HospitalInspections.org

Based on observation, staff interview, and document review the hospital failed to provide evidence that outpatient clinic patients received their patient rights upon admission (refer to tag A-0117); failed to ensure the emergency department check in area is continuously monitored for patients needing assistance; failed to ensure security and monitoring for one of ten emergency department patient records reviewed (Patient # 4); failed to provide monitoring and a means to signal for help in the case of an emergency for patients placed in two of two quiet rooms and one of one emergency department waiting rooms (refer to tag A-0144); and failed to ensure medical record information was kept confidential (refer to tag A-0147).

This systemic failure has the potential to create an unsafe patient care environment.

Based on document review and staff interview the hospital failed to provide evidence that outpatient clinic patients received their patient rights upon admission. This deficient practice has the potential for patients to be unaware of their rights, such as rights to be informed about their care, the privacy regarding their care, the participation in the planning of their care and the safety, protection, and comfort.

Finding include:

- Review on 2/14/2018 at 9:11 AM of the "Clinic Admission Packet" revealed it lacked evidence of the notice of patient rights.

Interview on 2/14/2018 at 9:11 AM with Receptionist Staff Z stated, "We do not go over patient rights with our clinic patients or offer to give them a copy of them."

The hospital failed to provide a policy directing staff to ensure clinic patients are made aware and offered a copy of their patient rights.

Based on observation, staff interview, social media post review and record review, the hospital failed to ensure the emergency department check in area is continuously monitored for patients needing assistance, failed to ensure security and monitoring for one of ten emergency department patients (Patient # 4) medical record reviewed, and failed to provide monitoring and a means to signal for help in the case of an emergency for patients placed in two of two quiet rooms and one of one emergency department waiting rooms. This deficient practice has the potential to place all emergency room patients at risk for harm or death.

Findings Include:

- Observation on 2/12/2018 at 11:05 AM of the Emergency Department and review of the facility map revealed the following layout of the ED:

An overhang covers two entrances/exits to the department; the west most entrance is a walk-in entrance labeled "Emergency Department Entrance," and the east most entrance, is labeled "Ambulance Entrance." Upon entering the walk-in entrance, there is a desk with a large computer screen displaying video surveillance of various areas of the hospital, and a computer for checking patients into the ED. There is also a small waiting room for patients containing five chairs. This check-in area is completely enclosed, with no view from the nursing station.

The ambulance entrance is a powered, sliding glass door that opens automatically from the outside, and can be manually pushed to exit the unit from the inside. Upon entering via the ambulance entrance, directly to the right, is a decontamination room with three shower stalls. A few feet further into the unit at the left and right are two treatment rooms, ED room 2 and ED room 3. Both rooms are enclosed by a door without a window. There is one trauma bay with frosted glass sliding doors. Nursing supplies are stored in the hallway in carts and on a metal rack. Two other locked rooms are on the unit, one with housekeeping supplies and the other with more nursing supplies. The entire unit is not observable from the nurse's station.

The nurse's station for the ED is located inside the hospital, but adjacent to the walk-in entrance, facing outpatient recovery rooms. There is a solid door without windows next to the nurse's station that leads into the check in area, and further down the hall from the nurse's station are solid double doors without windows that lead into the treatment area where the trauma bay and ED treatment rooms 2 and 3 are.

- Observation on 12/15/18 at 5:45 AM of Emergency Department check in area revealed an empty waiting area. A bell attached to the reception desk with a sign attached stating, "Please push bell for assistance". At 6:03 AM Security Guard Staff CC entered into the entrance area from the open emergency room hallway.

Interview on 12/15/2018 at 6:05 AM with Security Guard Staff CC, indicated he had been doing rounds around the hospital and had just returned to the check in area. Staff CC confirmed no other staff members are stationed at the check in desk from 12:00 AM until he leaves around 7:00 AM. Staff CC revealed when he is doing their rounds the check in area is unattended and no one is assigned to watch the security monitors.

Interview on 2/15/2018 at 2:00 PM Chief Nursing Officer staff B, explained that registration staff are at the check in desk from 8:00 AM until midnight. After the registration clerk goes home, one of the two nurses staffed at night is supposed to sit out at the desk in the check in area.

- Review on 2/15/2018 at 7:00 AM of "Social Media Post", revealed the reviewer (Social Media Reviewer # 39) had presented to the emergency department on 1/15/2018 "early in the morning" and stated they waited several minutes after pressing the bell before an unidentified male nurse came out and indicated they didn't hear the bell. Contact information for the reviewer was not available.

- Review on 2/15/2018 at 7:15 AM of "Social Media Post", revealed the reviewer (Social Media Reviewer # 40) had present to the emergency room with cardiac issues and no one was at the entrance area's desk when they walked in. Poster #40 indicated a security guard came in and said nothing to them. Contact information for the reviewer was not available.

Interview on 2/15/2018 at 4:30 PM with Administrative Staff A indicated they had no knowledge of the incidents mentioned by the reviewers on social media. Staff A reported they do follow up on social media reports.

