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Based on observation, interview and record review the facility failed to:

A. ensure cylinders of medical gas were securely stored. The facility failed to ensure all repairs were made to the medical air system as recommended by the service contractor. The facility also failed to have functional area alarms in Operating Rooms, Recovery Room, and Emergency room.

Refer to tag C0221 for additional information.

B. ensure there was written evidence of annual fire inspections for the past 2 years.

Refer to tag C0234 for additional information.

Based on observation and interview the facility failed to ensure cylinders of medical gas were securely stored. The facility failed to ensure all repairs were made to the medical air system as recommended by the service contractor.

This deficient practice had the likelihood to cause harm to all patients.

Findings include:

During an observation on 05/29/2014 after 9:00 a.m., four (4) cylinders of Nitrous Oxide gas were found stored in the medical gas storage room without being properly chained. Two (2) cylinders were chained loosely together and the other two (2) cylinders were not chained.

During an interview on 05/29/2014 after 9:00 a.m., Staff #4 and 13 confirmed the observations.

According to the NFPA 99 Chapter 5 the following was documented:

"5.1.3.2.10 When cylinder valve protection caps are supplied, they shall be secured tightly in place unless the cylinder is connected for use.


5.1.3.3.2 Design and Construction. Location for central supply systems and the storage of positive-pressure gasses shall meet the following requirements.


(7) They shall be provided with racks, chains, or other fastening to secure all cylinders from falling, whether connected, unconnected, full, or empty."


During an observation on 05/29/2014 after 9:00 a.m., the medical gas alarm in the recovery area was found not functioning.

Review of a "Leak and Observations Report" dated 08/20/2013 by a plant operations contracted service company revealed the following:

"Master alarms- Master panel at back dock entry still does not have a "Vacuum Abnormal" signal, nor monitors medical air at all. Emergency alarm panel still does not monitor medical air.

Recovery - Still no area alarm

O.R. s 1 & 2- Still no functioning area alarm

Emergency Department - Still no area alarm. The master alarm panel does not replace an area alarm.

Medical Air System- Air intake still not from outdoors, turned down, and screened.

Vacuum system- Pump exhaust still is not piped to outdoors.

Recovery Bed 1- Oxygen outlet leaks

Surgery 2- Vacuum hose drop connection leaks when disconnected and has low suction at 2.0 SCFM (minimum should be 3SCFM)."

Review of the "Leak and Observations Report" form revealed a place to document the work order number and the date it was corrected. There was no documentation of the work being completed.

During an interview on 05/27/2014 at 2:35 p.m., Staff #13 reported the company mentioned who provided the report was their contracted service who did the annual gas checks. Staff #13 confirmed some of the work had not been done because of financial reasons. He had no documentation showing if any of it was done. Staff # 13 reported the problems with the alarms and tanks should have been reported to quality assurance, but they were not.

Based on interview and record review the facility failed to ensure there was written evidence of annual fire inspections for the past 2 years.

This deficient practice had the likelihood to cause harm in all patients.

Findings include:

Review of a Fire Marshall Report dated 11/14/2012 revealed the fire extinguishers were serviced once a year. (Due January 2013). There was documentation on the report that the Commercial range hood extinguishment systems was to be inspected every six months (date: June 2012).

Review of forms revealed no documentation of a Fire Marshall Report for 2013 nor 2014.

During an interview on 05/27/2014 at 2:35 p.m., Staff #13 reported the Fire inspection for 2013 was missed and he would have to get documentation from the fire marshal for the 2014 inspection. Staff #13 provided a copy of an inspection report date 01/03/2014. The report did not have the fire marshal's signature on it. According to the report the kitchen hood (commercial range) needed to meet code and be tagged.

A work order dated 03/03/2014 ( 2 months later) indicated the commercial range was inspected.

The company who performed the inspection on the commercial range was on a list of facility contracted services who had a past due balance over 60 days owed to them.

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



A. ensure there was written evidence of annual fire inspections for the past 2 years 2013 and 2014.

Refer to tag C0234 for additional information.


B. ensure the quality assurance program was ongoing, monitored and identified problems with over 80 plus contracted services.

Refer to tag C0336 for additional information.


C. ensure an application for appointment and privileges was complete in 1 of 7 medical staff files reviewed (ED Physician #20).
Refer to tag C0241 for additional information.


D. ensure sufficient numbers of nursing staff on all units. They failed to ensure nursing staff were properly trained before being appointed the position of hospital nursing supervisor. They failed to ensure ongoing and accurate nursing assessments in the areas of pre-operative surgery procedures, respiratory complications, blood glucose monitoring, pain, nutrition, activities pursuit, bowel status assessments, anti-coagulant therapy, and allergies (Patient #s' 2, 10, 21, 22, and 23).

Refer to tag C0253, C0295 and C0297 for additional information.


E. ensure policies were reviewed annually by a group of professional personnel in the areas of Swing Bed, Surgical Services, Drug administration, Emergency Department, Organ and Tissue Donation, Medical Staff and Plants Operation.

Refer to tag C0280 for additional information.

Based on interview and record review the governing body failed to ensure an application for appointment and privileges was complete in 1 of 7 medical staff files reviewed (ED Physician #20).
This deficient practice had the likelihood to cause harm in all patients.

Findings include:

Review of the personnel file on ED Physician #20 revealed he initially requested and started application for appointment on 10/09/2013. The request for clinical privilege form was also completed by ED Physician #20. There was no documentation of an approving physician, medical executive committee or board of trustees signing the form to indicate the physician was qualified in all areas requested.

Review of references listed on the application revealed the names of physicians contacted, but there were no signatures to indicate the information provided came from the physician. Nor was there any e-mail correspondence provided to prove the physicians named provided the information about Physician #20.

During an interview on 05/29/2014 after 2:00 p.m., Staff #17 confirmed the missing information.

Review of the "Medical Staff Bylaws" dated 04/08/2013 revealed the following:

The application shall require detailed information concerning the applicant's professional qualifications; shall include the names of at least two(2) qualified persons who have had extensive experience in observing and working with the applicant, and who can provide adequate references pertaining to the applicant's professional competence and ethical character;

Applications for Staff appointment or reappointment must contain a request for the specific delineation of clinical privileges desired by the applicant, the applicant's relevant recent training and/or experience, and be submitted in writing on the prescribed form furnished by the hospital. Such requests will be processed in the same manner as applications for appointment or reappointment to the Medical Staff, as appropriate.

The delineation and approval of initial requests for clinical privileges shall be based upon the applicant's education, training, experience, references, specialty board qualifications, demonstrated current competence, ability and judgment and by the criteria as developed by respective departments of the Medical Staff, including an appraisal by the service in which privileges are requested. The applicant shall have the burden of establishing his/her qualifications and competence in the clinical privileges he requests.

Based on record review of guidelines and interviews, the facility failed to ensure appropriate training and education to provide appropriate nursing care.

This deficient practice had the likelihood to cause harm in all patients.

Findings include:

Review of the policy and procedure "Staffing Guidelines Intensive Care Unit" stated, "a ratio of one licensed person to two or three patients will be maintained unless patients meet the criteria for more intense staffing per patient. The house supervisor will assist as needed."

Review of the "House Supervisor Duties" guidelines revealed the house supervisor was responsible for the following;

1.) "House supervisors and cardiopulmonary will report to all RRT calls.

2.) The house supervisor will carry the pager on Friday, Saturday, and Sunday.

3.) Round at the start of the shift and every two hours.

4.) Evaluate and call any department on call staff.

5.) Assist and arrange for patient transfers.

