, Storage of Drugs and Biologicals dated May, 2000, indicated that throughout the hospital all spaces and areas used for drugs shall be lockable, and that all drugs shall be inaccessible to unauthorized personnel.

Based on record review and interview, the facility failed to ensure the medications that were ordered were entered, verified, calculated and dispensed accurately by the pharmacy services for 4 patients in a survey sample of 37 (Patients 12, 13, 14 and 15). In addition, the facility failed to report the medication errors for Patients 13 and 14 to Quality Assurance program to proactively identify causative factors and implement corrective actions to reduce or prevent reoccurrence.

Findings:

1. Patient 13's medical record was reviewed. The Admission Sheet disclosed the patient was admitted to the facility on October 17, 2009, with diagnoses that included cellulitis (inflammation of the soft tissue) and osteomyelitis (inflammation of bone due to infection).

The Physician's Order Sheet dated October 18, 2009, indicated an order for Vancomycin (intravenous antibiotic) 1 gram IV times one dose then pharmacy to dose. The Physician's Order Sheet dated October 20, 2009 at 10:30 a.m., indicated an order to hold Vancomycin and notify the pharmacy, as the patient's creatinine level was 1.9. At 2 p.m., the same day, the pharmacist wrote in the physician order sheet that as per protocol, to change Vancomycin to 1000 mg every 24 hours IVPB. The Medication Sheet revealed the Vancomycin was administered on October 20, 2009 at 4 p.m., and the second dose was stopped on October 21, 2009.

During an interview with the Pharmacist in Charge (PIC) on March 10, 2010 at 12:10 p.m., he stated the physician held the vancomycin because the creatinine level was high (1.9), but the pharmacist (Pharmacist 3) resumed the Vancomycin order. The PIC stated this led to worsening of the renal function of the patient. The PIC stated the incident was discussed with the physician concerned and human resources and the pharmacist was suspended for 2 days. When asked for the corrective action plan, the PIC stated there was no written action plan. The PIC stated the incident was not reported to the Quality Assurance program.

2. Patient 14's medical record was reviewed. The Admission Sheet disclosed the patient was admitted to the facility on November 25, 2009, with a diagnosis of lower extremities cellulitis, abscess. The Physician's Order Sheet dated December 1, 2009 at 3 p.m., reflected an order written by Pharmacy 2 per protocol for Vancomycin 750 mg IVPB every 24 hours, draw the trough level 30 minutes before the 3rd dose on December 3, 2009. On December 4, 2009 at 12 p.m., Pharmacy 3 wrote to hold Vancomycin until the trough result came back. On December 7, 2009 at 6 p.m., Pharmacy 2 wrote an order to resume/continue Vancomycin 750 mg every 24 hours per protocol. The Medication Sheet indicated Vancomycin was administered on December 1 & 2, 2009 at 10 p.m.

During an interview with the PIC on March 10, 2010 at 4:10 p.m., he reviewed the record and stated the order for Vancomycin 750 mg every 24 hours on December 1, 2009, for hemodialysis patient was wrong. Per protocol, Vancomycin may be given up to 1 gram times 1, repeat the dose after taking random level between 4-7 days. The PIC also stated the order to resume Vancomycin 750 mg every 24 hours on December 7, 2009 was an error. The PIC stated the pharmacist (Pharmacy 3) repeated the error, she overlooked the fact that the patient was on renal failure and was on hemodialysis. When asked for the corrective action plan, the PIC stated there was no written action plan. The PIC stated the incident was not reported to the Quality Assurance program. The PIC stated the Pharmacy schedule was rotated every 24 hours and the dosing of the previous pharmacist was verified on a daily basis.

The facility policy and procedure titled, "Aminoglycoside/Vancomycin Dosing per Pharmacy" dated November 2001, indicated that when pharmacy received and order for vancomycin or was requested to initiate, regulate, adjust dosing, an initial assessment of therapy is to be completed and to include pertinent past illnesses, history of present illness, laboratory data.

During an interview with the PIC on March 10, 2010 at 4:10 p.m., he reviewed the record and stated the order for Vancomycin 750 mg every 24 hours on December 1, 2009, for hemodialysis patient was wrong. Per protocol, Vancomycin may be given up to 1 gram times 1, repeat the dose after taking random level between 4-7 days. The PIC also stated the order to resume Vancomycin 750 mg every 24 hours on December 7, 2009 was an error. The PIC stated the pharmacist (Pharmacist 3) repeated the error, she overlooked the fact that the patient was on renal failure and on hemodialysis.

3. A review of Pharmacy 3's personnel file revealed three (3) counseling memos regarding "Work Quality." The counseling memos were as follows:

a. A warning was issued on November 17, 2009, as indicated by the pharmacist signature, regarding an error in dispensing an intravenous (IV) preparation of Metronidazole (Flagyl) on October 20, 2009 for Patient 12. The documentation indicated the physician's order was 250 milligrams (mg) the pharmacist supplied 500 mg and labeled the preparation as 250 mg.

During an interview with the PIC on March 10, 2010 at 12:10 p.m., he stated the label showed Flagyl 250 mg, but 500 mg was dispensed. The PIC stated Flagyl 500 mg was not administered, the nurse found the mistake.

