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Based on review of facility documentation, review of facility policies, staff interviews, and observation, the facility failed to ensure a safe environment by testing water and/or maintaining equipment in accordance with AAMI standards (ANSI/AAMI RD52:2004 A.6.2.5 Carbon adsorption) and/or manufacturer's directions. The findings include the following:


a. Review of the Acute Dialysis Unit documentation on 12/13/11 at 9:45 AM, failed to identify that the chlorine/chloramine results were recorded in a log sheet. Interview with Nurse #12 on 12/13/11 at 11:00 AM stated that he/she tested the water from the machine in the treatment room and documented each result in the patient's treatment record. RN #12 explained that he/she filled the test tube with water, added the reagent powder, held the tube up to a white background and if there was any color change, the water was not safe for use. The manufacture's directions for use directed a specific amount of water, a three minute development of the reagent after being added to the water, and that the sample be placed in an instrument to obtain a result. The facility failed to follow this procedure. Interview with staff and review of facility policy failed to direct that the water sample be obtained after the first carbon tank in accordance AAMI standards and/or specified the procedure for water testing in accordance with Manufacturer's directions.

In addition review of RN #12's file failed to identify that the employee had been tested for color blindness. Interview with Nurse #12 on 12/13/11 at 11:00 AM identified that he/she had never been tested to discern colors for reading colormetric tests in accordance with AAMI standards.

b. Review of the Main Reverse osmosis (RO) logs on 12/13/11 at 10:00 AM, failed to indicate the frequency of disinfection of the RO and/or treatment water loop. Review of facility documentation and interview with facility staff on 12/13/11 identified that the Main RO was disinfected semiannually and to the best of their knowledge, the loop had never been disinfected. AAMI standards require the loop to be low level disinfected monthly and the manufacturer's directions for use and maintenance states that at no time should the RO go more than 3 months (quarterly) without being disinfected. The facility failed to have a policy directing the time frame between disinfections of the RO and treatment water loop in accordance with standards of practice and/or manufacturer's directions.


Following these observations the facility provided the Department with an immediate action plan that included reeducation of all engineering staff & dialysis staff on proper testing procedures of water, that all personnel would be tested for color blindness, and that the RO and water loop would be disinfected prior to the start of any dialysis treatments on 12/14/11.

Based on medical record reviews, review of hospital documentation, hospital procedures and interviews for one of eight patients reviewed for medical record requests (Patient #25), the hospital failed to ensure that the patients records were sent to the correct patient. The finding include:

Patient #25 was admitted to the Emergency Department (ED) on 2/25/11 and 2/26/11 for an evaluation of depression. The patient's records identified that the patient was tearful and/or anxious and evaluation by the Crisis Team was ordered and/or completed. Facility documentation identified a written authorization by Patient #25 for his/her complete medical records dated 2/25/11 and 2/26/11. Facility documentation entitled event description indicated that the patient's medical records were sent (mistakenly) to Patient #81 on 3/7/11. Interview with the Health Information Director on 12/14/11 at 9:00 AM noted that a data entry error was made by hospital medical records staff and the contracted service sent a copy of Patient #25's medical records to the wrong patient. S/he further indicated that the error occurred, in part, because the contracted service changed their process without informing the hospital. The Health Information Director identified that subsequently, medical records staff was educated to refer to the written authorization release form to verify the address of the mailing destination and the contracted service added an additional step that prompts the medical records staff to verify mailing accuracy.

Based on a review of clinical records, review of facility polices, and interviews, the facility failed to ensure that facility staff implemented the least restrictive restraint for one of three patients, Patient #43, who required intervention based on escalating behaviors. The findings include:

a. Patient #43 was admitted to the facility's Intensive Care Unit (ICU) on 12/4/11 with diagnoses that included seizures and Alcohol abuse (ETOH abuse). A nursing care plan dated 12/5/11 identified the potential for metabolic disturbances related to ETOH withdrawal with interventions that included assessing for agitation, restlessness and cognitive ability and medication in accordance with the facility's CIWA protocol. Review of the clinical record identified that on 12/6/11, Patient #43 experienced agitated behaviors that included an immediate risk to self and pulling at critical lines and tubes. A physician order dated 12/6/11 at 6:01 PM was obtained for a "non-violent" restraint that included bilateral wrist restraints and a vest restraint. The Non-Violent Restraint Observation sheet dated 12/6/11 identified that Patient #43's agitation continued and that the patient was placed in four point restraints and a vest restraint at 7:30 PM (no corresponding physician order written until 9:53 PM on 12/6/11) but lacked documentation of any increased behaviors documented since the 6:01 PM assessment to warrant the addition of bilateral leg restraints.


b. Review of the written progress note dated 12/6/11 at 10:00 PM that corresponded with the 9:53 PM physician order for multiple restraints identified that Patient #43 had been verbally abusive, required the assistance of two staff members to keep him/her in bed, and displayed paranoid and impulsive behaviors. The clinical record lacked documentation to reflect that a comprehensive assessment was provided at the time of application of multiple restraints that included bilateral wrist restraints, bilateral leg restraints, and a vest restraint at 7:30 PM. In addition the record lacked documentation to reflect that less restrictive interventions were attempted before the application of more restrictive restraints (two point to four point restraints).

Review of facility policies directed that the use of restraints be limited to emergencies in which there is imminent risk of harm to the patient and/or other and when non-physical interventions would not be effective. The policy identified that violent and/or self-destructive behavior that jeopardizes the immediate safety of the patient, staff members, or others may warrant the use of restraints. The policy directed that a comprehensive assessment be completed and must include the identification of the behavior that poses the potential risk, the level of risk to self and/or others, alternative interventions tried and/or considered, identification of the least restrictive restraint required appropriate to circumstances. The policy further directed that the risks associated with the restraints must outweigh the benefits, and that the comprehensive assessment be documented in the clinical record.

Based on a review of clinical records, review of facility polices, and interviews, the facility failed to ensure that facility staff implemented the appropriate restraint protocols for one of three patients, Patient #43, who required intervention based on escalating behaviors. The findings include:

a. Patient #43 was admitted to the facility's Intensive Care Unit (ICU) on 12/4/11 with diagnoses that included seizures and Alcohol abuse (ETOH abuse). A nursing care plan dated 12/5/11 identified the potential for metabolic disturbances related to ETOH withdrawal with interventions that included assessing for agitation, restlessness and cognitive ability and medication in accordance with the facility's CIWA protocol. Review of the clinical record identified that on 12/6/11, Patient #43 experienced agitated behaviors that included an immediate risk to self and pulling at critical lines and tubes. Although a physician order dated 12/6/11 at 6:01 PM was obtained for a "non-violent" restraint that included bilateral wrist restraints and a vest restraint review of the Non-Violent Restraint Observation sheet dated 12/6/11 identified Patient #43's agitation but lacked documentation to reflect that the bilateral wrist and vest restraints were applied at that time.

b. Although the physician order for bilateral wrist and a vest restraint had been obtained but not documented as applied, the Non-Violent Restraint Observation sheet dated 12/6/11 identified that Patient #43 was placed in four point restraints and a vest restraint at 7:30 PM. A subsequent physician order for the additional restraints was not obtained until 9:53 PM, more than two hours after the application of the restraints. In addition, the record lacked documentation to reflect that a face to face evaluation for the restraints was conducted by a Licensed Independent Practitioner (LIP) within one hour of the restraint application. Review of the progress note dated 12/6/11 at 10:00 PM with facility staff identified that Patient #43 had been verbally abusive, required the assistance of two staff members to keep him/her in bed and displayed paranoid and impulsive behaviors which indicated violent behaviors and did not warrant the institution of the facility's non-violent restraint protocols.

c. Review of the clinical record dated 12/8/11 at 7:03 AM identified that Patient #43 again became increasingly agitated and that security staff was called to assist. A physician order for four point restraints was obtained and a face to face evaluation was completed based on the patient's violent behavior in accordance with facility policies. Review of the clinical record identified that although Patient #43 remained in restraints on 12/8/11 beyond the time limited order of four hours, no additional orders were obtained until 4:30 PM on 12/8/11. The 4:30 PM restraint order continued to direct that four point restraints remain but now identified the reason for the restraints as Patient #43's as non-violent behavior. Interview with the Regulatory Readiness Coordinator on 12/15/11 at 11:00 AM identified that staff members often believed that the use of restraints for violent behaviors was more a part of the Behavioral Health arena and that most restraints in the ICU were for non-violent behaviors. The Regulatory Readiness Coordinator stated that the facility continued to address the differences between violent and non-violent restraints with facility staff as well as the differences in documentation for each in their ongoing education programs.

