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Based on observation, interview and record review, the facility failed to provide adequate licensed nurses to provide nursing care to all patients as needed by failing to consistently implement its Staffing and Delivery of Care policy, and failed to maintain the licensed nurse-to-patient ratio in the critical care unit at 1:2 or fewer at all times in accordance with the State regulation nurse-to-patient ratio requirement of California Title 22 section 70217(a)(1) that states: The licensed nurse-to-patient ratio in a critical care unit shall be 1:2 or fewer at all times.

Findings:

On November 29, 2010, at 10:30 a.m., during an observation in the intensive care unit, Staff D was interviewed. She stated that she had 2 patients to care of during her shift. Staff D also stated that the staff relieve each other during breaks and lunches. During the break time, she stated she would have a total of four (4) patients.

On the same day, at 2:45 p.m., in Unit I, during an interview, Staff I stated there was no charge nurse in the unit that day and there were 4 registered nurses to care for 22 patients. She further stated that each RN was relieving each other for lunches and breaks.

A review of the Patient Assignment Record for pediatric unit dated November 10-29, 2010, indicated the break time and lunch time were documented. However, there was no documentation that a licensed nurse was assigned to cover the break and lunch relief when there was no charge nurse.

A review of the facility's policy on Staffing and Delivery of Care, effective date January 2000, stipulated the Charge Nurse (CN) is responsible for break and lunch relief, and if the CN is not available, the Administrative Supervisor is responsible to cover the break and lunch relief.

This was a repeat deficiency from the recertification survey completed on March 11, 2010.



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Based on observation, interviews with facility staff, review of patient medical records and review of facility documents, the facility failed to ensure that a registered nurse supervised and evaluated the nursing care for 7 of 21 patients (Patients 4, 6, 10, 18, 19, and 21).

For Patient 4, with stage 3 pressure ulcer, wound re-assessment was performed by a physical therapy assistant.

For Patient 6, requiring telemetry, the facility staff failed to connect the patient to the telemetry unit and monitor the patient's cardiac rhythm until 7 hours after the physician's order.

For Patient 10, requiring hemodialysis treatment, the staff failed to weigh the patient pre and post dialysis.

For Patient 18, the facility staff failed to ensure the patient's pacemaker information was in the clinical record while in the facility.

For Patient 19 and Patient 20, the facility staff failed to ensure its Skin Management and Physical Therapy Wound Assessment policies and procedures were implemented.

For Patient 21, the facility staff failed to ensure the Patient Assessment and Care Planning policy and procedure was implemented.

Findings:

1. On November 29, 2010 at 11:20 a.m., Patient 4 was observed lying in bed, on a low air loss mattress, orally intubated and on a ventilator.

During a concurrent interview, Staff D stated the patient has a sacral pressure ulcer and wound care is done by physical therapist.

A review of the medical record revealed the patient was admitted to September 23, 2010 with diagnosis of pulmonary embolus.

A review of the weekly Physical Therapy Wound Assessments revealed the wound re-assessments were done by a physical therapy assistant (PTA).

During an interview with Staff F (PT Director) on November 29, 2010 at 12 p.m., she reviewed the Physical Therapy Assessment sheets dated October 4, 11, 25, 2010, and November 1, 22, 2010, and acknowledged the wound assessments were performed by a physical therapy assistant.

2. A review of Patient 6's clinical record revealed the patient was admitted to the facility on November 26, 2010, with a chief complaint of epigastric pain.

A review of the Physician's Order Sheet dated November 27, 2010 at 8:30 a.m., indicated the following orders: Give normal saline with 20 mEq KCL (potassium chloride) to run at 75 milliliter per hour. Give 40 mEq potassium by mouth. Place patient on telemetry. However, a review of the Telemetry Record revealed an initial telemetry strip dated November 27, 2010 at 3:45 p.m., seven (7) hours and 15 minutes later.

A review of the laboratory report dated November 27, 2010 at 8:20 a.m., indicated a serum potassium level of 2.7 (reference range 3.6-5.2 meq/l).

During an interview on November 29, 2010 at 3:15 p.m., Staff J stated that possibly, there was no telemetry box available at that time. Staff J stated the practice was to call the physician. Staff J was not able to find documentation that the physician was informed.

At 3:40 p.m., Staff B reviewed the physician's order and the telemetry record and acknowledged the time of the order and the date and time of the initial telemetry strip.

A review of the facility policy and procedure on Monitor Technician Shift Duties, effective date April 2000, indicated all staff shall assist the transcription of physician orders and calling physicians as the Monitor Tech. would prioritize orders as follows: "stat" and "now" orders, admissions, and routine order.

3. On December 1, 2010 at 10:55 a.m., Patient 10 was observed lying in bed and was receiving oxygen connected to the tracheostomy tube. The patient was observed undergoing a dialysis treatment via Perma Catheter and a dialysis nurse was at the bedside.

