HospitalInspections.org

A Federal (Validation) life safety survey code inspection was conducted on January 23 to 26, 2017. Based on observation, staff interview, and review of documentation, it was determined that the life safety code requirement was not met on the condition level. The facility's fire alarm system had devices (sprinkler heads) that had the potential to not function as designed. The facility had dust laden sprinkler heads and corroded sprinkler heads.


Details of the deficient practices are cross-referred under the life safety code National Fire Protection Association 101 Standards. Cross Reference to K Tags 111, 293, 331, 353, 363, 379, and 511.


1. During the facility tour on January 23, 2017, at approximately 10:00 AM to 1:00 PM, in the presence of Employee #14, the inspector noticed the gift shop had received renovations to include the addition of a hand sink, in the left corner of the room.


At the time of the observation, Employee #14 was queried about permits or approvals for the renovations completed. Employee #14 was unable to provide documentation of prior permit or approval for the repair or modification of the gift shop.


2. During the facility tour conducted on January 23, 2017, at approximately 10:00 AM to 1:00 PM, in the presence of Employee #14, the exit sign in the Environmental Director's Office was observed not illuminated.


The failure to illuminate the exit sign creates a potential hazard for staff and patients exiting the facility in the event of an emergency.


3. During the facility tour conducted on January 23, 2017, at approximately 10:00 AM to 1:00 PM, in the presence of Employee #14, four (4) of 40 observations revealed missing ceiling tiles in the following areas:


1. Room across from B-1044
2. Room B103
3. "A" level storage room
4. Administration telephone closet


The missing ceiling tiles create a potential fire hazard for staff and patients, in the event of a fire emergency.


4. During the facility tour conducted on January 23, 2017, at approximately 10:00 AM to 1:00 PM, in the presence of Employee #14, the facility lockers in the following areas were not wall mounted:


1. Room across from B-1044
2. Maintenance shop


The unmounted lockers pose a potential safety hazard for staff when exiting the facility, in the event of an emergency.


5. During the facility tour conducted on January 23, 2017, at approximately 10:00 AM to 1:00 PM, in the presence of Employee #14, the facility's administration electrical closet had ceiling tile penetrations.


The ceiling tile penetrations create a potential fire hazard for staff and patients, in the event of a fire emergency.


6. During observations made January 23, 2017, in the presence of Employee #14, eight (8) of 200 sprinkler head were observed corroded in the following areas:


1. "A" Level storage room- two (2) of two (2)
2. Quality Control office- two (2) of two (2)
3. Wash Area of Kitchen- four (4) of four (4)


The corroded sprinkler heads pose a potential fire hazard, in the event of an emergency.


7. During observations on January 23, 2017, at 11:17 AM, in the presence of Employee #14, three (3) of four (4) sprinkler head and shaft surfaces were accumulated with dust, over the steam table in the Main Kitchen. Also, the sprinkler water supply lines were soiled with dust and other debris, over the steam tables in three (3) of four (4) observations.


The failure to properly maintain the sprinkler heads pose a potential fire hazard, in the event of an emergency.


8. During the tour of the rear hallway of the main Kitchen on January 23, 2017, at 11:20 AM, in the presence of Employee #14, three (3) of four (4) sprinkler heads, and shaft surfaces were observed covered with a dark residue.


The failure to properly maintain the sprinkler heads pose a potential fire hazard, in the event of an emergency.


9. During the facility tour conducted on January 23, 2017, at approximately 10:00 AM to 1:00 PM, in the presence of Employee #14, the facility's standpipe cabinet hardware, in the dietitian corridor, was damaged.


The damaged standpipe cabinet poses a potential hazard, in the event of an emergency.


10. During the facility tour conducted on January 23, 2017, at approximately 10:00 AM to 1:00 PM, in the presence of Employee #14, the facility's pump room was observed being used for storage.


The storage in the pump room creates a potential hazard, in the event of an emergency.


11. During the tour of 2North on January 24, 2017, at approximately 1:45 PM, in the presence of Employee #14, the entrance door to room 2006, leading to the hallway, made contact with the floor making it difficult to open and close.


The failure of the entrance door to open and close freely poses a potential fire hazard, allowing the passage of smoke, in the event of a fire emergency.


12. During observations on January 23 through 26, 2017, at approximately 9:00 AM through 4:00 PM, in the presence of Employee #14, four (4) of six (6) observations revealed wall penetrations as follows:


A. A two-inch penetration was observed in wall surfaces in Room 2007, in one (1) of one (1) observation.


B. A 12" X 12" inch opening was observed in the lower wall of the women bathroom stall, in one (1) of three (3) observations.