Based on review of the medical record, interview with hospital personnel and review of hospital policies, the hospital failed to ensure that one patients (#28) lower extremity was assessed for injury prior to discharge from the hospital. The finding includes:

a. Patient #28 was brought to the ED on 7/28/11, by EMS following a fall. Review of the clinical record reflected that the patient, who normally ambulatedwith a walker, was found in a kneeling position and unable to rise to his/her feet. The report identified that the patient developed cyanosis with an oxygen saturation of 88%. The patient was placed on oxygen via nasal cannula and transported to the ED.

The physician's review of systems reflected the patient had no difficulty walking with full range of motion and non-tender extremities. During interview with MD #7 on 12/15/11, the physician stated that the patient was not walked while in the ED (a discrepancy from the review of symptoms) due to the patient's Congestive Heart Failure (CHF). Patient #28 was admitted to the hospital with CHF and transferred to a nursing unit via stretcher.

Review of nursing documentation for the period of 7/28/11 through 7/31/11, identified that the patient required a maximum assist of two people to get out of bed, had an unsteady gait and right ankle/foot ecchymosis noted consistently for that time period. Review of the physician progress notes for the stated time period failed to reflect that a physician noted the bruises to the right ankle and/or reviewed the physical therapy consultation that had been ordered. Although Person #7 requested a physician to assess the patient's ankle prior to discharge on 7/31/11, the covering hospitalist (MD #8) failed to document that an assessment of the extremity was completed. During interview on 12/19/11, MD #8 stated that he/she did not document the patient's ecchymosis of the ankle and stated that he/she would have assessed the patient's ankles only for edema secondary to the patient's diagnosis of CHF. Review of the patient's discharge summary, written by MD #8, failed to reflect that a physical therapy consult was completed and/or that the patient continued to have ecchymosis of the right lateral ankle and foot on discharge. On 7/31/11, the patient was discharged to an extended care facility where a fracture of the distal fibula was diagnosed two days later. During interview on 12/15/11, the Chief Medical Officer stated that MD #8 failed to assess the patient's leg prior to discharge.

1. Based on a review of five patients' surgical records at the surgical center and interview with hospital personnel, for one patient (#50) the hospital failed to ensure that PACU (post anesthesia care unit) nursing patient assessment documentation reflected the progression of weaning the patient from oxygen post-surgical procedure. The finding includes:
a. Patient #50 underwent surgical repair of a left inguinal hernia on 12/13/11, at the off-site surgical center. Review of the PACU documentation reflected that the patient was sent from the operating room to the PACU at 8:36 AM on oxygen at 10 liters by mask. Although vital signs were completed every 10 minutes until 9:16 AM, the record lacked documentation as to when the oxygen was removed from the patient prior to discharge at 10:05 AM. During interview the nurse caring for the patient stated that she was unaware that she needed to document the removal of oxygen with subsequent recording of the patient's oxygen saturation prior to discharge home from the PACU. During interview on 12/13/11, the Director of Peri-operative Services stated that she would expect the PACU documentation to reflect when the patient was removed from oxygen and the patient's oxygen saturation on room air.
2. Based on review of the clinical record and review of facility policy, for one patient (Patient #28), the hospital failed to ensure that nursing completed a musculoskeletal exam following a fall. The finding includes:
a. Patient #28 was brought to the Emergency Department (ED) on 7/28/11 by EMS following a fall. Review of the clinical record reflected that the patient, who normally ambulates with a walker, was found in a kneeling position and unable to rise to his/her feet. The report identified that the patient was developing cyanosis about the lips and fingertips and had an oxygen saturation of 88%. The patient was placed on oxygen via nasal cannula and transported to the ED. Review of the ED nursing documentation reflected that the triage assessment was completed at 10:27 AM, focusing on the patient's presentation of cyanosis. The initial ED nursing assessment was completed at 1:46 PM (three hours later) and failed to reflect assessment of the musculoskeletal system other than an abrasion to the left knee. During interview on 12/27/11, Person #7 stated that he/she was present with Patient #28 in the ED during evaluation and that nursing staff never removed the patient's socks to fully evaluate the patient's ankles and/or feet. Review of the hospital policy identified that the nursing assessment in the ED should include, within the framework of holistic nursing, subjective and objective patient data significant to the nature and severity of the illness/injury obtained from the patient as well as significant others.
b. Review of Patient #28's nursing assessments for the period of 7/28/11 through 7/31/11 identified that the patient's right ankle, at the malleolus and extending into the top of the foot, was ecchymotic. Review of the clinical record failed to reflect that a physician was notified of the bruising.


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3. Based on medical record reviews, review of facility policies, observations and interviews for one of five patients reviewed for altered skin integrity (Patients #33, ), nursing staff failed to completely assess the patient's wound. The finding includes:

a. Patient #33 was admitted to the orthopedic unit on 12/10/11 with a left hip fracture. The skin assessment dated 12/10/11 identified that the patient had a open "slit" in the gluteal crease. The assessment lacked measurements and the exact location of the open area. Subsequent to surveyor inquiry, the day shift nurse assessed the wound on 12/12/11 and although s/he documented that the wound measured 0.9 centimeters (cm) and was narrow, the location of the wound was not documented. Interview with the Wound Nurse on 12/14/11 at 12:00 pm noted that a nurse's assessment of a wound should include measurements. The hospital policy for wound management directed to assess the wound and surrounding tissue, note location and size and document in the medical record accordingly. The policy for wound measurement procedure identified that all wounds requiring measurements by the Registered Nurses (RNs) will be accomplished, in part, using a single use disposable measuring guide noting centimeters or inches if more appropriate. The Integrated assessment policy identified that each patient is assessed each shift by an RN and is documented electronically.


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4. Based on a review of the clinical record, the facility failed to ensure that weights were obtained pre and/or post dialysis treatment. The finding includes the following:

a. Review of Patient #57's clinical record indicated that the patient had a history of end stage renal disease requiring hemodialysis. Review of the dialysis treatment flow sheet dated 12/12/11 identified under the pre and/or post weight section that the patient was unable to be weighed due to "no bed scale available". The dialysis note reflected that the patients "weight was unavailable due to poor functioning floor scale and no bed scale".


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5. Based on a review of the clinical record, review of facility polices, observations, and interviews, the facility failed to ensure that wound care was provided in accordance with physicians orders for two of four patients, Patient #33 and Patient #41, who were admitted to the facility with altered skin integrity and/or multiple venous stasis ulcers. The findings include:
a. Patient #33 was admitted to the orthopedic unit on 12/10/11 with a left hip fracture. The skin assessment dated 12/10/11 identified that the patient had a open "slit" in the gluteal crease. Nursing flow sheets indicated that a barrier cream was applied to the patient's gluteal wound on the day shifts on 12/ 11/11 and 12/12/11. However, the flow sheets noted that the gluteal wound was left untreated and open to air on the evening shifts on 12/10/11 and 12/10/11 and the night shifts on 12/11/11 and 12/12/11. The hospital policy for wound management identified that treatment for open wounds require a provider order. When treatment orders are delayed, RNs may institute dry sterile dressings to cover/protect the wound. The skin assessment and pressure ulcer risk assessment policy noted that appropriate nursing interventions via nursing care plans will be individualized and documented.
b. Patient #41 was admitted to the facility on 12/6/11 with diagnoses that included multiple venous stasis ulcers. Physician orders directed that dressing changes be provided daily and include the application of a Seasorb dressing. An observation on 12/12/11 at 9:20 AM identified that Patient #41 had bilateral leg dressings with what appeared to be dried, brownish yellow drainage that had soaked through the dressings and onto the pillow under the legs. Review of the clinical record with facility staff at the time of the observation identified that the last dressing change had occurred two days earlier at 2:00 PM on 12/10/11. Interview with RN #8 on 12/12/11 at 9:30 AM identified that although he/she last changed Patient #41's dressing at 3:00 PM on 12/11/11, he/she failed to document the dressing change and/or a description of Patient #41's leg wounds.
c. Observation of the dressing change to Patient #41's left leg provided by RN #8 at 10:00 AM on 12/12/11 identified that the wound drainage had thoroughly dried through the layers of the kerlix wrap and required that RN #8 soak the soiled dressing with water in order to remove it. Upon removal of the kerlix outer dressing wrap, a single wide piece of material was observed directly covering multiple leg ulcers on the patient's posterior and lateral left leg and was subsequently was removed by RN #8. RN #8 identified that the dressing removed was a Seasorb dressing as prescribed by the physician. RN #8 proceeded to cleanse the multiple venous stasis ulcers on Patient #41's left leg before moving to the patient's right leg. RN #8 used the same method (soaking the dressing with water due to dried drainage) to remove the soiled dressing and the same wide, single dressing was removed from the multiple right leg ulcer sites at the right posterior leg. Upon surveyor inquiry, RN #8 provided the box of the product/dressing material that RN #8 believed to be Seasorb dressings, the same dressing material he/she had removed from Patient #41's bilateral leg ulcers and planned to reapply. The product was identified as Interdry, a product used for management of moisture in skin folds. Review of the Interdry product manufacturer's instructions directed that the product not be placed on open wounds. Interview with RN #8 on 12/12/11 at 11:30 AM identified that he/she had made an error when he/she used the wrong product for Patient #41's dressing. Review of facility policies directed that dressing changes be provided in accordance with physician orders.