During a concurrent interview, Staff M (Dialysis Nurse-Contract Staff) handed the patient's Treatment Record dated December 1, 2010. The Treatment Record revealed a Patient Assessment pre and post dialysis treatment and the pre dialysis weight was left blank. Staff M stated he does not weigh the patient before and after dialysis treatments. Staff M stated the facility staff weigh the patient and document the weight in the graphic chart of the patient record.

A review of the patient's record including the Treatment Records from November 5-29, 2010 revealed no documentation of the patient's pre and post dialysis weights.

A review of the Dialysis agreement, dated December 1, 2009, indicated the Dialysis Staff would complete documentation required on the Treatment Record.

A review of the contract dialysis' Patient Assessment Pre & Post Dialysis policy and procedure dated June 2003 indicated that, "Weights: should be taken on each patient pre and post dialysis unless it is prohibited due to the critical nature of the illness. If the patient cannot stand, a bed scale should be used."



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4. A review of the admission record revealed Patient 19 was admitted to the facility on October 14, 2010, with a chief complaint of anoxic encephalopathy.

The nursing admission assessment documented the patient had pressure ulcers on sacral area, right hip, right wrist/hand, left and right elbow and left medial and lateral aspects of the foot.

On November 30, 2010, at 11 a.m., Patient 19 was observed lying in bed and was on a ventilator. Upon closer observation of the patient with Staff B and Staff E, it was noted the patient was lying on an air loss mattress. There were 4 layers of folded sheet, a pillow case, an ultrasorb pad and a pillowcase underneath the resident's buttocks.

During a concurrent interview with Staff B, she stated there should only be an ultrasorb pad underneath the patient on an air loss mattress.

A review of the facility's policy on Ultrashort AP in Skin Care Management, effective date August 2007, stipulated ultrasorb pads will be used on all patients. This pad does not block the air flow from the air loss mattress. It allows air to flow through the pad while acting as a barrier to moisture.

Further review of the clinical record specifically the Physical Therapy Wound Assessment conducted on October 15, 2010 revealed a physical therapy assistant (PTA) conducted the initial wound assessment. The weekly re-assessments of the wounds were still being performed by the PTA's.

During a concurrent interview with Staff F, she stated that the assessments and reassessments should be done by the physical therapy (PT). Review of the PT job description indicated PT was responsible for the treatment and care of patients within established guideline of the PT Department. The PTA job description stipulated assisting the PT in the treatment and care of patients.

5. A review of the admission record revealed Patient 20 was admitted to the facility on November 12, 2010, with chief complaints of fever , rule out sepsis dementia and gastroesophageal reflux disease. The patient resided in a skilled nursing facility.

The nursing admission assessment documented the patient had stage III pressure ulcers on coccyx area.

On November 29, 2010, at 4:30 p.m., Patient 20 was observed in bed lying on an air loss mattress and an indwelling catheter in place. Underneath the patient's buttocks, there were two (2) layers's of linen and an ultrasorb pad.

Review of the Physical Therapy Wound Assessment dated November 12, 21 and 28, 2010, revealed there was no documentation of the size of the pressure ulcer on the coccyx area on admission assessment and weekly re-assessments. Also the weekly Physical Therapy Wound Assessments revealed the wound re-assessments were done by a physical therapy assistant (PTA).

A review of the facility's policy on Wound Care Protocols, effective date May 2003, stipulated the assessment of the wound included the size (length, width and depth) in centimeters and to document undermining or tunneling via clock face.

During a concurrent interview with Staff B, she stated that there should only be an ultrasorb pad underneath the patient's buttocks when lying on an air loss mattress. She further stated the size of the pressure ulcer should always be taken during initial wound assessment and on weekly reassessments.

Further review of Patient 20's clinical record revealed on November 19, 2010, the physician ordered to place the patient on telemetry. The Telemetry Record revealed missing rhythm strips on November 20, 21, 22, 23, 24, 25, 26, 27 and 28, 2010.

A review of the facility's policy on Monitor Tech (MT) Shift Duties, effective date April 2000, stipulated the MT shall run rhythm strips every four (4) hours and post daily monitor sheet and document patient's rhythm every two (2) hours on the patient's progress notes.

On November 30, 2010, at 3 p.m., during an interview with Staff K, while reviewing the patient's clinical record revealed the rhythm strips could not be found.

6. A review of the clinical record of Patient 21 revealed she was admitted to the facility on November 27, 2010, with diagnoses that included fever, bronchitis, upper respiratory infection and urinary tract infection.

The Pediatric Nursing Assessment on admission failed to indicate who conducted the head to toe nursing assessment for the patient as the section under the signature was left blank.

The facility's policy on Patient Assessment and Care Planning, effective date March 2010, stipulated all patients shall be assessed by a registered nurse within 24 hours of admission.