Patient 12's medical record was reviewed. The Physician's Order Sheet dated November 8, 2009 (no time), noted by the licensed nurse at 5:30 p.m., indicated Flagyl 250 mg to be administered intravenous every 8 hours. The Medication Sheet dated November 9, 2009, revealed the patient received Flagyl 250 mg IV at 5 a.m., 1 p.m., and 9 p.m.

b. A 2-days suspension was issued on October 30, 2009, as indicated by the pharmacist signature, regarding a serious error in Vancomycin ordering and dispensing on October 20, 2009 for Patient 13.

c. A 2-day suspension was issued on December 16, 2009, as indicated by the pharmacist signature, regarding an error in the calculation and dispensing of Vancomycin on December 1, 2009 for Patient 14.

d. The same counseling memo dated December 16, 2009 indicated, that on December 5, 2009, the pharmacist made an entry/dispensing error for Patient 15. Pharmacist 3 dispensed Thorazine (Chlorpromazine - antipsychotic) instead of Librium (Chlordiazepoxide - medication for anxiety). "The patient received multiple doses of Thorazine during a 10 day period when this was not the medication ordered by the physician."

A review of the Physician's Order Sheet dated December 5, 2009 at 12:30 p.m., indicated increase Librium (Chlordiazepoxide) to 50 mg to be administered orally now then every 8 hours.

A review of the Medication Record indicated Chlorpromazine HCL (Thorazine) start date 12/5/09 and was initialed as administered on 12/6/09 at 1 p.m. A pharmacy note disclosed (generic dispensed).

A review of the document "Order Details" for Patient 15 disclosed the following: Requested: Chlorpromazine HCL 50 mg, RPh Note: Generic Dispensed. Start date 12/5/09, 1:16 p.m. The documented medication was entered and verified by Pharmacist 3 on 12/5/09.

On March 10, 2010, the PIC was asked to print out a copy of the Chlordiazepoxide issuance from the "Omnicell." A review of the "Omnicell" Transactions by Item/ Procedure with the PIC disclosed Librium (Chlordiazepoxide) was issued for Patient 15.

Based on observation, interview, and record review, the facility failed to ensure their policy and procedure on Portable Radiographs was implemented.

Findings:

On February 11, 2010 at 8:40 a.m., in the Intensive Care Unit (ICU), Staff I opened Bed 1's privacy curtain then pushed the portable x-ray machine out of the room. The patient room had no door, only a privacy curtain. Across from Bed 1, in the nurses' station, there were two surveyors and two nursing staff. There was no announcement heard.

During a concurrent interview with Staff I, he stated he took a portable chest x-ray.

In the Radiology Department on February 11, 2010 at 9:50 a.m., Staff I, Staff J, and Staff K were interviewed. Staff I stated he took a portable chest x-ray in the ICU that morning, and acknowledged that he did not call out and stated, "My mistake." Staff I stated he was called to go to the operating room. Staff J stated the procedure was to put the x-ray plate, announce the x-ray, and wait to clear the area. Staff J stated the mandate was six feet and further for everyone else.

The facility policy and procedure titled, "Portable Radiographs" indicated, "All visitors and hospital personnel will be asked to leave the room during the exposure part of the procedure." The policy and procedure stipulated that, "Before making the exposure, the Radiology Technologist will make sure the room is clear and announce "x-ray" exposure about to commence. After the exposure, the Radiology Technologist will say "clear."

Based on observation, interview, and record review, the facility staff failed ensure the nutritional needs on 2 patients in a survey sample of 37, were met in accordance with the physician's order and their policy on Responsibility for Transmitting Diet Orders (Patients 27 and 36). Patient 27 was observed receiving gastrostomy tube feeding at a rate of 50 cubic centiliters per hour (cc/hr), however, the physician's order indicated the tube feeding was to run at 30 cc/hour. The facility staff also failed to ensure that the food allergies in the physician's orders for Patient 36 were transmitted to the Dietary department and transcribed to the patient's diet profile card.

Findings:

1. On February 9, 2010, at approximately 3 p.m., during the observation tour, Patient 27 was noted lying in bed and was receiving a gastrostomy tube running at 50 cc/hr. The feeding formula was HN-Fibersource and there was 500 ml left in the 1500 ml bag. The feeding bottle did not have the patient's name, date it was hung, rate and who hung the feeding bag.

A review of the clinical record revealed the patient was admitted to the facility on February 7, 2010, with diagnoses that included gastro-intestinal bleeding and coffee ground emesis. On admission, the physician ordered Fibersource 30 cc/hr.

On February 8, 2010, the clinical record indicated the patient had esophagogastroduodenoscopy with gastrostomy tube replacement and biopsy. On February 8, 2010, the dietary assessment revealed the registered dietitian recommended to change the formula from Diabetic Source to HN-Fibersource to run at 30 cc per hour times twenty two (22) hours.

On February 9, 2010, at approximately 4:30 p.m., during an interview with Staff X, she stated the gastrostomy tube feeding should have been labeled with the patient's name, date it was hung, rate and the initial of the person who hung the feeding bag. She added that the rate of the tube feeding should be at 30 cc/hr as ordered by the physician.


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2. On February 11, 2010, between 8:35 a.m. and 11:10 a.m., the evaluator observed there were three food allergies written on the chart cover for Patient 36.

A review of the clinical record revealed the patient was admitted to the facility on February 8, 2010. The physician orders dated February 8, 9 and 10, 2010, indicated the patient had allergies to tomatoes, corn and grapefruit.

On February 11, 2010, between 11:10 a.m. and 11:59 a.m., during the lunch tray line service in the kitchen of the Norwalk campus, the evaluator observed paper forms (FORM BC 6010-840) instead of tray cards on patient trays that specified the type of diet the patients were to be served. There were no allergies identified on the form that was on the patient's tray.

At 11:59 a.m., during an interview, the patient stated she could not eat tomatoes because they upset her stomach.

At 12:15 p.m., during an interview, Staff Z stated that patient's food allergies were written next to the patient's name on the Diet Order List and on the cardex (Patients Profile), which was done by the dietician within 24 hours of admission.