6. Based on a review of the clinical record, review of facility polices, observations, and interviews, the facility failed to ensure that interventions in accordance with the nursing plan of care were implemented for one of four patients, Patient #41, who was assessed to be at risk to fall and required a bed alarm. The finding includes:
a. Patient #41 was admitted to the facility on 12/6/11 with diagnoses that included Congestive Heart Failure (CHF) and Atrial Fibrillation (A-Fib). Review of the clinical record identified that Patient #41 was assessed to be at high risk for falls. The nursing care plan dated 12/6/11 identified potential for injury related to the patient's risk to fall with interventions that included the use of a bed alarm when in bed. Observation of Patient #41 on 12/12/11 at 9:30 AM identified that Patient #41 was in bed with two half side rails in place but that the patient's bed alarm was off. Subsequent to surveyor inquiry, Patient #41's bed alarm was activated. Review of facility policies directed that a nursing care plan be developed to address the individual needs of the patient and to provide continuity of patient care among health team members and that the interventions be consistently implemented.

7. Based on a review of the clinical record, review of facility polices, observations, and interviews, the facility failed to ensure that documentation of a skin assessment upon admission was accurately completed for one of three patients, (Patient #44), who was identified with two unstageable pressure ulcers within twenty four-hours of admission. The finding includes:
a. Patient #44 was admitted to the facility from a skilled nursing facility on 12/7/11 at 11:23 AM via the Emergency Department (ED) with diagnoses that included fever and rapid Atrial Fibrillation (A-Fib). Review of the interagency referral form sent by the skilled nursing facility dated 12/7/11 lacked documentation to reflect that Patient #44 had pressure ulcers upon transfer to the ED. A Braden assessment dated 12/7/11 at 11:23 AM identified that Patient #44 was at risk to develop pressure ulcers. Review of an initial physical examination provided on 12/7/11 at 2:00 PM identified that Patient #44 had a "left heel closed ulcer" though lacked any further description of size and/or staging of the ulcer. A progress note dated 12/8/11 at 6:50 AM again identified a left heel ulcer without further description of size or staging. Documentation on 12/8/11 at 8:30 AM identified Patient #44 with bilateral heel ulcers. The documentation identified an unstageable rectangular shaped left heel ulcer that measured 3.0 centimeters (cm) by 2.5 cm and an unstageable oval shaped right heel ulcer that measured 3.0 cm by 2.0 cm. Interview with Nursing Director #2 on 12/12/11 at 1:45 PM identified that, although he/she believed that Patient #44's bilateral heel ulcers were present on admission, there was no supporting documentation based on the incomplete assessment of Patient #44's skin issues in the first twenty four hours of admission. Review of facility policies directed that all wounds be assessed upon admission and throughout the hospital stay. The policy directed that the assessment would include wound location and size and that the assessment be documented in the clinical record.


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8. Based on clinical record reviews, review of hospital policies and procedures and interviews with facility personnel for one of one sampled patients (Patient #37), the facility failed to ensure that an assessment for alcohol withdrawal was completed for a patient with a know history of alcohol abuse. The finding include:

Patient #37 was admitted to the hospital on 12/10/11 at 7:49 am with exacerbation of chronic obstructive pulmonary disease. Review of the history and physical dated 12/10/11 identified that the patient had a history of alcohol abuse and the physician recommended monitoring the patient for alcohol withdrawal. Review of admission nursing assessment dated 12/10/11 at 10:46 am failed to identify that an alcohol withdrawal assessment/pathway was implemented for Patient #37. Review of nursing documentation dated 12/10/11-12/12/11 failed to identify that the patient was assessed for alcohol withdrawl symptoms for a 48 hour period. Review of hospital practice identified that the hospital had no policy for assessment of alcohol withdrawl patients, however the hospital practice included assessing the patient every shift. Interview with the Nurse Manager on 12/12/11 identified that the patient never had an initial alcohol withdrawal assessment and needed to be on the alcohol pathway.


