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Based on interview and record review, the facility's Governing Body (GB) failed to ensure the hospital's operation was conducted in an effective, safe, and organized manner by failing to:

1. Ensure the hospital had an effective GB legally responsible for the conduct of the hospital as an institution (Refer to A0083);

2. Ensure the medical staff was accountable to the GB for the quality of patient care provided at the facility (Refer to A0341 and A0353); and

3. Ensure nursing services and operations were provided in a safe and effective manner that would meet the patients' needs (Refer to A0385, A0395, and A0396).

The cumulative effect of these systemic problems resulted in failure of the Governing Body to ensure patients were receiving quality care in a safe and effective manner.

Based on interview and record review, the facility failed to ensure the Governing Body (GB) had the responsibility for ensuring contracted services complied with all applicable conditions of participation and standards. This resulted in the GB not being responsible for services furnished under contracts.

Findings:

On September 17, 2014, at 1:30 p.m., an interview was conducted with the Governing Body.

They stated for Medical Staff Credentials Review they received a "high level summary" and could ask for additional information if wanted.

They stated the GB had nothing to do with services furnished under contracts and the GB did not ensure that a contractor furnished services that permitted the facility to comply with all applicable conditions of participation and standards for the contracted services. They stated the GB did not approve contracts and the approval of contracts was done by the "Corporation."

They stated the GB was informed when a contracted service was going to be changed such as the contract for Dietary Services and Environmental Services, but the "Corporation" reviewed and approved the contract.

They stated the GB was "told" about the facility's operational and capital budgets but the "Corporation" approved and managed the operational and capital budgets.

They stated the GB was interested to hear the concerns; members of the GB care about the facility and the community; and they had a "vested interest" in the facility.

On September 17, 2014, at 2:30 p.m., an interview was conducted with the Chief Nursing Officer (CNO), Assistant Chief Nursing Officer (ACNO), and the Executive Assistant (EA) who completed the GB meeting minutes. They stated the GB did not approve contracted services and were informed of the facility's new contracts as an informational item.

Based on interview and record review, the facility failed to complete the "Consent to Surgery ..." in its entirety, for one sampled patient (Patient 14). As a result, Patient 14 was not given the information needed to make an informed decision regarding his care.

Findings:

The record for Patient 14 was reviewed. Patient 14 was admitted to the facility on August 16, 2014, with diagnoses that included acute renal failure.

The "Consent to Surgery / Special Procedures / Anesthesia (With Physician Certification)," dated, August 25, 2014, was reviewed. The consent indicated a surgery for "Open Cholecystectomy" was to be performed. The type of anesthesia to be used was blank. The diagnosis was blank. The name of the practitioner who was to perform the procedure was blank. The consent was signed by both Patient 14 and a physician.

On September 15, 2014, at 10:50 a.m., RN 10 was interviewed. RN 10 stated the informed consent should have been completely filled out prior to Patient 14 signing the form. He stated the diagnosis, the type of anesthesia to be used, and the name of the physician to perform the surgery should have been filled out.

Based on interview and record review, the facility failed to ensure Ongoing Professional Practice Evaluations (OPPEs) were completed, for five of ten Medical Staff (Physicians 1, 3, 4, 5 and 6) credential files reviewed. This had the potential to place patients receiving services from these physicians, at risk for substandard healthcare.

Ongoing Professional Practice Evaluations (OPPE) were documented summaries of ongoing data collection for the purpose of assessing a practitioner's clinical competence.

Findings:

A review of the medical staff files was conducted on September 16, 2014. Five of the ten physician credential files did not contain completed OPPEs.

The Director of Medical Staff (DMS) reviewed the files during an interview on September 16, 2014, at 9:35 a.m. The DMS was unable to find evidence the Department Chair had completed current OPPEs for Physicians 1, 3, 4, 5, and 6. The DMS stated OPPEs were to occur every eight months.

During an interview with the Chief of Staff (CS) on September 16, 2014, at 11 a.m., the CS agreed that the OPPEs were not current.

The facility policy titled, "Focused and Ongoing Professional Practice Evaluation" revised June, 2012, was reviewed on September 16, 2014. The policy defined ongoing professional practice evaluation as "The continuous evaluation of the practitioner's professional performance in order to identify and resolve any potential problems with a practitioner's performance. It allows the Medical Staff to identify professional practice trends that impact on quality of care and patient safety on an ongoing basis and provides an evaluation of an individual practitioner's performance and include opportunities to improve patient care based on recognized standards. OPPE information is factored into the decision to allow a practitioner to maintain existing privilege(s), to revise existing privilege(s), or to revoke an existing privilege prior to or at the end of the initial appointment/reappointment period." The criteria listed included, "...Direct observation, compliance with hospital policies, clinical standards and the use of rates compared against established benchmarks or norms, and core measures compliance."

Based on interview and record review, the facility failed to ensure the physician's final progress notes contained the required elements if a discharge summary was not being dictated for three sampled patients (Patients 1, 2, and 4). This resulted in incomplete records and had the potential to result in the patients being discharged in an unstable condition.

