HospitalInspections.org

Based on review of facility Suicide Precaution policy, medical record (MR) review, and interviews with staff, it was determined the facility failed to ensure patients were cared for in a safe environment.

Refer to tags: A 144, A 166, A 171, A 174, A 175, A 178

Based on review of facility Suicide Precaution policy and procedure, ED (Emergency Department) medical record (MR), and interview with staff, it was determined the facility failed to:

1. Develop a policy for suicide precautions that included the frequency of monitoring for patients identified as high risk for suicide.

2. Follow the facility suicide precaution policy, document PI (Patient Identifier) # 25, one of one ED patients identified as high risk for suicide, was in direct line of sight of ED staff at all times while at the ED.

3. Document the patient/family were informed of suicide precautions and restrictions per the facility policy.

Findings include:

Facility Policy: Suicidal Precautions
Policy Number: NGEN-SAF-7
Date Revised: 10/2023

...Purpose: To guide staff in caring for the patient experiencing suicidal ideation...for providing safe nursing care for the suicidal patient.

Policy:

All adult patients treated in the ED...will be assessed for suicidal risk. Patients...identified...at risk will be placed on Suicide Precautions. Patients with physician orders for "suicide precautions"...should have an environmental assessment and room search for potentially dangerous items conducted....

...suicide precautions may be initiated by the Registered Nurse (RN).
1. A staff member should have direct line of sight at all times, including when toileting.
2. The physician...should be contacted immediately (for) consideration for a psychiatric consult.

Procedure:

1. Contact Director...to evaluate available resources.
2. Explain precautions to patient and family...Inform them of the restrictions and rationale for the precautions...removal of personal belonging and medications. Family should be informed of the necessity to limit items from outside...and some items may be restricted...Nurse should check any items brought from the outside.

Suggested items to look for/remove...
4...personal belongings should be removed from the room...
5. Meals shall be served on disposable products.

Definitions:
Suicide Precautions include the following:
Environmental assessment
Room search
Search of personal belongings
Staff have direct line of sight with patient
Psychiatric consult...

Securing the Environment
Sitter should be aware of...items...used...to harm one-self therefore patient should be constantly observed, even in the restroom and while sleeping...

...a complete list of personal items temporarily held...by staff should be documented in the MR...

1. PI # 25 presented to the ED on 10/16/23 at 10:28 AM, family present, the cc (chief complaint) was Suicidal Ideations (SI).

MR review revealed the nurse triage assessment performed at 10:41 AM included documentation of pediatric behavioral health concerns, and multiple lacerations to the left arm. Review of the CSSRS (Columbia Suicide Severity and Risk Screen-a standardized tool used to screen for risk of self-harm) revealed PI # 25's level of suicide risk, high risk.

Record review revealed PI # 25 was seen by the ED physician at 10:49 AM, assessment was suicidal ideation and a plan to set self on fire. The treatment was transfer to a mental health facility for further care.

Review of the ED nurse documentation dated 10/16/23 at 11:17 AM revealed PI # 25 was in paper scrubs, room in direct view of "this" nurse, all extra cords removed from room, suicidal precautions in place.

There was no documentation the ED staff explained precautions to the patient and family member, informed them of the restrictions/rationale for the precautions, the necessity to limit items from outside and some items restricted, and the need for the nurse to check items brought from the outside.

MR review revealed at 1:41 PM, family at bedside, staff updated the family member on the current plan of care.

Further MR review revealed at 4:55 PM, family member returned with requested paperwork requested from the receiving facility. There was no documentation of the time the family member left the hospital.

There was no documentation ED staff ensured PI # 25's safety from 1:41 PM to 4:55 PM, which was 2 hours and 11 minutes. There was no documentation staff offered toileting and/or accompanied PI # 25 during the greater than 8 hours ED stay.

An interview was conducted on 11/30/23 at 2:13 PM with Employee Identifier (EI) # 3, ED Manager who stated ED staff had additional patients assigned while caring for PI # 25. EI # 3 confirmed ED staff failed to document an explanation of suicide precautions/restrictions were provided and there was no documentation PI # 25 was in direct line of sight at all times while in the ED.

Based on medical record (MR) reviews, hospital policy and staff interview it was determined the hospital failed to document a written modification to the patient's Plan of Care (POC) with the use restraints.

This deficient practice affected one of two MR's reviewed of restrained patients including Patient Identifier (PI) # 20, and had the potential to affect all patients restrained at this facility.

Findings include:

Facility policy: Restraint Policy
Policy number: NGEN-LEG-7
Date reviewed: 4/2022

...Non-Violent/Non-Self Destructive Management...

Revise Plan of Care, including goals and release criteria...

...Violent/Self Destructive Management Restraint...

Revise Plan of Care, including goals and release criteria...

1. PI # 20 was admitted on 5/3/23 with diagnoses including Acute Exacerbation of Psychosis, Methamphetamine Abuse, Rhabdomyolosis, and UTI (Urinary Tract Infection).

Review of the Care Plan dated 5/3/23 at 11:50 PM revealed Care Plans including, monitor sleep patterns, encourage adequate nutritional intake, convey acceptance of feelings, assess for suicidal ideations, provide opportunities for patient to succeed, make frequent contact with patient early, assist patient with ADL's (activities of daily living), administer medications as ordered, provide constant structured environment, evaluate patient tolerance for interaction, implement risk for injury, encourage patient to discuss situation, facilitate grieving process.

Review of the Physician's Orders dated 5/4/23 at 12:03 AM revealed a telephone order for non-violent restraint monitoring.

Review of the Nursing Narrative Note dated 5/4/23 at 12:36 AM revealed the nurse documented PI # 20 indicated he/she was going to bite another nurse in the room and orders were given for soft, non-violent restraints and indwelling Foley catheter.

Further review of the Care Plan revealed no updates to the Care Plan after application of the restraints.

