HospitalInspections.org

Based upon record review and interview, the Governing Body failed to:


1. ensure a staff physician supervised the care of 1 of 1 (#1) patient while hospitalized. Patient #1 was admitted to the service of physician #1, a podiatrist, on 07/15/2016 at 16:55 (4:55pm). The hospitalist was consulted the morning of 07/16/2016 to manage the patient's medical care. Patient #1 expired prior to being seen by the hospitalist.

Refer to A0144, A347

2. ensure registered nursing staff supervised and evaluated nursing care of patient #1. Patient #1 was documented as having diabetes and being oxygen dependent. The nursing staff failed to act on behalf of the patient, contact a physician for orders, and provide routine nursing care.

Refer to A0144, A0395


3. ensure nursing administered a medication as ordered by the Emergency Department physician to 1 of 1 (#1) patients. Staff #6 applied Nitro-Bid Ointment to the chest wall of patient #1. The medication was ordered to be placed to the right lower foot dorsal aspect.

Refer to A0405

Based on document review and interview the facility failed to provide 1 of 1(#1) patient the right to receive care in a safe setting. The staff physician failed to supervised the care of 1 of 1 (#1) patient while hospitalized. Patient #1 was admitted to the service of physician #1, a podiatrist, on 07/15/2016 at 16:55 (4:55pm). The hospitalist was consulted the morning of 07/16/2016 to manage the patient's medical care. Patient #1 expired prior to being seen by the hospitalist.

Refer to tag A0144

Based on document review and interview, the facility failed to provide a safe environment for 1 of 1 patient (#1) to receive care. The facility failed to:

A. ensure a staff physician supervised the care of 1 of 1 (#1) patient while hospitalized. Patient #1 was admitted to the service of physician #1, a podiatrist, on 07/15/2016 at 16:55 (4:55pm). The hospitalist was consulted the morning of 07/16/2016 to manage the patient's medical care. Patient #1 expired prior to being seen by the hospitalist.

A review of the medical record revealed patient #1was a 68 year old male, admitted to the facility for gangrene of the right toe. Patient had a history of end stage renal disease, diabetes, chronic respiratory failure and Hypoxia in 06/19/2016, Encephalopathy and the patient was legally blind.

A review of the medical record revealed that patient #1 was oxygen dependent. The patient wore oxygen at 2 liters per nasal cannula, continuous, at home. The patients need for oxygen was not addressed by the Medical Staff. Oxygen was not ordered for patient #1.

The patient's blood sugar on 07/15/2016 at 5:31pm was 248. The normal range would be 70-110 mg/dl. No action was taken by the Medical staff or nursing staff to address the patient's elevated blood sugar.

The patient was being given Levemir 100u/ml, give 5 units subcutaneous one time a day for diabetes in his home setting. The patient was also receiving Humalog 100u/ml, give (0-6units) four times a day on a sliding scale. For blood sugars from 61 to 150 give 0 units, 151-200 give 1 unit, 201-250 give 2 units, 251- 300 give 3 units, 301-350 give 4 units, 351-400 give 5 units, 401 or greater give 6 units and re-check blood sugar in 15 minutes. If blood sugar still 401 or greater call the M.D.

A review of the patient's admitting orders dated and signed on 07/15/2016 at 16:55 (4:55pm) revealed:

Admit to inpatient.
Med/Surg
Attending Physician: Physician #1 (podiatrist)
Condition: good
Routine vital signs.
Daily weight
Renal diet
Activity: bedrest
Meds: Acetaminophen 650 mg every four hours (Incomplete order).


A review of the medical record provided no documentation of Emergency Room Physician #2 Medical Screening Exam/Assessment Note on 07/15/2016, the day the patient was seen in the Emergency Room and admitted to the hospital.


A document titled "Emergency Department Provider Documentation Addendum" with the date of service as 07/15/2016 for patient #1 revealed this document was generated on 07/28/2016 at 2:11pm. The document was faxed to the facility on August 01, 2016. Emergency Department Provider Documentation Addendum was generated 12 days after patient #1 died.