Findings:

a. On September 15, 2014, the record for Patient 1 was reviewed. Patient 1 was admitted to the facility on July 9, 2014, for the surgical procedure of right hip total arthroplasty (surgical replacement of the hip joint with an artificial prosthesis) with diagnosis of degenerative joint disease.

The "OR (Operating Room) Intraop(erative) Record" dated July 9, 2014, indicated Patient 1 entered the OR at 6:42 a.m. and left the OR at 8:45 a.m., following right hip total arthroplasty surgery.

The "Progress Notes - Physician" dated, July 10, 2014, at 1 p.m., indicated Patient 1 was alert, neurovascular was "intact," vital signs were stable, and "Home today."

The "Progress Notes - Physician" did not concisely recapitulate the reason for the hospitalization, the significant findings, the procedures performed and treatment rendered, and any specific instructions given to the patient and/or the family.

Patient 1 was discharged from the facility on July 10, 2014, at 6:20 p.m.

There was no discharge summary in the record.

b. On September 15, 2014, the record for Patient 2 was reviewed. Patient 2 was admitted to the facility on July 16, 2014, for the surgical procedure of left hip total arthroplasty with diagnosis of degenerative joint disease.

The "OR (Operating Room) Intraop(erative) Record" dated, July 16, 2014, indicated Patient 2 entered the OR at 9:20 a.m. and left the OR at 11:01 a.m., following the left hip total arthroplasty surgery.

The "Progress Notes - Physician" dated July 17, 2014, at 12 p.m., indicated Patient 2 was alert, neurovascular was "intact," vital signs were stable, and "Home today."

The "Progress Notes - Physician" did not concisely recapitulate the reason for the hospitalization, the significant findings, the procedures performed and treatment rendered, and any specific instructions given to the patient and/or the family.

Patient 2 was discharged from the facility on July 17, 2014, at 3:28 p.m.

There was no discharge summary in the record.

c. On August 1, 2014, and September 15, 2014, the records for Patient 4 were reviewed. Patient 4 was admitted to the facility on May 21, 2014, for the surgical procedure of right hip total arthroplasty (surgical replacement of the hip joint with an artificial prosthesis) with diagnoses of hypertension and degenerative joint disease.

The "OR (Operating Room) Intraop(erative) Record" dated, May 21, 2014, indicated Patient 4 entered the OR at 1:45 p.m. and left the OR at 3:28 p.m., following right hip total arthroplasty surgery.

The "Pre-Anesthesia Evaluation" dated, May 21, 2014, at 1:45 p.m., indicated Patient 4's blood pressure was "137/90 (systolic blood pressure is pressure on the arteries when the heart contracts - normal is below 120 and diastolic blood pressure is the pressure in the arteries when the heart rests between beats - normal is below 80)."

The "Patient Assessment Vital Signs" indicated Patient 4's blood pressure was:
On May 21, 2014,
- at 1:08 p.m., 137/90,
- at 3:30 p.m., 117/66,
- at 4 p.m., 132/71,
- at 5 p.m., 112/70,
- at 8:01 p.m., 110/62; and
On May 22, 2014,
- at 12:05 a.m., 90/52,
- at 4:19 a.m., 90/54,
- at 8 a.m., 104/64,
- at 12 p.m., 88/53.

There was no indication in the record of a blood pressure being obtained after 12 p.m., on May 22, 2014.

The "Hematology" report indicated Patient 4's hemoglobin (Hgb - molecule in red blood cells that carries oxygen, normal/reference range 13.0 to 17.0) and hematocrit (Hct - percentage of the volume of whole blood that is made up of red blood cells, normal/reference range 38.0 to 50.0) were 13.9 and 41.0 respectively on May 20, 2014, at 9:25 a.m., and had dropped to 10.0 (Hgb) and 29.7 (Hct) on May 22, 2014, at 5:39 a.m.

The "Progress Notes - Physician" dated, May 22, 2014, untimed, indicated Patient 4 was alert, neurovascular was "intact," vital signs were stable, and "Home today."

The "Progress Notes - Physician" did not concisely recapitulate the reason for the hospitalization, the significant findings, the procedures performed and treatment rendered, and any specific instructions given to the patient and/or the family.

There was no discharge summary in the record.

There was no documentation in the record to indicate the physician or the nursing staff had recognized Patient 4's drop in blood pressure from his pre-anesthesia evaluation and his drop in hemoglobin and hematocrit following surgery.

Patient 4 was discharged home on May 22, 2014, at 3:30 p.m. (24 hours after right hip total arthroplasty surgery), returned to the facility through the Emergency Department on May 22, 2014, at 8:09 p.m. (4 hours and 39 minutes later), was admitted to the Intensive Care Unit (ICU) on May 22, 2014, at 8:53 p.m., and was pronounced dead on May 24, 2014, at 12:54 a.m. (33 hours and 24 minutes after being discharged from the facility following a right hip total arthroplasty).

During an interview with the Director Health Information Management (DHIM), on August 1, 2014, at 12:35 p.m., he reviewed the record and was unable to find documentation of a discharge summary or a final progress note which met the medical staff requirements as a substitute for a discharge summary. In addition, the DHIM stated the physician's progress note dated May 22, 2014, was untimed.