An interview was conducted on 11/30/23 at 1:50 PM with Employee Identifier (EI) # 8, Registered Nurse (RN), Team Leader, who confirmed there were no changes made to the Care Plan after the application of the restraints.

Based on Medical Record (MR) review, facility policy, and staff interview, it was determined the facility failed to obtain and/or document an appropriate physician's order every four hours for the use of restraints for the management of violent or self-destructive behavior in an adult above the age of 18.

This deficient practice affected one of two MR's reviewed of restrained patients including Patient Identifier (PI) # 20 and had the potential to affect all patients requiring restraints at this hospital.

Facility policy: Restraint Policy
Policy number: NGEN-LEG-7
Date reviewed: 4/2022

...Physician Orders:

Can be initiated by RN (Registered Nurse) in an emergency with immediate notification of the Physician/LIP (Licensed Independent Practitioner)...

Re-evaluation:

Renewal of the original order is based on established time frames...

Every 4 (four) hours for adults 18 years and older...

1. PI # 20 was admitted on 5/3/23 with diagnoses including Acute Exacerbation of Psychosis, Methamphetamine Abuse, Rhabdomyolosis, and UTI (Urinary Tract Infection).

Review of the Physician's Orders dated 5/4/23 at 12:03 AM revealed a telephone order for non-violent restraint monitoring.

Review of the Nursing Narrative Note dated 5/4/23 at 12:36 AM revealed the nurse documented "...In trying to calm the pt. (patient), (he/she) began to indicate (he/she) was going to bite another nurse in the room. Orders given for soft, non-violent restraints...).

Review of the nursing documentation, Restraints Information, revealed PI # 20 was in constant restraints on 5/4/23 at 12:38 AM until 5/5/23 at 6:07 AM, which was 30 hours.

In an interview on 11/30/23 at 1:50 PM with Employee Identifier (EI) # 8, RN, Team Leader, EI # 8 confirmed PI # 20 was displaying violent behavior and the orders should have been written for Violent/Self Destructive Management and the orders were not renewed every four hours per facility policy.

Based on review of medical records, hospital policy, and interviews it was determined the hospital failed to ensure restraint justification and rationale for continued use of the restraint were documented.

This deficient practice affected one of two patients reviewed with restraints including Patient Identifier (PI) # 24 and had the potential to affect all patients requiring restraints admitted to this hospital.

Findings include:

Facility policy: Restraint Policy
Policy Number: NGEN-LEG-7
Date Reviewed: 4/2022

Purpose:
To provide guidelines on appropriate and safe use of restraints...with adequate clinical justification...The safest, most least-restrictive restraint method should be used.

...Registered Nurse (RN):

...Employs the use of alternatives and interventions to avoid the use of restraint.

...Documents criteria present, nursing assessment, and attempted alternative measures to prevent the use of restraint.

Initiates, assesses, and ensures safe monitoring of the restrained patient for the duration of the restraint episode...

Procedure:

Non-Violent/Non-Self Destructive Management Restraint

...Re-evaluation:

1. RN will re-evaluate the patient at least every 2 hours for the continued use of restraint...

RN Assessment/Monitoring and Documentation every 2 hours for...
7. Readiness for discontinuation of use of restraint...
Discontinuance and Removal of Restraint:
As soon as the patient's behavior no longer meets the criteria, the RN may discontinue the restraint...physician order is not required...

1. PI # 24 presented to the ED (Emergency Department) on 9/30/23 at 3:00 PM via emergency medical transport (EMT), combative, screaming, not following commands, and unconsolable.

Review of the ED record included Restraints Information documentation dated 9/30/23 at 3:00 PM, patient attempting to climb out of bed, soft restraint initiated to left upper and right upper limb, and Patient Care Orders dated 9/30/23 at 3:11 PM, restraint initiate non violent (behavior), reduce injury, soft limb valid for 1 calendar day, restraint monitoring non violent every 2 hours (hrs).

Record review revealed Medication Orders for Geodon 20 mg (milligram) IM (intramuscular) was administered on 9/30/23 at 3:31 PM, and Lorazepam 2 mg IVP (intravenous push), was administered on 9/30/23 at 3:37 PM.

Further review of ED Restraint Information documentation dated 9/30/23 at 5:00 PM revealed behavior unchanged, does not respond to other interventions, continue restraint episode, and at 7:00 PM, behavior interfering with medical care, continue restraint activity.

Record review revealed no order to discontinue restraint use and no documentation PI # 24 was evaluated for the need for continued restraints, no criteria for continued restraint use, no nursing assessment, and no attempted alternative measures to prevent restraint use were documented after 7:00 PM.

Record review revealed transfer documentation dated 9/30/23 at 10:43 PM, PI # 24 was transferred to a higher level of care.

An interview was conducted on 11/30/23 at 1:56 PM with Employee Identifier (EI) # 3, ED Manager who stated PI # 24 was transferred in restraints. EI # 3 confirmed staff failed to document clinical justification and rationale for continued use of the restraint.

Based on review of medical records (MR), facility policies, and interview, it was determined the facility failed to ensure patients in restraints due to violent/self destructive behavior and non-violent/non-destructive behavior were monitored per facility policy.

This deficient practice affected two of two MR's reviewed of patients in restraints including Patient Identifier (PI) # 20, PI # 24 and had the potential to affect all patients requiring restraints at this facility.

Findings include:

Facility policy: Restraint Policy
Policy number: NGEN-LEG-7
Date reviewed: 4/2022

Purpose:
To provide guidelines on appropriate and safe use of restraints...

Registered Nurse (RN):

...Initiates, assesses, and ensures safe monitoring of the restrained patient for the duration of the restraint episode...

...Non-Violent/Non-Self Destructive Management Restraint...

Re-evaluation:

RN (Registered Nurse) will re-evaluate the patient at least every 2 hours for the continued use of restraint...

Procedure:

Violent/Self Destructive Management Restraint and/or Seclusion...

Re-evaluation:

... The RN will assess at a minimum of every 2 hours for the continued use of restraint...