6.) Respond to all code blues.

7.) Attend all deaths and may pronounce the patient if ordered. Call the JP, call the funeral home, and call Southwest Transplant.

8.) Retrieve old charts from medical records

9.) Provide dietary trays after hours.

10.) Staffing and employee call-ins.

11.) Make sure the facility was locked up after 9:00 PM."

Review of the Daily Staffing Schedules from 4/1/2014- 5/22/2014 revealed the following;

1. There was no documented house supervisor from 7:00 AM to 7:00 PM in 13 out of 52 shifts.

2. There was no documented house supervisor from 7:00 PM to 7:00 AM in 38 out of 52 shifts.

3. There was no documentation of anticipated admissions, discharges or transfers to a unit in 104 out of 104 shifts.

4. There was no documented coverage of non- licensed personnel in 19 out of 104 shifts.

Interview with staff #4 and #12 on 5/29/14 revealed the facility did not have a designated house supervisor. Staff #4 reported the managers are the house supervisors on the day shift and one of the Emergency Room (ER) nurses was the house supervisor on weekends and nights. Staff #4 stated, "All the nurses that serve as house supervisors have had training."

Review of the nursing schedule revealed the ER only has two nurses per shift. If the house supervisor follows "the house supervisor guidelines" the ER will be left with only one RN at any time. Staff #4 reported the ER was not that busy at night and he didn't see any problems with leaving one nurse in the ER alone.

Interview with staff #26 and 27 revealed they have both worked as house supervisors. Staff #27 reported she has not had any official training. Staff #27 stated, "We were just given the pager and the house supervisor notebook. We were never oriented." Staff #26 also confirmed he was never given orientation for house supervision. Staff #26 and 27 reported they have to leave the ER unit multiple times per shift and leave only one nurse in the ER department.

Review of the "House Supervision Orientation Meeting Attendance Record" revealed no documentation of orientation for staff #26 or 27.

Based on observation, interview and record review the facility failed to:

A. ensure a sanitary environment for 2 of 2 departments toured (Emergency Department and surgery).

Refer to tag C0278 for additional information.


B. ensure the kitchen was properly cleaned, patients had a prescribed diet, regular review of diets, updated diets, and to ensure the patient had a diet ordered before serving in 5 (#6, 11, 12, 13, and 27) of 5 (#6, 11, 12, 13, and 27) charts reviewed. The facility failed to include the Dietary department in the Quality Assessment Performance Improvement Process (QAPI).
Refer to tag C0279 for additional information.


C. ensure to ensure policies were reviewed annually in the areas of Swing Bed, Surgical Services, Drug administration, Emergency Department, Organ and Tissue Donation, Medical Staff and Plants Operation.
Refer to tag C0280 for additional information.


D. ensure appropriate training and education to provide appropriate nursing care.
Refer to tag C0294 for additional information.



E. ensure on-going assessments and timely interventions in 5 of 5 patients (Patient #s' 2, 10, 21, 22, and 23).

Refer to tag C0295 for additional information.


F. obtain and follow physician orders in the administration of medications for 4 (#2, 9, 11, and 12) of 5 (#2, 9, 11, 12, and 13) charts reviewed. The facility failed to follow their own policy/procedures for administering blood transfusions in a safe manner on 3 (#4, 11, and 13) of 4 (#4, 11, 12, and 13) blood administration charts reviewed.

Refer to tag C0297 for additional information.


G. ensure the facility failed to have current and ongoing care plans for 6 of 6 patient charts (#4, 5, 6, 11, 12, and 13).
Refer to tag C0298 for additional information.



H. ensure physician orders were followed and a written plan of treatment was documented in the patient chart on 2 (#11 and 12) out of 4 (#4, 9, 11, and 12) charts reviewed.


Refer to tag C0299 for additional information.

Based on observation and interview the facility failed to insure a sanitary environment for 2 of 2 departments toured (Emergency Department and surgery).

This deficient practice had the likelihood to cause harm in all patients.
Findings include:

On 5/27/2014 at 9:00 AM in the pre-operative holding bay, pt #2 indicated she had arrived to the surgery area around 8:30 and was placed in a bed. Pt #2 indicated she pre-registered earlier in the week and came straight from home. She and her daughter walked in to the surgery department unescorted.

On 5/27/2014 at 1:30 PM in the conference room an interview with staff #4 confirmed that patients often pre-registered and simply walked into the hospital straight to the surgery department. Staff #4 further indicated an RN in the surgery department would take them to a room and make them comfortable. Staff #4 was questioned regarding the process in place to insure a person who walked in from the community would stop walking through the surgical department when they came to the red line (indicates sterile zone) if they were looking for staff? Staff #4 confirmed there was no process in place.


On 5/27/2014 at 2:30 PM, during a tour of the Emergency Department (ED), areas of damage to the sheet rock walls were observed in each of the three ED patient bays. Paint was missing and the sheet rock was observed with deep tears to the surface making it unable to be sanitized between patient care. Paint was also observed missing from the corners of the nurses station desk and doorway also making it unlikely to be sanitized. Interview with staff #37 confirmed it was hard to keep the area free form scrapes and keep the paint intact.


The facility could not insure a sanitary environment in the ED with visible torn and damaged sheet rock and missing paint from walls and corners. The facility also could not insure the sterility in the surgical department without a process in place to stop patients from walking into the sterile area.

Based on observation, review of policy and procedures, interviews, and patient chart reviews, the dietician failed to monitor the dietary director to ensure the kitchen was properly cleaned, patients had a prescribed diet, regular review of diets, updated diets, and to ensure the patient had a diet ordered before serving in 5 (#6, 11, 12, 13, and 27) of 5 (#6, 11, 12, 13, and 27) charts reviewed. Based on interviews, the facility failed to include the Dietary department in the Quality Assessment Performance Improvement Process (QAPI).

Review of policy and procedure "Cleaning Procedure: Garbage Container, Dry Storage, Bins, and Boxes" stated, "Garbage containers: Each time the container is emptied scrub inside and outside surfaces using a long handled brush and detergent solution or any acceptable cleaning agent. Rinse, sanitize, drain dry."

Review of policy and procedure "Cleaning Procedures for Walk-in Refrigerators and Freezers" stated, "All equipment must be properly cleaned to ensure safe, sanitary food production. Procedure: Pick up scraps and particles and damp mop the floor. Do not damp mop the freezer. ONCE A WEEK ( freezers once a month)."

Review of the daily cleaning schedule stated, "refrigerator wipe down/pull outdated items." There was no schedule for the freezer.

During a tour of the kitchen on 5/29/14 the following issues were found;

1.) Shipping boxes were found in the walk in cooler. Cardboard shipping boxes may contain bacteria, rodents, or insects.

2.) Inside the walk-in refrigerator. wire carts were found to be caked with a dirty, greasy substance. Dried food particles were found on the floor around and under it. The bottom wire racks had no barriers to protect the food from floor particles and mop water. Exposed food to unclean conditions allows for potential food borne illnesses.

3.) The freezer was accessed through the cooler. The freezer was found to have a heavy ice build-up on the door and outside wall of the freezer. The freezer was unable to be cleaned properly due to ice buildup allowing for a potential food borne illness.

4.) One out of four muffin pans had a carbon greasy build up preventing the muffin pan from being properly cleaned allowing for a possible food borne illness.

5.) 2 plastic measuring cups had a white substance buildup on the inside of the cup. The measuring cups were not properly cleaned allowing for a possible food borne illness.

6.) Rolling food preparation table had a greasy dirty build up on the wheels and the floor below. Food exposed to unsanitary conditions can possibly cause food borne illnesses.