- Review on 2/13/2018 of Patient #4's medical record, revealed patient #4 presented to the ED on 10/9/2017 at 4:09 AM by ambulance with a complaint of abdominal pain. Patient #4 was also experiencing symptoms of psychosis (a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality) such as flight of ideas (rapid shifting of ideas), delusions (false beliefs), and hallucinations (perceptions of things that are not there). A medical screening exam was initiated including laboratory studies, a CT scan (three dimensional x-ray), and a psychiatric exam by an outside source. The medical record revealed the last set of vital signs was taken at 6:37 AM. At 7:15 AM, a note entered by the physician revealed the patient had eloped from the department and was returned to the department by law enforcement.

Interview on 2/15/2018 at 3:59 PM with Emergency Department staff DD, confirmed the facility failed to conduct an investigation regarding the elopement of patient #4.

Interview on 2/12/2018 at 11:30 AM with Emergency Department Staff DD, explained that if the three ED rooms are in use, ED staff may have to move patients from a treatment room into the shared waiting room or into the quiet room to take care of a patient that is more emergent, and security monitors the shared waiting room since it cannot be seen from the nurse's station.

- Observation on 2/14/2018 at 3:51 PM of the Quiet Room across from the double doors leading to the ED, revealed a room with a solid door, lacking a window, automatically locking from the inside, and without an emergency call system.

- Observation on 2/14/2018 at 3:51 PM of the large shared Waiting Room, past the Quiet Room, revealed a waiting room unobservable from the nurse's station, and lacking in an emergency call system.

Interview on 2/15/2018 at 3:51 PM with Emergency Department Staff DD, acknowledges the absence of an emergency call system in the quiet room or the waiting room. Staff DD also acknowledges the large shared waiting room is not observable by the nurse's station, or hospital staff.

Based on observation, staff interview, and policy review the hospital failed to ensure three patients medical record information (Patient #'s 11, 15, and 36) was kept confidential in two of six patient care areas (Pre/Post-operative area and the telemetry unit). This deficient practice has the potential for unauthorized personnel and the public to have access to patient's confidential health information.

Findings include:

- Observation on 2/12/2018 at 8:51 AM of the Pre/Post-operative Area, revealed Patient # 15 in bay # IU-3 with their medical record information laying on a rolling stand outside the curtained bay, allowing any passersby including visitors to read the patient's private health information.

Interview on 2/12/2018 at 5:00 PM with Risk Manager Staff G, confirmed the patient information was easily accessible to anyone walking by the bays.


- Observation on 2/13/2018 at 7:20 AM of the Pre/Post-operative Area, revealed Patient # 11 in bay # IU-5 with their medical record information laying on a rolling stand outside the curtained bay allowing any passersby including visitors to read the patient's private health information.

Interview on 2/13/2018 at 2:30 PM with Registered Nurse Staff D, confirmed patient information should always be protected and should not be left unattended and in view of passersby.


- Observation on 2/13/2018 at 2:00 PM of the Telemetry unit, revealed Patient # 37's nurse (Registered Nurse Staff H) accessing their medical record at the computer station located between room #'s 103 and 104). Staff H failed to log out of the electronic health record before she left the immediate area. The patient's medication information was displayed on the screen with several patient identifiers displayed (Name, date of birth, and allergies).

Interview on 2/13/2018 at 2:00 PM with Registered Nurse Staff H, stated, "You made me nervous! I usually turn off the screen".


- Observation on 2/13/2018 at 11:57 AM of the Telemetry unit, revealed Patient # 36's nurse (Registered Nurse Staff I) accessing their medical record at the computer station located outside of room # 102. Staff I failed to log out of the electronic health record before she left the immediate area. Staff I pushed the monitor's power button prior to walking away. When the computer monitor power is turned back on the patient's information is immediately displayed.

Interview on 2/14/2018 at 9:20 AM with Information Technology Staff F, indicated staff are instructed to log in and out during each use of the electronic medical record system. They are not supposed to just turn the power off at the monitor as that leaves the patient's medical record open and accessible. Staff F stated, "All someone would have to do is turn the monitor back on and they would have access to the patient's medical records." Staff F indicated they receive orientation training, but it is up to their preceptor on the unit to fully train them on the use of the computer system.


- Review on 2/15/2018 of policy titled "Patient Privacy and Confidentiality" directed, Do not leave patient documents, orders, report sheets, or anything else with the patient's name or information on it, in the patient's rooms, public areas, or in staff areas where patients or visitors can see them. Never leave a computer unattended with patient information visible.