RN Assessment/Monitoring and Documentation every 2 hours for signs of injury...level of distress...readiness for discontinuation...

At a minimum of every 15 minutes the following assessment criteria should be collected. This function may be delegated to direct care staff:

Assessment of need for restraint placement...(Readiness for discontinuation of use of restraint).

1. PI # 20 was admitted on 5/3/23 with diagnoses including Acute Exacerbation of Psychosis, Methamphetamine Abuse, Rhabdomyolosis, and UTI (Urinary Tract Infection).

Review of the Physician's Orders dated 5/4/23 at 12:03 AM revealed a telephone order for non-violent restraint monitoring.

Review of the Nursing Narrative Note dated 5/4/23 at 12:36 AM revealed the nurse documented "...In trying to calm the pt. (patient), (he/she) began to indicate (he/she) was going to bite another nurse in the room. Orders given for soft, non-violent restraints..."

Review of the Nursing documentation, Restraints Information, revealed the RN documented every two hours the continued use of restraints from 5/4/23 at 12:38 AM through 5/5/23 at 6:07 AM.

There was no documentation of every 15 minute checks.

An interview was conducted on 11/30/23 at 1:50 PM with Employee Identifier (EI) # 8, RN, Team Leader, who confirmed PI # 20 was exhibiting violent behavior and the physician's orders should have been for Violent/Self Destructive management. EI # 8 further confirmed there was no documentation of every 15 minute patient checks for a patient in restraints for violent/self destructive behavior.



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2. PI # 24 presented to the ED on 9/30/23 at 3:00 PM combative, screaming, not following commands, unconsolable. ED documentation revealed via emergency medical transport (EMT) administered Valium 10 mg (milligram) IM (intramuscular) prior to arrival.

Review of the ED record documentation revealed Patient Care Orders dated 9/30/23 at 3:11 PM, restraint initiate non violent (behavior), reduce injury, soft limb valid for 1 calendar day, restraint monitoring non violent every 2 hours (hrs).

Further review of ED Restraint Information documentation dated 9/30/23 at 7:00 PM, behavior interfering with medical care, continue restraint activity.

Record review revealed transfer documentation dated 9/30/23 at 10:43 PM, PI # 24 was transferred to a higher level of care.

There was no documentation the RN assessed and monitored PI # 24 every 2 hours from 7:00 PM to 10:43 PM for signs of injury, distress, and readiness for restraint discontinuation. There was no documentation the restraints were discontinued.

An interview was conducted on 11/30/23 at 1:56 PM with EI # 4, ED Manager who reported PI # 24 was transferred in restraints. EI # 4 confirmed staff failed to document clinical justification and rationale for continued use of the restraint.

Based on medical record (MR) review, facility policy, facility Medical Staff Rules and Regulations, and interview, it was determined the facility failed to ensure a one hour face to face was conducted.

This affected one of two MR's reviewed of restrained patients including Patient Identifier (PI) # 20, and had the potential to affect all patients restrained at this facility.

Findings include:

Facility policy: Restraint Policy
Policy number: NGEN-LEG-7
Date reviewed: 2/2022

...Physician/Licensed Independent Practitioner (LIP):

Evaluates need for patient restraint...

Conducts a face to face evaluation of the patient restrained based on the criteria for non-violent...verses violent/self destructive management restraint criteria and reassesses need within appropriate time frame per age specific criteria...

Violent/Self Destructive Management Restraint and/or seclusion...

A required face to face evaluation by the Physician/LIP within 1 hour of restraint application...

Atmore Community Hospital Rules & Regulations

Revised: 12/2/21

...Article X. Restraints...

1. If restraints are necessary for Behavior Management (the patient has abusive/aggressive behaviors that are harmful to themselves or others). The physician must physically see the patient within 1 (one) hour of restraint application and may verbally renew this after the first four hours for an additional 4 (four) hours for an additional 4 hours. Then, the physician must physically see and assess the patient every 8 hours...

1. PI # 20 was admitted on 5/3/23 with diagnoses including Acute Exacerbation of Psychosis, Methamphetamine Abuse, Rhabdomyolosis, and UTI (Urinary Tract Infection).

Review of the Physician's Orders dated 5/4/23 at 12:03 AM revealed a telephone order for non-violent restraint monitoring.

Review of the Nursing Narrative Note dated 5/4/23 at 12:36 AM revealed the nurse documented "...In trying to calm the pt. (patient), (he/she) began to indicate (he/she) was going to bite another nurse in the room. Orders given for soft, non-violent restraints..."

Review of the History and Physical dated 5/4/23 at 9:30 AM revealed the physician documented PI # 20 was displaying signs of acute psychosis, hallucinating, agitated and fighting with staff and was verbally and physically abusive to staff.

Further review of the MR and physician documentation revealed no documentation a face to face was conducted within one hour of the restraint application and no documentation the physician or LIP assessed the patient every eight hours while in restraints.

An interview was conducted on 11/30/23 at 1:50 PM with Employee Identifier (EI) # 8, Registered Nurse (RN) Team Leader, who stated the restraint order should have been for violent behavior and confirmed there was no documentation of a face to face by the physician or LIP.

Based on review of the facility QAPI (Quality Assurance and Performance Improvement) program documentation, facility policy and interviews, it was determined the hospital QAPI program failed to include reporting data for each department of the hospital.

This deficient practice had the potential to affect all patients admitted to this hospital.

Findings include:

Facility policy: Performance Improvement Plan
Policy number: Not provided
Date reviewed: 1/2023

...The purpose of the plan for improving organizational performance is to provide the framework for ensuring the involvement for the entire organization's performance...

Objectives: ...

e. Ensure coordination of efforts and collaboration among departments, services, patient care and areas and professional teams.

f. Improve patient care processes and outcomes through continually monitoring and evaluating the quality and appropriateness of patient care, clinical performance and other patient related processes...

Each clinical area and support service department defines the scope of care and services which is provided...All performance improvement activities are coordinated and communicated through the PI (Performance Improvement) Committee...