7.) The trash can next to the food preparation area was being taken out of the kitchen and through the hospital to empty. The trash can was wheeled back to the clean kitchen. The trash can exposed to the patient care areas and back to the kitchen allows for possible food contamination from viral and bacterial exposure.

8.) 15 condiment containers were placed back into the cooler for later use. The containers had no date of preparation written on them. Food items with no dates can expire and cause a possible food borne illness.

9.) The refrigerator handles on the doors were caked in grease and food particles. Touching the unclean handles repeatedly allows for possible food borne illnesses.

10.) The sides of the stove were rusted with paint missing. The outside of the stove was unable to be cleaned properly due to the rust and missing paint.

11.) The gas pipes along the side of the stove were caked in grease, dust, and hair. Unclean areas close to the food preparation area can possibly lead to a food borne illness.

12.) The oven handles were found to have greasy substance, dried food particles, dust and hair on the inside and outside of the handles.

13.) The Large ice machine had hard water stains and rust on the front. The small ice bin in the serving line had no cleaning schedule. There was no log for the cleaning of the ice bins. Staff #5 could not state when the ice bin was last cleaned. Unclean ice can lead to water borne illnesses.

Staff #5 confirmed the above findings and reported that the freezer icing over had been an issue for some time. Staff #5 reported the maintinence department was aware of the problem.

Review of policy and procedure "Diet Order Clarification" policy stated, "The following list will be used for Diet Order Clarification. Each patient will receive the appropriate diet and this diet should be consistent with the patient's medical condition and standards as outlined in the approved diet manual.

To provide consistent, accurate diets to the patient.

Procedure

Director of Dietary, Food Service Supervisor will ensure that, the following guide will be used when diets are ordered which need clarification:

Diet Ordered Diet Sent

Diet as tolerated Regular

Liquid Diet Clear Liquid

Unspecified sodium restriction 2 gm sodium

No concentrated sweets Calorie controlled with slugger substitute

Cardiac or Artherogenic Low fat & cholesterol, 2 gm sodium"

Review of patient #11, 12, 13, and 27 charts revealed meals were served with no physician orders.

Review of patient # 6's chart revealed the patient had a physician order for a pureed diet with thickened liquids. The patient was a diabetic. Patient #6's chart had no documentation that the patient was assessed by the dietician or that his diabetes was considered in his pureed diet.

Interview with staff #4 on 5/29/14 at 3:00 PM revealed the electronic charting the facility is currently using has been very difficult to navigate. Staff #4 stated, "We are trying to correct the computer system when we find errors or missing pieces as we find them." Staff #4 reported no surprise when errors are found but they will try to rectify them as soon as possible.

Interview with staff #5 on 5/28/14 revealed the dietary director has not been involved in the QAPI process. Staff #5 stated, "they have the meetings at lunch time and I don't have the chance to attend." Staff #5 reported she did not know how to put a problem into a performance improvement action. Staff #8 confirmed staff #5 had not been involved in the QAPI process.

Based on interview and record review the facility failed to ensure policies were reviewed annually by a group of professional personnel.

This deficient practice had the likelihood to cause harm in all patients.

Findings include:

Review of policies in the areas of Swing Bed, Surgical Services, Drug administration, Emergency Department, Organ and Tissue Donation, Medical Staff and Plants Operation revealed the last review was over a year old dating back to April 2013 and older.

During an interview on 05/28/2014 after 9:00 a.m., Staff #8 reported their policies were reviewed and updated every other year instead of annually.

Based on record review of guidelines and interviews, the facility failed to ensure appropriate training and education to provide appropriate nursing care.

This deficient practice had the likelihood to cause harm in all patients.

Findings include:

Review of the policy and procedure "Staffing Guidelines Intensive Care Unit" stated, "a ratio of one licensed person to two or three patients will be maintained unless patients meet the criteria for more intense staffing per patient. The house supervisor will assist as needed."

Review of the "House Supervisor Duties" guidelines revealed the house supervisor was responsible for the following;

1.) "House supervisors and cardiopulmonary will report to all RRT calls.

2.) The house supervisor will carry the pager on Friday, Saturday, and Sunday.

3.) Round at the start of the shift and every two hours.

4.) Evaluate and call any department on call staff.

5.) Assist and arrange for patient transfers.

6.) Respond to all code blues.

7.) Attend all deaths and may pronounce the patient if ordered. Call the JP, call the funeral home, and call Southwest Transplant.

8.) Retrieve old charts from medical records

9.) Provide dietary trays after hours.

10.) Staffing and employee call-ins.

11.) Make sure the facility was locked up after 9:00 PM."

Review of the Daily Staffing Schedules from 4/1/2014- 5/22/2014 revealed the following;

1. There was no documented house supervisor from 7:00 AM to 7:00 PM in 13 out of 52 shifts.

2. There was no documented house supervisor from 7:00 PM to 7:00 AM in 38 out of 52 shifts.

3. There was no documentation of anticipated admissions, discharges or transfers to a unit in 104 out of 104 shifts.

4. There was no documented coverage of non- licensed personnel in 19 out of 104 shifts.

Interview with staff #4 and #12 on 5/29/14 revealed the facility did not have a designated house supervisor. Staff #4 reported the managers are the house supervisors on the day shift and one of the Emergency Room (ER) nurses was the house supervisor on weekends and nights. Staff #4 stated, "All the nurses that serve as house supervisors have had training."

Review of the nursing schedule revealed the ER only has two nurses per shift. If the house supervisor follows "the house supervisor guidelines" the ER will be left with only one RN at any time. Staff #4 reported the ER was not that busy at night and he didn't see any problems with leaving one nurse in the ER alone.

Interview with staff #26 and 27 revealed they have both worked as house supervisors. Staff #27 reported she has not had any official training. Staff #27 stated, "We were just given the pager and the house supervisor notebook. We were never oriented." Staff #26 also confirmed he was never given orientation for house supervision. Staff #26 and 27 reported they have to leave the ER unit multiple times per shift and leave only one nurse in the ER department.

Review of the "House Supervision Orientation Meeting Attendance Record" revealed no documentation of orientation for staff #26 or 27.

Based on observation, interview and record review the facility failed to provide on-going assessments and timely interventions in 5 of 5 patients (Patient #s' 2, 10, 21, 22, and 23).

This deficient practice had the likelihood to cause harm in all patients.

Findings include:


On 5/27/2014 at 9:00 AM pt #2 was observed in a pre-operative holding bed awaiting a colonoscopy. Pt #2 was wearing a hospital gown and the RN had already completed her initial patient assessment. After two failed attempts to insert the IV, the RN told pt #2 she could not get the IV in and would send the CRNA to insert her IV.

After the RN left the room pt #2 was interviewed as to what time she arrived in the pre-operative holding room. Pt #2 indicated about 8:30 AM that morning. Pt #2 was asked if she had an ID band on and she raised both arms up for viewing and said "NO". At nearly 11:00 AM the CRNA entered pt #2's room and placed the IV into her right wrist. At no time did the CRNA ask pt #2 her name or verify her identity. Once the IV was started the consent was obtained by the CRNA and the RN placed the ID band, the allergy band and the falls risk band on pt #2. Pt #2 had been in the pre-operative holding area, in a patient bed, under the care of the facility for 2.5 hours without a patient identification arm band in place.

On 5/27/2014 in the conference room the Nursing Service policy for patient admission and identification was reviewed and revealed the following: Policy- All patients will be required to wear hospital identification, allergy, blood, fall and DNR bands at all times during their stay as appropriate to their care.