During an interview with the Chief of Staff (CS), on September 16, 2014, at 11 a.m., he reviewed the records for Patients 1, 2, and 4 and was unable to find documentation of a discharge summary or a final progress note which met the medical staff requirements as a substitute for a discharge summary. The CS stated if a pattern of incomplete discharge summaries, or a final progress notes which did not meet the medical staff requirements as a substitute for a discharge summary, was recognized, the physician would be "spoken to." The CS stated the incomplete discharge progress notes had not been brought to his attention.

The Medical Staff "Rules and Regulations" revised November 2013, revealed "... Discharge Summary - ... A final progress note may be submitted for the discharge summary in the case of patients hospitalized less than forty-eight (48) hours. ... This discharge summary or final progress note should concisely recapitulate the reason for hospitalization, the significant findings, the procedures performed and treatment rendered, the condition of the patient upon discharge, and any specific instructions given to the patient and/or the family. Date and Time of Entry - All orders must be dated and timed. ..."

Based on interview and record review, the facility failed to ensure it provided an organized nursing service to all patients by failing to:

1. Ensure its procedure, "Removing a CVC" (Central Venous Catheter-a flexible tube placed into a large vein and used for the administration of medications and fluids), was followed by the Registered Nurse (RN) for one sampled patient (Patient 24). This failure resulted in Patient 24 sustaining multiple air emboli (air bubbles) to the brain, causing irreversible brain damage and subsequently resulted in the patient's death. (Refer to A0395);

2. Ensure the facility's practice regarding CVC monitoring was followed for two sampled patients (Patients 24 and 26). This failure placed both patients at risk for potential complications of the CVC. (Refer to A0395);

3. Ensure an assessment prior to discharge was completed and a safe discharge occurred for one sampled patient (Patient 4). This resulted in Patient 4 returning to the facility Emergency Department (ED) four hours and 39 minutes after discharge from the facility on May 22, 2014, and had the potential to result in Patient 4's death on May 24, 2014. (Refer to A0395);

4. Ensure an assessment, to include vital signs, was completed prior to discharging patients from the facility for two sampled patients (Patients 1 and 4). This had the potential to result in unstable patients being discharged from the facility. (Refer to A0395);

5. Ensure Registered Nurses (RNs) responsible for the care and maintenance of CVCs were competent when performing those tasks. This failure had the potential for the delivery of inappropriate care and management for all patients with CVCs. (Refer to A0395); and

6. Ensure a plan of care was developed when wounds/skin tears were identified upon admission for one sampled patient (Patient 5). This had the potential to result in a delay in care and treatment. (Refer to A0396).

The cumulative effects of these systemic problems resulted in the failure of the nursing department to ensure care was being provided in a safe and effective manner.

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

1. Ensure its procedure, "Removing a CVC" (Central Venous Catheter-a flexible tube placed into a large vein and used for the administration of medications and fluids), was followed by the Registered Nurse (RN) for one sampled patient (Patient 24). This failure resulted in Patient 24 sustaining multiple air emboli (air bubbles) to the brain, causing irreversible brain damage and subsequently resulted in the patient's death;

2. Ensure the facility's practice regarding CVC monitoring was followed for two sampled patients (Patients 24 and 26). This failure placed both patients at risk for potential complications of the CVC;

3. Ensure an assessment prior to discharge was completed and a safe discharge occurred for one sampled patient (Patient 4). This resulted in Patient 4 returning to the facility Emergency Department (ED) four hours and 39 minutes after his discharge from the facility on May 22, 2014, and had the potential to result in Patient 4's death on May 24, 2014;

4. Ensure an assessment, to include vital signs, was completed prior to discharging patients from the facility for two sampled patients (Patients 1 and 4). This had the potential to result in unstable patients being discharged from the facility; and

5. Ensure Registered Nurses (RNs) responsible for the care and maintenance of CVCs were competent when performing those tasks. This failure had the potential for the delivery of inappropriate care and management for all patients with CVCs.

Findings:

1. During an interview with Senior Performance Improvement Analyst (SPIA), on August 15, 2014, at 9:30 a.m., the SPIA stated on August 5, 2014, during the removal of Patient 24's central venous catheter line (CVC- a flexible tube placed into a large vein and used to administer medications and fluids), the patient had a seizure (a surge of electrical activity to the brain).

The SPIA stated the facility's preliminary investigation and tests results, indicated the patient sustained an irreversible injury to the brain, from air being introduced to the venous (blood) system when RN 1 removed the patient's CVC.

During an interview conducted with the Risk Manager (RM), on August 15, 2014, at 9:50 a.m., the RM stated the facility's preliminary investigation that included an interview with RN 1, revealed RN 1 did not follow the facility's policy and procedure regarding the removal of a CVC. The RM stated RN 1 removed the patient's CVC while the patient remained sitting upright in a chair.