1. A review of the QAPI data was conducted on 11/30/23 at 2:00 PM. There was no documentation of data submitted for Dietary or for Dialysis services.

An interview was conducted on 11/30/23 at 2:40 PM with Employee Identifier (EI) # 1, Registered Nurse (RN) Manager, who stated the Dietary and the Dialysis departments were contract services and neither had submitted any QAPI data and were not included in the overall QAPI plan.



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2. During a review of the Swing Bed program services on 11/29/23 from 9:22 AM until 9:50 AM with EI # 4, Case Management, the surveyor asked, "What data is the Swing Bed unit collecting, and reporting to the hospital quality assurance improvement committee? EI # 4 stated, "the Swing bed unit is not reporting data to the hospital quality committee. The surveyor then asked EI # 4, "Does the Swing bed unit report any quality indicators that are integrated into the hospital quality program? EI # 4 responded, "No".

In an interview conducted on 11/29/23 at 9:22 AM, EI # 4 confirmed the Swing Bed unit failed to collect, analyze, and submit quality data to the hospital quality improvement committee.

Based on review of facility policy and procedure, medical records (MR), and interviews, it was determined the facility failed to ensure:

1. Wounds were assessed per facility policy.

2. Wound care was provided as ordered.

This affected two of three MR's reviewed with wounds, including PI (Patient Identifier) # 19, PI # 1, and had the potential to affect all patients with wounds.

Findings include:
Facility Policy: Pressure Ulcer/Wound/Skin Assessment and Care
Policy Number: NGEN-SKI-2
Date Revised: 3/2019

...Policy:

The nurse shall assess and document the condition of the skin upon admission, daily...and prior to the discharge.
...The nurse shall assess changes in existing dermal lesions or pressure ulcers at the time of each treatment or dressing change.

...Pressure ulcer/Wound Documentation

Assess/documentation of wound(s) should be done within 24 hours of admission.

Change in status (...acute to swing bed)-Admission assessment/weekly measurements...

Documentation of wound appearance should include...
Location.
...Shape.
Tunneling/undermining/margins.
Description of surrounding tissue.
Description of exudates (drainage)
Wound care provided including dressing...

1. PI # 19 was admitted to the Swing Bed unit on 11/9/23 with diagnoses including Sepsis and Generalized Weakness and was discharged on 11/22/23.

Record review revealed Medication Reconcilation documentation dated 11/9/23 at 10:44 AM, revealed orders, left inner buttock apply triad cream daily and as needed.

MR review revealed a nutritional assessment completed by the Registered Dietician on 11/20/23 revealed PI # 19 had a left inner buttock wound.

Further MR review revealed no wound assessment documentation, and no documentation triad cream was applied daily from admission to discharge.

An interview was conducted on 11/30/23 at 10:44 AM with EI (Employee Identifier) # 4, Case Management, who confirmed there were no wound assessments and no wound care documentation.



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2. PI # 1 was admitted to the hospital on 11/16/23 with diagnoses including Adult Neglect, Heart Failure, Multiple Wounds, Necrotic Toes and Protein Calorie Malnutrition.

Review of the physicians order dated 11/17/23 revealed wounds to the right lateral ankle, left lateral ankle, right hip, left lateral elbow, left hip, and sacrum were to be cleaned with 0.25% acetic acid, patted dry, covered with a nickel thick layer of Santyl, a 0.25% acetic acid moistened gauze applied, over the Santyl, within the confines of the wound edges, then a dry gauze and either Mepilex or tape applied to create a pressure dressing daily.

Review of the nursing notes documentation for the wounds to the right lateral ankle, left lateral ankle, right hip, left lateral elbow, left hip, and sacrum revealed the following:

On 11/17/23 there was no documentation of a wound assessment for the six wounds.

On 11/18/23 there was no documentation of the tunneling/undermining/margins, surrounding tissue, and exudates for the six wounds.

On 11/19/23 there was no documentation of a wound assessment for the six wounds.

On 11/20/23 there was no documentation of the tunneling/undermining/margins, surrounding tissue, and exudates for the six wounds. Further review revealed the six wounds were cleaned with Normal Saline instead of the 0.25% acetic acid as ordered during the daily wound care.

On 11/21/23 there was no documentation of the surrounding tissue and exudates for the six wounds. Further review revealed the six wounds were cleaned with Normal Saline instead of the 0.25% acetic acid as ordered during the daily wound care.

On 11/22/23 and 11/23/23 there was no documentation of the tunneling/undermining/margins, surrounding tissue, and exudates for the six wounds.

Further review on 11/23/23 revealed the six wounds were cleaned with Normal Saline instead of the 0.25% acetic acid as ordered during the daily wound care.

On 11/24/23 there was no documentation of a wound assessment and wound care for the six wounds.

On 11/26/23 there was no documentation of a wound assessment and wound care for the six wounds.

On 11/27/23 there was no documentation of a wound assessment for the six wounds and no documentation of wound care to the left lateral ankle, right hip, left lateral elbow, left hip, and sacrum wounds.

An observation was conducted on 11/29/23 to observe wound care to the right lateral ankle, left lateral ankle, and left lateral elbow with EI # 12, Registered Nurse and EI # 11, Medical-Surgical Manager. During the observsation, EI # 12 failed to apply the 0.25% acetic acid moistened gauze, over the Santyl, prior to the placement of Mepilex to cover the three wounds.

Review of the physicians order dated 11/20/22 revealed wounds to the left shoulder, right shoulder, left hip, right lateral lower thigh, right lateral upper calf, left lower lateral thigh, left lateral knee, and left upper lateral calf were to be cleaned with normal saline, patted dry, and Mepilex applied every three days and as needed.

Review of the nursing notes from 11/23/23 to 11/27/23 revealed care was performed to the eight wounds on 11/23/23. There no documentation wound care was performed right shoulder, right lateral lower thigh, right lateral upper calf, left lower lateral thigh, left lateral knee, and left upper lateral calf wounds after care performed on 11/23/23.