Procedure:
1. The admitting nurse is responsible for banding the patient with a white ID band when admitted to the unit.

3. All hospital personnel providing care of the patient will check the identification band prior to performance of the treatment or procedure.




10135

Review of the Swing bed physician orders dated 05/15/2014 revealed Patient #23 was a 75 year old female with a diagnosis of status post hip fracture /syncope (fainting). Review of an admission summary sheet revealed Patient #23 was admitted into a Swing bed on 05/16/2014.

Review of the initial assessment dated 05/16/2014 revealed the nutrition section was incomplete. The section of the assessment to indicate if the patient had unexplained weight loss was left blank. A referral for dietary was not selected, although the physician order dated 05/15/2014 requested a nutritional screening.

There was no assessment of activities pursuit on Patient #23.

According to the assessment the patient had a history of constipation and the prompt to determine the number of stools in the last 24 hours was left blank.

The assessment indicated the patient had a pain scale level of 8 (0 being the lowest and 10 the highest) in the right hip. The sections for facial expression, legs, activity, crying, and consolability were left blank.

Review of the physician orders revealed Patient #23 being allergic to contrast dye, sulfa drugs, and codeine. Review of the physician's history and physical dated 05/17/2014 revealed patient #23 had no known drug allergies.

During an interview on 05/28/2014 after 9:00 a.m., Staff #8 confirmed the entries and assessment problems.


Review of an "Admission Summary Sheet" revealed Patient #21 was a 65 year old female admitted on 05/18/2014 with diagnoses of intractable back pain, sacral contusion and fall.

Review of a history and physical dated 05/20/2014 the patient had a bilateral femoral popliteal bypass one week ago.

Review of MARs revealed Patient #21 was on the pain medication Morphine 2 milligrams , IV push as needed every 2 hours.

Review of nursing documentation and MARs from 05/18-19/2014 revealed the Patient #21 was medicated for pain during this timeframe. There was no consistent assessment of the quality of pain nor follow-up after administration of the medication.

Review of "Adult Deep Vein Thrombosis " nursing assessment dated 05/19/20/2014 revealed Patient #21 was at moderate risk for developing blood clots. Review of the "Adult Deep Vein Thrombosis (DVT) Assessment and Prophylaxis" revealed it had not been completed by the physician. The interventions for a patient who was assessed as moderate risk was: Lovenox 40 milligrams Sub Q daily and intermittent pneumatic compression devices or graduated compression stockings. The physician had not signed the protocol to order any interventions.

Review or MARs on Patient #21 revealed she was on the anti-coagulant Lovenox 40 milligrams subcutaneous daily starting on 05/19/2014. There was no documentation that any of the other interventions outside of the medication was initiated.

Review of physician orders dated 05/24/2014 revealed Patient #21 was admitted to Swing bed status. The orders were not signed off by the physician. Written on the orders were instructions to see the electronic MAR and to continue medications per medication reconciliation. The medications were not written out on the physician orders and signed off by the physician.


Review of an admission summary sheet revealed Patient #22 was a 63 year old male who presented to the ED on 05/26/2014 at 8:39 a.m, for ETOH (alcohol) intoxication. The patient's oxygen saturation was 93 and 94 percent on room air in the ED.

Review of a physician history and physical that was dictated on 05/26/2014 at 12:17 p.m., revealed the nurses would be checking for respiratory suppression since Patient #22's alcohol level was so high and they had added Librium (anti-anxiety/sedative agent).

Review of nurses notes dated 05/26/2014 at 12:50 p.m. revealed a dose of Librium 25 milligrams was administered to Patient #22. Over 12 hours later nursing documentation on Patient #22's respiratory status was found on 05/27/2014 at 1:54 a.m. There was documentation of the patient having diminished (breath sounds) in the right and left lower lobes.

Review of nurses notes dated 05/27/014 at 1:59 p.m. (over 12 hours later) revealed Patient #22 was discharged from the hospital. There was no documentation of continued assessment of the patient's respiratory status during the 12 hour time frame prior to discharge.

During an interview on 05/30/2014 after 9:00 a.m., Staff #16 confirmed the lack of documentation of an assessment.

Review of ED notes revealed Patient #10 was a 56 year old male who presented on 05/27/2014 at 8:31 a.m. with a chief complaint of respiratory problems. Review of the ED notes revealed Patient #10 had a diagnosis of Diabetes Type II and was on an oral diabetic agent daily at home.

Review of a complete metabolic profile dated 05/27/2014 and completed at 9:23 a.m. revealed Patient #10 had an elevated blood glucose level of 265 (reference ranges being 74-106).

Review of physician orders dated 05/27/2014 at 10:00 a.m. revealed the following orders:

Accuchecks QID ( four times a day) AC (before meals) and HS ( at bedtime)

Standard sliding scale of Regular insulin

The sliding scale order did not include how much insulin to administer and what type of sliding scale to use. There were no parameters for low and high blood glucose levels.

Review of a computerized order with a start date of 05/28/2014 (the next day) revealed the following sliding scale order:

60-150=0 units
151-200=2 units
201-250=4 units
251-300=6 units
301-350=8 units
351-400=10 units
401-999=12 unit
<60 give ½ amp D50 and notify the MD
>400 give 12 units and notify the MD

Review of the record revealed documentation of a total 5 accuchecks being taken and they were at an elevated range from 214-427. There was no documentation of the amount of sliding scale insulin administered to the patient in the record.

During an interview on 05/30/2014 after 9:00 a.m., Staff #16 confirmed the problems with the physician and the lack of documentation of a consistent assessment of Patient #10's blood sugars.


Review of a policy named "Scope of Service" dated 11/2011 revealed the following:

Patient care needs for nursing care are assessed and reassessed by Registered nurses. The RN is responsible for coordinating the patients' plan of care while facilitating assurance of physician orders were followed and a written plan of treatment was documented in the patient chart.

Based on review of policy/procedures, interviews, and patient chart review, nursing failed to obtain and follow physician orders in the administration of medications for 4 (#2, 9, 11, and 12) of 5 (#2, 9, 11, 12, and 13) charts reviewed. The facility failed to follow their own policy/procedures for administering blood transfusions in a safe manner on 3 (#4, 11, and 13) of 4 (#4, 11, 12, and 13) blood administration charts reviewed.

Failure to safely administer blood and blood products created the likelihood of harm to all patients receiving blood products.

Findings include:

Review of policy and procedure "Blood Administration" states the following;

1.) Physician must write the order for the blood transfusion.

3.) Explain the procedure to the patient and make sure that informed consent is obtained."

Review of patient #4's chart revealed a three physician orders on 5/23/14 at 8:29AM. The orders read as follows;

1.) "Type and screen.

2.) Crossmatch 1 (Crossmatch 1st unit).

3.) Crossmatch 2nd (Crossmatch 2nd unit.)"

Review of patient #4's chart revealed two blood administration records dated 5/23/14. Patient #4 was administered 1 unit of PRBC at 3:10PM and completed at 6:00PM. The second unit of PRBC was administered at 6:15PM and completed at 9:30PM. There were no orders found to transfuse the blood, what component of the blood to administer, or duration.

Review of patient #11's chart revealed two blood administration records. The first blood administration record revealed a unit of fresh frozen plasma (FFP) was administered on 4/25/14 at 6:10PM and completed at 6:25PM. The second unit of FFP was administered at 6:25PM and completed at 6:50PM. There were no orders found to transfuse the blood, what component of the blood to administer, or duration. No consent was found to administer blood.