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9. Based on review of clinical records, review of the hospital policy and staff interviews for one of three sampled patients (Patient #22), who was admitted for an induction and/or augmentation of labor the facility failed to ensure that the administration of intravenous Oxytocin was titrated, and/or interventions were implemented in accordance with the hospital policy. The findings include:
a. Patient #22 was admitted to the labor and delivery unit on 3/13/11 at 2:14 PM. Patient #22 presented at 38 and ½ weeks gestation with reported spontaneous rupture of membranes at 12:30 PM. Patient #22 developed pregnancy induced hypertension which was stable throughout labor. On admission to the delivery room a Category 1 (normal) fetal heart rate tracing was noted, however contractions were not palpable or demonstrated on the monitor, therefore Oxytocin was started per protocol at 3:00 PM to induce labor. At 5:20 PM Patient #22 was found to be contracting every 2-3 minutes via palpation by the nurse. Epidural anesthesia was administered at 6:00 PM for pain control. At 6:30 PM review of the clinical record identified that due to the patient ' s habitus and obesity it was difficult to monitor the fetal heart rate and contraction status, therefore a fetal scalp electrode and intrauterine pressure catheter were placed and Oxytocin continued to be titrated. Further review of the clinical record identified at 9:00 PM Patient #22 continued with the Category 1 fetal tracings, however labor was not deemed to be adequate and Oxytocin continued to be increased. At 10:00 PM Category 2 (indeterminate and not predictive of fetal acid base status requiring surveillance and reevaluation) fetal heart tracings were noted with variable decelerations (a decrease in the fetal heart rate below the baseline) and contractions were occurring every 1-2 minutes. Oxytocin was decreased by 2 milliunits/minute due to frequent contractions. According to the clinical record Patient #22 had progressed in labor and the variable decelerations were relieved with repositioning. At 10:23 PM recurrent variable decelerations and frequent contractions continued. MD #6 directed the discontinuation of Oxytocin administration. A position change was made with no relief therefore Terbutaline 0.25 milligrams (mg) subcutaneous (SC) was administered for tachysystole (contractions that occur more then 5 times in 10 minutes). Further review of the clinical record indicated at 10:36 PM contractions decreased in frequency to every 2-3 minutes and tachysystole was no longer present. At 10:39 PM Patient #22 was fully dilated and began the second stage of labor with the assist of a vacuum extraction without success. At 10:56 PM Category 3 (predictive of abnormal fetal-acid base status), fetal tracing was noted and a decision for a cesarean section was made. A second dose of Terbutaline 0.25mg SC was administered, the epidural was redosed for surgery, a Foley catheter was placed, with fetal heart tracings that were 110-120 beats/minute with variable decelerations. At 11:15 PM Patient #22 arrived in the operating room. At 11:19 PM the initial incision was made and the fetal heart rate was noted to be 50-60 beats/minute. The uterine incision was made at 11:21 PM with a difficult extraction and vacuum assist. According to the clinical record upon entry into the uterus blood clots were noted and a placental abruption was presumed. Patient # 21 was delivered at 11:25 PM with Apgar scores of 1/0/0. Patient #21 was resuscitated with intubation, chest compressions, Epinephrine, Sodium Bicarbonate and a fluid bolus. Patient #21 was transferred to a large area hospital for required specialty beyond the primary facility's capability. Interview and review of the clinical record with RN #7 on 12/15/11 at 2:45 PM identified that on 3/13/11 at 10:00 PM she decreased the Oxytocin by 2 milliunits/minute due to tachysystole with a Category 2 fetal heart tracing however did not discontinue the Oxytocin until 10:23 PM per physician order. Further interview with RN # 7 indicated that she was not aware that the hospital policy directed the Oxytocin rate to be reduced by ½ and to notify the physician and the triage nurse with a Category 1 tracing in the presence of tachysystole. In addition RN #7 identified that she was not aware that the hospital policy directed to discontinue of Oxytocin in the presence of tachysystole with a Category 2 fetal tracing. Interview and review of the clinical record with MD #6 on 12/16/11 at 10:00 AM identified that she verbally ordered the Oxytocin to be discontinued at 10:23 PM due to variable decelerations and frequent contractions and was not aware of the hospital policy that directed the Oxytocin rate to be decreased by ½ with Category 1 tracings with tachysystole and the discontinuation of Oxytocin with tachysystole and a Category 2 fetal heart tracing. Interview and review of the clinical record with the Nurse Manager of Obstetrics on 12/16/11 at 11:00 AM identified that she would have expected the Oxytocin rate to be reduced by ½ when tachysystole was first identified and to discontinue Oxytocin when tachysystole was present with a Category 2 fetal tracing at 10:00 PM. The hospital policy for the administration of intravenous Oxytocin directed in part, that Oxytocin may be decreased by 2 milliunits/minute if Oxytocin has been increased within the last 30 minutes and tachysystole occurs and/or fetal heart rate changes from Category 1 to Category 2 fetal tracings. The policy further directed that the Oxytocin rate is to be reduced by ½ with a Category 1 fetal tracing and to notify the obstetrical care provider and the triage nurse. In addition, Oxytocin is to be discontinued with a Category 2 fetal tracing in the presence of tachysystole.
b. Interview and review of the clinical record on 12/15/11 at 2:50 PM with RN #7 and interview and review of the clinical record on 12/16/11 at 11:10 AM with MD #6 failed to indicate that oxygen was administered to Patient #22 when tachysystole was identified with a Category 2 fetal tracing. Interview and review of the clinical record with the Nurse Manager of Obstetrics on 12/16/11 at 11:00 AM identified that Patient #21 should have received oxygen when tachysystole and a Category 2 tracing was first noted. The hospital policy for the administration of intravenous Oxytocin directed in part to administer oxygen to the mother with a nonrebreather oxygen mask at 10 liters/minute per physician order for tachysystole with a Category 2 fetal heart tracing.
c. Interview and review of the clinical record with RN #7 on 12/15/11 at 2:55 PM identified that she assessed the intensity of uterine contractions by Montevideo units and titrated the Oxytocin according to the sum of the Montevideo units over a ten minute contraction pattern. According to Stedman's Medical Dictionary Copyright 2006, a Montevideo unit is a measurement of uterine contraction intensity in labor expressed as the sum of the intensity of each contraction within a 10 minute period, with intensity defined as the peak pressure achieved by the contraction minus the baseline tone. Adequate uterine activity is defined as a contraction pattern that generates 200 Montevideo units. Interview with the Nurse Manager of the Obstetrical Unit on 12/16/11 at 11:00 AM identified that, although it is a practice in obstetrical care to utilize Montevideo units it was not part of the hospital policy as an assessment and/or intervention to increase Oxytocin.

1. Based on a review of clinical records, the record failed to identify the credentials (except for physicians) of the administering caregivers for two records reviewed rendering the records incomplete. The findings include:
a. Patient #27 was assessed in the Emergency Department (ED) on 6/24/11 for injuries received when bitten by a dog. Review of the ED record reflected that the credentials of the caregiver failed to be consistently electronically documented, ie, during triage assessment, during ED education and discharge. Physician orders give the impression that the orders were written by a physician when, in fact, the orders were written by a physician's assistant (PA).
b. Patient #28 was assessed in the ED on 7/28/11 following a fall in addition to shortness of breath. Review of the clinical record reflected that an electronic documentation of the caregivers credentials failed to be present for all entries except an expanded written note. Review of triage intake, assessments (pain, transfers, etc) wound assessments, vital signs, activities of daily living and discharge documentation failed to have the caregivers credentials documented following the electronic signature.


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2. Based on a review of the clinical record and interview, the facility failed to ensure that the clinical record was accurate to reflect the dialysis bath administered. The finding includes the following:

a. Review of Patient #55's clinical record indicated that the patient had a history of end stage renal disease requiring hemodialysis. Review of the physicians order dated 12/11/11 directed the hemodialysis treatment include a 3 potassium bath and a 2.5 calcium bath. Review of the treatment flow sheet dated 12/12/11 identified the patient received a 2 potassium, 2.5 calcium dialysis bath. Interview with the RN on 12/13/11 indicated that the patient did receive the correct bath and that it was a documentation error.

1. Based on medical record reviews and interviews for one of two patients who signed an authorization for a voluntary admission to the behavioral unit (Patient #25), the hospital failed to ensure that the patient ' s record was complete. The finding includes:

Patient #25 was admitted to the ED on 2/26/11 for evaluation of depression. The crisis assessment by the Licensed Professional Counselor dated 2/26/11 noted that initially the patient agreed to a voluntary in- patient admission then withdrew the consent. The assessment further indicated that the Patient did not meet the criteria for emergency confinement and was discharged to home. ED documentation by RN #6 dated 2/26/11 identified that the patient was tearful and did not want to stay after signing the voluntary form with the crisis clinician. Interview with Patient #25 on 12/7/11 at 3:40 PM indicated that s/he was not informed by the Licensed Professional Counselor that s/he may not be able to leave for 3 days if s/he signed the voluntary form. Patient #25 further noted that the Licensed Professional Counselor yelled and tore up the voluntary form after s/he refused to stay. Interview with the Licensed Professional Counselor on 12/13/11 at 10:30 AM noted that s/he explained the voluntary admission to the patient on 2/26/11, the patient changed his/her mind, did not fit the criteria for an emergency confinement and was discharged to home with phone numbers for outpatient treatment. Review of the record and interview with the Licensed Professional Counselor on 12/13/11 at 10:30 AM identified that, although the voluntary consent signed by the patient could not be located in the patient's record, s/he did not know what happened to the documentation.


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2. Based on a review of the clinical record, review of facility polices, observations, and interviews, the facility failed to ensure that wound care was documented as provided in accordance with physician orders for one patient, Patient #41, who was admitted to the facility with multiple venous stasis ulcers. The findings include:

a. Patient #41 was admitted to the facility on 12/6/11 with diagnoses that included multiple venous stasis ulcers. Physician orders directed that dressing changes be provided daily and include the application of a Seasorb dressing. An observation on 12/12/11 at 9:20 AM identified that Patient #41 had bilateral leg dressings with what appeared to be dried, brownish yellow drainage that had soaked through the dressings and onto the pillow under the legs. Review of the clinical record with facility staff at the time of the observation identified that the last dressing change had occurred two days earlier at 2:00 PM on 12/10/11. Interview with RN #8 on 12/12/11 at 9:30 AM identified that although he/she last changed Patient #41's dressing change at 3:00 PM on 12/11/11, he/she failed to document the dressing change and/or a description of Patient #41's leg wounds. Facility policy directed that treatments provided be documented in the clinical record.