Review of the nursing notes dated 11/25/23 revealed documentation wound care was performed to the the left shoulder and left hip wounds with the use of 0.25% acetic acid instead of the normal saline as ordered.

An interview was conducted on 11/30/23 at 2:17 PM with EI # 11, Medical-Surgical Manager, who confirmed the hospital staff failed to perform wound assessments per the hospital policy and wound care per the physician's orders. EI # 11 also confirmed EI # 12 failed to apply the 0.25% acetic acid moistened gauze to the three wounds during the observation of wound care on 11/29/23.

Based on review medical records (MR) and interview, it was determined the nursing staff failed to administer sliding scale insulin as ordered by the physician. This deficient practice affected two of fourteen current inpatient MR reviews including, Patient Identifier (PI) # 14 and PI # 4, and had the potential to affect all patients served by the facility.

Findings Include:

1. PI # 14 was admitted to the facility on 11/27/23 with diagnoses including intractable nausea and vomiting, abdominal cramping, and hypokalemia (low potassium level).

Record review revealed an insulin Regular sliding scale order modification dated 11/27/23 at 11:14 PM for the following:

Equal to or < (less than) 50 institute hypoglycemic (low blood sugar-BS) protocol
51-149 no coverage
150-200 10 U (units) sq (subcutaneously)
201-250 12 U sq
251-300 14 U sq
301-350 16 U sq
351-400 20 U sq
> 400 20 U sq, recheck BS (blood sugar/blood glucose) in one hour, if greater than 350, call M.D. (medical doctor).

Record review revealed the Point of Care (POC) Blood Glucose (BG) level documentation dated 11/28/23 at 11:33 AM, the BG was 199 (high) and the Medication Administration Summary Report (MASR) documentation revealed 4 units insulin was administered at 11:40 AM.

Staff failed to follow the modified sliding scale insulin orders and administer insulin 10 U for BG 150-200.

Further review of the POC BG Level documentation dated 11/29/23 at 6:25 AM revealed BG was 195 (H). The MASR documentation revealed insulin 12 U was administered at 6:32 AM.

Staff failed to follow the modified sliding scale insulin orders and administer insulin 10 U for BG 150-200.

An interview was conducted on 11/30/23 at 10:45 AM with EI (Employee Identifier) # 11, Medical Surgical Unit Manager, who confirmed staff failed to follow physician orders for sliding scale insulin administration.



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2. PI # 4 was admitted to the facility on 11/28/23 with diagnoses including Uncontrolled Type 2 DM (Diabetes Mellitus) with Hyperosmolar Nonketotic Hyperglycemia and Benign Essential Hypertension.

Record review revealed a physician's order for NPO (nothing by mouth) dated 11/28/23 at 6:47 PM and discontinued on 11/30/23 at 8:41 AM.

Record review revealed a physician's order for Humalog sliding scale dated 11/29/23 at 8:30 PM for the following:

Equal to or < 50 institute hypoglycemic protocol
51-149 no coverage
150-200 4 U sq
201-250 6 U sq
251-300 8 U sq
301-350 12 U sq
351-400 16 U sq
> 400 20 U sq, recheck BS in one hour, if greater than 350, call M.D.

Record review revealed the POC BG level documentation dated 11/29/23 at 9:14 PM, the BG was 178 and the MAR (Medication Administration Report) documentation revealed the 4 U of Humalog sliding scale insulin was not administered as ordered due to the patient NPO status.

An interview was conducted on 11/30/23 at 1:45 PM with EI # 2, Director of Nursing, who verbalized the patient had been NPO since admission, due to being on an insulin drip, and the patient should have received the ordered sliding scale insulin. EI # 2 confirmed the staff failed to follow physician orders for sliding scale insulin administration.

Based on review of facility policy and procedure, medical record (MR), and interview, it was determined staff failed to follow the RD (Registered Dietician) nutritional recommendations in one of one Swing Bed records reviewed, and did affect PI (Patient Identifier) # 19, and had the potential to affect all patients admitted to the Swing Bed unit.

Findings include:

Facility Policy: Nutrition Assessment
Policy Number NGEN-SWB-7
Date Reviewed: 7/2022

Policy:

Based on a patient's comprehensive assessment, the facility will ensure that a patient maintain in acceptable parameters of nutritional status ...

Procedure:

...2. If there is an identified need for dietary consultations, she/he will review the chart and interview the patient/family ...make recommendations for diet type, supplement ...

3. The dietician ...participates in all interdisciplinary team meetings...makes recommendation as needed ...

Facility Policy Physician's Orders
Policy Number: None listed
Date Revised 6/2021

...Policy:

All orders for treatment shall be in writing. A verbal order shall be considered in writing if dictated to ...to practitioners by an appropriately registered or licensed person ...Nurse ...Dietician ...

...orders may be taken...to those involving performance of the particular professional skills of the person taking the order ...

1. PI # 19 was admitted to the Swing Bed unit on 11/9/23 with diagnoses of Sepsis and Generalized Weakness.

MR review revealed a nutritional assessment completed by the RD on 11/20/23 revealed PI # 19 was on a regular diet, had a left buttock wound, and a history of ulcerative colitis. The dietary recommendations included Ensure (oral nutritional supplementation drink) three times daily, RD follow-up as needed.

Further medical record review revealed no order to modify PI # 19's diet to include Ensure. There was no documentation PI # 19 received Ensure.

An interview was conducted on 11/30/23 at 10:44 AM with Employee Identifier # 4, Case Management, who confirmed there was no documentation PI # 19 was provided the recommended nutritional supplementation.

Based on observations during facility tour with hospital staff by the Life Safety Surveyor and staff interviews, it was determined the facility was not constructed, arranged and maintained to ensure patient safety. This had the potential to negatively affect all patients served by the hospital.