Review of patient #13's chart revealed two blood administration records. The first blood administration record revealed a unit of fresh frozen plasma (FFP) was administered on 5/16/14 at 1:55AM and completed at 2:15AM. The second blood administration record revealed a unit of fresh frozen plasma (FFP) was administered on 3:35AM and completed at 3:55AM. There were no orders found to transfuse the blood, what component of the blood to administer, or duration.

An interview with staff #12 and #8 on 5/29/14 at 1:50PM reported the computer software currently used does not have an appropriate choice for a blood administration order. Staff #12 stated,"The orders you can choose from just say type and cross match. The orders do not say to transfuse." Staff #12 reported the physicians that use the computer to order the blood have incomplete orders. The physicians that choose to hand write their orders have complete orders. Staff #8 stated,"The computer generated orders are wrong and we will fix the orders where they say transfuse and give a choice for duration."

Review of patient #11's chart revealed medications administered on the patient MAR with no physician orders. Medications given without an order are as follows;

1.) Fleet oil enema 1 bottle administered on 4/26/14 at 4:00AM.

2.) Humulin R (insulin) 100 units administered on 4/28/14 at 6:08PM.

3.) Levoquin IV (antibiotic) 750mg administered on 4/28/14 at 8:50AM

4.) Albuterol 3ml (bronchodilator) administered on 4/26/14 at 2:56PM.

Review of patient #13's chart revealed medication administered on the patient MAR with no signed or noted physician orders. Medications given are as follows;


1.) Protonix 40mg (Proton-pump inhibitor) administered on 5/16/14 at 8:13AM.

Review of patient #12's chart revealed medications administered on the patient MAR with no signed or noted physician orders. Medication given are as follows;

1.) Mylicon chew tablets (anti-gas) 80mg administered on 5/4/14 at 9:23PM.

2.) Cardizem CD 120mg (Calcium channel blocker) administered 5/4/14 at 9:45AM.

3.) Zyloprim 100mg (Xanthine oxidase inhibitor for gout) administered on 5/7/2014 at 9:21AM.

4.) Xanax .5mg ( Benzodiazepine) administered 5/6/14 at 8:58PM.

5.) Celexa 20mg (Selective serotonin reuptake inhibitor) administered 5/7/14 at 9:21AM.

6.) Neurontin 300mg (Analgesic) administered on 5/7/2014 at 5:07AM.

7.) Lopressor 25mg (betai-adrenoreceptor blocking agent) administered 5/6/14 at 8:59PM.

8.) Cardizem CD (Calcium channel blocker) 120mg administered 5/3/14 at 6:44AM.

Review of patient #9's chart revealed medications administered on the patient MAR with no signed or noted physician orders. Medications given are as follows;

1.) Celexa 20 mg (Selective serotonin reuptake inhibitor) administered on 5/27/14 at 9:32AM

2.) Plavix 75mg (P2Y12 Platelet Inhibitor) administered 5/27/14 at 9:32AM

3.) Synthroid 75mg (Hypothyroidism) administered 5/27/14 at 9:31AM.

4.) Namenda 5mg (NMDA receptor antagonist) 5/27/14 at 9:32AM.

5.) Lopressor 25mg (betai-adrenoreceptor blocking agent) administered at 5/27/14 at 9:32AM.

6.) Protonix 40mg (Proton-pump inhibitor) administered 5/27/14 at 9:32AM.

7.) Rocephin 1gm IV (antibiotic) administered on 5/27/14 at 9:32AM



28659



On 5/27/2014 in the pre-operative holding area at 9:30 AM, the Gastroenterologist interviewed pt #2 prior to her scheduled colonoscopy. During the review of pt #2 laboratory results physician #21 noticed her potassium was low and told the RN to give 20 MEQ of potassium in pt #2's IV. Review of pt #2 MR revealed the physician had written the order for 20 MEQ of potassium to run at 75 cc hour in the IV. Interview with pt #2 revealed she arrived around 8:30 that morning to the pre-operative holding room. Observation of pt #2 revealed she did not have her IV at the time of the order.

The physician #21 returned at 10:00 AM and checked on the progress of the IV and asked the RN why the potassium had not been started. The RN explained the IV was difficult to start and the CRNA was going to put it in.

At 10:30 the physician #21 returned a second time to inquire about the potassium after it was noticed pt #2 still had no IV. Again he was told the CRNA had to put the IV in.

At nearly 11:00 AM the CRNA placed the IV in pt #2 right wrist. The physician #21 again entered the room asking about the Potassium. The CRNA told the physician #21 he knew nothing about potassium, but he would give it during the procedure.

At 11:00 Am review of the MR for pt #2 revealed the physician's order for potassium had not been signed off by a RN and no RN had taken responsibility for the order. The drug order did not get faxed to the pharmacy. A phone call was placed to the pharmacy for the potassium and it was delivered by hand and given by the CRNA during the procedure shortly after 11:00 AM.

At 2:00 PM in the Pharmacy, an interview with staff #7 confirmed the physician's order for potassium had not been faxed to the pharmacy as is the usual method orders reach the pharmacy. Staff #7 further confirmed a phone call was received for the potassium and it was walked to the surgery area for immediate usage.

At 3:00 PM in the conference room the policy for Drugs Administration: General, page #2 b. Doses are considered "on time" if administered within one-half hour before or one-half hour after scheduled time. Physician #21 ordered Pt #2's potassium at 9:30 AM. The RN failed to order the drug until 11:00 AM. It was given during the procedure that started after 11:00 AM.

Based on record reviews, and interviews the facility failed to have current and ongoing care plans for 6 (#4, 5, 6, 11, 12, and 13) out of 6 (#4, 5, 6, 11, 12, and 13) patient charts.

Review of patient charts #4, 5, 6, 11, 12,and 13 had no documented care plan. Patient #9 's care plan was incomplete. There are no short or long term goals. The care plan was not kept current with ongoing assessments, discharge planning, or patient responses to interventions.

An interview with staff #4 on 5/29/14 reported the care plans have not been kept up to date. Staff #4 stated, "I know we are having problems with care plans. I'm trying to find someone to come in and do some training on documentation."

Based on chart reviews the facility failed to ensure physician orders were followed and a written plan of treatment was documented in the patient chart on 2 (#11 and 12) out of 4 (#4, 9, 11, and 12) charts reviewed.

Review of patient #11's chart revealed a physician order on 4/26/14 at 11:00 AM. The order stated, "PT/OT eval and treat as needed." In the abnormal assessment section a note under assessment stated, "physical therapy evaluation." A full Physical Therapy (PT) assessment was not found. There was no Occupational Therapy (OT) assessment found.

Review of patient #12's chart revealed a physician order on 5/26/14 at 1:35 PM. The order stated, "PT/OT to evaluate." No PT or OT assessment found.

Based on observation, interview and record review the facility failed to:


A. ensure there were complete physician orders for administration of medications for 4 (#2, 9, 11, and 12) of 5 (#2, 9, 11, 12, and 13) charts reviewed. The facility failed to ensure there were complete physician orders for blood administration in 3 (#4, 11, and 13) of 4 (#4, 11, 12, and 13) blood administration charts reviewed.

Review of patient #4's chart revealed a three physician orders on 5/23/14 at 8:29AM. The orders read as follows:

1.) "Type and screen.

2.) Crossmatch 1 (Crossmatch 1st unit).

3.) Crossmatch 2nd (Crossmatch 2nd unit.)"

Review of patient #4's chart revealed two blood administration records dated 5/23/14. Patient #4 was administered 1 unit of PRBC at 3:10PM and completed at 6:00PM. The second unit of PRBC was administered at 6:15PM and completed at 9:30PM. There were no orders found to transfuse the blood, what component of the blood to administer, or duration.