C. Penetrations approximately one (1) inch in diameter were observed in wall surfaces around steam pipes in the rear of the flat skillet and steamer, in two (2) of two (2) observations.


The wall penetrations pose a potential fire hazard, in the event of a fire emergency.


13. During observations on January 23 through 26, 2017, in the presence of Employee #14, two (2) of two (2) electrical outlet covers, in trash room, were missing.


The missing electrical covers create a potential hazard.


14. During observations on January 23 through 26, 2017, in the presence of Employee #14, one (1) of two (2) electrical closets in the auditorium was not labeled.




The missing door label poses a potential hazard in the event of an emergency.

1. Based on record review and staff interview, it was determined the Governing Body failed to ensure that contracted services performed by the dialysis staff, are consistent with prevailing professional patient safety and quality standards relative to quality data and action plans for portable reverse osmosis machine to prevent the spread of infections, and to provide safe and effective treatment, in five (5) of eight (8) months reviewed.


The findings include:


In-Hospital Dialysis Services Agreement signed January 28, 2016 stipulates, "1.07 PROVIDER agrees to maintain an ongoing Quality Management Program that includes the following activities: continuous quality improvement, safety and infection control, and risk management. PROVIDER acknowledges the Services provided under this Agreement are subject to monitoring by HOSPITAL for quality and safety in accordance with performance expectations as set forth under the Joint Commission or other hospital accreditation standards. HOSPITAL monitoring may include utilizing various methods and quality indicators which may include, but is not limited to: direct observation of care relating to proper use of contact isolation and aseptic technique, and/or review of water and dialysate samples and/or equipment maintenance logs, and ii audit of documentation ..."


On January 26, 2017 at 9:17 AM, the surveyor reviewed the water culture data from June 2016 through January 2017 for the Portable Reverse Osmosis (PRO) machines used by the contracted dialysis staff. The review revealed episodes where the PROs had water culture standards above allowable limits.




A. On June 14, 2016, PRO #32 and 33 were found to have water culture results above "Action Level". A "PRO Action Plan A" was developed, implemented and approved" by the Medical Director and Technical Manager on June 30, 2016. However, in the area reserved for the review and approval of the plan by the Clinical Manager, the signature line was left blank.


B. Subsequent water cultures on June 26, 2016 revealed the water cultures for PRO #33 were above "Action Level". A "PRO Action Plan A" was developed, implemented and approved by the Medical Director and Technical Manager on August 1, 2016 and July 30, 2016, respectively. However, in the area reserved for the review and approval of the plan by the Clinical Manager, the signature line was left blank. The re-sampling results were within acceptable limits.


C. On June 19, 2016, PRO #35 was found to have water culture results above "Action Level". A "PRO Action Plan A" was developed, implemented and approved by the Medical Director and Technical Manager on June 30, 2016. However, in the area reserved for the review and approval of the plan by the Clinical Manager, the signature line was left blank. The re-sampling results were within acceptable limits.


D. On July 9, 2016, PRO #35 was found to have water culture results above "Action Level". A "PRO Action Plan A" was developed, implemented and approved by the Technical Manager. However, the surveyor was unable to determine the date of the implementation and approval; the area reserved for authentication of the date was left. Additionally, the Medical Director and Clinical Manager did not authenticate the action plan. The re-sampling results were within acceptable limits.


E. On September 30, 2016, the dialysis staff documented on PRO Action Plan that PRO# 33 had "no follow-up on over action level results". The review of the action revealed the dialysis staff left Sections 3 and 4 blank. The surveyor was unable to determine the results that corresponded to the action plan. On page 2 of the "PRO Action Plan A", there is a handwritten note which stated "Biomed Re-counsel on following policy". However, the Medical Director and Clinical Manager did not authenticate the action plan.


F. On October 4, 2016, the dialysis staff documented on PRO Action Plan that PRO# 34 had "no follow-up on over action level results". The review of the action revealed the dialysis staff entered the date "10-4-16" in Section 2 and left the "Person Responsible" blank. Additionally, Sections 1, 3 and 4 blank. The surveyor was unable to determine the results that corresponded to the action plan. On page 2 of the "PRO Action Plan A", there is a handwritten note which stated "Biomed Re-counsel on following policy", authenticated by the Clinical Manager and Technical Manager on November 28, 2016 and October 4. However, the Medical Director did not authenticate the action plan.