Based on staff interview and document review, the hospital failed to provide evidence the governing body provided clear oversight and specifics of how often the performance improvement projects will collect data and the frequency the data will be collected for performance improvement projects reviewed (refer to tag A-0273); failed to ensure the Quality Assessment and Performance Improvement (QAPI) program collected data related to patient safety issues from the Emergency Department (ED) and reported the data into the ongoing QAPI program (refer to tag A-0283); failed to document the reasons why certain quality improvement projects are being conducted and the measurable progress achieved on the projects (refer to tag A-0297); failed to have a performance improvement program whose efforts addressed priorities for improved quality of care and patient safety; and failed to ensure that all improvement actions were evaluated and determine the number of distinct improvement projects that would be conducted annually (refer to tag A-0309).


These deficient practices have the potential to affect the quality and safe delivery of care and may place patients at risk for substandard care.

Based on document review and staff interview, the hospital's governing body failed to provide clear oversight and specifics of how often the performance improvement projects will collect data, and failed to provide data collected and the frequency data is collected for performance improvement projects reviewed from three of three Performance Improvement Meeting Minutes reviewed (March 2017, August 2017 and November 2017). This deficient practice impacts all patients of the hospital related to the monitoring of the quality, effectiveness, and safety of all services provided.


Findings include:

- Review on 2/14/2088 of the "Governing Body Minutes" from 3/30/2017, 8/31/2017, and 12/7/2017, revealed performance indicator data is reported, but lacked evidence the governing body provided clear oversight, and specifics of how often the performance improvement projects will collect data.

- Review on 2/14/2018 at 10:15 AM of the "Performance Improvement Meeting Minutes" from 3/2017, 8/2017, and 11/2017, revealed the hospital failed to provide the specifics of how often the performance improvement project will collect data and evidence of the data collected.

Interview on 2/15/2018 at 8:41 AM with Clinical Executive Staff M, indicated that every department has to develop a performance improvement project. The project is at the discretion of the department manager and they may start a project any time and begin a new one as soon as the current project is completed. Staff M confirmed the governing body is informed of the projects and their results, but they are not involved in selecting the number of distinct projects that would be conducted annually.

- Review on 2/19/2018 at 4:40 PM of the "Quality Assurance and Performance Improvement Program" document directed, KMC's program includes, but is not limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will improve health outcomes and identify and reduce medical errors and KMC's QA/PI program measures, analyzes and tracks quality indicators, including adverse patient events and other aspects of performance that assess processes of care, hospital services and operations.

Based on observations, staff interview and document review it was determined the hospital staff failed to ensure the Quality Assessment and Performance Improvement (QAPI) program collected data related to patient safety issues from the Emergency Department (ED) and reported the data into the ongoing QAPI program. This deficient practice has the potential to cause harm to patients due to the lack of monitoring safety issues in the ED.

Findings include:

- Observation on 2/15/2018 at 5:45 AM of the Emergency Department check in area, revealed an empty waiting area. A bell attached to the reception desk with a sign attached stating, "Please push bell for assistance". At 6:03 AM, Security Guard Staff CC entered into the entrance area from the open emergency room hallway.

Interview on 2/15/2018 at 6:05 AM with Security Guard Staff CC, indicated he had been doing rounds around the hospital and had just returned to the check in area. Staff CC confirmed no other staff members are stationed at the check in desk from 12:00 AM until he leaves around 7:00 AM. Staff CC revealed when he is doing their rounds the check in area is unattended and no one is assigned to watch the security monitors.

Interview on 12/15/2018 at 2:15 PM with Chief Nursing Officer staff B, explained that registration staff are at the check in desk from 8:00 AM until midnight. After the registration clerk goes home, one of the two nurses staffed at night is supposed to sit out at the desk in the check in area.

- Review on 2/15/2018 at 7:00 AM of "Social Media Post", revealed the reviewer (Social Media Reviewer # 39) had presented to the emergency department on 1/15/2018 "early in the morning" and stated they waited several minutes after pressing the bell before an unidentified male nurse came out and indicated they didn't hear the bell. Contact information for the reviewer was not available.

- Review on 2/15/2018 at 7:15 AM of "Social Media Post", revealed the reviewer (Social Media Reviewer # 40) had presented to the emergency room with cardiac issues and no one was at the entrance area's desk when they walked in. Poster # 40 indicated a security guard came in and said nothing to them. Contact information for the reviewer was not available.

Interview on 2/15/2018 t 4:30 PM with Administrative Staff A, indicated they had no knowledge of the incidents mentioned by the reviewers on social media. Staff A reported they do follow up on social media reports.

- Review on 2/13/2018 of Patient #4's medical record, revealed patient #4 presented to the ED on 10/9/2017 at 4:09 AM by ambulance with a complaint of abdominal pain. Patient #4 was also experiencing symptoms of psychosis (a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality) such as flight of ideas (rapid shifting of ideas), delusions (false beliefs), and hallucinations (perceptions of things that are not there). A medical screening exam was initiated including laboratory studies, a CT scan (three dimensional x-ray), and a psychiatric exam by an outside source. The medical record revealed the last set of vital signs was taken at 6:37 AM. At 7:15 AM, a note entered by the physician revealed the patient had eloped from the department and returned to the department by law enforcement.