Review of patient #11's chart revealed two blood administration records. The first blood administration record revealed a unit of fresh frozen plasma (FFP) was administered on 4/25/14 at 6:10PM and completed at 6:25PM. The second unit of FFP was administered at 6:25PM and completed at 6:50PM. There were no orders found to transfuse the blood, what component of the blood to administer, or duration. No consent was found to administer blood.

Review of patient #13's chart revealed two blood administration records. The first blood administration record revealed a unit of fresh frozen plasma (FFP) was administered on 5/16/14 at 1:55AM and completed at 2:15AM. The second blood administration record revealed a unit of fresh frozen plasma (FFP) was administered on 3:35AM and completed at 3:55AM. There were no orders found to transfuse the blood, what component of the blood to administer, or duration.

An interview with staff #12 and #8 on 5/29/14 at 1:50PM reported the computer software currently used does not have an appropriate choice for a blood administration order. Staff #12 stated,"The orders you can choose from just say type and cross match. The orders do not say to transfuse." Staff #12 reported the physicians that use the computer to order the blood have incomplete orders. The physicians that choose to hand write their orders have complete orders. Staff #8 stated,"The computer generated orders are wrong and we will fix the orders where they say transfuse and give a choice for duration."

Review of policy and procedure "Blood Administration" states the following;

1.) Physician must write the order for the blood transfusion.

3.) Explain the procedure to the patient and make sure that informed consent is obtained."


Review of patient #11's chart revealed medications administered on the patient MAR with no physician orders. Medications given without an order are as follows;

1.) Fleet oil enema 1 bottle administered on 4/26/14 at 4:00AM.

2.) Humulin R (insulin) 100 units administered on 4/28/14 at 6:08PM.

3.) Levoquin IV (antibiotic) 750mg administered on 4/28/14 at 8:50AM

4.) Albuterol 3ml (bronchodilator) administered on 4/26/14 at 2:56PM.

Review of patient #13's chart revealed medication administered on the patient MAR with no signed or noted physician orders. Medications given are as follows;


1.) Protonix 40mg (Proton-pump inhibitor) administered on 5/16/14 at 8:13AM.

Review of patient #12's chart revealed medications administered on the patient MAR with no signed or noted physician orders. Medication given are as follows;

1.) Mylicon chew tablets (anti-gas) 80mg administered on 5/4/14 at 9:23PM.

2.) Cardizem CD 120mg (Calcium channel blocker) administered 5/4/14 at 9:45AM.

3.) Zyloprim 100mg (Xanthine oxidase inhibitor for gout) administered on 5/7/2014 at 9:21AM.

4.) Xanax .5mg ( Benzodiazepine) administered 5/6/14 at 8:58PM.

5.) Celexa 20mg (Selective serotonin reuptake inhibitor) administered 5/7/14 at 9:21AM.

6.) Neurontin 300mg (Analgesic) administered on 5/7/2014 at 5:07AM.

7.) Lopressor 25mg (betai-adrenoreceptor blocking agent) administered 5/6/14 at 8:59PM.

8.) Cardizem CD (Calcium channel blocker) 120mg administered 5/3/14 at 6:44AM.

Review of patient #9's chart revealed medications administered on the patient MAR with no signed or noted physician orders. Medications given are as follows;

1.) Celexa 20 mg (Selective serotonin reuptake inhibitor) administered on 5/27/14 at 9:32AM

2.) Plavix 75mg (P2Y12 Platelet Inhibitor) administered 5/27/14 at 9:32AM

3.) Synthroid 75mg (Hypothyroidism) administered 5/27/14 at 9:31AM.

4.) Namenda 5mg (NMDA receptor antagonist) 5/27/14 at 9:32AM.

5.) Lopressor 25mg (betai-adrenoreceptor blocking agent) administered at 5/27/14 at 9:32AM.

6.) Protonix 40mg (Proton-pump inhibitor) administered 5/27/14 at 9:32AM.

7.) Rocephin 1gm IV (antibiotic) administered on 5/27/14 at 9:32AM



B. ensure patients had documented diet orders in 5 (#6, 11, 12, 13, and 27) of 5 (#6, 11, 12, 13, and 27) charts reviewed.

Review of patient #11, 12, 13, and 27 charts revealed meals were served with no physician orders.

Review of patient # 6's chart revealed the patient had a physician order for a pureed diet with thickened liquids. The patient was a diabetic. Patient #6's chart had no documentation that the patient was assessed by the dietician or that his diabetes was considered in his pureed diet.

Interview with staff #4 on 5/29/14 at 3:00 PM revealed the electronic charting the facility is currently using has been very difficult to navigate. Staff #4 stated, "We are trying to correct the computer system when we find errors or missing pieces as we find them." Staff #4 reported no surprise when errors are found but they will try to rectify them as soon as possible.

Review of policy and procedure "Diet Order Clarification" policy stated, "The following list will be used for Diet Order Clarification. Each patient will receive the appropriate diet and this diet should be consistent with the patient's medical condition and standards as outlined in the approved diet manual.

To provide consistent, accurate diets to the patient.

Procedure

Director of Dietary, Food Service Supervisor will ensure that, the following guide will be used when diets are ordered which need clarification:
Diet Ordered Diet Sent
Diet as tolerated Regular
Liquid Diet Clear Liquid
Unspecified sodium restriction 2 gm sodium
No concentrated sweets Calorie controlled with slugger substitute
Cardiac or Artherogenic Low fat & cholesterol, 2 gm sodium"



28659

C. ensure pre-operative, post -operative physician orders and discharge instructions were dated, timed, signed and complete in 1 of 1 patients (Patient #2).

On 5/27/2014 at 9:30 Am in the three bay pre-operative holding room, physician #21 was observed signing his name and dating a single paged document containing both post-operative orders and discharge instructions. Physician #21 failed to include a signature,date aand time for the post-operative orders and failed to fill the blanks in on the post-operative portion indicating what medications were to be given, at what dosage and route. No line was available for the physician to sign, date and time orders for the post-operative period. When the physician signed and dated (physician failed to time the order) the discharge orders on the only signature line, he allowed the post-operative orders, which were printed above the discharge orders, to potentially be completed by anyone.

On 5/27/2014 at 2:00 and interview with staff #8 indicated when the physician left the preprinted order set blank it meant he didn't want any medications given. When asked if a policy existed to explain that she replied "no". It was explained that post-operative orders and discharge orders are two separate types of orders. One signature activates all orders on the page.

On 5/27/2014 at 3:30 the MR policy titled Hospital Wide effective date 2/2003: item F. All entries in the medical record show author, date and authentication of all entries ...

On 5/27/2014 at 4:00 PM in the conference room the Medical Staff Rules and Regulations were reviewed and the following was identified: found under A. VIII Physician's Orders: All orders should be recorded on the patient's clinical chart, timed, dated and signed by the staff member in charge of the case. B. Standing orders shall be formulated by the medical staff. They can be changed only by consent...These orders shall be followed when specific orders are not written by the physician and shall be authenticated by the physician.



10135

D. ensure admission assessment, history and physicals, pain assessments and respiratory assessments were complete and accurate. They failed to ensure deep vein thrombosis protocols and sliding scale insulin orders/protocols were complete and signed by a physician before administration of medications. This deficient practice was found in 4 of 4 patient charts (Patient #s' 10, 21, 22, and 23).