3. Based on a review of the clinical record, review of facility polices, and interviews, the facility failed to ensure that the neurological consult for one patient, Patient #20, who presented to the Emergency Department (ED) with new neurological symptoms, was included in the clinical record. The finding includes:

a. Patient #20 presented to the Emergency Department (ED) on 6/3/11 at 4:05 PM with symptoms of confusion, expressive aphasia that had progressively worsened throughout the day, and increased weakness of the right arm and leg. The clinical record identified that Patient #20 was examined by Physician Assistant #2 (PA #2) at 6:03 PM, nearly two hours after his/her arrival in the ED with new neurological symptoms. The clinical record identified that upon examination of the patient, PA #2 contacted the ED attending physician and the on call neurologist. Interview with the neurologist, MD #11, on 12/16/11 at 1:00 PM identified that he/she was already in the facility when he/she was called to examine Patient #20. MD #11 stated that he/she was very concerned about Patient #20's expressive aphasia and right-sided weakness. MD #11 stated that he/she spoke with Patient #20's family to gather more history and found that Patient #20 had experienced some slurred speech the previous day that did not completely resolve, that the weakness was new, and that the patient had become worse overnight though did not come back to the ED until later in the day. MD #11 stated that he/she would place a possible dissection very high on the list of possible diagnoses based on the patient's age and health status. MD #11 stated that although he/she had discussed obtaining a spinal tap for diagnostic purposes, Patient #20 needed a Magnetic Resonance Imaging study (MRI) which was not available at the facility. Patient #20 was subsequently transferred to Acute Care Hospital #2 at 8:15 PM. Review of Patient #20's clinical record lacked documentation to reflect MD #11's evaluation of Patient #20 and/or discussions with the patient's family. MD #11 stated that he/she was unable to explain why he/she did not document his/her assessment and/or recommendations for Patient #20. Facility policy directed that all consults be included in the clinical record.


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4. Based on review of the clinical record, review of the hospital policy and staff interviews for one patient (Patient #21), reviewed for neonatal resuscitation the facility failed to utilize documentation in accordance with the hospital policy. The findings include:

a. Patient #21 was delivered by cesarean section at 38 and ½ weeks gestation for fetal distress on 3/13/11 at 11:25 PM. Review of the clinical record identified that Patient #21 had no respiratory effort, poor tone and color with a heart rate of less than 30 beats/minute. Patient #21 was immediately suctioned for copious amounts of secretions, and bag mask ventilation was initiated. Chest compressions began at 11:27 PM and a hospital "Team Pediatric Response" (Cardiopulmonary Resuscitation) was called at 11:28 PM. An endotracheal tube (ET) was inserted at 11:29 PM and Epinephrine 1 milliliter (ml) was administered via the endotracheal tube. The ET was reinserted at 11:35 PM as the tube was not in the trachea. Epinephrine 1 ml via the ET was administered again at 11:38 PM. An umbilical line was inserted for the administration of fluids, medications and blood draw access. At 11:40 PM a heart rate of less than 60 beats/minute was detected and chest compressions and ventilation continued. Patient #21's heart rate at 11:50 PM was 60 beats/minute and the infant's color was pink. Compressions continued with improved perfusion and Patient #21's heart rate was over 100 beats/minute at 11:58 PM. Chest compressions were discontinued at this time and Patient #21 was moved to the special care nursery. Patient #21 was placed on a ventilator with oxygen saturations that increased from 60-97% on 100 % oxygen. Patient # 21's heart rate was 160 at 12:28 AM on 3/14/11. Imaging was completed for ET and umbilical line placement. Patient #21 was transferred to a large area hospital for required specialty beyond the primary facility's capability. Patient #21 expired on 3/17/11 due to cardiorespiratory failure as a consequence of neonatal encephalopathy/hypoxic ischemic encephalopathy. Interview and review of the clinical record on 12/15/11 at 4:00 PM with RN #9 identified the "Team Pediatric Response" code sheet was not utilized as it was not a part of routine recording due to the rare occurrence of pediatric emergencies in the facility. Interview and review of the clinical record with the Nurse Manger of obstetrics on 12/15/11 at 4:15 PM identified that it is the responsibility of the recorder in a pediatric code to ensure that the "Team Pediatric Response" documentation record is being utilized. The hospital policy for "Team Pediatric Response" (Cardiopulmonary Resuscitation) directed in part, that a "Team Pediatric" record will be utilized for the documentation of the resuscitation and that the recorder is responsible for completing the documentation that must sequentially time any noted rhythm, vital signs, procedures, medications and results.

Based on clinical record review, review of hosptial policies and procedures and interviews with facility personnel for one of one sampled patients (Patient #65), the facility failed to ensure that a consent for physicial therapy was signed by the practitioner. The findings include:

Patient #65 was admitted to the hospital on 11/28/11 for chronic pain syndrome. Review of the consent form identified that although the patient signed the form on 11/28/11, the consent form was not signed by the practitioner. Subsequently to surveyor inquiry on 12/13/11, the practitioner signed the consent form. Review of hospital practice and interview with the Director of Risk Management on 12/15/11 identified that hospital practice is that consent forms are to be signed by the practitioners.

Based on review of facility documentation, review of facility policies, staff interviews, and observation, the facility failed to ensure that water was tested and equipment was maintained in accordance with AAMI standards (ANSI/AAMI RD52:2004 A.6.2.5 Carbon adsorption) and/or manufacturer's directions. The findings include the following:

a. Review of the Acute Dialysis Unit documentation on 12/13/11 at 9:45 AM, failed to identify that the chlorine/chloramine results were recorded in a log sheet. Interview with Nurse #12 on 12/13/11 at 11:00 AM stated that he/she tested the water from the machine in the treatment room and documented each result in the patient's treatment record. RN #12 explained that he/she filled the test tube with water, added the reagent powder, held the tube up to a white background and if there was any color change, the water was not safe for use. The manufacture's directions for use directed a specific amount of water, a three minute development of the reagent after being added to the water, and that the sample be placed in an instrument to obtain a result. The facility failed to follow this procedure. Interview with staff and review of facility policy failed to direct that the water sample be obtained after the first carbon tank in accordance AAMI standards and/or specified the procedure for water testing in accordance with Manufacturer's directions.

In addition review of RN #12's file failed to identify that the employee had been tested for color blindness. Interview with Nurse #12 on 12/13/11 at 11:00 AM identified that he/she had never been tested to discern colors for reading colormetric tests in accordance with AAMI standards. (ANSI/AAMI RD52:2004 A.6.2.5 Carbon adsorption).

b. Review of the Main Reverse osmosis (RO) logs on 12/13/11 at 10:00 AM, failed to indicate the frequency of disinfection of the RO and/or treatment water loop. Review of facility documentation and interview with facility staff on 12/13/11 identified that the Main RO was disinfected semiannually and to the best of their knowledge, the loop had never been disinfected. AAMI standards require the loop to be low level disinfected monthly and the manufacturer's directions for use and maintenance states that at no time should the RO go more than 3 months (quarterly) without being disinfected. The facility failed to have a policy directing the time frame between disinfections of the RO and treatment water loop in accordance with standards of practice and/or manufacturer's directions.


Following these observations the facility provided the Department with an immediate action plan that included reeducation of all engineering staff & dialysis staff on proper testing procedures of water, that all personnel would be tested for color blindness, and that the RO and water loop would be disinfected prior to the start of any dialysis treatments on 12/14/11.

1. Based on observation, interview, and review of hospital policy, the hospital failed to ensure that infection control practices were followed. The findings include:

a. During tour of the operating suite on 12/12/11, several rooms, including the cysto room, were observed to be stocked with supplies including extra pillows, stacked upon the top shelves and/or the top of covered carts within the room, hindering the complete cleaning of horizontal surfaces according to hospital policy and the AORN Standards 2010. Review of hospital policy for cleaning of ORs identified that the extent of cleaning was dependent upon equipment left in place. During interview on 12/12/11, the Director of Peri-operative Services stated that a process had begun to ensure that supplies and equipment were either eliminated from the OR or stored in such a manner to facilitate cleaning.

b. Review of the sterrad biological testing log on 12/12/11, with the Manager of Central Sterile, identified that on 12/9/11, the test failed to be left in the incubator for a full 24 hours, according to manufacturer's directions, to ensure an accurate test result.

c. Review of the documentation logs for each biological testing process on 12/12/11, identified that on most days, staff failed to document the date the test was removed from the incubator. Review of the hospital policy for documentation of biological testing identified a failure to list all elements required in the biological log documentation.