During an interview with the Director of Progressive Care Unit (DPCU), on August 15, 2014, at 1:15 p.m., the DPCU stated the facility's policy and procedure for removing a CVC indicated the patient should be positioned laying in bed, with the head of the bed in the lowest possible position for the CVC removal. The DPCU stated positioning the patient's head in a low position reduced the chance of air getting into the blood stream and causing an injury to the patient.

The record for Patient 24 was reviewed on August 15, 2014, and September 17, 2014. Patient 24 was admitted on August 2, 2014, with the diagnosis Abdominal Aortic Aneurysm (AAA- an enlarged area in the lower part of the Aorta, the major blood vessel that supplies blood to the body).

The record indicated Patient 24 had an emergency surgical procedure to repair the AAA, on August 2, 2014. The record indicated a CVC was inserted in the right jugular vein by the anesthesiologist.

A document titled "Progress Notes-Physician" dated August 5, 2014, at 6:45 a.m., indicated "D/C (discontinue) IJ (internal jugular). D/C (discharge) planning for AM."

A document titled "Orders" dated August 5, 2014, at 6:55 a.m., indicated "Central Line Removal."

A nursing assessment document dated August 5, 2014, at 7:47 a.m., indicated Patient 24 had normal vital signs (heart rate, blood pressure), was alert, awake, and denied any problems.

A document titled "Nursing/Clinical Info (information)...Nursing Note" entered on August 5, 2014, at 10:54 a.m., indicated "8:30 (a.m.) Pt (patient) sitting in chair A/O (alert/oriented) x 4. VSS (vital signs stable). Pt c/o (complained of) pain in left foot...8:40 a.m. Pt became stiff with labored breathing and unresponsive. Pt appears to be having a seizure. Charge nurse called for assistance with pt. Pt moved from chair to bed ...still unresponsive. Code Blue (announced in a hospital when a patient's heart and/or breathing had stopped, to alert the necessary personnel) called..."

A document titled "Death Summary" dated August 11, 2014, at 12:22 p.m., indicated "Patient had a right internal jugular vein (CVC), which was inserted in the operating room by anesthesiologist. This was ordered to be discontinued by the nursing staff, while the patient sitting at the bedside, the internal jugular...(CVC) was removed by the nurse, immediately...(the patient) developed seizure activity..."

A phone interview was conducted with RN 1 on August 18, 2014, at 12:20 p.m. RN 1 stated, on August 5, 2014, at approximately 8:00 a.m., she assisted Patient 24 into a chair at the bedside, for breakfast.

RN 1 stated at approximately 8:30 a.m., she prepared to remove the CVC located in Patient 24's right jugular vein (a blood vessel that carries blood from the head to the lungs). RN 1 stated Patient 24 was sitting in a "regular hospital chair." RN 1 stated she instructed Patient 24 to hold his breath, removed the CVC, held pressure to the site, waited for the bleeding to stop, and then applied a dressing to cover the removal site.

RN 1 stated approximately 10 minutes after the removal of the CVC, she observed Patient 24 in the chair having a seizure (a sudden surge of electrical activity in the brain).

RN 1 stated "In retrospect (to think back on a situation), I am really not sure what happened. I don't think I could have done anything different."

The hospitals policy and procedure titled, "Nursing Procedures...Removing a CVC" dated August 1, 2005, indicated "Place the patient in a supine position (lying down) to prevent an air embolism."

A phone interview was conducted with the Deputy Coroner (DC), on August 18, 2014, at 2:15 p.m. The DC stated an autopsy had been completed. The DC stated Patient 24's death was "ruled accidental related to the removal of the right jugular catheter leading to an air embolus."

The facility's policy and procedure titled "Lippincott's Nursing procedures...Removing a CVC" undated, was reviewed with SPIA, on September 16, 2014. The policy indicated "place the patient in a supine position to prevent an air embolism."

The facility failed to ensure RN 1 followed the facility's policy and procedure regarding patient positioning during the removal of Patient 24's CVC. Patient 24 sustained irreversible brain damage from the introduction of air bubbles into the blood stream, during the removal of the CVC. This failed practice was directly responsible for Patient 24's death.

2a. During an interview with the Intensive Care Unit Educator (ICUE), on September 17, 2014, at 9:30 a.m., the ICUE stated it was the facility's practice for RNs to assess and document the assessment of a CVC every two hours.

The record for Patient 24 was reviewed. Patient 24 was admitted on August 2, 2014, with the diagnosis of Abdominal Aortic Aneurysm (AAA-an enlarged area in the lower part of the Aorta, the major blood vessel that supplies blood to the body).

The record indicated a CVC was inserted into Patient 24's right jugular vein by the anesthesiologist on August 4, 2014.

The document titled "Death Summary" dated August 11, 2014, at 12:22 p.m., indicated on August 5, 2014, at 8:30 a.m., Patient 24's CVC was discontinued by the RN.

The document further indicated " ...the (CVC) was removed by the nurse, immediately ... (the patient)developed seizure activity ..."