A continued review of patient #1 medical record revealed a document titled Progress Note, dated 07/16/2016, timed 1:02pm, and documented by physician #3, the hospitalist. The document read as follows: ...."the patient was admitted to Physician #1 service last evening and the hospitalist was consulted this A. M. for medical management. Apparently, the patient had a code blue and subsequently passed away before my evaluation ....."


A review of the facility's Medical Staff Rules and Regulations revealed:

4.3 ADMISSION OF PODIATRIC PATIENTS
A patient admitted for podiatric care is the dual responsibility of the podiatrist who is a staff member and the physician member of the Medical Staff designated by the podiatrist.

4.3(a) Podiatrist's Responsibilities

The responsibilities of the podiatrist are:

(1) To provide a detailed podiatric history justifying hospital admission; complete preoperative history and physical for outpatient surgery

(2) To provide a detailed description of the podiatric findings and a preoperative diagnosis;

(3) To complete an operative report describing the findings and technique. All tissue shall be sent to the hospital pathologist for examination;

(4) To provide progress notes as are pertinent to the podiatric condition; and

(5) To provide a clinical summary.


4.3(b) Physician's Responsibilities

The responsibilities of the physician are:

(1) To provide medical history pertinent to the patient's general health, which shall be on the patient's chart prior to induction of anesthesia and start of surgery;

(2) To perform a physical examination to determine the patient's condition, which shall be on the patient's chart prior to anesthesia and surgery; and

(3) To supervise the patient's general health status while hospitalized.


An interview with staff #3 and staff #5 on 08/12/2016 confirmed patient #1 should have had
a physician co-admitting with the podiatrist.


B. provide registered nursing staff to supervise and evaluate nursing care of patient #1. Patient #1 was documented as having diabetes and being oxygen dependent. The nursing staff failed to act on behalf of the patient, contact a physician for orders, and provide routine nursing care.

A document titled "Clinical Documentation Report" completed on 07/15/2016, timed 8:57pm revealed the following: "Clinical History Profile: Current, patient had no oxygen. In the section of the document titled "Assessment, Admission Systems History" revealed the question, "Oxygen Dependency at Home?" The question was answered "Yes".
"Previous Hospitalization ... 6/19/2016 Chronic Respiratory Failure with Hypoxia."

The document revealed the home medications were reviewed and entered into the computer system by the nursing staff along with the diabetic medications Levemir 100u/ml, give 5 units subcutaneous one time a day for diabetes in his home setting, Humalog 100u/ml, give (0-6units) four times a day on a sliding scale. For blood sugars from 61 to 150 give 0 units, 151-200 give 1 unit, 201-250 give 2 units, 251- 300 give 3 units, 301-350 give 4 units, 351-400 give 5 units, 401 or greater give 6 units and re-check blood sugar in 15 minutes. If blood sugar still 401 or greater call the M.D. No evidence was provided the nursing staff took actions on behalf of the patient to have the medication ordered.

The patient's blood sugar on 07/15/2016 at 3:45pm was 248. The normal range would be 70-110 mg/dl. No action was taken by the nursing staff to address the patient's elevated blood sugar.

A review of the patient's admitting orders dated and signed on 07/15/2016 at 16:55 (4:55pm) revealed the order for "routine vital signs".

A review of the document titled Clinical Documentation Report revealed vital signs were documented on 07/15/2016 at 7:00pm, 07/16/2016 at 4:00am and 07/16/2016 at 9:38am, which was after the patient had died.

A review of the document titled "Policy: Early Warning Scoring System" revealed the following:

"Purpose: To outline the process to be followed using the early warning scoring system tool to ensure

a. The recognition in management of the patient who is deteriorating or at risk of deteriorating.

b. Early intervention for the deteriorating patient.

c. Reduce mortality.