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2. Based on review of the clinical record, review of facility polices, observations, and interviews, the facility failed to ensure that facility staff adhered to infection control standards during the provision of wound care to one patient, Patient #41, who was admitted to the facility with multiple venous stasis ulcers. The findings include:
a. Patient #41 was admitted to the facility on 12/6/11 with diagnoses that included multiple venous stasis ulcers. Physician orders directed that dressing changes be provided daily and include the application of a Seasorb dressing. An observation on 12/12/11 at 9:20 AM identified that Patient #41 had bilateral leg dressings with what appeared to be dried, brownish yellow drainage that had soaked through the dressings and onto the pillow under the legs. Observation of the dressing change to the left leg provided by RN #8 at 10:00 AM on 12/12/11 identified that the wound drainage had thoroughly dried through the layers of the kerlix outer wrap and required that RN #8 soak the soiled dressing with water in order to remove it. Upon removal of the soiled dressings, RN #8 discarded the soiled dressings, now soaked with a moderate to large amount of serosanguineous drainage, into the regular trash.
b. RN #8 was observed to remove his/her gloves and without the benefit of washing his/her hands, donned another pair of gloves and proceeded to cleanse the multiple venous stasis ulcers on Patient #41's left leg before moving to the patient's right leg.
c. Upon completion of cleaning Patient #41's left leg ulcers, RN #8 again removed his/her gloves and without the benefit of washing his/her hands, donned another pair of gloves and proceeded to remove the soiled dressing on Patient #41's right leg and discarded the soiled dressing into the regular trash. RN #8 again changed his/her gloves, failed to wash his/her hands between glove changes, and cleansed the multiple venous stasis ulcers on Patient #41's right leg. Interview with RN #8 on 12/12/11 at 11:30 AM identified that while he/she was sure to change gloves between soiled to clean procedures, he/she had not realized that he/she needed to wash his/her hands between glove changes. Review of facility policies directed that hands must be decontaminated after removing gloves. In addition, facility policy directed that any items, including soiled dressings that are soaked and/or saturated with blood or body fluids be placed into a regulated medical waste bag.

Based on a review of clinical records, review of facility policies, observations, and interviews, the facility failed to ensure that a crisis evaluation directed by the physician was completed timely for one patient (Patient #25), who was admitted to the Emergency Department and required treatment for depression. The findings include:
Patient #25 was admitted to the ED for depression on 2/25/11, was hypertensive and was without suicidal/homicidal ideation. The physician's assessment dated 2/25/11 at 5:00 PM indicated that the patient agreed to stay to be seen by a crisis clinician, was aware that the evaluation would not take place for awhile and could eventually go home if s/he chose. Physician orders dated 2/25/11 at 5:15 PM directed crisis service suicide risk assessment. The crisis flow sheet indicated that the patient was moved to the crisis area at approximately 8:32 PM on 2/25/11. Clinical nursing notes and review of the patient's record identified that the patient was not seen by the crisis clinician (6 hours after the physician's order), wanted to be discharged and was discharged to home with family at 11: 42 PM. Interview with the Licensed Professional Counselor on 12/13/11 indicated that crisis clinicians are available until midnight and on call psychiatrists are available thereafter for emergency evaluations. Review of the facility policy indicated the crisis workers complete a psychiatric assessment as soon as possible.

Based on a review of clinical records, review of facility polices, and interviews, for one of four patients reviewed (Patient #20), the facility failed to ensure that the patient was promptly examined by an Emergency Department (ED) physician and/or mid-level practitioner when the patient presented to the ED with new neurological symptoms. The findings include:

1. Patient #20 presented to the Emergency Department (ED) on 6/2/11 at 8:20 PM with symptoms that included headache, a "knot" in the left side of his/her neck, blurred vision with some white flashes, and numbness in the right hand. Patient #20 further reported feeling slightly "off balance" and complained of impaired depth perception. Patient #20 was triaged by the ED nurse at 8:27 PM and examined by the physician at 8:47 PM. Patient #20 reported that he/she had experienced the headaches for "several months" and that a current prescription for birth control pills were suspected to be the cause of the symptoms. A Computerized Tomography Scan (CT scan) was obtained. The CT scan report dated 6/2/11 identified no acute intracranial abnormality, no hemorrhage and/or midline shift. Blood work was obtained and was reported within normal limits. Interview with MD #9 on 12/15/11 at 8:35 AM identified that he examined Patient #20 in the ED on 6/2/11. MD #9 stated that he/she discussed Patient #20's symptoms with the on call neurologist, MD #11, who agreed at that time that Patient #20's symptoms were likely due to a complex migraine related to birth control pills. Review of the discharge instructions dated 6/2/11 at 11:14 PM identified that Patient #20 was treated for a migraine headache and directed Patient #20 to discontinue her current birth control and to follow up with the neurologist within two to three days. Patient #20 was further advised to seek prompt medical attention if she experienced symptoms that included difficulty with speech and/or confusion.
Review of the ED record dated 6/3/11 identified that Patient #20 returned to the ED at 4:05 PM with symptoms of confusion. Review of the triage assessment at 4:14 PM identified that Patient #20 reported feeling "totally disoriented". Review of the clinical record identified that Patient #20 was assigned a triage level of 3 (urgent) by the triage nurse. Interview with the triage nurse, RN #10 on 12/15/11 at 11:15 AM identified that although he/she was aware that Patient #20 had been to the ED with similar symptoms the day before, he/she did not recall Patient #20 reporting any other symptoms at the time of triage except for confusion. RN #10 stated that based on the high volume of patients in the ED at that time, sent Patient #20 back to the waiting area and did not provide any further assessments of Patient #20. The clinical record identified that Patient #20 was not brought back into the ED until 5:46 PM and not examined by Physician Assistant #2 (PA #2) until 6:03 PM, nearly two hours after his/her arrival in the ED with new neurological symptoms. Review of the ED attending physician's (MD #12) dictation final report dated 6/3/11 identified that upon his/her examination of Patient #20, the patient reported symptoms that included expressive aphasia that had progressively worsened throughout the day, and increased weakness of the right arm and leg. The clinical record identified that upon examination of the patient, PA #2 contacted the ED attending physician, MD #12 and the on call neurologist, MD #11. The clinical record identified that Patient #20's differential diagnoses included an evolving Cerebral Vascular Accident (CVA) and/or encephalopathy. Based on the urgent need for a Magnetic Resonance Imaging (MRI) study not available at the facility, Patient #20 was transferred to Acute Care Hospital #2 at 8:15 PM. Review of Patient #20's clinical record from Acute Care Hospital #2 identified that Patient #20 experienced a left watershed acute infarct and a left and right carotid dissection. Interview with the ED Medical Director, MD #11, on 12/16/11 at 12:00 PM identified that he/she agreed that it was a long time for Patient #20 to wait to be seen based upon the patient's presenting symptoms. MD #11 stated that a triage level III was the most common assignment level and that the triage level assignment may have been incorrect. MD #11 stated that although there was a delay from the time Patient #20 presented at the ED to the time of examination by the ED physician/PA, he/she could not say that the delay impacted the outcome of Patient #20's subsequent clinical course. Subsequent to a review by the facility of Patient #20's ED visit on 6/3/11, the facility revised policies in the ED to include a change in the order in which patients are seen in the ED if the patient has presented to the ED within the previous forty eight hours.

1. Based on a review of five patients' surgical records at the surgical center and interview with hospital personnel, for one patient (#50) the hospital failed to ensure that PACU (post anesthesia care unit) nursing patient assessment documentation reflected the progression of weaning the patient from oxygen post-surgical procedure. The finding includes:
a. Patient #50 underwent surgical repair of a left inguinal hernia on 12/13/11, at the off-site surgical center. Review of the PACU documentation reflected that the patient was sent from the operating room to the PACU at 8:36 AM on oxygen at 10 liters by mask. Although vital signs were completed every 10 minutes until 9:16 AM, the record lacked documentation as to when the oxygen was removed from the patient prior to discharge at 10:05 AM. During interview the nurse caring for the patient stated that she was unaware that she needed to document the removal of oxygen with subsequent recording of the patient's oxygen saturation prior to discharge home from the PACU. During interview on 12/13/11, the Director of Peri-operative Services stated that she would expect the PACU documentation to reflect when the patient was removed from oxygen and the patient's oxygen saturation on room air.
2. Based on review of the clinical record and review of facility policy, for one patient (Patient #28), the hospital failed to ensure that nursing completed a musculoskeletal exam following a fall. The finding includes:
a. Patient #28 was brought to the Emergency Department (ED) on 7/28/11 by EMS following a fall. Review of the clinical record reflected that the patient, who normally ambulates with a walker, was found in a kneeling position and unable to rise to his/her feet. The report identified that the patient was developing cyanosis about the lips and fingertips and had an oxygen saturation of 88%. The patient was placed on oxygen via nasal cannula and transported to the ED. Review of the ED nursing documentation reflected that the triage assessment was completed at 10:27 AM, focusing on the patient's presentation of cyanosis. The initial ED nursing assessment was completed at 1:46 PM (three hours later) and failed to reflect assessment of the musculoskeletal system other than an abrasion to the left knee. During interview on 12/27/11, Person #7 stated that he/she was present with Patient #28 in the ED during evaluation and that nursing staff never removed the patient's socks to fully evaluate the patient's ankles and/or feet. Review of the hospital policy identified that the nursing assessment in the ED should include, within the framework of holistic nursing, subjective and objective patient data significant to the nature and severity of the illness/injury obtained from the patient as well as significant others.
b. Review of Patient #28's nursing assessments for the period of 7/28/11 through 7/31/11 identified that the patient's right ankle, at the malleolus and extending into the top of the foot, was ecchymotic. Review of the clinical record failed to reflect that a physician was notified of the bruising.