Interview on 2/12/2018 at 11:30 AM with Emergency Department Staff DD explained that if the three ED rooms are in use, ED staff may have to move patients from a treatment room into the shared waiting room or into the quiet room to take care of a patient that is more emergent, and security monitors the shared waiting room since it cannot be seen from the nurse's station.

Interview on 2/15/2018 at 3:59 PM with Emergency Department staff DD, confirmed the facility failed to conduct an investigation regarding the elopement of patient #4.

- Observation on 2/14/2018 at 3:51 PM of the Quiet Room across from the double doors leading to the ED, revealed a room with a solid door, lacking a window, automatically locking from the inside, and without an emergency call system.

- Observation on 2/14/2018 at 3:51 PM of the Large Shared Waiting Room, past the Quiet room, reveals a waiting room unobservable from the nurse's station, and lacking in an emergency call system.

Interview on 2/15/2018 at 3:51 PM with Emergency Department staff DD, acknowledges the absence of an emergency call system in the quiet room or the waiting room. Staff DD also acknowledges the large shared waiting room is not observable by the nurse's station, or hospital staff.

- Review on 2/14/2018 at 10:15 AM of the "Performance Improvement Meeting Minutes" from March 2017, August 2017, and November 2017 revealed the documents lacked evidence the QAPI program collected data related to patient safety issues from the ED and reported the data into the ongoing QAPI program.


- Review on 2/19/2018 at 4:40 PM of the "Quality Assurance and Performance Improvement Program" document, directed, KMC's program includes, but is not limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will improve health outcomes and identify and reduce medical errors and KMC's QA/PI program measures, analyzes and tracks quality indicators, including adverse patient events and other aspects of performance that assess processes of care, hospital services and operations.

Based on staff interview and document review, the hospital failed to document the reasons why certain quality improvement projects are being conducted and the measurable progress achieved on the projects. This deficient practice has the potential for the hospital to not clearly recognize the impact of the Quality Assurance and Performance Improvement (QAPI) project on health care quality and effectively monitor its progress.

Findings include:


Interview on 2/15/2018 at 8:41 AM with Clinical Executive Staff M, indicated that every department has to develop a performance improvement project. The project is at the discretion of the department manager and they may start a project any time and begin a new one as soon as the current project is completed. Staff M confirmed the governing body is informed of the projects and their results, but they are not involved in selecting the number of distinct projects that would be conducted annually.

- Review on 2/20/2018 at 9:00 AM of the "Quality Meeting Minutes" from 3/2017, 8/2017, and 11/2017, revealed the hospital staff failed to identify measurable goals and document specific reasons why all projects were chosen.

- Review on 2/14/2018 of the "Governing Body Minutes" from 3,/30/2017, 8/31/2017, and 12/7/2017 revealed performance indicator data is reported, but lacked evidence the governing body provided clear oversight, and specifics of how often the performance improvement projects will collect data.

Interview on 2/14/2018 at 11:00 AM with Respiratory Therapy Manager Staff EE, indicated they chose their performance improvement project only because, "I had to pick something". Staff EE confirmed their project was not chosen based on priorities for improved quality of care.


Review on 2/19/2018 at 4:40 PM of the "Quality Assurance and Performance Improvement Program" document directed, program includes, but is not limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will improve health outcomes and identify and reduce medical errors ...and...the number and scope of distinct improvement projects conducted annually are proportional to the scope and complexity of the hospitals services and operations.

Based on staff interview and document review the hospital failed have a performance improvement program whose efforts addressed priorities for improved quality of care and patient safety, ensure that all improvement actions were evaluated and determine the number of distinct improvement projects that would be conducted annually. This deficient practice has the potential to harm patients due to the lack of ensuring the Performance Improvement Plan was effective in improving care to the patients.


Findings include:

- Review on 2/14/2018 of the "Governing Body Minutes" from 3/30/2017, 8/31/2017, and 12/7/2017, revealed performance indicator data is reported, but lacked evidence the governing body evaluated and determine the number of distinct improvement projects that would be conducted annually.

Interview on 2/15/2018 at 8:41 AM with Clinical Executive Staff M, indicated that every department has to develop a performance improvement project. The project is at the discretion of the department manager and they may start a project any time and begin a new one as soon as the current project is completed. Staff M confirmed the governing body is informed of the projects and their results, but they are not involved in selecting the number of distinct projects that would be conducted annually.

Interview on 2/14/2018 at 11:00 AM with Respiratory Therapy Manager Staff EE, indicated they chose their performance improvement project only because, "I had to pick something". Staff EE confirmed their project was not chosen based on priorities for improved quality of care.

- Review on 2/19/2018 at 4:40 PM of the "Quality Assurance and Performance Improvement Program" document directed, program includes, but is not limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will improve health outcomes and identify and reduce medical errors and the number and scope of distinct improvement projects conducted annually are proportional to the scope and complexity of the hospitals services and operations.