Policy: Nursing staff are required to obtain an accurate EWS (Early Warning Score) every 4 hours, follow guidelines in managing the patient and to maintain accurate documentation including plan and outcome. Procedure: 2. Adult Patients a. take the patient's five vital signs. Temperature, Heart Rate, Blood Pressure, Respiratory Rate and Mental Status."

A review of the document titled "Policy: Routine Vital Signs revealed: All patients will have vital signs taken and monitored at intervals ....

Procedure: on the general floors ...routine vital signs consist of temperature, pulse, respiration, blood pressure and oxygen saturation .... Routine vital signs are taken and recorded at 8:00am, 16:00pm (4:00pm) and 12:00am (midnight)."

An interview with Staff #5 revealed, when asked, what is the abnormal vital sign criteria nursing aides follow and guides them when to report findings to the primary nurse. Staff #5 provided the document titled "Policy: Early Warning Scoring System" which stated VS every 4 hours. When asked what the frequency of routine vital signs was, Staff #5 provided a conflicting document titled "Policy: Routine Vital Signs" which indicated VS every 8 hours.


It was determined this deficient practice created an Immediate Jeopardy situation and placed patients at risk for the likelihood of harm, serious injury, and subsequent death. These deficient practices had the likelihood to affect all patients admitted to the facility.

Based on document review and interview, the facility failed to ensure a staff physician to supervise the care of 1 of 1 patient(#1) while hospitalized as outlined in the Medical Staff Rules and Regulations. Patient #1 was admitted to the service of physician #1, a podiatrist, on 07/15/2016 at 16:55 (4:55pm). The hospitalist was consulted the morning of 07/16/2016 to manage the patient's medical care.

Refer to tag A0347

Based on document review and interview, the facility failed to ensure that a staff physician supervised the care of patient #1 while hospitalized. Patient #1 was admitted to the service of physician #1, a podiatrist, on 07/15/2016 at 16:55 (4:55pm). The hospitalist was consulted the morning of 07/16/2016 to manage the patient's medical care. Patient #1 expired prior to being seen by the hospitalist.

A review of the medical record revealed, the patient #1was a 68 year old male, admitted to the facility for gangrene of the right toe. Patient had a history of end stage renal disease, diabetes, chronic respiratory failure and Hypoxia in 06/19/2016, Encephalopathy and the patient was legally blind.

A review of the medical record revealed the patient #1 was oxygen dependent. The patient wore oxygen at 2 liters per nasal cannula, continuous. The patient's need for oxygen was not addressed by the Medical Staff. Oxygen was not ordered for patient #1.

The patient's blood sugar on 07/15/2015 at 5:31pm was 248. The normal range would be 70-110 mg/dl. No action was taken by the Medical staff or nursing staff to address the patient's elevated blood sugar.

The patient was being given Levemir 100u/ml, give 5 units subcutaneous one time a day for diabetes in his home setting. The patient was also receiving Humalog 100u/ml, give (0-6units) four times a day on a sliding scale. For blood sugars from 61 to 150 give 0 units, 151-200 give 1 unit, 201-250 give 2 units, 251- 300 give 3 units, 301-350 give 4 units, 351-400 give 5 units, 401 or greater give 6 units and re-check blood sugar in 15 minutes. If blood sugar still 401 or greater call the M.D.

A review of the patient's admitting orders dated and signed on 07/15/2016 at 16:55 (4:55pm) revealed:

Admit to inpatient.
Med/Surg
Attending Physician: Physician #1 (podiatrist)
Condition: good
Routine vital signs.
Daily weight
Renal diet
Activity: bedrest
Meds: Acetaminophen 650 mg every four hours (Incomplete order).


A review of the medical record provided no documentation of Emergency Room Physician #2's "Medical Screening Exam/Assessment Note" on 07/15/2016, the day the patient was seen in the Emergency Room and admitted to the hospital.


A document titled "Emergency Department Provider Documentation Addendum" with the date of service as 07/15/2016 for patient #1 revealed this document was generated by Emergency Room Physician #2 on 07/28/2016 at 2:11pm. The document was faxed to the facility on August 01, 2016. Emergency Department Provider Documentation Addendum was generated 12 days after patient #1 died.