Findings include:


Refer to Life Safety Code violations at K 0133, K 0211, K 0226, K 0324, K 0355, K 0363, K 0511, K 0781, K 0918, K 0920, K 00353 and K 0929.

Based on review of facility policies and procedures, Sani-T-10 Plus Sanitizer manufacturer's instructions, BNC -15 (disinfectant solution brand) manufacturer's instructions, Centers for Disease Control and Prevention (CDC) Environmental Cleaning in Healthcare Facilities, observations, and interview it was determined the facility failed to ensure staff:

1. Followed the policy for hand hygiene and glove use.

2. Followed the manufacturer's instructions to ensure the sanitation of dietary pots and pans.

3. Followed the manufacturer's guidelines and CDC environmental cleaning procedures to ensure the disinfection of a patient room.

4. Maintained the disinfected status of cleaned patient reusable equipment.

This affected PI (Patient Identifier) # 37, and PI # 38 in two of two outpatient care observations, one of one observations for the sanitation of dietary pots and pans, and one of one dietary plating observations and had the potential to affect all patients treated at the facility.

Findings include:

Facility Policy: Hand Hygiene Guidelines
Policy Number: NGEN-INF-27
Date Revised: 01/2023

...Policy:

...The following are the CDC's (Centers for Disease Prevention) recommendations for hand washing ...

Procedure:

B. Hand Hygiene Technique

2. Soap and water wash:

b. Apply soap ...
d. Rinse hands with water
e. Dry ...with a disposable towel
f. Use disposable towel to turn off faucet ...

Facility Policy: Guideline for Appropriate Glove Use and Glove Technique
Policy: None listed
Date Revised: 01/23

...Procedure:

...Hand hygiene must be performed before donning gloves.
Hand hygiene must be performed immediately after removing gloves.

...D. Gloves should be changed...between each task (example, after contact with a contaminated surface or environment)

Sani-T-10 Plus Sanitizer Manufacturer's Instructions
Date: 12/14

...3. Sanitize.
Fill...sanitizer sink with Sani-T-10 Plus solution...using room temperature water.
...Check to be sure Sani-T-10 Plus is between 150 - 400 ppm (parts per million) with test strips.
Immerse the equipment for at least 1 (one) minute, then air dry.

Sani-T-10 Plus Sanitizer Test Strip Instructions.
...Test should reach 150-400 ppm, with a target of 200 ppm.

CDC Environmental Cleaning in Healthcare Facilities.
Date reviewed: 4/21/2020

...4. Environmental Cleaning Procedures... provides the current best practices for environmental cleaning procedures in patient care areas...

4.1 General environmental cleaning techniques.

...Proceed from cleaner to dirtier areas to avoid spreading dirt and microorganisms. Examples include:

...Clean patient areas...before patient toilets...

...Common high-touch surfaces include: ...doorknobs...light switches.

...4.2.3 Terminal or discharge cleaning of inpatient wards.

Terminal cleaning of inpatient areas, which occurs after the patient is discharged...includes the patient zone and the wider patient care area and aims to remove organic material and significantly reduce and eliminate microbial contamination to ensure that there is no transfer of microorganisms to the next patient.

...This is the general terminal cleaning process:

...5. Clean and disinfect all low and high-touch surfaces...

BNC-15 Manufacturer's Instructions
Date: Not documented.

This product is bactericidal...Contact time...3 minutes...

1. An observation was conducted on 11/28/23 at 9:55 AM with EI # 14, dietary sanitation staff, to observe the cleaning of the dietary pots and pans using a three compartment sink.

EI # 14 turned on the cold water faucet over the third sink compartment then turned the knob of the Sani-T-10 Plus Sanitizer to fill the third sink compartment. EI # 14 failed to ensure the water was room temperature per the manufacturer's instructions.

While the third sink compartment continued to fill, EI # 14 dipped the sanitizer test strip into the water in the third sink compartment then compared the test strip to the sanitizer test strip container. The test strip when compared to the test strip container measured the sanitizer at 50 ppm, which was 100 ppm below the recommended ppm of the sanitizer concentration.

EI # 14 filled the third sink compartment until approximately two inches below the fill line marked on the outside of the sink failing to fill the sink to the designated fill line.

EI # 14 then obtained a second sanitizer test strip and dipped the sanitizer test strip into the water in the third sink compartment then compared the test strip to the sanitizer test strip container. The test strip when compared to the test strip container measured the sanitizer at 50 ppm, which was 100 ppm below the recommended ppm of the sanitizer concentration.

EI # 14 filled the other two sink compartments and started to individually clean four pots and two pans. EI # 14 immersed each pot and pan into the sanitizer solution then immediately removed failing to fully immerse each pot and pan for at least one minute per the manufacturer's instructions.

An interview was conducted on 11/28/23 at 2:54 PM with EI # 6, Culinary Director, who confirmed EI # 14 failed to follow the manufacturer's instructions for the concentration of the sanitizer and ensuring each pot and pan was immersed for one minute in the sanitizing water.

2. An observation was conducted on 11/28/23 at 11:05 AM with EI # 13, dietary staff, to observe the plating of patient lunches.

During the observation, EI # 13 donned gloves, removed the containers of green beans, mash potatoes, gravy, and meatloaf from the oven, placed the food containers on the steam table, then obtained the temperature of each food without performing hand hygiene prior to donning gloves.

EI # 13 then proceeded to obtain water from the kitchen sink faucet and vegetable base from the walk in refrigerator, then mixed the vegetable base into the water over the stove to prepare vegetable soup without removing gloves and perform hand hygiene prior preparing vegetable soup.

EI # 13 removed gloves then donned gloves without performing hand hygiene after removing gloves then donned oven mitts over the gloves, removed a tray of bacon from the oven, used gloved hands to break bacon into small pieces, removed the used parchment paper on the bacon tray, placed the parchment paper in the trash can, and used gloved hand to push the parchment paper down into the trash can.

EI # 13 then donned a second pair of gloves over the gloves used for the bacon and cut up green beans and meatloaf on cutting board into small pieces and placed on four patient trays.