Based on medical record review, staff interview and policy review the hospital failed to ensure that 10 of 30 patient's medical records reviewed (Patient #'s 16, 17, 18, 19, 20, 31, 32, 33, 34 and 35) had current, individualized and updated nursing care plans. The deficient practice to include a current, individualized, and updated nursing care plan in the medical record has the potential to result in an incomplete nursing assessment of a patient's needs and goals for improvement of health status.

Findings include:

- Review on 2/13/2018 of Patient # 16's medical record revealed the patient was admitted on 2/9/2018 and is a current in-patient. The medical diagnoses for Patient # 16 include sepsis (a severe infection), cellulitis (skin infection), and hypoxia (low oxygen levels). The patient also had an infection to their third finger on their right hand requiring an amputation. The nursing care plan included interventions and goals for pain. No other nursing diagnosis, interventions, or goals were identified in the medical record. The medical record lacked evidence of a nursing care plan that addressed the specific care and needs of the patient, interventions and goals for any other problem except pain.


- Review on 2/13/2018 of Patient # 17's medical record revealed the patient was admitted on 2/10/2018 and is a current in-patient. The medical diagnosis for Patient # 17 include a right femur (thigh bone) fracture (break) requiring surgical repair, chronic essential hypertension (high blood pressure), coronary artery disease, COPD (breathing disorder). The nursing care plan included interventions and goals for pain. No other nursing diagnosis, interventions, or goals were identified in the medical record. The medical record lacked evidence of a nursing care plan that addressed the specific care and needs of the patient, interventions and goals for any other problem except pain.


- Review on 2/13/2018 of Patient # 18's medical record revealed the patient was admitted on 2/8/2018 and is a current in-patient in room. The medical diagnosis for Patient # 18 included a right femur fracture requiring surgical repair. The nursing care plan included interventions and goals for pain. No other nursing diagnosis, interventions, or goals were identified in the medical record. The medical record lacked evidence of a nursing care plan that addressed the specific care and needs of the patient, interventions and goals for any other problem except pain.


- Review on 2/13/2018 of Patient # 19's medical record revealed the patient was admitted on 2/8/2018 and is a current in-patient. The medical diagnosis for Patient # 19 included a right total knee replacement, chronic essential hypertension, dyslipidemia (high cholesterol), neuropathy (nerve damage). The nursing care plan included interventions and goals for pain. No other nursing diagnosis, interventions, or goals were identified in the medical record. The medical record lacked evidence of a nursing care plan that addressed the specific care and needs of the patient, interventions and goals for any other problem except pain.

- Review on 2/13/2018 of Patient # 20's medical record revealed the patient was admitted on 1/25/2018 and was discharged to the funeral home of the family's choice on 1/25/2018. The medical diagnoses for Patient #20 included a cerebral vascular accident (stroke), acute renal azotemia (kidney failure), and dehydration. No nursing diagnosis, interventions, or goals were identified in the medical record. The medical record lacked evidence of a nursing care plan that addressed the specific care and needs of the patient, interventions and goals.

- Review on 2/14/2018 Patient # 31's medical record revealed the patient was admitted on 5/21/2017 with a medical diagnosis of appendicitis requiring surgical removal of the appendix and the patient was discharged on 5/27/2017. No nursing diagnosis, interventions, or goals were identified in the medical record. The medical record lacked evidence of a nursing care plan that addressed the specific care and needs of the patient, interventions and goals.
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- Review on 2/14/2018 of Patient # 32's medical record revealed the patient was admitted on 7/23/2017 with medical diagnoses of non-rheumatic aortic valve stenosis (stiffening of a valve in the heart), hypertension, hyperlipidemia, type 2 diabetes, hypothyroidism, varicose veins and obesity. Patient #32 was discharged on 7/28/2017. No nursing diagnosis, interventions, or goals were identified in the medical record. The medical record lacked evidence of a nursing care plan that addressed the specific care and needs of the patient, interventions and goals.

- Review on 2/14/2018 of Patient # 33's medical record revealed the patient was admitted on 5/17/2018 with the following medical diagnoses: COPD (breathing disorder), Diabetes, and on day eight of the admission the patient suffered a STEMI (heart attack) and was discharged to the funeral home of the family's choice on 5/26/2018. No nursing diagnosis, interventions, or goals were identified in the medical record. The medical record lacked evidence of a nursing care plan that addressed the specific care and needs of the patient, interventions and goals.


- Review on 2/14/2018 of Patient # 34's medical record revealed the patient was admitted on 1/30/2017 with medical diagnoses of liver failure, alcohol abuse, acute kidney injury, and hypokalemia (low potassium). Patient # 34 was discharged on 2/3/2018. No nursing diagnosis, interventions, or goals were identified in the medical record. The medical record lacked evidence of a nursing care plan that addressed the specific care and needs of the patient, interventions and goals.

- Review on 2/14/2018 of Patient # 35's medical record revealed the patient was admitted on 6/11/2017 with a medical diagnosis of aortic aneurism, and hypertension. Patient # 35 was discharged on 6/15/2017. No nursing diagnosis, interventions, or goals were identified in the medical record. The medical record lacked evidence of a nursing care plan that addressed the specific care and needs of the patient, interventions and goals.