Document review with Staff Z revealed the patient's allergies were not documented on the Diet Order List. The review also revealed there was no Patient Profile for the patient. The Patient Profile in the dietary department that corresponded with the patient's room and bed identifier was dated July 25, 2009, and had another patient's name on it.

Staff Z stated that the patient allergies would only be documented on the tray form, Diet Order List, and the Patient Profile, that there was no other documentation in the dietary department that would indicate patient's allergies.

The facility's policy and procedure entitled, Responsibility for Transmitting Diet Orders dated November 2002, indicated that the Nursing Department Responsibilities were for the nurse in charge to transcribe the diet order and other information from the patient's chart as it was written by the physician on the diet profile card. The nurse was then to transmit the information to the Dietary Department and that information related to food allergies were to be received by the dietary department.

The policy also indicated the Dietary Departments Responsibilities were for the Diet Aide or designee to record the diet order in the patient nutritional profile form and the Clinical Dietician would visit new patients, check diet orders in the medical record and the tray cards for accuracy, and also for screening assessment of an individual patients's nutritional needs.

Based on observation, interview and record review, it was determinedd that the facility did not meet the Condition of Participation (CoP) for Physical Environment.

The facility failed to maintain the physical plant and the overall hospital environment in a manner that the safety and well-being of patients was assured. (Refer to A 700)

The facility failed to maintain the integrity of two-hour fire resistance rated walls. (Refer to K 011)

The facility failed to ensure that the interior finish between the Norwalk campus kitchen and dining room, and the kitchen ceiling had a flame spread rating of Class A, Class B, or Class C at all times. (Refer to K 015)

The facility failed to ensure there was no impediment to the closing of corridor doors and that a means was provided for keeping corridor doors closed. (Refer to K 018)

The facility failed to maintain the integrity of a smoke barrier walls in a condition to provide at least a one half hour fire resistance rating. (Refer to K 025)

The facility failed to separate a hazardous area from other spaces. (Refer to K 029)

The facility failed to maintain space under two interior stairways free of storage. Refer to K 034)

The facility failed to ensure that the exit access corridor remains clear and unobstructed. (Refer to K 039)

The facility failed to maintain manual fire alarm boxes unobstructed and test smoke detectors for sensitivity in accordance with NFPA 72. (Refer to K 052)

The facility failed to maintain storage a minimum of 18 inches below sprinkler deflectors and provide a sprinkler guard. (Refer to K 062)

The facility failed to maintain two fire extinguishers free form obstruction, properly install one fire extinguisher and ensure a safety seal and tamper indicator was not broken or missing for one fire extinguisher. (Refer K 064)

The facility failed to prevent the use of portable space heating devices within the facility. (Refer to K 070)

The facility failed to maintain means of egress free of obstructions and impediments to full instant use. (Refer to K 072)

The facility failed to ensure and provide adequate numbers of electrical outlets for patients in the Critical Care Areas so as to preclude the use of extension cords and multiple outlet adapters, under normal power and during an interruption of normal power. This is a repeat deficiency from the Life Safety Report dated 8/18/2009. (Refer to K 130)

The facility failed to ensure oxygen cylinders were restrained. The pressure inside the tank may be high enough to propel the cylinder, possibly resulting in the cylinder injuring a person or impacting an object. (Refer to K130)

The facility failed to ensure that the oxygen canisters were readily available and easily identified and in case of an emergency. (Refer to K 130)

The facility failed to prevent the use of multi-tap power strips and extension cords as a substitute for fixed wiring and failed to maintain electrical receptacle cover plates. (Refer to K 147)

Based on observation, interview and record review, the facility failed to maintain the physical plant and the overall hospital environment in a manner that the safety and well-being of patients was assured.

Findings:

LOS ANGELES FACILITY

On February 9, 2010 at 8:10 a.m., during a tour of the kitchen, the evaluator observed a jacket hung over a food preparation table, meat slicer and utensils, including 3 scoops and 5 serving spoons. The dietary supervisor stated the jacket was routinely hung over the food preparation table, because it was used by all the kitchen staff when they enter the walk-in refrigerator and freezer.

Between 8:10 a.m. and 8:30 a.m., there was a soiled light shield and a second light shield with two holes burned through it in the kitchen walk in refrigerator. Further observation revealed a light shield was missing at the ceiling fluorescent lamp fixture between the office and the pantry in the kitchen. At this time the dietary supervisor was shown and made aware of the soiled, damaged and missing light shields. On February 16, 2010 at 12:26 p.m., the damaged light shield remained and the ceiling lamp was still missing the light shield.

Between 8:10 a.m. and 8:30 a.m., there was food stored in the walk in refrigerator that was not dated or labeled. The food items included sliced jalapeno peppers, salsa, guacamole, tuna salad, sliced pineapple, sliced melon, strawberries, grapes, sliced ham, sliced turkey, sliced cheese, sliced tomatoes, leafed lettuce, raw chicken and raw beef. Closer observation revealed a sign on the refrigerator door that stated `Reminder Cover Label Date'. There was half a five gallon glass container of a green suspension that was stored not dated, labeled or covered on a counter top. During an interview, the dietary supervisor stated the suspension was zucchini juice that had been made earlier that morning.

At 10:32 a.m., the was water damage at the purchasing storage room wall and ceiling above boxes sealed boxes. During an interview the purchasing room staff stated the boxes contained tent mist canopies used for respiratory therapy of infants.

At 11:09 a.m., there was a nightstand in disrepair that was readily accessible to unauthorized persons located at the opposite end from the nurses station across from room 202. The facility's environmental staff opened the drawers before removing the nightstand, at that time the evaluator observed there were medical supplies stored in the nightstand, including three saline flushes (sodium chloride), one syringe, G.I. tubing, and an isolation gown that had been opened.
The Medical Surgery RN was called to the location of the nightstand and made aware of the medical supplies stored in the nightstand. During an interview, the Medical Surgery RN stated the saline solutions should have been stored in the medication cart, the syringe and the G.I. tubing should have been in the supply room and that the individually packaged isolation gown should not of been opened and should have been stored in the isolation cart.

