HospitalInspections.org

Based on staff interviews and review of clinical records, policy and procedures it was determined that the Registered Nurse (RN) failed to supervise and evaluate the nursing care for one (#7) of eight patients sampled. This practice does not ensure patient safety and goals are maintained.

Findings include:

Review of patient #7's medical record revealed on 3/20/11 at 7:00 p.m. a LPN (Licensed Practical Nurse) was assigned to the care of the patient. Documentation revealed on 3/20/11 at 9:30 p.m. the LPN performed a nursing assessment of the patient. There was no evidence the RN supervised or evaluated the nursing care of the patient. On 3/21/11 at 7:00 a.m. the care of the patient was transferred to another LPN. Documentation revealed on 3/21/11 at 8:00 a.m. the LPN performed a nursing assessment of the patient. There was no evidence the RN supervised or evaluated the nursing care of the patient. On 3/21/11 at 7:00 p.m. the care of the patient was transferred to another LPN. On 3/21/11 at 7:20 p.m. the LPN performed a nursing assessment of the patient. There was no evidence an RN supervised or evaluated the nursing care of the patient. On 3/22/11 at 7:00 a.m. the care of the patient was transferred to another LPN. On 3/22/11 at 8:00 a.m. the LPN performed a nursing assessment of the patient. There was no evidence that the RN supervised or evaluated the nursing care of the patient. On 3/22/11 at 7:00 p.m. the care of the patient was transferred to an RN. Review of the documentation revealed an RN did not supervise or evaluate the nursing care of the patient for 48 hours.

Review of the facility's policy, "Assessment of Patients", last reviewed 6/2010, stated the patient will be reassessed at least every 8 hours with an RN performing the assessment at least once in each 24 hour period.

On 4/01/11 at 1:30 p.m. the risk manager confirmed the findings. Interview with the Chief Nursing Officer (CNO) revealed LPN and RN's should rotate each shift so that the patient is assessed by an RN at least once in each 24 hour period.

Based on staff interview, review of personnel files, and review of policy and procedures it was determined the Chief Nursing Officer (CNO) failed to provide for adequate supervision and evaluation of the clinical activities for one non employee licensed nurse. This practice does not ensure the competency and safety of nursing care being provided.

Findings include:

1. A tour of the Intensive Care Unit (ICU) was conducted on 3/31/11 at 2:40 p.m. An agency nurse currently working on the unit was interviewed. The nurse stated he had been working in the facility for approximately 3 months. He was asked about the orientation he received at the facility. He stated on his first shift he was to be oriented with the charge nurse. The interview revealed the charge nurse walked off the unit so he did not receive an orientation. He stated that he just started caring for the patients. The CNO interrupted the agency nurse to tell him this was a surveyor and was here on a complaint. She stated the surveyor was not here about the other situation. The agency nurse then stated that he received about four hours of orientation on his first shift.

Review of the facility's policy, "Agency Personnel, Orientation", last reviewed 11/2009, states each agency nurse will receive one shift of orientation on an appropriate unit. The policy also stated the agency nurse will work with a facility employee on a one-to-one basis for the shift to become familiar with the facility's routines and policy and procedures.

On 4/01/11 the personnel file for the agency nurse interviewed was requested and reviewed. Review of the file revealed a completed orientation form dated 3/31/11. The form stated "the above individual has oriented with me and has demonstrated the behavior, competency and understanding of the above" . The form was signed by the agency nurse and the Chief Nursing Officer and dated 3/31/11.

The Chief Nursing Officer was interviewed on 4/01/11 at 1:00 p.m. The CNO confirmed the form was completed and signed on 3/31/11. The CNO was questioned if she oriented and observed the agency nurse's competencies. She denied she oriented or observed the nurse's competencies.

Review of the facility's policy, "Agency Personnel Evaluation", last reviewed 6/2010, stated an evaluation form will be completed at the end of the orientation shift, first shift and whenever deemed necessary.

Based on staff interview and review of policy and procedures it was determined the facility failed to ensure nursing staff supervised the administration of medication. This practice does not ensure medications are administered according to physician orders.

Findings include:

On 3/30/11 at 2:40 p.m. the risk manager was interviewed regarding a patient concern that medications were left by nursing at the patient's bedside. The risk manager stated nursing will leave a medication in a medication cup at the patient's bedside if the patient requests to take the medication with a meal.