On November 29, 2010, at 9 a.m., in an interview with Staff M, she stated that it should have been signed.

7. A review of Patient 18's medical record revealed she was admitted to the facility on November 21, 2010, with diagnoses that included congestive heart failure, hyponatremia and diabetes mellitus. The patient resided in a skilled nursing facility.

On December 1, 2010, at 10: 20 a.m., the patient was observed lying in bed and an indwelling catheter was in place.

The admission nursing assessment indicated the patient had a pacemaker implanted in 2009. Further review of the clinical record failed to show documentation of basic information regarding date and location of implant, type, serial and model number of the pacemaker.

During concurrent interview with Staff O, she stated that she was aware that the nursing staff should have the pacemaker information in the clinical record while providing care to the patient.

A review of the undated facility's policy on Permanent Pacemaker: Care of the Patient stipulated baseline information such as date and location of the implant, type of pacemaker, manufacturer's model and serial number, heart rate and threshold measurements at time of implant, ECG tracing with or without magnet held over generator should be documented in the clinical record.

This was a repeat deficiency from the recertification survey completed on March 11, 2010.



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Based on record review and interview, the facility failed to ensure the physician authenticated all prescribed verbal orders within 48 hours for 7 of 21 patients (Patients 4, 10, 14, 15, 16, 17 and 18).

Findings:

1. On November 29, 2010, in the Intensive Care Unit, Patient 4's medical record was reviewed.

The Physician Order Sheet dated November 12, 2010 at 7:20 p.m., revealed the following telephone orders: Discontinue Aspirin, Hold Lactulose and Ammonia level in the morning. However, there was no documented evidence that a physician or licensed practitioner had authenticated the verbal/telephone order.

The Physician Order Sheet dated November 8, 2010 at 2:35 p.m., revealed a physician medication order to renew Flagyl 500 milligrams (mg) intravenous piggy back every 8 hours. However, there was no documented evidence that a physician or licensed practitioner had authenticated the verbal/telephone order.

During an interview with Staff D on November 29, 2010 at 11:30 a.m., she stated the physician must sign the verbal/telephone order within 24 hours.

2. On December 1, 2010, in the East Wing, Patient 10's medical record was reviewed.

The Physician Order Sheet dated November 7, 2010, revealed the following physician medication telephone orders: At 2:30 a.m., a telephone order indicated Clonidine 0.2 milligrams (mg) via gastrostomy tube times one now and Hydralazine 50 mg three times a day via gastrostomy tube. At 7:30 p.m., the telephone order indicated to give K-rider (potassium chloride) 20 mEq intravenous piggy back times one dose today. However, there was no documented evidence that a physician or licensed practitioner had authenticated the verbal/telephone orders.

During an interview on December 2, 2010 at 8:45 a.m., Staff K stated telephone orders must be signed by the physician within 48 hours.



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3. On November 29, 2010, at 2:45 p.m., in the Telemetry Unit, Patient 14's medical record was reviewed.

The Physician Order Sheet dated November 27, 2010 at 3:15 a.m., revealed the following orders: Admit to Telemetry with diagnoses of Asthma, respiratory distress, hypertension, chronic obstructive pulmonary disease/bronchitis, oxygen 2 liters/min, Clindamycin 300 mg intravenous every 6 hours and hand held nebulizer every 4 hours. However, there was no documented evidence that the physician or licensed practitioner had authenticated the verbal/telephone order.

4. On December 2, 2010, at 3:30 p.m., during a closed record review, Patient 15 was admitted to the facility on October 23, 2010, with chief complaints of chest pain and acute coronary syndrome.

The Physician Order Sheet dated October 25, 2010 revealed the following telephone orders: Restoril 15 mg orally at hour of sleep and as needed for sleep; Haldol 5 mg, Ativan 2 mg and Benadryl 25 mg intramuscular (IM) or intravenously (IV) every 6 hours and as needed for agitation and aggression ; vest and soft restraints for aggression times 24 hours, release at least every 2 hours, circulation check every 20 minutes. However, there was no documentation to indicate the physician or licensed practitioner had authenticated the verbal/telephone order.

5. On December 2, 2010, at 7:15 a.m., in the intensive care unit (ICU) Patient 16's medical record was reviewed. The patient was admitted on November 24, 2010, with chief complaints of hypotension and respiratory failure.

Review of the Physician Order Sheets revealed the following telephone orders which were not signed by the physician or licensed practitioner:

a. On November 25, 2010, the telephone orders for Digoxin 0.25 mg daily, Zocor 40 mg daily, Lisinopril 10 mg daily and Coreg 12.5 mg twice a day, hold if systolic blood pressure is less than 90 mmHg.

b. On November 29, 2010, an order for Hematology Consult with various physicians.

c. On November 30, 2010, an order for vent settings, assist control (AC) 16, tidal volume (TV) 450 and FIO2 30.