Between 11:09 a.m. and 11:52 a.m., there was blood between the window and frame of the sharps container's in rooms 204, 207 and 209.

Between 11:20 a.m. and 11:39 a.m., the evaluator observed the wall was missing from a section of it,s finish surface next to the bathroom in room 217. the missing finish exposed a surface that was not smooth and easily cleanable.

Between 11:20 a.m. and 3:20 a.m., there were missing call light covers throughout, including at rooms 8, 122, 207, 210 and the tub room across from room 207.

At 11:39 a.m., there was a 1/2 inch penetration through the ceiling of the clean linen room located between rooms 217 and 209.

At 11:44 a.m., there was a cracked window pane in room 209.

At 11:52 a.m., there was a 3 inch diameter section of floor tile missing at the corridor floor across from room 205 creating an unlevel section of floor.

Between 11:52 a.m. and 1:47 p.m., a one foot section of wall was damaged at the base of corridor wall across from room 203.

Between 11:52 a.m. and 1:47 p.m., a two foot section of edge banding veneer was missing from the sink counter in room 201. The missing edge exposed the particle board material that was not smooth and easily cleanable.

Between 2:15 p.m. and 2:33 p.m., there was a loose thermostat in room 128. Closer observation revealed a penetration through the wall behind the thermostat.

At 2:49 p.m., there was tape placed over the call bell annunciator at the OB nurses station and at 3:30 p.m., there was folded paper taped over the call bell annunciator at the unit 1 nurses station. Closer observation revealed that when the call bells were activated the call bell alarm was muffled. Further observation revealed that once the tape and paper were removed from the annunciators the alarm was clearly audible.

On February 16, 2010 at 11:57 a.m., during the lunch time meal service, the evaluator reviewed the tray line Temperature Log. No temperatures were recorded in the log for the breakfast and lunch meal services that day. At the time of the log review the evaluator observed 6 meal trays had already been served and were placed in a tray cart. At that same time during an interview, the tray line staff stated 19 other meals had already left the kitchen to be served to patients. During an interview, the kitchen supervisor stated temperatures for the lunch service meals were not entered in the log because the tray line temperatures were routinely taken half way through the tray line service. The kitchen supervisor did not have an explanation of why temperatures for the breakfast service meals were not entered in the log.

Between 11:57 a.m. and 12:14 p.m., four of four thermometers at the kitchen tray line were placed in an ice water bath to test for accurate calibration of the thermometers. Two of the thermometers registered incorrect temperatures. One of the thermometers was 10 degrees below accurate calibration and the second thermometer was 188 degrees above accurate calibration.

Between 11:57 a.m. and 12:14 p.m., there was a pot with a broken handle used to store cup covers next to the tray line.

At 2:31 p.m., there was peeling paint at the ceiling of the room 202.

On February 16, 2010 at 10:58 a.m., there was a damaged wall in the central service room. The damaged section of wall was at the hand sanitizer dispenser next to the sink.

Between 11:37 a.m. and 3:38 p.m., there was a damaged wall in X ray room 1.


NORWALK FACILITY

On February 11, 2010 at 12:48 p.m., there was four dented cans of food in the dry storage pantry.

At 11:59 a.m., 1:03 p.m. and 1:26 p.m., there was no hot water in the bathroom of room 109 and at the north wing nurses station. The maintenance supervisor ran the water for three minutes over a thermometer probe at the sinks of the room 109 bathroom and north wing nurses station, the thermometer registered temperature readings of 76.5 and 77 degrees Farenheit respectively. The nursing staff stated that the water could be run for 15 minutes at the north wing nurses station sink and the water would not get hot. The facility's policy and procedure entitled Domestic Hot Water dated September 11, 2009 indicated the water temperatures would be maintained between 105 and 120 degrees Farenheit.

Between 1:03 p.m. and 2:00 p.m., the door frame protector of room 107 was damaged creating a sharp edge, The door frame protector of room 104 was separated from the wall creating 1 inch gap, and the door frame protectors of rooms 103, 151 and 154 were missing end caps.

Between 1:11 p.m. and 2:18 p.m., there were two emergency power receptacles missing electrical cover plates at room 110 and at the recovery room. There was also a cracked electrical cover plate at an emergency power receptacle in the recovery room.

At 1:16 p.m., there was a stainless steel wall protector plate at the wall between rooms 110 and 111. The plate was bent and separated from the wall, exposing the edge.

Between 1:16 p.m. and 1:21 p.m., there was a water damaged and blackened ceiling tile at the dirty utility room.

Between 1:21 p.m. and 2:46 p.m., two medication refrigerators were not connected to alternative electrical power receptacles. One refrigerator was at the north wing nurses station and contained Novolin 70/30, Novolin N, Novolin R, Levemir and five Ativan Injections 2mg/ml. The other refrigerator was at the east wing nurses station and contained Novolin 70/30, Novolin N and Novolin R. During an interview the Director of Pharmacy stated the medications in the north wing medication refrigerator needed to be kept cold.

Between 1:21 p.m. and 1:26 p.m., there were two cracked windows in room 105.

Between 1:38 p.m. and 1:58 p.m., an end cap was missing from the handrail next to the supply room across from room 104.

Between 1:38 p.m. and 1:58 p.m., there were two loose hinges at the corridor door of room 154.

At 2:46 p.m., the ceiling tile liner was peeling off exposing the brown stained ceiling tile in the Cardio-Pulmonary room.

At 2:50 p.m., there was a splintered corridor door at room 154.