Interview on 2/13/2018 at 5:00 PM with Registered Nurse Manager Staff C, indicated nurses were told to only choose one nursing diagnosis by the representatives of the electronic health record manufacturer because multiple nursing diagnosis would be difficult for the system.

Review on 2/14/2018 Policy titled "Nursing Standards of Care" directed, each patient will receive positive care and intervention in relation to each patient's condition. The nurse develops a plan of care specific to the individual needs and patient rights. The nurse will reassess the pan of care, evaluate and revise on as needed basis.

Based on staff interview and record review the hospital failed to ensure physician orders were authenticated (the process or action of proving or showing something to be true, genuine or valid) for a verbal diagnostic order in 1 of thirty-five records reviewed (Patient #4). This deficient practice of the facility to accurately and timely authenticate physician orders puts all patients at risk for receiving medications, treatments and unsafe care with the potential for causing harm.

Findings include:

- Review on 2/14/2018 at 10:00 AM of Patient #4's medical record, revealed an EKG order was electronically entered by Respiratory Therapy Staff AA. The order was signed and reviewed by nursing staff BB on 10/9/2017 and was not signed by a physician as of survey date 2/14/2018 (128 days later).

Interview on 2/12/2018 at 11:00 AM Registered Nurse Staff E, stated, "The order wasn't signed" and confirmed it should have been.

- Review on 2/15/2018 at 10:00 AM Document titled "Medical Staff Rules and Regulations" read, verbal orders are authenticated as required by the State of Kansas or federal law (Kansas law requires authentication within 72 hours of patient's discharge or 30 days, whichever occurs first).

Based on interview and record review the hospital failed to provide an admission History and Physical (H&P) for one of thirty-five patient records reviewed (Patient #26). Failure to ensure patients' medical history and physical are competed in a timely manner has the potential for poor patient outcomes.

Findings include:

- Review on 2/13/2018 on 11:00 AM of Patient #26's medical record revealed the record lacked an H&P.

Interview on 2/14/2018 at 11:00 AM with Clinical Receptionist Staff M stated, "He doesn't have one" when asked of patient's H&P.

- Review on 2/15/2018 at 10:00 AM of Documentation titled "Medical Staff Rules and Regulations" read, a complete history and physical examination shall in all cases, be performed and a report thereof dictated or written within twenty-four (24) hours after admission of the patient.

Based on document review and staff interview, the hospital failed to ensure transfer documentation was complete for 2 of 10 emergency department (ED) records reviewed (Patient #1 and Patient #7). This deficient practice has the potential to effect the continuity of care for all emergent patients that are transferred.

Findings include:

- Review on 2/13/2018 of Patient #1's medical record revealed patient #1 was admitted to the ED on 9/3/2017 with a diagnosis of a fall. The medical record review revealed the patient had a medical screening exam and was diagnosed with a subdural hematoma (bleeding in the spaces of the brain) and needed to be transferred for stabilizing care. Review of the transfer documentation and physician's notes lacked evidence of the condition of the patient prior to the transfer.

- Review on 2/13/2018 Patient #7's medical record revealed patient #1 was admitted to the ED on 9/3/2017 with a diagnosis of vomiting, pelvic pain, sepsis (severe infection) and early pregnancy. The medical record revealed the patient received a medical screening exam, and subsequently transferred for stabilizing care. Medical record review, including transfer documentation, lacked evidence of documentation indicating the medical record was sent with the patient to the receiving hospital.

Interview on 2/13/2018 at 1:40 PM with Emergency Staff DD, acknowledged the documentation was missing from the medical record.

Based on medical record review, staff interview and document review the hospital failed to ensure two of 35 medical records reviewed (Patient #'s 32 and 35) contained a discharge summary. This deficient practice to complete a discharge summary puts all patients at risk for receiving follow-up care that is unsafe and inaccurate resulting in harm, and poor outcomes.

Findings include:

- Review on 2/14/2018 of Patient # 32's medical record revealed the patient was admitted on 7/23/2017 and was discharged on 7/28/2017. The medical record lacked evidence a discharge summary was completed.

- Review on 2/14/2018 of Patient # 35's medical record revealed the patient was admitted on 6/11/2017 and was discharged on 6/15/2017. The medical record lacked evidence a discharge summary was completed.

Interview on 2/15/2018 at 10:45 AM with Utilization Review Coordinator Staff E, confirmed the electronic medical record lacked evidence a discharge summary was performed within 24 hours for Patient # 32 and Patient 35. Staff E indicated they do not have problems with either physician getting medical records completed as required.

- Review on 2/15/2018 Document titled "Medical Staff Rules and Regulations" directed, discharge summaries must be completed within 24 hours.