EI # 13 removed both sets of gloves, removed knife and cutting board used to cut up green beans and meatloaf then donned gloves without performing hand hygiene, and placed covers over the food on the steam table.

An interview was conducted on 11/28/23 at 2:54 PM with EI # 6, Culinary Director, who confirmed EI # 13 failed to follow the facility policy for hand hygiene and glove use.

Observations of care were conducted on 11/28/23 in the Outpatient infusion and Outpatient Therapy departments with the following hand hygiene observations:

3. At 1:00 PM in the Outpatient infusion department the surveyor observed care during an iron infusion for PI # 38. EI (Employee Identifier) # 9, Outpatient Registered Nurse (RN), cleaned the overbed table with disinfectant wipes, removed gloves, washed hands, and turned off the faucet with bare hands and not a disposable towel.

After starting PI # 38's IV (Intravenous access) EI # 9 washed hands in the sink, turned off the faucet with bare hands and not a disposable paper towel.

EI # 9 failed to follow the facility hand hygiene policy.

An interview was conducted on 11/29/23 at 2:20 PM with EI # 1, RN Manager who confirmed after hand hygiene staff should turn off the faucet with the disposable paper towel.

4. At 2:00 PM in the Outpatient Therapy department, EI # 10, Licensed Physical Therapy Assistant provided therapy treatment with PI # 37.

EI # 10 evaluated PI # 37 during therapy which included patient contact with ungloved hands. Next EI # 10 performed hand washing in the sink, and turned the faucet off with a bare hand. After PI # 37's treatment was complete, EI # 10 removed the sheet from the treatment table and pillow case from the pillow, discarded the used linens into the linen hamper, and performed hand hygiene at the sink. EI # 10 turned the faucet off with clean bare hands.

EI # 10 failed to follow the facility hand hygiene policy.

An interview was conducted on 11/29/23 at 2:20 PM with EI # 1 who confirmed after hand hygiene staff should turn off the faucet with the disposable paper towel.

5. An observation was conducted on 11/29/23 at 10:04 AM with EI # 15, Environmental staff, to observe the terminal cleaning of patient room 265.

EI # 15 removed used linen from the room bed and proceeded to clean the air mattress pad with BNC-15 solution cloth. As the air mattress pad was cleaned it was then rolled onto itself immediately without allowing a contact time of three minutes per the manufacturer's instructions. After the air mattress pad was fully rolled onto itself, EI # 15 removed the air mattress pad from the room and laid the mattress pad on the hallway floor outside of the patient room. EI # 15 failed to maintain the disinfected status of the air mattress pad by placing the disinfected mattress pad on the hospital hallway floor.

After cleaning the toilet in the patient bathroom, EI # 15 proceeded to clean a patient reusable walker then the room sink with the same gloves used to clean the patient bathroom toilet.

EI # 15 failed to clean the bed frame of the hospital bed, the room and bathroom light switches, and the room and bathroom door knobs during the observation.

An interview was conducted on 11/30/23 at 2:41 PM with EI # 16, Environmental Director, who confirmed EI # 15 failed to disinfect the air mattress pad per the manufacturer's instructions, maintain the disinfected status of the air mattress by placing the disinfected mattress pad on the hospital hallway floor, changed gloves per the hospital policy, and cleaned the patient room per CDC guidelines.



40119

Based on medical record (MR) reviews, facility policy, and interview, it was determined the facility failed to ensure a post anesthesia assessment was completed for all patients receiving anesthesia

This affected one of six MR reviewed of patients receiving anesthesia including Patient Identifier (PI) # 35 and had the potential to affect all patients receiving anesthesia at this facility.

Findings include:

Facility policy: Post-Anesthetic Patient Assessment
Policy number: ANES-09
Date reviewed: 6/2020

...All patients who have received anesthesia other than "local only" should be evaluated...prior to discharge from the PACU (Post Anesthesia Care Unit)...each patient should be evaluated by the anesthesia provider and a note should be written on the anesthetic record documenting the patient's status, including any post-anesthesia complications...

1. PI # 35 was admitted for an outpatient Colonoscopy on 11/21/23.

Review of the Anesthesia Record dated 11/21/23 revealed the CRNA (Certified Registered Nurse Anesthetist) administered anesthesia medications including Ketamine 12.5 mg (milligrams), Lidocaine 80 mg, and Propofal 230 mg during the procedure.

Review of the Anesthesia Record, Post-Anesthesia Note, revealed no documentation an assessment was completed by the CRNA.

In an interview conducted on 11/30/23 at 2:03 PM, Employee Identifier # 5, Operating Room Manager, confirmed the staff failed to document a post-anesthesia note per facility policy.

Based on review of facility policy, ED (Emergency Department) medical records (MR's), and interview with facility staff, it was determined the facility failed to ensure the staff:

1. Screened all adult patients for suicide risk assessment, which affected three of four ED records reviewed on ED patients able to be screened for suicide risk and included PI # 21, PI # 23, and PI # 28.

2. Submitted ED records to the receiving facility upon transfer per policy and procedure. This affected six of six ED transfers and included PI # 21, PI # 25, PI # 30, PI # 26, PI # 22, PI # 27.

3. Followed the facility policy, documented orders were received or no order was received after critical lab (laboratory) results were reported to the ED physician in one of ten record reviews that included PI # 30.

This had the potential to negatively affect all patients who were treated in the ED.

Findings include:

Facility Policy: Suicidal Precautions
Policy Number NGEN-SAF-7
Date Revised: 10/2023

...Purpose: To guide staff in caring for the patient experiencing suicidal ideation...for providing safe nursing care for the suicidal patient.

Policy:

All adult patients treated in the ED...will be assessed for suicidal risk. Patients...identified...at risk will be placed on Suicide Precautions...

Facility Policy: Transfer/Discharge of an Unstabilized Patient to Another Acute care/Specialty Facility Policy
Policy Number: None listed
Date Reviewed: 5/2021

...Transfer/Discharge of an Unstabilized Patient to Another Acute care/Specialty Facility Procedure.