The record was reviewed with RN 2, on September 17, 2014, at 8:20 a.m. RN 2 was unable to find documentation that indicated the CVC was assessed by a RN after 6:35 p.m., on August 4, 2014. The record revealed, the last time Patient 24's CVC was assessed was 14 hours prior to the discontinuation of the CVC.

b. The record for Patient 26 was reviewed. Patient 26 was admitted on August 13, 2014, with the diagnosis of cardiac arrest (a condition when heart functioning stops). The record indicated Patient 26 had a CVC inserted on August 13, 2014, and discontinued prior to discharge on August 22, 2014.

The record was reviewed with RN 2, on September 17, 2014, at 10 a.m. RN 2 was unable to find documentation indicating Patient 26's CVC was assessed on August 14 and August 15, 2014.

Patient 26's CVC was not assessed for 48 hours or two days, during the 11 day admission.

3. On August 1, 2014, and September 15, 2014, the records for Patient 4 were reviewed. Patient 4 was admitted to the facility on May 21, 2014, for the surgical procedure of right hip total arthroplasty (surgical replacement of the hip joint with an artificial prosthesis) with diagnoses of hypertension and degenerative joint disease.

The "OR (Operating Room) Intraop(erative) Record" dated May 21, 2014, indicated Patient 4 entered the OR at 1:45 p.m. and left the OR at 3:28 p.m., following the right hip total arthroplasty surgery.

The "Pre-Anesthesia Evaluation" dated May 21, 2014, at 1:45 p.m., indicated Patient 4's blood pressure was "137/90 (systolic blood pressure is pressure on the arteries when the heart contracts - normal is below 120 and diastolic blood pressure is the pressure in the arteries when the heart rests between beats - normal is below 80)."

The "Patient Assessment Vital Signs" indicated Patient 4's blood pressure was:
On May 21, 2014,
- at 1:08 p.m., 137/90,
- at 3:30 p.m., 117/66,
- at 4 p.m., 132/71,
- at 5 p.m., 112/70,
- at 8:01 p.m., 110/62; and
On May 22, 2014,
- at 12:05 a.m., 90/52,
- at 4:19 a.m., 90/54,
- at 8 a.m., 104/64, and
- at 12 p.m., 88/53.

There was no indication in the record of a blood pressure being obtained after 12 p.m., on May 22, 2014.

The "Hematology" report indicated Patient 4's hemoglobin (Hgb - molecule in red blood cells that carries oxygen, normal/reference range 13.0 to 17.0) and hematocrit (Hct - percentage of the volume of whole blood that is made up of red blood cells, normal/reference range 38.0 to 50.0) were 13.9 and 41.0 respectively on May 20, 2014, at 9:25 a.m., and had dropped to 10.0 (Hgb) and 29.7 (Hct) on May 22, 2014, at 5:39 a.m.

The "Progress Notes - Physician" dated May 22, 2014, untimed, indicated Patient 4 was alert, neurovascular was "intact," vital signs were stable, and "Home today."

There was no indication in the record the physician or the nursing staff had recognized Patient 4's drop in blood pressure from his pre-anesthesia evaluation and his drop in hemoglobin and hematocrit following surgery.

Patient 4 was discharged home on May 22, 2014, at 3:30 p.m.

Patient 4 returned to the facility through the Emergency Department on May 22, 2014, at 8:09 p.m. (4 hours and 39 minutes after discharge from the facility).

The "Patient Assessment Vital Signs" indicated Patient 4's blood pressure was:
On May 22, 2014,
- at 8:38 p.m., 101/38,
- at 8:50 p.m., 82/35, and
- at 9 p.m., 84/50.

A physician's order was written for Patient 4 to be admitted to the Intensive Care Unit (ICU) on May 22, 2014, at 8:53 p.m.

The "Nursing Note" dated May 22, 2014, at 9 p.m., indicated Patient 4 was on the computed tomography (CT - scan imaging method that uses x-rays to create pictures of cross-sections of the body) table for a head and neck scan when the patient became unresponsive, was very pale, had shallow respiratory effort, and was brought back to the ED. In addition, Patient 4's blood pressure was low and fluids were started as ordered.

The "Echocardiogram" dated May 26, 2014 (correct date was May 23, 2014), indicated Patient 4 had "severe aortic stenosis (narrowing of the heart's aortic valve opening which does not allow normal blood flow through the heart)."

Patient 4 was pronounced dead on May 24, 2014, at 12:54 a.m. (33 hours and 24 minutes after being discharged from the facility following a right hip total arthroplasty).

During an interview with the Director Joint and Spine (DJS) on August 1, 2014, at 11:25 a.m., she reviewed the record and was unable to find documentation of vital signs to include a blood pressure after 12 p.m., on May 22, 2014. The DJS stated vital signs and an assessment were generally done at the time of discharge. In addition, the DJS stated there was no documentation in the record to indicate the nurse and/or physician were aware Patient 4's blood pressure was low and his hemoglobin and hematocrit had dropped following surgery. The DJS stated "confirmation vital signs" should have been taken when Patient 4's blood pressure was low. The DJS stated based on Patient 4's blood pressure, the nurse should have monitored the patient's blood pressure, held the discharge, and notified the physician.