6. On December 1, 2010, at 9:15 a.m., in the ICU, Patient 17's medical record was reviewed. The patient was admitted on November 24, 2010, with chief complaints of sepsis, respiratory failure and calf swelling left leg.

Review of the Physician Order Sheets revealed the following telephone orders which were not signed by the physician or licensed practitioner:

a. On November 24, 2010, an order for IV fluid normal saline at 100 ml/hr for 2 liters, Levaquin 750 mg IV daily, Protonix 40 mg IV daily, Lovenox 1 mg/kg (136 mg) subcutaneously every 12 hours, Albuterol and Atrovent every 4 hours hand held nebulizer, Zyvox 600 mg IV every 12 hours, Zofran 4 mg IV every 6 hours/as needed nausea/vomiting and Tylenol 650 mg every 4 hours for fever.

7. On December 1, 2010, at 10:20 a.m., in the ICU Patient 18's medical record was reviewed. The patient was admitted to the facility on November 22, 2010, with chief complaints of congestive heart failure, hyponatremia and diabetes mellitus.

Review of the Physician Order Sheet on admission revealed a telephone order for Lasix 40 mg intravenously daily that was not signed by the ordering physician.

On December 1, 2010, at 11 a.m., during an interview with Staff K, while reviewing the clinical records of Patients 14, 15, 16, 17 and 18, she stated the physician's telephone orders should have been signed and/or authenticated within forty eight (48) hours as the facility's policy stipulated.

A review of the facility's policy on Treatment Orders stipulated within forty eight (48) hours, the physician would sign the verbal order and his failure to do so shall be brought to the attention of the Medical Executive Committee for appropriate action.

This was a repeat deficiency from a recertification survey completed on March 11, 2010.

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 one of 21 patients (Patient 12).

Findings:

A review of Patient 12's closed medical record revealed the patient was admitted to the facility on July 10, 2010, and was discharged on July 15, 2010.

A review of a pre-printed History and Physical (H & P) dated July 10, 2010, revealed a Systemic Review section which included Skin, Cardiorespiratory, Gastrointestinal, Gynecology, Neurological and Musculoskeletal section. This section was left blank except for musculoskeletal.

During an interview with MD 1 on December 3, 2010 at 10 a.m., he reviewed the History and Physical dated July 10, 2010 and stated it was incomplete.

This was a repeat deficiency from a recertification survey completed on March 11, 2010.

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Based on record review and interview, the facility failed to consistently document in the 24 hour ventilator flowsheet that the doctor's order was verified, back-up battery was checked and ventilator was plugged in a red outlet in the 24 Hour Ventilator Flow Sheet, in accordance with the facility Mechanical Ventilators Checks policy.

Findings:

1. Patient 16 was admitted to the facility on November 24, 2010, with diagnoses that included hypotension and respiratory failure.

On December 2, 2010, at 7:15 a.m., the patient was observed connected to a ventilator with the following setting: tidal volume of 450, assist control mode, rate of 16 and 30 % of FIO2 (fractionated inspired oxygen).

A review of 24 Hour Ventilator Flow Sheet dated November 24, 26, 27, 28, 29 and 30, 2010, failed to show documentation of the following: doctor's order verified, back-up battery checked and checked ventilator was plugged in a red outlet.

2. Patient 17 was admitted to the facility on November 24, 2010, with diagnoses that included sepsis, respiratory failure and calf swelling of the leg.

On December 1, 2010, at 9:15 a.m., the patient was observed connected to a ventilator with the following setting: tidal volume of 700, assist control mode, rate of 14, PEEP of 5 and 30 % of FIO2.

A review of 24 Hour Ventilator Flow Sheet dated November 27, 28, 29 and 30, 2010, failed to show documentation of the following: doctor's order verified, back-up battery checked and checked ventilator was plugged in a red outlet.

3. Patient 10 was admitted to the facility on October 14, 2010, with a diagnosis of respiratory failure.

On December 1, 2010, at 10:55 a.m., the patient was observed connected to a ventilator with the following setting: tidal volume of 600, assist control rate of 14, PEEP of 5 and 50 % of FIO2.

A review of 24 Hour Ventilator Flow Sheet dated November 5 and 11, 2010, failed to show documentation of the following: doctor's order verified, back-up battery checked and checked ventilator was plugged in a red outlet.

On December 1, 2010, at 8:30 a.m., during an interview, Staff N stated that verifying the doctor's order, checking the back-up battery, and plugging the ventilator in the red outlet were being done daily on both shifts and should be documented in the 24 Hour Ventilator Flowsheet.

A review of the facility's policy on Mechanical Ventilators Checks, revised February 19, 2010, stipulated the therapist should check daily every shift on ventilator orders, back-up battery and ventilator connected to a red electric outlet at all times.



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