...3. Continue to provide medical treatment within the hospital's capacity that minimizes the risk...
7. Send all medical records relating to the emergency medical condition with the patient...
8. Fully complete the transfer to acute care/specialty facility summary form...

Facility Policy and Procedure: Panic (Critical) Values and Critical Tests
Policy Number: None listed
Review Date: 5/21

...Policy:

Critical results are defined as results of tests...that fall significantly outside the normal range and may indicate a life threatening situation...provide the responsible licensed caregiver these results...so...the patient can be promptly treated.

Procedure:

1. The critical result...called to the physician...patient's licensed nurse.
...4. Document in the MR the date, time, who was notified, result given and any orders received, If no new orders are received, note that in the MR also...

1. PI # 21 presented to the ED on 11/23/23, chief complaint (cc), right sided abdominal pain.

Review of the ED record documentation failed to reveal PI # 21 was assessed for suicide risk.

MR review revealed on 11/23/23 at 5:16 PM PI # 21 was transferred to a higher level of care. There was no documentation ED records were sent to the receiving facility upon transfer.

An interview was conducted on 11/30/23 at 3:20 PM with EI (Employee Identifier) # 3, ED Manager, who confirmed there was no documentation PI # 21 was assessed for suicide risk and no documentation ED records were sent to the receiving facility at transfer.

2. PI # 25 presented to the ED on 10/16/23 at 10:28 AM, family present, and the cc was Suicidal Ideations (SI).

Record review revealed PI # 25 was seen by the ED physician at 10:49 AM, assessment was SI, and a plan to set self on fire. The treatment plan was transfer to a mental health facility for further care.

MR review revealed PI # 25 was transferred on 10/16/23 at 8:15 PM. There was no documentation ED records were sent to the receiving facility.

An interview was conducted on 11/30/23 at 3:20 PM, with EI # 3 who confirmed there was no documentation the ED record was provided to the receiving facility at transfer.

3. PI # 23 presented to the ED on 11/26/23, cc was rat bite.

MR review revealed no documentation PI # 23 was assessed for suicidal risk.

An interview was conducted on 11/30/23 at 3:20 PM with EI # 3 who confirmed there was no documentation PI # 23 was assessed for suicidal risk.

4. PI # 30 presented to the ED on 9/30/23 via Emergency Medical Transport (EMT), combative, screaming, unconsolable, was triaged at 3:00 PM and ED nurse documentation revealed PI # 30 was crying, disruptive, explosive, hostile, and disheveled.

MR review revealed a critical glucose level 657 resulted on 9/30/23 at 3:28 AM.

Record review revealed the ED physician saw PI # 30 at 3:34 PM, the assessment was psychiatric paranoia, atrial fibrillation with rapid ventricular response.

Further record review revealed the glucose level, critical results 657, were called to the ED RN on 9/30/23 at 4:57 PM, and physician communication log documentation completed by the ED RN on 9/30/23 at 5:13 PM revealed the ED physician was notified of the glucose 657.

Further record review revealed no order for treatment for the critical glucose, and no repeat glucose testing was completed.

There was no documentation of orders received after the physician was notified of the critical glucose per facility policy.

Record review revealed PI # 30 was transferred to a facility with an intensive care admission on 9/30/23 at 6:51 PM. There was no documentation ED records were sent to the receiving facility upon transfer.

An interview was conducted on 11/30/23 at 1:56 PM with EI # 3 who confirmed there was no documentation treatment was provided for the critical blood glucose. The surveyor asked EI # 3 if he/she asked the ED physician if orders were provided for treatment of the 657 glucose? EI # 3's response was no.

5. PI # 26 presented to the ED on 5/28/23, cc, 35 weeks pregnant, premature ruptured membranes.

Record review revealed PI # 26 was transferred to a higher level of care 5/28/23 at 12:15 PM. There was no documentation the ED records were sent to the receiving facility.

An interview was conducted on 11/30/23 at 2:13 PM with EI # 3 who confirmed there was no documentation ED records were sent to the receiving facility at transfer.

6. PI # 22 presented to the ED on 11/9/23, cc was unresponsive, cardiac and/or respiratory arrest, accidental overdose.

MR review revealed PI # 22 was transferred to a critical care facility 11/9/23 at 10:00 PM. There was no documentation ED records were sent to the receiving facility.

An interview was conducted on 11/30/23 at 2:24 PM with EI # 3 who confirmed there was no documentation the ED record was sent to the receiving facility at transfer.

7. PI # 27 presented to the ED on 6/17/23, cc was unresponsive, overdose.

MR review revealed PI # 27 was transferred to a critical care facility 11/9/23 at 11:20 PM. There was no documentation ED records were sent to the receiving facility.

An interview was conducted on 11/30/23 at 1:42 PM with EI # 3 who confirmed there was no documentation the ED record was sent to the receiving facility at transfer.



49603

8. PI # 28 presented to the ED on 8/04/23, cc was syncope.

MR review revealed no documentation PI # 28 was assessed for suicidal risk.

An interview was conducted on 11/30/23 at 3:20 PM with EI # 3 who confirmed there was no documentation PI # 28 was assessed for suicidal risk.

Based on review of the employee files, and interview with the staff it was determined the facility failed to ensure contracted staff completed the initial Emergency Preparedness (EP) training.

This deficient practice did affect one of two contract employee files reviewed, including Employee Identifier (EI) # 6, Director of Culinary Services and had the potential to negatively affect all staff and patients served by the clinic.

Findings include:

1. A review of employee files conducted on 11/30/23 revealed EI # 6 was hired on 2/20/23.

There was no documentation EI # 6 had received initial training in emergency preparedness.

An interview was conducted on 11/30/23 at 12:02 PM with EI # 1, Registered Nurse Manager, who confirmed EI # 6 had not received initial emergency preparedness training.