The Lippincott Advisor dated 2014, utilized by the facility for their care policy and procedures, revealed "Discharge - If appropriate, take and record the patient's vital signs on the discharge summary form. Notify the practitioner if any signs are abnormal such as an elevated temperature. If necessary, the practitioner may alter the patient's discharge plan. ... Before the patient is discharged, perform a physical assessment. If you detect abnormal signs or the patient develops new symptoms, notify the practitioner and delay discharge until he has seen the patient. ..."

4a. On September 15, 2014, the record for Patient 1 was reviewed. Patient 1 was admitted to the facility on July 9, 2014, for the surgical procedure of right hip total arthroplasty with diagnosis of degenerative joint disease.

The "OR (Operating Room) Intraop(erative) Record" dated July 9, 2014, indicated Patient 1 entered the OR at 6:42 a.m. and left the OR at 8:45 a.m., following the right hip total arthroplasty surgery.

The "Patient Assessment Vital Signs" indicated Patient 1's vital signs were taken:

On July 9, 2014, at 6:21 a.m., 8:50 a.m., 8:55 a.m., 9 a.m., 9:20 a.m., 9:35 a.m., 9:50 a.m., 10:43 a.m., 12 p.m., 4 p.m., and 8 p.m.

On July 10, 2014, at 12 a.m., 4:17 a.m., 8 a.m., and 12 p.m.

There was no indication in the record of vital signs/a blood pressure being obtained after 12 p.m., on July 10, 2014.

Patient 1 was discharged home on July 10, 2014, at 6:20 p.m. (6 hours and 20 minutes since his last set of vital signs).

b. On August 1, 2014, and September 15, 2014, the records for Patient 4 were reviewed. Patient 4 was admitted to the facility on May 21, 2014, for the surgical procedure of right hip total arthroplasty (surgical replacement of the hip joint with an artificial prosthesis) with diagnoses of hypertension and degenerative joint disease.

The "OR (Operating Room) Intraop(erative) Record" dated May 21, 2014, indicated Patient 4 entered the OR at 1:45 p.m. and left the OR at 3:28 p.m., following the right hip total arthroplasty surgery.

The "Patient Assessment Vital Signs" indicated Patient 4's vital signs were taken:

On May 21, 2014, at 1:08 p.m., 3:30 p.m., 4 p.m., 5 p.m., and 8:01 p.m.

On May 22, 2014, at 12:05 a.m., 4:19 a.m., 8 a.m., and 12 p.m.

There was no indication in the record of vital signs/a blood pressure being obtained after 12 p.m., on May 22, 2014.

Patient 4 was discharged home on May 22, 2014, at 3:30 p.m. (3 hours and 30 minutes since his last set of vital signs).

During an interview with the Director Joint and Spine (DJS) on September 17, 2014, at 12:10 p.m., she reviewed the records and was unable to find documentation of vital signs to include a blood pressure after 12 p.m., on the day of discharge for each patient. The DJS stated vital signs and an assessment were generally done at the time of discharge. The DJS stated vital signs should be taken within 30 minutes of discharge and recorded on the discharge summary.

The Lippincott Advisor dated 2014, utilized by the facility for their care policy and procedures, revealed "Discharge - If appropriate, take and record the patient's vital signs on the discharge summary form. Notify the practitioner if any signs are abnormal such as an elevated temperature. If necessary, the practitioner may alter the patient's discharge plan. ... Before the patient is discharged, perform a physical assessment. If you detect abnormal signs or the patient develops new symptoms, notify the practitioner and delay discharge until he has seen the patient. ..."

5. An interview with the Director of Intensive Care Unit (DICU), was conducted on September 17 , 2014, at 11 a.m. The DICU stated, the care and maintenance of a CVC was a skill necessary for RNs to perform when providing patient care. The DICU stated Registered Nurses (RNs) who worked in the ICU were required to have their knowledge and skills evaluated to verify competency initially on hire, and on an annual basis.

The DICU stated, the evaluation was done to ensure the RNs were competent to care and manage a patient's CVC.

The personnel files of four RNs who worked in the ICU were reviewed on September 16, 2014, at 2:55 p.m., with the Human Resources Manager (HRM).

The HRM was unable to find documentation to indicate the four RNs' skills and knowledge of the care and maintenance of CVCs was evaluated initially on hire, and on an annual basis.

The facility's policy and procedure titled "Competency, Staff Education, and Continuing Professional Development" dated December 31, 2013, indicated "To ensure a standard of safety and expertise within the hospital...to ensure the staff are educationally in knowledge and skills necessary to perform their responsibilities ..."

The policy further indicated "Competency shall be assessed...upon hire...(and have an) annual competency assessment..."

Based on interview and record review, the facility failed to ensure a plan of care was developed when wounds/skin tears were identified upon admission for one sampled patient (Patient 5). This had the potential to result in a delay in care and treatment.

Findings:

On September 15, 2014, the record for Patient 5 was reviewed. Patient 5 was admitted to the facility on September 1, 2014, with diagnoses including left hip fracture, high blood pressure, and chronic obstructive pulmonary disease.