On February 11, 2010 at 11:10 a.m., the kitchen ceiling above the food preparation table had signs of water damage, a 2 inch by 2 inch penetration, and flaking paint.

There was peeling paint at the wall abutting the steam table in the kitchen.

Two drawers at the food preparation table were missing sections of veneer exposing the particle board that was not smooth and easily cleanable.

At 2:42 p.m., an outside patio bench was missing two 2X4 pieces of lumber and had three 2x4 pieces of lumber with pointed edges at knots holes. The bench was located at the outside patio by the outside walk in freezer and the CT scan trailer. During an interview the Director of Plant Operations stated that patients use the bench.

At 3:30 p.m., there was a loose wood support used to support an air conditioning unit at the exterior wall of the storage room next to the maintenance office and parking lot. The loose support had exposed nails and the the air conditioning unit was leaning toward the damaged support. During the survey a patient accompanied by nursing staff was observed to walk by the damaged support.


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LOS ANGELES FACILITY

On February 9, 2010 at 11:20 a.m., Room 211 - Janitor Closet had a cross connection caused by a black hose inserted into the dump sink and damaged wall; Side table missing a drawer in Room 207; and damaged wall in Central Supply; Damaged ceiling in Central supply;

The evaluator observed a medication refrigerators was not connected to alternative electrical power receptacles located near room 126. An interview was held with the Building Supervisor and he stated, "Oh we missed that refrigerator." This is a repeat deficiency from a previous report dated


NORWALK FACILITY

On February 9, 2010 at 8:10 a.m., the evaluator observed a side rail was detached at the corridor near room103 and 104 at the North Wing corridor.
Cloth terry cloth towels lined the sinks - Cardio Pulmonary, Nurse Station, Medication Room, Room 106; Damage floor located near the dark room, and bubbled ceiling tile - Radiology Dept. ICU supply room entry; Damaged door or door frame - Supply Room door, near room 104, 105, 107; Damaged wall or floor - Room 110, behind Bed A & C, Dump Sink room, Environmental Office Medical Equipment - IV Pump pole was taped up with layers of cellophone tape; Bed side table was missing a drawer - Room 105C, 111 - Bed B, 153 B; Stained or dirty ceiling tiles - Room 111, Environment Office, Admitting office, Administration Office (2), Conference Room (2); Corridor side rails damaged - Near room 103, Supply Room and room 107; Damaged and/or missing bedboards - Room 111, beds G & H, Room 153 - Bed B; Damaged counter top - Nurse Station and a section of Physician table was missing along the side panel; Wall fixtures - Room 105 temperature wall control face missing; Dump sink room detached soap dispenser; fly zapper located over a crashed cart; ICU - faucet goose neck wrapped in cloth tape; and Room 151 - dirty light shield, empty bed pan directly on floor.

At 9:40 a.m., the toilet of room 153 had feces and urine, and a soiled linen cart was stored in the bathroom. There was also a section of the bathroom floor marked off so the linen cart could be parked in the area. During an interview the patient in Bed 2 stated he was able to ambulate and used the bathroom.

At 9:42 a.m., the evaluator conducted an inspection of the Dietary Department. The evaluator observed the following at the Norwalk location: Food stained paper lined food cart, bubbled and peeling ceiling finish over the prep area, a floor storage cabinet missing the door, a cracked plastic ceiling light cover and unclean floor along the edge of the walls,

Based on observation and interview, the facility failed to maintain equipment in optimal condition and quality.

Finding:

On February 9, 2010, the evaluator conducted an inspection of the Norwalk campus and observed that in the Nurse Station - the ice make filter was dated February 9, 2007. The evaluator also observed an aerator attached to the faucet for the hand wash sink, a dump sink located in the dirty utility room had a rubber hose inserted directly into the bowl below the water level (cross contamination),

An interview was held with the Building Engineer and she stated that the ice filter is changed two times a year.

Based on observation and interview, the facility failed to ensure proper temperature control in a pharmaceutical area by not having 5 medication refrigerators connected to electrical receptacles powered by an alternative emergency power. In the event of normal power failure, medication refrigerators not connected to emergency power receptacles would fail to maintain temperature sensitive medications at the required temperatures. This is repeat deficiency from an official report dated August 18, 2009.

Findings:

On February 11, the evaluator conducted an inspection of the facility and observed that the medication refrigerator located near Resident Room 126 and the ICU were not connected to emergency outlet.

A review of the Plan of Correction, submitted by the facility, stated that all the medication refrigerators would be connected to the emergency outlets at all time and that the Building Engineer would monitor compliance.

In case of an interruption of normal power, medication refrigerator are required to maintain temperature sensitive medications at all times.

Based on observation, interview and record review, the facility staff failed to ensure their infection control program designed to prevent and control infections was implemented.

Findings:

1. On February 9, 2010, at approximately 11:05 a.m., during an observation tour, Patient 22 was noted lying on a special bed (Air Loss Mattress) with an indwelling catheter in place. The indwelling catheter had 600 cubic centiliter of cloudy, amber colored urine. The indwelling catheter bag was observed on the floor.

Staff T, who was wearing gloves, picked up the indwelling catheter bag from the floor, raised the bag over the patient, and placed it on the left side of the bed. The staff without changing the gloves and washing her hands proceeded to provide care for the patient.

During a concurrent interview, the staff stated that she should have washed her hands and put on a new pair of gloves before touching the patient. She acknowledged that she should have not raise the indwelling catheter bag higher than the patient's bladder because of the backflow of the urine.