Review of the Swing bed physician orders dated 05/15/2014 revealed Patient #23 was a 75 year old female with a diagnosis of status post hip fracture /syncope (fainting). Review of an admission summary sheet revealed Patient #23 was admitted into a Swing bed on 05/16/2014.

Review of the initial assessment dated 05/16/2014 revealed the nutrition section was incomplete. The section of the assessment to indicate if the patient had unexplained weight loss was left blank. A referral for dietary was not selected, although the physician order dated 05/15/2014 requested a nutritional screening.

There was no assessment of activities pursuit on Patient #23.

According to the assessment the patient had a history of constipation and the prompt to determine the number of stools in the last 24 hours was left blank.

The assessment indicated the patient had a pain scale level of 8 (0 being the lowest and 10 the highest) in the right hip. The sections for facial expression, legs, activity, crying, and consolability were left blank.

Review of the physician orders revealed Patient #23 being allergic to contrast dye, sulfa drugs, and codeine. Review of the physician's history and physical dated 05/17/2014 revealed patient #23 had no known drug allergies.

During an interview on 05/28/2014 after 9:00 a.m., Staff #8 confirmed the entries and assessment problems.


Review of an "Admission Summary Sheet" revealed Patient #21 was a 65 year old female admitted on 05/18/2014 with diagnoses of intractable back pain, sacral contusion and fall.

Review of a history and physical dated 05/20/2014 the patient had a bilateral femoral popliteal bypass one week ago.

Review of MARs revealed Patient #21 was on the pain medication Morphine 2 milligrams, IV push as needed every 2 hours.

Review of nursing documentation and MARs from 05/18-19/2014 revealed the Patient #21 was medicated for pain during this timeframe. There was no consistent assessment of the quality of pain nor follow-up after administration of the medication.

Review of "Adult Deep Vein Thrombosis " nursing assessment dated 05/19/20/2014 revealed Patient #21 was at moderate risk for developing blood clots. Review of the "Adult Deep Vein Thrombosis (DVT) Assessment and Prophylaxis" revealed it had not been completed by the physician. The interventions for a patient who was assessed as moderate risk was: Lovenox 40 milligrams Sub Q daily and intermittent pneumatic compression devices or graduated compression stockings. The physician had not signed the protocol to order any interventions.

Review or MARs on Patient #21 revealed she was on the anti-coagulant Lovenox 40 milligrams subcutaneous daily starting on 05/19/2014. There was no documentation that any of the other interventions outside of the medication was initiated.

Review of physician orders dated 05/24/2014 revealed Patient #21 was admitted to Swing bed status. The orders were not signed off by the physician. Written on the orders were instructions to see the electronic MAR and to continue medications per medication reconciliation. The medications were not written out on the physician orders and signed off by the physician.

Review of an admission summary sheet revealed Patient #22 was a 63 year old male who presented to the ED on 05/26/2014 at 8:39 a.m, for ETOH (alcohol) intoxication. The patient's oxygen saturation was 93 and 94 percent on room air in the ED.

Review of a physician history and physical that was dictated on 05/26/2014 at 12:17 p.m., revealed the nurses would be checking for respiratory suppression since Patient #22's alcohol level was so high and they had added Librium (anti-anxiety/sedative agent).

Review of nurses notes dated 05/26/2014 at 12:50 p.m. revealed a dose of Librium 25 milligrams was administered to Patient #22. Over 12 hours later nursing documentation on Patient #22's respiratory status was found on 05/27/2014 at 1:54 a.m. There was documentation of the patient having diminished (breath sounds) in the right and left lower lobes.

Review of nurses notes dated 05/27/014 at 1:59 p.m. (over 12 hours later) revealed Patient #22 was discharged from the hospital. There was no documentation of continued assessment of the patient's respiratory status during the 12 hour time frame prior to discharge.

During an interview on 05/30/2014 after 9:00 a.m., Staff #16 confirmed the lack of documentation of an assessment.

Review of ED notes revealed Patient #10 was a 56 year old male who presented on 05/27/2014 at 8:31 a.m. with a chief complaint of respiratory problems. Review of the ED notes revealed Patient #10 had a diagnosis of Diabetes Type II and was on an oral diabetic agent daily at home.

Review of a complete metabolic profile dated 05/27/2014 and completed at 9:23 a.m. revealed Patient #10 had an elevated blood glucose level of 265 (reference ranges being 74-106).

Review of physician orders dated 05/27/2014 at 10:00 a.m. revealed the following orders:

Accuchecks QID ( four times a day) AC (before meals) and HS ( at bedtime)

Standard sliding scale of Regular insulin

The sliding scale order did not include how much insulin to administer and what type of sliding scale to use. There were no parameters for low and high blood glucose levels.

Review of a computerized order with a start date of 05/28/2014 (the next day) revealed the following sliding scale order:
60-150=0 units
151-200=2 units
201-250=4 units
251-300=6 units
301-350=8 units
351-400=10 units
401-999=12 unit
<60 give ½ amp D50 and notify the MD
>400 give 12 units and notify the MD

Review of the record revealed documentation of a total 5 accuchecks being taken and they were at an elevated range from 214-427. There was no documentation of the amount of sliding scale insulin administered to the patient in the record.

During an interview on 05/30/2014 after 9:00 a.m., Staff #16 confirmed the problems with the physician and the lack of documentation of a consistent assessment of Patient #10's blood sugars.



Review of a policy named "Scope of Service" dated 11/2011 revealed the following:

Patient care needs for nursing care are assessed and reassessed by Registered nurses. The RN is responsible for coordinating the patients' plan of care while facilitating assurance of physician orders were followed and a written plan of treatment was documented in the patient chart.

Based on observation, interview and record review the facility failed to ensure the quality assurance program was ongoing, monitored and identified problems with contracted services.
This deficient practice had the likelihood to cause harm in all patients.

Findings include:


During an observation on 05/29/2014 after 9:00 a.m., the medical gas alarm in the recovery area was found not functioning.

Review of a "Leak and Observations Report" dated 08/20/2013 by a plant operations contracted service company revealed the following:

Master alarms- Master panel at back dock entry still does not have a "Vacuum Abnormal"signal, nor monitors medical air at all. Emergency alarm panel still does not monitor medical air.

Recovery - Still no area alarm

O.R. s 1 & 2- Still no functioning area alarm

Emergency Depart. - Still no area alarm. The master alarm panel does not replace an area alarm.

Medical Air System- Air intake still not from outdoors, turned down, and screened.

Vacuum system- Pump exhaust still is not piped to outdoors.

Recovery Bed 1- Oxygen outlet leaks

Surgery 2- Vacuum hose drop connection leaks when disconnected and has low suction at 2.0 SCFM (minimum should be 3SCFM).

Review of the "Leak and Observations Report" form revealed a place to document the work order number and the date it was corrected. There no documentation of the work being completed.

During an interview on 05/27/2014 at 2:35 p.m., Staff #13 reported the company was their contracted service who did the annual gas checks. Staff #13 confirmed some of the work had not been done because of financial reasons. He had no documentation showing if any of it was done. Staff # 13 reported the problems with the alarms and tanks should have been reported to quality assurance, but they were not.

On 05/27/2014 the facility provided a list of over 80 plus contracted services for the entire facility. Another list provided on 05/30/2014 revealed approximately 29 contracted services had bills which were over 60 days late.

During an interview on 05/28/2014 after 9:00 a.m., Staff #8 (Director of QA) confirmed they were not incorporating contracted services into quality assurance. Staff #8 reported Staff #17 kept up with the contracted services and reported concerns up to the CEO. Staff #8 confirmed not knowing anything about the concern areas with the contracted services.