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3. Based on medical record reviews, review of facility policies, observations and interviews for one of five patients reviewed for altered skin integrity (Patients #33, ), nursing staff failed to completely assess the patient's wound. The finding includes:

a. Patient #33 was admitted to the orthopedic unit on 12/10/11 with a left hip fracture. The skin assessment dated 12/10/11 identified that the patient had a open "slit" in the gluteal crease. The assessment lacked measurements and the exact location of the open area. Subsequent to surveyor inquiry, the day shift nurse assessed the wound on 12/12/11 and although s/he documented that the wound measured 0.9 centimeters (cm) and was narrow, the location of the wound was not documented. Interview with the Wound Nurse on 12/14/11 at 12:00 pm noted that a nurse's assessment of a wound should include measurements. The hospital policy for wound management directed to assess the wound and surrounding tissue, note location and size and document in the medical record accordingly. The policy for wound measurement procedure identified that all wounds requiring measurements by the Registered Nurses (RNs) will be accomplished, in part, using a single use disposable measuring guide noting centimeters or inches if more appropriate. The Integrated assessment policy identified that each patient is assessed each shift by an RN and is documented electronically.


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5. Based on a review of the clinical record, review of facility polices, observations, and interviews, the facility failed to ensure that wound care was provided in accordance with physicians orders for two of four patients, Patient #33 and Patient #41, who were admitted to the facility with altered skin integrity and/or multiple venous stasis ulcers. The findings include:
a. Patient #33 was admitted to the orthopedic unit on 12/10/11 with a left hip fracture. The skin assessment dated 12/10/11 identified that the patient had a open "slit" in the gluteal crease. Nursing flow sheets indicated that a barrier cream was applied to the patient's gluteal wound on the day shifts on 12/ 11/11 and 12/12/11. However, the flow sheets noted that the gluteal wound was left untreated and open to air on the evening shifts on 12/10/11 and 12/10/11 and the night shifts on 12/11/11 and 12/12/11. The hospital policy for wound management identified that treatment for open wounds require a provider order. When treatment orders are delayed, RNs may institute dry sterile dressings to cover/protect the wound. The skin assessment and pressure ulcer risk assessment policy noted that appropriate nursing interventions via nursing care plans will be individualized and documented.
b. Patient #41 was admitted to the facility on 12/6/11 with diagnoses that included multiple venous stasis ulcers. Physician orders directed that dressing changes be provided daily and include the application of a Seasorb dressing. An observation on 12/12/11 at 9:20 AM identified that Patient #41 had bilateral leg dressings with what appeared to be dried, brownish yellow drainage that had soaked through the dressings and onto the pillow under the legs. Review of the clinical record with facility staff at the time of the observation identified that the last dressing change had occurred two days earlier at 2:00 PM on 12/10/11. Interview with RN #8 on 12/12/11 at 9:30 AM identified that although he/she last changed Patient #41's dressing at 3:00 PM on 12/11/11, he/she failed to document the dressing change and/or a description of Patient #41's leg wounds.
c. Observation of the dressing change to Patient #41's left leg provided by RN #8 at 10:00 AM on 12/12/11 identified that the wound drainage had thoroughly dried through the layers of the kerlix wrap and required that RN #8 soak the soiled dressing with water in order to remove it. Upon removal of the kerlix outer dressing wrap, a single wide piece of material was observed directly covering multiple leg ulcers on the patient's posterior and lateral left leg and was subsequently was removed by RN #8. RN #8 identified that the dressing removed was a Seasorb dressing as prescribed by the physician. RN #8 proceeded to cleanse the multiple venous stasis ulcers on Patient #41's left leg before moving to the patient's right leg. RN #8 used the same method (soaking the dressing with water due to dried drainage) to remove the soiled dressing and the same wide, single dressing was removed from the multiple right leg ulcer sites at the right posterior leg. Upon surveyor inquiry, RN #8 provided the box of the product/dressing material that RN #8 believed to be Seasorb dressings, the same dressing material he/she had removed from Patient #41's bilateral leg ulcers and planned to reapply. The product was identified as Interdry, a product used for management of moisture in skin folds. Review of the Interdry product manufacturer's instructions directed that the product not be placed on open wounds. Interview with RN #8 on 12/12/11 at 11:30 AM identified that he/she had made an error when he/she used the wrong product for Patient #41's dressing. Review of facility policies directed that dressing changes be provided in accordance with physician orders.

6. Based on a review of the clinical record, review of facility polices, observations, and interviews, the facility failed to ensure that interventions in accordance with the nursing plan of care were implemented for one of four patients, Patient #41, who was assessed to be at risk to fall and required a bed alarm. The finding includes:
a. Patient #41 was admitted to the facility on 12/6/11 with diagnoses that included Congestive Heart Failure (CHF) and Atrial Fibrillation (A-Fib). Review of the clinical record identified that Patient #41 was assessed to be at high risk for falls. The nursing care plan dated 12/6/11 identified potential for injury related to the patient's risk to fall with interventions that included the use of a bed alarm when in bed. Observation of Patient #41 on 12/12/11 at 9:30 AM identified that Patient #41 was in bed with two half side rails in place but that the patient's bed alarm was off. Subsequent to surveyor inquiry, Patient #41's bed alarm was activated. Review of facility policies directed that a nursing care plan be developed to address the individual needs of the patient and to provide continuity of patient care among health team members and that the interventions be consistently implemented.

7. Based on a review of the clinical record, review of facility polices, observations, and interviews, the facility failed to ensure that documentation of a skin assessment upon admission was accurately completed for one of three patients, (Patient #44), who was identified with two unstageable pressure ulcers within twenty four-hours of admission. The finding includes:
a. Patient #44 was admitted to the facility from a skilled nursing facility on 12/7/11 at 11:23 AM via the Emergency Department (ED) with diagnoses that included fever and rapid Atrial Fibrillation (A-Fib). Review of the interagency referral form sent by the skilled nursing facility dated 12/7/11 lacked documentation to reflect that Patient #44 had pressure ulcers upon transfer to the ED. A Braden assessment dated 12/7/11 at 11:23 AM identified that Patient #44 was at risk to develop pressure ulcers. Review of an initial physical examination provided on 12/7/11 at 2:00 PM identified that Patient #44 had a "left heel closed ulcer" though lacked any further description of size and/or staging of the ulcer. A progress note dated 12/8/11 at 6:50 AM again identified a left heel ulcer without further description of size or staging. Documentation on 12/8/11 at 8:30 AM identified Patient #44 with bilateral heel ulcers. The documentation identified an unstageable rectangular shaped left heel ulcer that measured 3.0 centimeters (cm) by 2.5 cm and an unstageable oval shaped right heel ulcer that measured 3.0 cm by 2.0 cm. Interview with Nursing Director #2 on 12/12/11 at 1:45 PM identified that, although he/she believed that Patient #44's bilateral heel ulcers were present on admission, there was no supporting documentation based on the incomplete assessment of Patient #44's skin issues in the first twenty four hours of admission. Review of facility policies directed that all wounds be assessed upon admission and throughout the hospital stay. The policy directed that the assessment would include wound location and size and that the assessment be documented in the clinical record.