2. On February 10, 2010, at approximately 10 a.m., during the tour of the unit with Staff U, the patient in room 103 bed B had an indwelling catheter bag that was touching the floor. Staff U picked up the indwelling catheter bag and placed it on the side of the bed frame. The staff then took a pair of gloves from the gloves box by the wall and handed it to the patient in bed A who requested the pair of gloves. The employee then moved the garbage cans in the room which was touching the privacy curtain and placed it by the wall. The staff failed to wash her hands after touching the catheter bag and before giving gloves to the patient.

3. On February 9, 10, 12, 2010, from 9 a.m. through 4 p.m., during and observation tour, the following was observed:

a. In Patient 27's room, there was a 60 cc syringe with dried brown colored substance inside the syringe. The syringe had no label or date to ascertain when it was initially used.

During a concurrent interview with Staff W, he stated the 60 cc syringe was used for flushing the gastrostomy tube with water prior to medication administration. He acknowledged the 60 cc syringe should be changed every twenty four (24) hours.

b. In Room 8, there was a box of opened Povidone swab on top of the bedside table.

c. There were bottles of 0.9% sodium chloride solution (1000 ml) which were opened and undated in rooms 105 and 206 bed A.

d. There were bottles of sterile water for irrigation that were opened and undated in rooms 106-b, 108-b, 204-a, 206-a.

e. There was an oxygen tubing hanging by the flowmeter exposed to the elements in rooms 107-a, b and c, 108-a, 106-a, 205-a,

f. There were irrigation syringes which were used and undated in
rooms 202-a and b and 206-a and b.

g. There was an aerosol tubing for mist tent that had no label in room 208-a, b and c.

h. There were basins, bedpans, and urine collecting hats in rooms 204, 206 and 207 with three (3) patients in each room.

A review of the facility's Respiratory Therapy Infection Control Policy stipulated all containers of sterile water shall be dated and timed when opened and discarded within 24 hours after it was opened.

Based on observation, interview, and review of facility documents, the facility failed to ensure their Nursing Triage and Emergency Services structure Standards policies and procedures were implemented in the standby emergency room (ER).

Findings:

On February 16, 2010 at 4:15 p.m., two patients (Patients 16 & 17) that were on a gurney and brought in by ambulance were observed in the hallway outside the emergency room waiting to be seen. The patients were identified as residents from another skilled nursing facility.

During an interview with Staff DD on February 16, 2010 at 4:40 p.m., he stated there was one licensed nurse (himself) and one certified nurse assistant on duty in the emergency room. Staff DD also stated he was the triage nurse. He stated he had five (5) patients in the emergency room.

At 5:10 p.m., another patient (Patient 18) was observed in the hallway, brought in by ambulance.

At 5:15 p.m., there were five patients, two of which were seated on a chair observed in the emergency room.

On March 11, 2010 at 8:15 a.m., a tour of the emergency room was conducted. There was one patient and one licensed staff. There were three (3) beds (gurneys), one was in a room and could be used as an obstetric examination table.

During a concurrent interview with Staff DD, he stated there was one patient with an abdominal pain and waiting for an ultrasound. He stated he was physically on his own right now. Staff DD stated the practice was if the ER is empty, he would take patients to the bed and if the beds are full, he would take patient to the triage area and pointed to the area by the window, adjacent to Room 3. Staff DD stated his shift was 7 a.m. to 7 p.m., and a Certified Nurse Assistant (CNA) would come at 11 a.m.

When asked regarding the number of patients in the afternoon of February 16, 2010, he stated it was very busy that day. He stated there were three (3) patients on the bed and two (2) patients were on the chair waiting for laboratory. He stated there was a CNA working with him.

The Emergency Room Register (Log Book) disclosed Patient 16 was seen at 9 p.m., Patient 17 was seen at 10:10 p.m., and Patient 18 was seen at 9:20 p.m., on February 16, 2010.

a. The ER Registration Sheet indicated the ED admission dated and time as February 16, 2010 at 3:14 p.m., for Patient 16. The Sign-In Log dated February 16, 2010, reflected the arrival time for Patient 16 at 3:10 p.m.

The Emergency Department Patient Care Record for Patient 16 dated February 16, 2010 at 9 (did not indicate a.m. or p.m.) disclosed the patient was brought in by ambulance from a skilled nursing facility with right arm pain for 3 years. The patient also reported increase agitation to staff. The patient was brought to the treatment area at 9 p.m. The documentation indicated the patient was triaged but the form did not address the triage time.

The Emergency Provider Record for Patient 16 dated February 16, 2010, indicated the patient was seen by the physician at 9 p.m. for altered mental status and disposition order time was at 1:30 a.m.

The Nursing Transfer Summary reflected the transferring unit was ER and dated February 16, 2010 at 8:50 a.m. However, the receiving unit reflected medical/ surgical and was dated February 17, 2010 at 9 (a.m. or p.m. not indicated).

b. The Sign-In Log dated February 16, 2010, reflected the arrival time for Patient 17 at 4:10 p.m. The ER Registration Sheet indicated the ED admission date and time as February 16, 2010 at 5:18 p.m.

The Emergency Department Patient Care Record for Patient 17 dated February 16, 2010 at 9 (a.m. or p.m.) indicated the patient was brought in by ambulance from a skilled nursing facility with general body weakness. The patient was brought to the treatment area at 9 p.m. The documentation indicated the patient was triaged but the form did not address the triage time.

The Emergency Provider Record for Patient 17 dated February 16, 2010, indicated the patient was seen by the physician at 9 p.m. for dizziness and disposition order time was at 11:50 p.m.

The Nursing Transfer Summary reflected the transferring unit was ER and dated February 17, 2010 (no time) and the receiving unit reflected medical/ surgical and dated February 17, 2010 at 12:15 p.m.

c. The Sign-In Log dated February 16, 2010, reflected the arrival time for Patient 18 at 5: 09 p.m. The ER Registration Sheet indicated the ED admission date and time as February 16, 2010 at 5:22 p.m.