G. On December 19, 2016, PRO #37 was found to have water culture results above "Action Level". A "PRO Action Plan A" was developed, implemented and approved by the Clinical Manager and Technical Manager on December 29, 2016 and December 19, 2016, respectively. However, in the area reserved for the review and approval of the plan by the Medical Director was left blank. Additionally, Sections 1, 3 and 4 blank. The surveyor was unable to determine the results that corresponded to the action plan. The re-sampling results were pending.


H. On November 1 and 30, 2016, Pre-disinfect water cultures were obtained. The water culture result reports lacked documented evidence of a review by the Medical Director.


The surveyor conducted a face to face interview with Employee # 64 on January 26, 2017 at approximately 9:30 AM. S/he explained that in June 2016, the dialysis contractor assumed responsibility for dialysis services and that reports are reviewed at a monthly Clinical Quality Meeting that addresses quality data from the previous month. Upon starting the contract, each of the PROs was checked for water quality and cultures were obtained. The initial water cultures revealed that PROs # 32, 33 and 35 water culture values were above the "action level". The action plan was developed to include obtaining water samples for culturing every week for four (4) weeks.



Subsequent interview with Employee #15 on January 26, 2017 at approximately 11:50 AM was conducted. S/he explained that the water culture results reports were not authenticated because they were not presented to him/her personally.




34093

2. Based on medical record, policy review and staff interview, it was determined that the contracted dialysis staff failed to ensure pre and post dialysis weights were performed, according to the dialysis agreement, in five (5) of six (6) patient records reviewed (Patients #6, 13, 19, 20, and 31).


The findings include:


The 'In Hospital Dialysis Services Agreement' signed and dated January 28, 2016 stipulates, "Provider shall provide policies, procedures, and techniques pertaining to the methods by which the Services are rendered at Hospital pursuant to this Agreement.


[Contracted Dialysis Company] policy effective August 25, 2008 titled, 'Patient Evaluation Pre Treatment in FMS Inpatient Services' stipulates, " ...Data Collection, Follow the steps below for obtaining pretreatment evaluation ...Step 1, obtain the patient's weight prior to treatment and document on the inpatient treatment record ..." Additionally, [Contracted Dialysis Company] policy effective August 25, 2008, titled, 'Evaluating the Patient Post Treatment in FMS Inpatient Services' stipulates, " ...Purpose, the purpose of this document is to provide direction on evaluating the patient after renal replacement or apheresis treatment ...9. Weigh the patient and compare pretreatment weight. Document results on the treatment record.


A. Patient #6 was admitted with diagnoses that included Respiratory Failure and End Stage Renal Disease.


On January 25, 2017, at approximately 9:40 AM, a review of the dialysis treatment summary revealed the patient received dialysis on January 13, 16, and 18, 2017. Further review revealed there were no pre or post dialysis weights documented on those dates, in the medical record.


The record lacked evidence that staff provided necessary care and treatment to include performing pre and post dialysis weights.


On January 25, 2017, at approximately 10:00 AM, a face-to-face interview was conducted with the Employee #15. S/he was queried regarding the performance of pre and post dialysis weights. Employee #15 explained that the policy requires the nurse to obtain a weight, if possible; however, the physician is more concerned with the volume of fluid removed. S/he acknowledged the findings during the above interview.


B. Patient #13 was admitted with diagnoses that included Respiratory Failure, Diabetes Mellitus and End Stage Renal Disease.


On January 25, 2017, at approximately 9:50 AM, a review of the dialysis treatment summary revealed the patient received dialysis on January 20, 2017. Further review revealed there were no pre or post dialysis weights documented, in the medical record.


The record lacked evidence that staff provided necessary care and treatment to include performing pre and post dialysis weights.


On January 25, 2017 at approximately 10:00 AM, a face-to-face interview was conducted with the Employees #15. S/he was queried regarding the performance of pre and post dialysis weights. Employee #15 explained that the policy requires the nurse to obtain a weight if possible; however, the physician is more concerned with the volume of fluid removed. S/he acknowledged the findings.


35226




C. Patient #19 was admitted with Osteomyelitis, and End Stage Renal Disease requiring dialysis.


A review of the medical record conducted on January 24, 2017, at approximately 10:50 AM, revealed Dialysis Treatment Summaries dated January 6, 9, 20, and 21, 2017. The nurse documented the pre-dialysis weights on January 9 and 20, 2017, as "unable," and the post weights are left blank. The nurse documented the pre-dialysis weights on January 6 and 21, 2017, as "bed scale was not calibrated or not functioning."