A continued review of patient #1 medical record revealed a document titled "Progress Note", dated 07/16/2016 and timed 1:02pm and documented by physician #3, the hospitalist. The document read as follows: ..." the patient was admitted to Physician #1 service last evening and the hospitalist was consulted this A. M. for medical management. Apparently, the patient had a code blue and subsequently passed away before my evaluation ....."


A review of the facility's Medical Staff Rules and Regulations revealed:

4.3 ADMISSION OF PODIATRIC PATIENTS

A patient admitted for podiatric care is the dual responsibility of the podiatrist who is a staff member and the physician member of the Medical Staff designated by the podiatrist.

4.3(a) Podiatrist's Responsibilities

The responsibilities of the podiatrist are:

(1) To provide a detailed podiatric history justifying hospital admission; complete preoperative history and physical for outpatient surgery

(2) To provide a detailed description of the podiatric findings and a preoperative diagnosis;

(3) To complete an operative report describing the findings and technique. All tissue shall be sent to the hospital pathologist for examination;

(4) To provide progress notes as are pertinent to the podiatric condition; and

(5) To provide a clinical summary.

4.3(b) Physician's Responsibilities

The responsibilities of the physician are:

(1) To provide medical history pertinent to the patient's general health, which shall be on the patient's chart prior to induction of anesthesia and start of surgery;

(2) To perform a physical examination to determine the patient's condition, which shall be on the patient's chart prior to anesthesia and surgery; and

(3) To supervise the patient's general health status while hospitalized.


An interview with staff #3 and staff #5 on 08/12/2016 confirmed patient #1 should have had a physician co-admitting with the podiatrist.


It was determined this deficient practice created an Immediate Jeopardy situation and placed patients at risk for the likelihood of harm, serious injury, and subsequent death. These deficient practices had the likelihood to affect all patients admitted to the facility.

Based on document review and interview the facility failed to:

A. provide registered nursing staff to supervise and evaluate nursing care of patient #1 (1 of 1 patients). Patient #1 was documented as having diabetes and being oxygen dependent. Based on these finding the nursing staff failed to act on behalf of the patient and provide routine nursing care. The facility failed to establish a time frame for "Routine Vital Signs."

Refer to tag A0395

B. identify a medication error. Staff #6 applied Nitro-Bid Ointment to the chest wall of patient #1. The medication was ordered to be placed to the right lower foot dorsal aspect.

Refer to tag A0405

Based on document review and interview, nursing failed to supervise and evaluate nursing care of 1 of 1 patients (#1). Patient #1 was documented as having diabetes and being oxygen dependent. The nursing staff failed to act on behalf of the patient, contact a physician for orders, and provide routine nursing care.


A review of the medical record revealed patient #1was a 68 year old male, admitted to the facility for gangrene of the right toe. Patient had a history of end stage renal disease, diabetes, chronic respiratory failure and Hypoxia in 06/19/2016, Encephalopathy and the patient was legally blind.

A review of the patient's admitting orders dated and signed on 07/15/2016 at 16:55 (4:55pm) revealed:

Admit to inpatient.

Med/Surg
Attending Physician: Physician #1 (podiatrist)
Condition: good
Routine vital signs.
Daily weight
Renal diet
Activity: bedrest
Meds: Acetaminophen 650 mg every four hours


A document titled "Clinical Documentation Report" completed on 07/15/2016 and timed 8:57pm revealed the following: "Clinical History Profile: Current, patient had no oxygen. In the section of the document titled "Assessment, Admission Systems History" revealed the question, "Oxygen Dependency at Home?" The question was answered "Yes".
"Previous Hospitalization ... 6/19/2016 Chronic Respiratory Failure with Hypoxia." Nursing staff failed to implement nursing interventions and contact a physician for orders for patient's known respiratory needs.