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8. Based on clinical record reviews, review of hospital policies and procedures and interviews with facility personnel for one of one sampled patients (Patient #37), the facility failed to ensure that an assessment for alcohol withdrawal was completed for a patient with a know history of alcohol abuse. The finding include:

Patient #37 was admitted to the hospital on 12/10/11 at 7:49 am with exacerbation of chronic obstructive pulmonary disease. Review of the history and physical dated 12/10/11 identified that the patient had a history of alcohol abuse and the physician recommended monitoring the patient for alcohol withdrawal. Review of admission nursing assessment dated 12/10/11 at 10:46 am failed to identify that an alcohol withdrawal assessment/pathway was implemented for Patient #37. Review of nursing documentation dated 12/10/11-12/12/11 failed to identify that the patient was assessed for alcohol withdrawl symptoms for a 48 hour period. Review of hospital practice identified that the hospital had no policy for assessment of alcohol withdrawl patients, however the hospital practice included assessing the patient every shift. Interview with the Nurse Manager on 12/12/11 identified that the patient never had an initial alcohol withdrawal assessment and needed to be on the alcohol pathway.


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9. Based on review of clinical records, review of the hospital policy and staff interviews for one of three sampled patients (Patient #22), who was admitted for an induction and/or augmentation of labor the facility failed to ensure that the administration of intravenous Oxytocin was titrated, and/or interventions were implemented in accordance with the hospital policy. The findings include:
a. Patient #22 was admitted to the labor and delivery unit on 3/13/11 at 2:14 PM. Patient #22 presented at 38 and ½ weeks gestation with reported spontaneous rupture of membranes at 12:30 PM. Patient #22 developed pregnancy induced hypertension which was stable throughout labor. On admission to the delivery room a Category 1 (normal) fetal heart rate tracing was noted, however contractions were not palpable or demonstrated on the monitor, therefore Oxytocin was started per protocol at 3:00 PM to induce labor. At 5:20 PM Patient #22 was found to be contracting every 2-3 minutes via palpation by the nurse. Epidural anesthesia was administered at 6:00 PM for pain control. At 6:30 PM review of the clinical record identified that due to the patient ' s habitus and obesity it was difficult to monitor the fetal heart rate and contraction status, therefore a fetal scalp electrode and intrauterine pressure catheter were placed and Oxytocin continued to be titrated. Further review of the clinical record identified at 9:00 PM Patient #22 continued with the Category 1 fetal tracings, however labor was not deemed to be adequate and Oxytocin continued to be increased. At 10:00 PM Category 2 (indeterminate and not predictive of fetal acid base status requiring surveillance and reevaluation) fetal heart tracings were noted with variable decelerations (a decrease in the fetal heart rate below the baseline) and contractions were occurring every 1-2 minutes. Oxytocin was decreased by 2 milliunits/minute due to frequent contractions. According to the clinical record Patient #22 had progressed in labor and the variable decelerations were relieved with repositioning. At 10:23 PM recurrent variable decelerations and frequent contractions continued. MD #6 directed the discontinuation of Oxytocin administration. A position change was made with no relief therefore Terbutaline 0.25 milligrams (mg) subcutaneous (SC) was administered for tachysystole (contractions that occur more then 5 times in 10 minutes). Further review of the clinical record indicated at 10:36 PM contractions decreased in frequency to every 2-3 minutes and tachysystole was no longer present. At 10:39 PM Patient #22 was fully dilated and began the second stage of labor with the assist of a vacuum extraction without success. At 10:56 PM Category 3 (predictive of abnormal fetal-acid base status), fetal tracing was noted and a decision for a cesarean section was made. A second dose of Terbutaline 0.25mg SC was administered, the epidural was redosed for surgery, a Foley catheter was placed, with fetal heart tracings that were 110-120 beats/minute with variable decelerations. At 11:15 PM Patient #22 arrived in the operating room. At 11:19 PM the initial incision was made and the fetal heart rate was noted to be 50-60 beats/minute. The uterine incision was made at 11:21 PM with a difficult extraction and vacuum assist. According to the clinical record upon entry into the uterus blood clots were noted and a placental abruption was presumed. Patient # 21 was delivered at 11:25 PM with Apgar scores of 1/0/0. Patient #21 was resuscitated with intubation, chest compressions, Epinephrine, Sodium Bicarbonate and a fluid bolus. Patient #21 was transferred to a large area hospital for required specialty beyond the primary facility's capability. Interview and review of the clinical record with RN #7 on 12/15/11 at 2:45 PM identified that on 3/13/11 at 10:00 PM she decreased the Oxytocin by 2 milliunits/minute due to tachysystole with a Category 2 fetal heart tracing however did not discontinue the Oxytocin until 10:23 PM per physician order. Further interview with RN # 7 indicated that she was not aware that the hospital policy directed the Oxytocin rate to be reduced by ½ and to notify the physician and the triage nurse with a Category 1 tracing in the presence of tachysystole. In addition RN #7 identified that she was not aware that the hospital policy directed to discontinue of Oxytocin in the presence of tachysystole with a Category 2 fetal tracing. Interview and review of the clinical record with MD #6 on 12/16/11 at 10:00 AM identified that she verbally ordered the Oxytocin to be discontinued at 10:23 PM due to variable decelerations and frequent contractions and was not aware of the hospital policy that directed the Oxytocin rate to be decreased by ½ with Category 1 tracings with tachysystole and the discontinuation of Oxytocin with tachysystole and a Category 2 fetal heart tracing. Interview and review of the clinical record with the Nurse Manager of Obstetrics on 12/16/11 at 11:00 AM identified that she would have expected the Oxytocin rate to be reduced by ½ when tachysystole was first identified and to discontinue Oxytocin when tachysystole was present with a Category 2 fetal tracing at 10:00 PM. The hospital policy for the administration of intravenous Oxytocin directed in part, that Oxytocin may be decreased by 2 milliunits/minute if Oxytocin has been increased within the last 30 minutes and tachysystole occurs and/or fetal heart rate changes from Category 1 to Category 2 fetal tracings. The policy further directed that the Oxytocin rate is to be reduced by ½ with a Category 1 fetal tracing and to notify the obstetrical care provider and the triage nurse. In addition, Oxytocin is to be discontinued with a Category 2 fetal tracing in the presence of tachysystole.
b. Interview and review of the clinical record on 12/15/11 at 2:50 PM with RN #7 and interview and review of the clinical record on 12/16/11 at 11:10 AM with MD #6 failed to indicate that oxygen was administered to Patient #22 when tachysystole was identified with a Category 2 fetal tracing. Interview and review of the clinical record with the Nurse Manager of Obstetrics on 12/16/11 at 11:00 AM identified that Patient #21 should have received oxygen when tachysystole and a Category 2 tracing was first noted. The hospital policy for the administration of intravenous Oxytocin directed in part to administer oxygen to the mother with a nonrebreather oxygen mask at 10 liters/minute per physician order for tachysystole with a Category 2 fetal heart tracing.
c. Interview and review of the clinical record with RN #7 on 12/15/11 at 2:55 PM identified that she assessed the intensity of uterine contractions by Montevideo units and titrated the Oxytocin according to the sum of the Montevideo units over a ten minute contraction pattern. According to Stedman's Medical Dictionary Copyright 2006, a Montevideo unit is a measurement of uterine contraction intensity in labor expressed as the sum of the intensity of each contraction within a 10 minute period, with intensity defined as the peak pressure achieved by the contraction minus the baseline tone. Adequate uterine activity is defined as a contraction pattern that generates 200 Montevideo units. Interview with the Nurse Manager of the Obstetrical Unit on 12/16/11 at 11:00 AM identified that, although it is a practice in obstetrical care to utilize Montevideo units it was not part of the hospital policy as an assessment and/or intervention to increase Oxytocin.






























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4. Based on a review of the clinical record, the facility failed to ensure that weights were obtained pre and/or post dialysis treatment. The finding includes the following:

a. Review of Patient #57's clinical record indicated that the patient had a history of end stage renal disease requiring hemodialysis. Review of the dialysis treatment flow sheet dated 12/12/11 identified under the pre and/or post weight section that the patient was unable to be weighed due to "no bed scale available". The dialysis note reflected that the patients "weight was unavailable due to poor functioning floor scale and no bed scale".