Based on observation and staff interview the hospital failed to ensure medications were monitored in one of one sample medication supply rooms located in the Cardiac Clinic. This deficient practice to monitor and document sample medications stored and dispensed has the potential to allow unauthorized removal from stock and recalled medications to be untraceable which could cause patient harm.

Findings include:

- Observation on 2/13/2018 at 9:00 AM of Medication Supply Room, revealed the room failed to contain a tracking mechanism to ensure all medications stored in the supply room were inventoried and a log kept after the dispensing of medications to patients.

Interview on 2/13/2018 at 9:00 AM with Clinic Receptionist Staff Z, confirmed the clinic staff did not know what kind or how many medications were in the medication sample room. Staff Z stated, "The drug representatives bring the medication supplies and they keep their own log". Staff Z indicated the staff would not know if something went missing from the medication sample room. Staff Z reported when they give a sample to a patient they put the information in the patient's medical record but do not document on any type of log.

The hospital failed to provide a policy directing staff to ensure there is an accurate inventory of sample medications and a sample medication dispensing log for the clinic.

Based on observation, staff interview, and policy review the hospital failed to ensure all expired medications were removed from patient care areas and unavailable for patient use in one of one observed Cardiac clinics. This deficient practice has the potential to expose patients to expired medications that could cause ineffective treatment or worsening of an illness.

Findings include:

- Observation on 2/13/2018 at 8:59 AM of Medical Sample Room, revealed six bottles of Corlanor 5mg (a medication used to treat chronic heart failure) with an expiration date of 10/2017.

Interview on 2/13/2018 at 8:59 AM Risk Manager Staff G, confirmed the Corlanor bottles were expired. Staff G indicated the drug company representative is responsible for the medication inventory.

The facility failed to provide a policy requiring staff to dispose of outdated medication for one of one observed Cardiac Clinics.

Based on observation and document review the hospital failed to ensure that 2 of 6 blanket warmers (1 located in ICU, 1 located in the telemetry unit) were maintained at an acceptable temperature range and failed to ensure that a temperature monitoring log was maintained for 6 of 6 blanket warmers observed (1 located in the ICU, 2 located in the telemetry unit, and 3 located in the medical surgical unit). This deficient practice places patient at risk for a thermal burn injury.

Findings include:

- Observation on 2/12/2018 of Blanket warmers in the Intensive Care Unit (ICU) and the telemetry units, labels indicating "temperature to be maintained at 130 degrees". The large blanket warmer observed in the ICU had a digital display that read 142 degrees (12 degrees higher than the recommendation). A blanket warmer in the telemetry unit had a digital display that read 139 degrees (9 degrees higher than the recommendation). All blanket warmers observed (1 located in the ICU, 2 located in the telemetry unit, and 3 located in the medical surgical unit) failed to have a temperature monitoring log.

Interview on 2/12/2018 at 11:00 AM with Clinical Executive Staff M states, "That's more than 130 degrees" in acknowledgement of the blanket warmer temperatures. Staff M acknowledged the maximum temperature for the blanket warmer should be below 130 degrees.

- Review on 2/14/2018 at 4:00 PM of Policy titled "Blanket Warmer Operating Temperature Policy" directed, blanket warmers shall be maintained at 130 degrees Fahrenheit or 54.4 degrees Celsius as recommended by Emergency Care Research Institute or ECRI.

Based on observation, staff interview, and document review the hospital failed to ensure staff monitored the humidity and air exchanges in six of six operating rooms, two of two endoscopy rooms, and two of two catheterization procedure rooms. These deficient practices have the potential to expose patients to blood borne pathogens or other infectious materials which could lead to patient harm or death.

Findings include:

- Observation on 2/13/2018 at 1:45 PM of the Central Processing, Sterile Storing, and Operating Room areas, revealed the area lacked a log for tracking temperatures, humidity, and air exchanges.

Interview on 2/13/2018 at 1:45 PM with Central Processing Technician Staff X indicated they do not track temperature, humidity, or air exchanges in the sterile processing and supply areas because the maintenance person does that via their computer system.

Interview on 2/13/2018 at 2:00 PM with Maintenance Staff W indicated temperature, humidity, and air exchanges are not currently being monitored daily in any areas of the hospital. Staff W indicated they were getting a new computer system for the heating, ventilation, and air condition system and the system will be set up to do the monitoring then, but lacked knowledge they should have been tracking that information.

- Review on 2/15/2018 at 12:00 PM of Policy titled "Staff Responsibilities in the Operating Room" directed, temperature and humidity settings shall be chosen on the basis of the well-being of the patient and the OR team, the staff is encouraged to participate in a professional organization such as the Association of Operating Room Nurses (AORN), Association of Surgical Technologists (AST).

The Association of Perioperative Registered Nurses (AORN) website on May 25, 2016 stated, "The recommended temperature range in an operating room is between 68 [degrees] F [Fahrenheit] and 75 [degrees] F, The recommended humidity range in an operating room is between 20% [percent] to 60% based on addendum d to ANSI (American National Standards Institute)/ASHRAE (American Society of Heating, Refrigerating, and Air-Conditioning Engineers)/ASHE (American Society for Healthcare Engineering) Standard 170-2008.