The admission nursing assessment dated September 1, 2014, at 7 a.m., indicated Patient 5 had tenderness to a right outer thigh wound which was an "unstageable wound" measuring 1.5 centimeters, red, and scabbed; left and right arm bruising; and the sacrum (tail bone/buttocks) was red.

The "Wound Care Note" dated September 5, 2014, at 2:30 p.m., indicated a wound care consult was done. Patient 5 had a skin tear to the coccyx (tail bone), a healing scab to the right thigh, and there was a "High risk plan of care in place for prevention."

The "Wound Care Note" dated September 9, 2014, at 1:45 p.m., indicated a skin assessment revealed an open area to the coccyx and the previous skin tear was larger.

The "Interdisciplinary Plan of Care" initiated on September 1, 2014, and reviewed every shift, indicated the focus areas with interventions were fall/injury; alteration in comfort/pain; and anticoagulation/fibrinolytic therapy.

There was no indication an "Interdisciplinary Plan of Care" had been developed for Patient 5's impaired skin integrity.

During an interview with the Manager Medical/Surgical Services (MMSS), on September 15, 2014, at 10:20 a.m., she reviewed the record for Patient 5 and was unable to find documentation of a plan of care being developed for impaired skin integrity. The MMSS stated a plan of care should have been developed for Patient 5's impaired skin integrity.

The facility policy and procedure titled "Interdisciplinary Plan of Care Documentation" revised June 20, 2013, indicated "To ensure that a plan of care is developed for each patient upon hospitalization that reflects patient's needs based on the nursing assessment with contribution from other disciplines. ... The plan of care will be reviewed every shift by the Registered Nurse and changes will be made as needed to reflect the current status and needs of the patient. ..."

Based on interview and record review, the facility failed to ensure the record included accurate and pertinent documentation to include interventions, care, and treatment, for one sampled patient (Patient 24). This failure resulted in the omission of pertinent information regarding the hospitalization for Patient 24.

Findings:

During an interview with Senior Performance Improvement Analyst (SPIA), on August 15, 2014, at 9:30 a.m., the SPIA stated on August 5, 2014, during the removal of Patient 24's central venous catheter line (CVC- a flexible tube placed into a large vein and used to administer medications and fluids), the patient had a seizure (a surge of electrical activity to the brain).

The SPIA stated the facility's preliminary investigation and tests results, indicated the patient sustained an irreversible injury to the brain, from air being introduced to the venous (blood) system during the improper positioning of Patient 24, when the CVC was removed.

The record for Patient 24 was reviewed on August 15 and September 17, 2014. Patient 24 was admitted in August 2, 2014, with the diagnosis abdominal aortic aneurysm (an enlarged area in the lower part of the Aorta, the major blood vessel that supplies blood to the body).

The document titled, "Nursing/Clinical Info (information)", dated August 5, 2014, indicated, "8:30 Pt (patient) sitting in chair A/O (awake/oriented) x 4. VSS (vital signs stable). Pt c/o (complained of) pain in left foot....8:40 a.m. Pt became stiff with labored breathing and unresponsive. Pt appears to be having a seizure. Charge nurse called for assistance..."

There was no documentation regarding the removal of the CVC by the RN.

The document titled, "Death Summary," dated August 11, 2014, at 12:22 p.m., indicated, "Patient had a right internal jugular vein (CVC), which was inserted in the operating room by anesthesiologist. This was ordered to be discontinued by the nursing staff, while the patient sitting at the bedside, the internal jugular...(CVC) was removed by the nurse, immediately...(the patient) developed seizure activity..."

During an interview and concurrent record review with the SPIA, on August 15, 2014, at 10:35 a.m., the SPIA stated it was the facility's practice to document details of an incident/unusual occurrence to include the intervention, care, and treatment in the medical record.

The SPIA was unable to find nursing documentation of the pertinent observations and the relevant nursing documentation of the care and treatment that involved the removal of Patient 24's CVC.

Based on interview and record review, the facility failed to ensure a discharge summary/final progress note, which recapitulated the significant findings and events of the patient's hospitalization, was in the record for three patients (Patients 1, 2, and 4). This resulted in an incomplete medical record.

Findings:

a. On September 15, 2014, the record for Patient 1 was reviewed. Patient 1 was admitted to the facility on July 9, 2014, for the surgical procedure of right hip total arthroplasty (surgical replacement of the hip joint with an artificial prosthesis) with diagnosis of degenerative joint disease.

The "OR (Operating Room) Intraop(erative) Record" dated July 9, 2014, indicated Patient 1 entered the OR at 6:42 a.m. and left the OR at 8:45 a.m., following the right hip total arthroplasty surgery.

The "Progress Notes - Physician" dated July 10, 2014, at 1 p.m., indicated Patient 1 was alert, neurovascular was "intact," vital signs were stable, and "Home today."

The "Progress Notes - Physician" did not concisely recapitulate the reason for the hospitalization, the significant findings, the procedures performed and treatment rendered, and any specific instructions given to the patient and/or the family.

Patient 1 was discharged from the facility on July 10, 2014, at 6:20 p.m.