During an interview with the Director of Admitting on March 11, 2010 at 9:50 a.m., he stated admitting staff would call administration if the back is full. The Director of admitting stated the facility had a 20-minute rule.

At 10:10 a.m., the same day, in an interview, the Director of Admitting, stated the time of arrival in the Sign-In Log was the actual time the patient arrived in ER. When informed of the different times, he stated the timing was off but was not able to explain.

The facility policy and procedure titled, " Emergency Services Structure Standards " dated as last reviewed in March 2003, indicated the facility's ER consists of three beds, one of which can be utilized for patient requiring gynecological examination.

The policy and procedure titled, "Triage, Medical Screening Exam and Care of ER Patients" indicated that, "Each person presenting to the Emergency Department for medical attention will be triaged by the Registered Nurse within 15 minutes to ensure that all patients are seen promptly by medical personnel in order to identify and treat those patients who require immediate attention." The policy and procedure indicated the general goal was "to have all patients arriving by ambulance triaged and appropriately assigned to a bed or chair in the waiting area within twenty (20) minutes of arrival."

Based on observations, staff interviews, and review of records the facility failed to provide respiratory services in accordance with the physician's order for 13 patients in a sample of 37 (Patients 1, 2, 3, 4, 6, 8, 9, 21, 23, 24, 25, 33, and 24). Patient 8 was orally intubated and connected to a ventilator, however, there was no written order for the ventilator settings and no ambu bag at the bedside. Patient 9 was observed receiving oxygen at 2 liters per minute via nasal canula. However, there was no written order for the oxygen. Patient 6 had a tracheostomy tube that was connected to a ventilator, however, there was no obturator or an extra tracheostomy tube of the same size and type at the bedside in accordance with their Tracheostomy Tube policy and procedure.

For Patients 21, 25, 23, 24, they were observed receiving oxygen and there were no physicians' orders for the oxygen. For Patients 33 and 34, they were observed on ventilators and there were no physicians's order for the ventilator settings.

Patient 1 was observed with an FIO2 (fractionated inspired oxygen) at 40%, however the physician's order indicated 60% and there was no extra tracheostomy tubing at the bedside. Patient 2 was observed with an FIO2 at 24%, however the physician's order indicated 60%. Patient 3's mist tent was observed at 28%, however the physician's order indicated 30%. Patient 4 was observed receiving oxygen via nasal canula at 2 liters per minute, however, there was no physician's order for the oxygen. These deficient practices had the potential to cause a decrease in quality of respiratory care and services to the patients.


Findings:

1. On February 10, 2010 at 9 a.m., Patient 8 was observed lying in bed, was orally intubated and connected to a ventilator (Esprit). There was no ambu bag at the bedside. The ventilator settings were as follows: assist control mode rate of 16, tidal volume 500, and FIO2 (fractionated inspired oxygen) of 30%.

The patient's medical record was reviewed on February 10, 2010, and revealed the following:

a. The admission sheet indicated the patient was admitted to the facility on February 9, 2010 at 7:55 p.m., with diagnoses that included respiratory failure and sepsis.

b. The physician admission order sheet dated February 9, 2010 at 9 p.m., revealed there was no order for the ventilator settings.

c. The Ventilator Flowsheet reflected the actual ventilator setting observed.

During an interview with Staff F on February 10, 2010 at 9:30 a.m., she reviewed the patient's record and was not able to find the order for the ventilator settings. Staff F stated the patient was transferred last night and the practice was to use the transfer ventilator settings until the pulmonologist says otherwise. Staff F stated the transfer record was in the respiratory department.

During the same interview, Staff F stated the ambu bag should have been at the patient's bedside.

At 9:45 a.m., the same day, during an interview, Staff E reviewed the patient's record and was not able to find the order for the ventilator settings. Staff E stated there must be an order for the ventilator settings.

The facility policy and procedure titled, Mechanical Ventilator Checks dated as last revised/reviewed on April 4, 2006, indicated that, "All ventilator orders must be checked by the therapist every shift."

The facility policy and procedure titled, Equipment Check Outs and in Use Measurement stipulated to check and maintain resuscitator.

2. On February 10, 2010 at 1:45 p.m., during tour of the East Wing with Staff G, Patient 9 was observed in bed, with oxygen at 2 liters per minute via nasal canula.

A review of the physician transfer order dated February 9, 2010 at 11:30 a.m., revealed there was no written order for oxygen.

During an interview with Staff G on February 9, 2010 at 2:30 p.m., she reviewed the patient's record and was not able to find the physician's order for oxygen.

During an interview with Staff R on February 11, 2010 at 2:40 p.m., she stated there should be a physician's order for oxygen.

3. On February 9, 2010 at 9:45 a.m., Patient 6 was observed in bed with a tracheostomy tube that was connected to a ventilator (Esprit). There was no obturator observed at the patient's bedside. When asked what size was the patient's tracheostomy tube and if there was an extra tracheostomy tube at the bedside, the licensed nurse was not able to find another tracheostomy tube.

A review of the face sheet revealed the patient was admitted on January 25, 2010, with a chief complaint of respiratory failure.

The facility policy and procedure titled, "Tracheostomy Tube" dated as last revised/reviewed on April 4, 2006, indicated to, "Keep obturator taped to the head of the bed. This is optional if an extra tracheostomy tube of the same size and type is at bedside."


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4. On February 9, 2010, at approximately 10:15 a.m., during the tour of the facility with Staff P, Patient 21 was observed lying in bed. A nasal cannula was lying on the bed and the oxygen flowmeter indicated one (1) liter. Upon interview, the patient stated he uses oxygen daily to help him breathe easily. The patient picked up the tubing from the bed and placed it on his nares.