The document revealed the home medications were reviewed and entered into the computer system by the nursing staff along with the diabetic medications Levemir 100u/ml, give 5 units subcutaneous one time a day for diabetes in his home setting, Humalog 100u/ml, give (0-6units) four times a day on a sliding scale. For blood sugars from 61 to 150 give 0 units, 151-200 give 1 unit, 201-250 give 2 units, 251- 300 give 3 units, 301-350 give 4 units, 351-400 give 5 units, 401 or greater give 6 units and re-check blood sugar in 15 minutes. If blood sugar still 401 or greater call the M.D. No evidence was provided that the nursing staff took actions on behalf of the patient to have the medication ordered by a physician.

The patient's blood sugar on 07/15/2016 at 5:31pm was 248. The normal range would be 70-110 mg/dl. There was no other documentation of monitoring the patient's blood sugar. No action was taken by the nursing staff to address the patient's elevated blood sugar.

A review of the patient's admitting orders dated and signed on 07/15/2016 at 16:55 (4:55pm) revealed the order for "routine vital signs".

A review of the document titled "Clinical Documentation Report" revealed vital signs were documented on 07/15/2016 at 7:00pm, 07/16/2016 at 4:00am and 07/16/2016 at 9:38am, which was after the patient had died.

A review of the document titled "Policy: Early Warning Scoring System" revealed the following:

"Purpose: To outline the process to be followed using the early warning scoring system tool to ensure

a. The recognition in management of the patient who is deteriorating or at risk of deteriorating.

b. Early intervention for the deteriorating patient.

c. Reduce mortality.

Policy: Nursing staff are required to obtain an accurate EWS (Early Warning Score) every 4 hours, follow guidelines in managing the patient and to maintain accurate documentation including plan and outcome. Procedure: 2. Adult Patients a. take the patient's five vital signs. Temperature, Heart Rate, Blood Pressure, Respiratory Rate and Mental Status."

A review of the document titled "Policy: Routine Vital Signs revealed: All patients will have vital signs taken and monitored at intervals ....

Procedure: on the general floors ...routine vital signs consist of temperature, pulse, respiration, blood pressure and oxygen saturation .... Routine vital signs are taken and recorded at 8:00am, 16:00pm (4:00pm) and 12:00am (midnight)."

An interview with Staff #5 revealed, when asked, what is the abnormal vital sign criteria nursing aides follow and guides them when to report findings to the primary nurse. Staff #5 provided the document titled "Policy: Early Warning Scoring System" which stated VS every 4 hours. When asked what the frequency of routine vital signs was, Staff #5 provided a conflicting document titled "Policy: Routine Vital Signs" which indicated VS every 8 hours.

Nursing failed to follow either policy related to monitoring the patient's vital signs.

It was determined this deficient practice created an Immediate Jeopardy situation and placed patients at risk for the likelihood of harm, serious injury, and subsequent death. These deficient practices had the likelihood to affect all patients admitted to the facility.

Based on document review and interview, nursing failed to administer a medication as ordered by the Emergency Department physician to 1 of 1 (#1) patients. Staff #6 applied Nitro-Bid Ointment to the chest wall of patient #1. The medication was ordered to be placed to the right lower foot dorsal aspect.

A review of the Emergency Room document dated 07/15/2016, timed 16:32 (4:32pm) and titled "Order Sheet" revealed an order for Nitro Ointment 2%, 1 inch transdermal once; to right lower foot, dorsal aspect.

A review of the document dated 07/15/2016, timed 17:00 (5:00pm) and titled ED Nurse Documentation revealed Nitro-Bid Ointment 2%, 1 inch transdermal was applied to patient #1's anterior chest wall.

Staff #5 confirmed via phone conference on 08/18/2016 at approximately 2:30pm the application of the medication was an error and applied to the wrong area of the patient #1's body.

It was determined this deficient practice created an Immediate Jeopardy situation and placed patients at risk for the likelihood of harm, serious injury, and subsequent death. These failed practices had the likelihood to affect all patients admitted to the facility.