There was no discharge summary in the record.

b. On September 15, 2014, the record for Patient 2 was reviewed. Patient 2 was admitted to the facility on July 16, 2014, for the surgical procedure of left hip total arthroplasty with diagnosis of degenerative joint disease.

The "OR (Operating Room) Intraop(erative) Record" dated July 16, 2014, indicated Patient 2 entered the OR at 9:20 a.m. and left the OR at 11:01 a.m., following the left hip total arthroplasty surgery.

The "Progress Notes - Physician" dated July 17, 2014, at 12 p.m., indicated Patient 2 was alert, neurovascular was "intact," vital signs were stable, and "Home today."

The "Progress Notes - Physician" did not concisely recapitulate the reason for the hospitalization, the significant findings, the procedures performed and treatment rendered, and any specific instructions given to the patient and/or the family.

Patient 2 was discharged from the facility on July 17, 2014, at 3:28 p.m.

There was no discharge summary in the record.

c. On August 1, 2014, and September 15, 2014, the records for Patient 4 were reviewed. Patient 4 was admitted to the facility on May 21, 2014, for the surgical procedure of right hip total arthroplasty (surgical replacement of the hip joint with an artificial prosthesis) with diagnoses of hypertension and degenerative joint disease.

The "OR (Operating Room) Intraop(erative) Record" dated May 21, 2014, indicated Patient 4 entered the OR at 1:45 p.m. and left the OR at 3:28 p.m., following the right hip total arthroplasty surgery.

The "Progress Notes - Physician" dated May 22, 2014, untimed, indicated Patient 4 was alert, neurovascular was "intact," vital signs were stable, and "Home today."

The "Progress Notes - Physician" did not concisely recapitulate the reason for the hospitalization, the significant findings, the procedures performed and treatment rendered, and any specific instructions given to the patient and/or the family.

Patient 4 was discharged from the facility on May 22, 2014, at 3:30 p.m.

There was no discharge summary in the record.

During an interview with the Director Health Information Management (DHIM), on August 1, 2014, at 12:35 p.m., he reviewed the record and was unable to find documentation of a discharge summary or a final progress note which met the medical staff requirements as a substitute for a discharge summary. In addition, the DHIM stated the physician's progress note dated May 22, 2014, was untimed.

During an interview with the Chief of Staff (CS), on September 16, 2014, at 11 a.m., he reviewed the records for Patients 1, 2, and 4 and was unable to find documentation of a discharge summary or a final progress note which met the medical staff requirements as a substitute for a discharge summary. The CS stated if a pattern of incomplete discharge summaries, or a final progress notes which did not meet the medical staff requirements as a substitute for a discharge summary, was recognized, the physician would be "spoken to." The CS stated the incomplete discharge progress notes had not been brought to his attention.

The Medical Staff "Rules and Regulations" revised November 2013, revealed "... Discharge Summary - ... A final progress note may be submitted for the discharge summary in the case of patients hospitalized less than forty-eight (48) hours. ... This discharge summary or final progress note should concisely recapitulate the reason for hospitalization, the significant findings, the procedures performed and treatment rendered, the condition of the patient upon discharge, and any specific instructions given to the patient and/or the family. Date and Time of Entry - All orders must be dated and timed. ..."

Based on interview and record review, the facility failed to ensure a post-anesthesia evaluation was completed per facility policy and procedure for one sampled patient (Patients 7). This had the potential to result in complications from anesthesia to go undetected.

Findings:

On September 15, 2014, the record for Patient 7 was reviewed. Patient 7 was admitted to the facility on September 12, 2014, with diagnosis of repeat cesarean section (abdominal birth of an infant).

Patient 7 delivered a baby boy on September 12, 2014, at 8:36 a.m., by repeat cesarean section.

The "Pre-Anesthesia Eval (evaluation) reviewed & agree with proposed plan" and "Pre-Anes. Eval reviewed; changes to anes. plan (see notes)" was dated September 12, 2014, at 7:02 a.m., and signed by the anesthesia provider.

The "Post-Anes. (Anesthesia) Evaluation" was dated September 12, 2014, untimed, and the vital signs, pain, mental status, airway, hydration, postoperative nausea/vomiting, respiratory function, and cardiac function assessments were blank.

During an interview with the Director Perinatal Services (DPS), on September 15, 2014, at 11:30 a.m., she reviewed the record and was unable to find documentation of the required elements for a post anesthesia evaluation. The DPS stated Patient 7's post anesthesia evaluation should of been completed.

The facility policy and procedure titled "Pre and Post Evaluation" revised June 23, 2014, revealed "... All patients receiving anesthesia services shall have a post anesthesia evaluation completed and documented by an anesthesia provider, no later than 48 hours post anesthesia. The evaluation may not begin until the patient is sufficiently recovered from the acute administration of the anesthesia so as to participate in the evaluation. The post anesthesia evaluation shall include, but is not limited to, assessment of: Respiratory function, including respiratory rate, airway patency and oxygen saturation; Cardiovascular function, including pulse rate and blood pressure; Mental status; Temperature; Pain; Nausea and vomiting; (and) Postoperative hydration."