Based on observation, staff interview, and document review the hospital failed to ensure the decontamination shower located in the laboratory had a curtain and drainage system to prevent cross-contamination of infectious materials, failed to ensure staff (Staff I, Staff K, and Staff U) performed hand hygiene after removal of gloves in three of seven random observations, failed to ensure potentially contaminated patient care items were cleaned or disposed of in one of one wound dressing change observations, and failed to ensure all surfaces in one of one operating rooms observed were cleanable and a non-alcohol based hand rub was available for use. These deficient practices have the potential to expose patients to blood borne pathogens or other infectious materials which could lead to patient harm or death.

Findings include:

- Observation on 2/12/2018 at 9:55 AM Laboratory revealed a decontamination shower which lacked a curtain and a drain.

Interview on 2/12/2018 at 10:00 AM with Laboratory Staff T confirmed they have a curtain but it is not kept near the shower and is only brought out to test the system. Staff T indicated when they test the shower they have to place a garbage can under it to collect the water to keep it from running under the door and into the hallway because there is not a drain below the shower.

- Observation on 2/13/2018 between 9:30 AM and 10:45 AM of Operating Room Nurse Staff U apply and remove gloves five times during a surgical procedure for Patient #11 without performing hand hygiene. Operating Room # 5 lacked hand sanitizer.

Interview on 2/13/2018 10:55 AM with Operating Room Nurse Staff U, acknowledged they should have been performing hand hygiene between glove changes and confirmed the operating room lacked hand sanitizer.


- Observation on 2/13/2018 at 1:30 PM of Housekeeping Staff K and Housekeeping Management Staff J on the Medical Surgical Unit room 112 performing a terminal cleaning. Staff K came out of the room and removed their gloves and put on clean gloves without performing hand hygiene between them glove changes.

Interview on 2/15/2018 at 9:30 AM with Housekeeping Management Staff J revealed housekeeping staff are instructed to perform hand hygiene every time they remove their gloves.


- Observation on 2/13/2018 at 11:50 AM of Registered Nurse Staff I, revealed them exiting room 106 which contained a patient (unidentified patient # 38) who is on isolation precautions. Staff I still had their gloves on when they exited the room and then took them off in the hallway and placed them in the hallway trash. Staff I failed to perform hand hygiene. Management Staff G gave Staff I nonverbal cues to perform hand hygiene. Staff I then proceeded down the hallway to the Pyxis (medication administration machine) to perform the required hand hygiene.

Interview on 2/13/2018 at 1:00 PM with Risk Manager Staff G acknowledged Registered Nurse Staff I should have removed their gloves in the room and performed hand hygiene immediately.

- Review on 2/15/2018 at 11:40 AM of policy titled "Isolation Procedures" directed, droplet precautions (used for diseases or germs that are spread in tiny droplets caused by coughing and sneezing [examples: pneumonia, influenza, whooping cough, bacterial meningitis]). HANDS- will be washed when entering and leaving room.


- Observation on 2/12/2018 at 4:38 PM of Registered Nurse Staff H performing a dressing change on Patient # 37's foot. During the dressing change a bottle of iodine fell off the bed and onto the floor then rolled under the bed. The uncapped iodine remained on the floor until the procedure was completed and then was picked up, recapped with the dirty lid and placed by the sink in the patient's room for future use without cleaning and disinfecting the bottle.

Interview on 2/12/2018 at 4:50 PM with Registered Nurse Staff H stated, "Yes, the cap was off of the iodine. Should I have thrown it away?" Staff H then indicated she should have thrown it away and said she was going to go throw it away.


- Observation on 2/13/2018 between 9:30 AM and 10:45 AM of Operating Room # 5 revealed two pieces of paper taped to the wall without being in protective plastic sheeting, one piece of paper taped to a white wall mounted box without being in protective plastic sheeting, multiple pieces of peeling tape applied to the wall mounted metal drawers, and tape wrapped around a wall mounted telephone. Peeling tape and unprotected paper allows harmful bacteria and other infectious materials to collect and could cause infections to surgical patients.

Interview on 2/13/2018 at 11:00 AM Registered Nurse Staff V at 11:00 AM acknowledged the items observed in the operating room should be in plastic covers and indicated they had not identified the tape as an infection risk.

- Review on 2/15/2018 at 7:45 AM of policy titled "Hand hygiene" directed: Indication for hand hygiene, before and after each patient contact. Before and after touching wounds/non-intact skin, whether surgical, traumatic or associated with an invasive device. Whenever nails or hands are visibly dirty. Before donning gloves to prevent contamination of gloves in the box. After removing gloves to remove contaminants that may have been present before donning sterile gloves. (Gloves are an adjunct to, not a substitute for hand washing). After performing personal hygiene activities (i.e., toileting, sneezing, coughing, and combing hair).