During an interview on 05/29/2014 after 2:00 p.m., Staff #17 reported she only kept up with the paperwork for contracted services. The individual department heads monitored the programs and were to report to quality assurance themselves.

Based on interview and record review the facility failed to:


A. ensure complete and accurate physician orders were written for admission to the Swing bed status in 2 of 2 Swing bed patients (#s' 21 and 23).

This deficient practice had the likelihood to cause harm in all patients.

Findings include:

Review of the Swing bed physician orders dated 05/15/2014 revealed Patient #23 was a 75 year old female with a diagnosis of status post hip fracture /syncope (fainting). Review of an admission summary sheet revealed Patient #23 was admitted into a Swing bed on
05/16/2014.
Review of the physician orders revealed no nursing or physician signatures to indicate who wrote the orders. The orders did not indicate the patients code status nor list the medications the patient was on. There were instructions on the physician orders to see the electronic MAR. There was no detailed instructions on medication administration.

During an interview on 05/28/2014 after 9:00 a.m., Staff #8 confirmed there was no physician's order.


Review of an "Admission Summary Sheet" revealed Patient #21 was a 65 year old female admitted on 05/18/2014 with diagnoses of intractable back pain, sacral contusion and fall.

Review of physician orders dated 05/24/2014 revealed Patient #21 was admitted to Swing bed status. The orders were not signed off by the physician. Written on the orders were instructions to see the electronic MAR and to continue medications per medication reconciliation. The medications were not written out on the physician orders and signed off by the physician.

During an interview on 05/30/2014 after 9:00 a.m., Staff #16 confirmed the condition of the physician orders.


Review of a facility policy named"Swing Bed Admit Process" dated November 2007 revealed the following:

"When a patient is transferred to Swing Bed status new orders must be written, MARS reconciled, and the Business Office must be notified that the patient is changing statuses. The Case Manager or the House Supervisor will write the Swing Bed Orders for Physicians."

B. ensure accurate information was provided when reporting violations of patient rights to the State Agency.

Review of the Swing bed physician orders dated 05/15/2014 revealed Patient #23 was a 75 year old female with a diagnosis of status post hip fracture /syncope (fainting). Review of an admission summary sheet revealed Patient #23 was admitted into a Swing bed on 05/16/2014

Review of patient rights information dated 05/16/2014 revealed patients were to report rights violations to the State Agency and a number was provided. Patient #23 was provided an incorrect State Agency number for calling in complaints.

Review of medical consent for treatment revealed it was signed off on 05/17/2014 (a day after admission).

During an interview on 05/28/2014 after 9:00 a.m., Staff #8 confirmed the incorrect information was being provided. All of the patient admission packets contained the incorrect number.


C. ensure complete and accurate pain, nutrition, activities pursuit, bowel status assessments and failed to ensure a patient on an anti-coagulant received interventions as needed in 2 of 2 patients (Patient #21 and 23).

Review of an "Admission Summary Sheet" revealed Patient #21 was a 65 year old female admitted on 05/18/2014 with diagnoses of intractable back pain, sacral contusion and fall.

Review of a history and physical dated 05/20/2014 the patient had a bilateral femoral popliteal bypass one week ago.

Review of MARs revealed Patient #21 was on the pain medication Morphine 2 milligrams , IV push as needed every 2 hours.

Review of nursing documentation and MARs from 05/18-19/2014 revealed the Patient #21 was medicated for pain during this timeframe. There was no consistent assessment of the quality of pain nor follow-up after administration of the medication.

Review of "Adult Deep Vein Thrombosis " nursing assessment dated 05/19/20/2014 revealed Patient #21 was at moderate risk for developing blood clots. Review of the "Adult Deep Vein Thrombosis (DVT) Assessment and Prophylaxis" revealed it had not been completed by the physician. The interventions for moderate risk for a patient who was Lovenox 40 milligrams Sub Q daily and intermittent pneumatic compression devices or graduated compression stockings. The physician had not signed approving or addressed the protocol.

Review or MARs on Patient #21 revealed she was on the anti-coagulant Lovenox 40 milligrams subcutaneous daily starting on 05/19/2014. There was no documentation that any of the other interventions outside of the medication was initiated .

Review of physician orders dated 05/24/2014 revealed Patient #21 was admitted to Swing bed status. The orders were not signed off by the physician. Written on the orders were instructions to see the electronic MAR and to continue medications per medication reconciliation. The medications were not written out on the physician orders and signed off by the physician.


Review of the Swing bed physician orders dated 05/15/2014 revealed Patient #23 was a 75 year old female with a diagnosis of status post hip fracture /syncope (fainting). Review of an admission summary sheet revealed Patient #23 was admitted into a Swing bed on 05/16/2014

Review of the initial assessment dated 05/16/2014 revealed the nutrition section was incomplete. There was a section to indicate if the patient had unexplained weight loss that was left blank. A referral for dietary was not selected, although the physician order dated 05/15/2014 requested a nutritional screening.

There was no assessment on activities pursuit for Patient #23.

According to the assessment the patient had a history of constipation and the prompt to determine the number of stools in the last 24 hours was left blank.

The initial assessment indicated the patient had a pain scale level of 8 (0 being the lowest and 10 the highest) in the right hip. The sections for facial expression, legs, activity, crying, and consolability were left blank.

Review of the physician orders revealed Patient #23 being allergic to contrast dye, sulfa drugs, and codeine. Review of the physician's history and physical dated 05/17/2014 revealed Patient #23 had no known drug allergies.

During an interview on 05/28/2014 after 9:00 a.m., Staff #8 confirmed the entries and assessment problems.


D. ensure polices and procedures were complete and update timely for operation of Swing beds.

Review of the policy and procedure manual revealed the last update on the policies was in 10/2012.

During an interview on 05/28/2014 after 1:30 p.m., Staff #3 confirmed the policies/ procedures had not been updated.



E. ensure an updated dental agreement was available for Swing bed patients.


During an interview on 05/28/2014 after 1:30 p.m., Staff #3 revealed she was currently over the Swing bed unit. She did not know about there being a dental agreement for the patients. Staff #8 reported they used to have one.

Review of an dental agreement provided by Staff #8 on 05/30/2014 after 8:30 a.m. revealed it was dated October 13, 2010. Staff #8 reported not knowing if the agreement had been updated.

Based on interview and record review the facility failed to ensure 2 of 2 patients had signed consents for treatment (Patient #s' 8 and 16).

This deficient practice had the likelihood to cause harm in all patients.
Findings include:

On 5/29/2014 at 10:00 AM in the conference room the medical records (MR) for patient's #8 and 16 were identified with the following:

Pt #8 was an 84 year old male received from a long term care facility to the ED of the hospital. Review of the consent to treat revealed no signature of the patient or family. The abbreviation "AMS" was found on the signature line. "No family present" was written beside "AMS". Further review of the ED documentation revealed "Spouse in ER" was identified in the nursing documentation. Staff #8 confirmed the nursing documentation indicated there was in fact, family present in the ED, however no signature for consent was obtained from the family.

Pt #16 was a 48 year old female who was brought to the ED with depression and over dose. Pt #16 was not conscious upon arrival to the ED. Documentation indicated pt #16 was admitted to the hospital for a 5 day stay. Review of the consent to treat revealed no signature was obtained upon arrival. On the signature line was written "Patient unable to sign". At the time of discharge, 5 days later, the consent still read "Patient unable to sign" Staff #8 confirmed Pt #16 was admitted and treated. Staff #8 also confirmed no signature was obtained, indicating the staff failed to explain pt #16's rights once she was awake, able to understand, and give consent.