A review of the clinical record failed to show documentation of a physician's order for the use of oxygen for the patient.

During a concurrent interview with ADON while reviewing the clinical record revealed that there was no written documentation of a physician order for oxygen.

5. On February 9, 2010, at approximately 1:20 a.m., during the tour of the facility with Staff P, Patient 25 was observed lying in bed and receiving 2 liters of oxygen via nasal cannula.

A review of the clinical record failed to show documentation of a physician's order for oxygen use.

During a concurrent interview with Staff P, while reviewing the clinical record, Staff P stated that there was no documentation of a physician order for the oxygen.

6. On February 10, 2010, at 10 a.m., during the tour of the unit with Staff U, Patient 23 was observed in bed and was receiving oxygen at 2 liters per minute via nasal cannula.

According to the medical record, the patient was admitted to the facility on February 6, 2010, with a diagnosis of gastro-intestinal bleed.

At 11 a.m., during an interview with Staff U, while reviewing the clinical record, Staff U stated there was no documentation of a physician order for oxygen.

7. On February 10, 2010, at 10:15 a.m., during the tour of the unit, with Staff U, Patient 24 was observed in bed and receiving oxygen at 2 liters per minute via nasal cannula.

According to the medical record, the patient was admitted to the facility on January 25, 2010, with a diagnosis of aspiration pneumonia.

At 11 a.m., during an interview with Staff U, while reviewing the clinical record, Staff U stated there was no documentation of a physician order for oxygen.

8. On February 12, 2010, at approximately 9:30 a.m., during an observation tour, Patient 33 was observed in bed and was connected to a ventilator. The ventilator settings were as follows: assist control mode rate of 16, tidal volume of 600 and FIO2 of 40%.

According to the clinical record, the patient was admitted to the facility on February 9, 2010, with diagnoses that included status post (S/P) tracheostomy, S/P gastrostomy, encephalopathy, and respiratory failure.

Further review of the clinical record failed to show documentation of a physician's order for the ventilator settings. During an interview, Staff P concurred that there was no written evidence in the clinical record for an order for ventilator settings.

9. On February 12, 2010, at approximately 10 a.m., during an observation tour, Patient 34 was observed in bed and was connected to a ventilator. The ventilator settings were as follows: tidal volume of 550, and FIO2 of 50 %.

According to the clinical record, the patient was admitted to the facility on February 8, 2010, with diagnoses that included acute anemia, acute renal failure and respiratory failure, ventilator dependent.

Further review of the clinical record failed to show documentation of a physician's order for the ventilator setting. During an interview, Staff P stated that there was no written evidence in the clinical record for an order for the ventilator settings.



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10. The medical record was reviewed on February 9, 2010. The facesheet indicated Patient 1 was a twenty-three year old and admitted to the facility on August 18, 2010, with diagnoses which included sepsis and respiratory failure.

During an observation on February 9, 2010 at 10 a.m., Patient 1's ventilator machine was observed with an FIO2 at 40%.

During an interview with Staff FF for Patient 1 on February 9, 2010 at 10:05 a.m., when asked if there was an extra tracheostomy tube for Patient 1 she stated no, they did not have an extra tracheostomy tube at the bedside and asked the nurse surveyor if she should call the respiratory therapist to bring it.

A review of the physician's orders dated February 5, 2010, indicated Patient 1 was to receive FIO2 at 60%.

During an interview with Staff B on February 9, 2010 at 11:15 a.m., he stated the nurse should clarify the physician's order because there was a discrepancy. The licensed nurse further stated he had to call the physician to clarify the order.

During an interview with Staff GG (RT) on February 9, 2010 at 11:40 a.m., he stated the physician's order reads FIO2 at 60%. When Staff GG was asked why Patient 1 received FIO2 at 40%, he did not answer.

11. The medical record was reviewed on February 10, 2010. The face sheet indicated Patient 2 was admitted to the facility on January 31, 2010, with diagnoses which included renal insufficiency.

During an observation on February 10, 2010 at 9:40 a.m., Patient 2's ventilator setting was observed with an FIO2 at 24%.

During an interview with Staff F and Staff E on February 10, 2010 at 9:50 a.m., Staff F stated she received a verbal order from the physician's assistant to decrease the oxygen for Patient 2, to maintain oxygen saturation greater than 92%. Staff E searched the medical record, stated she could not find the order from the physician's assistant and that she would call the doctor.

12. The medical record was reviewed on February 11, 2010. The face sheet indicated Patient 3 was admitted to the facility on February 8, 2010 with diagnoses which included foreign body ingestion.

During an observation on February 11, 2010 at 3:30 p.m., Patient 3 received oxygen vial nasal canula at 2 liters per minute.

During an interview with Staff HH on February 11, 2010 at 3:35 p.m., she stated she set up the oxygen for Patient 3 during the esophagogastroduodenoscopy (EGD) procedure (flexible tube with camera to examine the stomach). Staff HH stated there was no physician's order for the oxygen and that there should be a order for the oxygen. Staff HH then removed the oxygen from Patient 3.

13. The medical record was reviewed on February 12, 2010. The face sheet indicated Patient 4 was seven months old and admitted to the facility on February 7, 2010, with diagnoses which included bronchitis.

During an observation on February 12, 2010 at 8:45 a.m., Patient 4 was in bed asleep with a plastic cover (mist tent) over the top half of the bed. The mist tent was observed at 30% and the humidifier was not dated.

A review of the physician's order dated February 7, 2010 indicated Patient 4 was to receive the mist tent at 28%.

During an interview with Staff L on February 7, 2010 at 8:50 a.m., she stated the respiratory therapist gave Patient 4 a treatment at 8 a.m., and that she would call him.