Review of the facility's policy, "Medication Administration, General Guidelines", last revised 2/2011, stated medications are not to be left in patient rooms. Pyxis medications are to be returned to Pyxis when not administered.

Based on staff interview the facility failed to demonstrate if the facility was in compliance with the Condition of Participation for Infection Control based on the lack of documentation. This does not ensure the provision of quality health care in a safe environment.

1. The facility failed to provide documentation that the infection control officer maintained a log of incidents related to infections and communicable diseases (refer to A750).

2. The facility failed to ensure the chief executive officer, the medical staff, and the chief nursing officer addressed problems identified by the infection control officer and implemented the problems identified into the hospital wide quality assurance program and training programs. The facility failed to ensure the chief executive officer, the medical staff, and the chief nursing officer were responsible for the implementation of successful corrective action plans in affected problem areas (refer to A756).

Lack of documentation provided by the facility failed to ensure the facility maintained an infection control program for the prevention, control, and investigations of infections and communicable diseases.

Based on staff interview and requested infection control log it was determined the facility failed to maintain a log of incidents related to infections and communicable diseases, including healthcare associated infections and infections identified through employee health services. This practice does not ensure a successful infection control program

Findings include:

On 3/30/11 during the entrance conference the infection control log was requested. The administrative staff stated the facility was a PSO (Patient Safety Organization) and upon advice from legal counsel the facility could not provide the infection control log stating log was a patient safety work product.

In reference to 73 FR 70743, November 21, 2008:

"Information is not patient safety work product if it is collected to comply with external reporting, such as ..... certification or licensing records for compliance with health oversight agency requirements .....compliance with required disclosures by particular providers or suppliers pursuant to Medicare's Condition of Participation or Conditions of Coverage ..... "

In reference to 73 FR 70742, November 21, 2008

"Providers have the flexibility to protect this information as patient safety work product within their patient safety evaluation system while they consider whether the information is needed to meet external reporting obligations. Information can be removed from the patient safety evaluation system before it is reported to a PSO to fulfill external reporting obligations."

An interview was conducted with the IC (Infection Control) Officer on 3/31/11 at 1:15 p.m. The log of incidents related to infections and communicable diseases was requested. The IC Officer denied access to the information stating it was protected information as she was informed by administration. The IC Officer stated she maintains a log, monitors the program and reports finding to corporate and to hospital administration. She stated the reports are taken to the infection control committee, quality committee, and then to the Board. Infection control meeting minutes were requested but the facility refused to provide any type of meeting minutes.

It could not be determined if the facility was in compliance with the Condition of Participation for Infection Control based on the lack of documentation.

Based on staff interview and requested Quality Assessment Performance Improvement (QAPI) documentation it was determined the facility failed to ensure the chief executive officer, the medical staff, and the chief nursing officer were responsible for the implementation of successful corrective action plans in affected problems identified through the infection prevention and control program. This practice does not ensure the prevention of potential hospital acquired infections or decrease the exposure or potential infections.

Findings include:

On 3/30/11 during the entrance conference the QAPI documentation and meeting minutes were requested. The administrative staff stated the facility was a PSO (Patient Safety Organization) and upon advice from legal counsel the facility could not provide the requested documentation stating the information was patient safety work product.

73 FR 70743, November 21, 2008 states:

"Information is not patient safety work product if it is collected to comply with external reporting, such as ..... certification or licensing records for compliance with health oversight agency requirements .....compliance with required disclosures by particular providers or suppliers pursuant to Medicare's Condition of Participation or Conditions of Coverage ..... "

73 FR 70742, November 21, 2008 states:

"Providers have the flexibility to protect this information as patient safety work product within their patient safety evaluation system while they consider whether the information is needed to meet external reporting obligations. Information can be removed from the patient safety evaluation system before it is reported to a PSO to fulfill external reporting obligations."

An interview was conducted with the IC (Infection Control) Officer on 3/31/11 at 1:15 p.m. She revealed the facility uses a program called Medmined to identify, track and trend the facility's infections including HAI (Healthcare Associated Infections) and multiple drug resistant organisms. The IC Officer stated she monitors the program and reports findings to corporate and to hospital administration. She stated the reports are taken to the infection control committee, quality committee, and then to the Board. Infection control meeting minutes were requested but the facility refused to provide them. The facility's QAPI program could not be reviewed to determine that the hospital wide QAPI program addressed problems identified through the infection prevention and control program. It could not be determined if the facility was in compliance with the Condition of Participation for Infection Control based on the lack of documentation.