The medical record lacked documented evidence that the nursing or dialysis staff obtained pre or post-dialysis weights.


On January 23, 2017, at approximately 11:45 AM, a face to face interview was conducted with Employee #33, regarding pre and post dialysis weights. S/he explained that the patients are weighed every Sunday using either a bed scale or a Hoyer lift, but they do not weigh the patient routinely before dialysis.


On January 25, 2017at approximately 11:50 AM, a face-to-face interview was conducted with Employee #15 regarding dialysis weights. S/he stated that the physicians do not use the pre and post weights in the care of the dialysis patients; therefore they are not necessary. Additionally, if the patient's bed scale is not working; the staff is unable to obtain the weights. When queried about the pre/post dialysis weight policy provided to the surveyor for review, s/he stated that s/he was unaware of the policy. Employee #15 acknowledged the findings mentioned above.


D. Patient #20 was admitted with End Stage Renal Disease on Dialysis and a past medical history of an Anoxic Brain Injury.


A review of the medical record conducted on January 25, 2017, at approximately 10:00 AM revealed Dialysis Summaries dated January 16 and 18, 2017. The pre-dialysis weight on January 16, 2017, was documented as "scale not working." On January 18, 2017, the pre-dialysis weight was recorded as "unable." The post-dialysis weights are documented as "unable" and "bed scale not working."


The medical record lacked documented evidence that the nursing or dialysis staff obtained pre or post-dialysis weights.


On January 25, 2017, at approximately 11:50 AM, a face-to-face interview was conducted with Employee #15 regarding dialysis weights. S/he stated that the physicians do not use the pre and post weights in the care of the dialysis patients; therefore they are not necessary. Additionally, if the patient's bed scale is not working; the staff is unable to obtain the weights. When queried about the pre/post dialysis weight policy provided to the surveyor for review, s/he stated that s/he was unaware of the policy. Employee #15 acknowledged the findings mentioned above during the face to face interview.


E. Patient #31 was admitted with diagnoses to include End Stage Renal Disease.


Review of the medical record conducted January 25, 2017, at approximately 10:45 AM revealed Dialysis Treatment Summaries dated December 2, 5, 7, and 12, 2016. The nursing staff documented the pre-dialysis weights as "bed scale broken," "bed scale not calibrated," or "unable to weigh." Additionally, the post-dialysis weights were documented as "unable" and "bed scale broken."


The medical record lacked documented evidence that the nursing or dialysis staff obtained pre or post-dialysis weights.


On January 25, 2017at approximately 11:50 AM, a face-to-face interview was conducted with Employee #15 regarding dialysis weights. S/he stated that the physicians do not use the pre and post weights in the care of the dialysis patients; therefore they are not necessary. Additionally, if the patient's bed scale is not working; the staff is unable to obtain the weights. When queried about the pre/post dialysis weight policy provided to the surveyor for review, s/he stated that s/he was unaware of the policy. Employee #15 acknowledged the findings mentioned above during the face to face interview.

Based on observation, policy review and staff interviews, it was determined that staff failed to provide information in a manner for the patient/patient representative to make informed decisions, regarding medical treatment, in (1) of one (1) observation (Patient #6).


The findings include:


The BridgePoint Capitol Hospital Policy #PCS.012, effective December 2014 titled, 'Patient Rights,' stipulates, "PURPOSE ... Policies and mechanisms are established to preserve the human rights, dignity and safety of patients admitted to the facility ...3. The patient has the right to be informed about and participate in decisions regarding his or her care ..."


On January 23, 2017 at approximately 11:00 AM, Patient #6 was observed awake, nonverbal, and weaning from the ventilator, and placed on 28% tracheostomy collar. The patient's representative was at the patient's bedside, visiting. S/he shared concerns that the patient and s/he were of Korean decent and was only able to understand 10% of the medical terminology used by the staff. S/he explained that an employee at the hospital speaks his/her language and has been translating but that the employee doesn't work nights, when s/he visits.


On January 24, 2017 at approximately 11:15 AM, a face-to-face interview was conducted with Employees #20 and 28. Both were asked how staff communicated with the patient/patient's representative. Employee #28 explained the patient followed simple commands and both the patient and representative understood, "a little English." Employee #20 shared that the language line was also an available tool for use by staff; however, it had not been used.


The practices lacked evidence that staff provided the patient's representative information in a manner that s/he could understand to make informed care decisions.


On January 24, 2017 at approximately 12:00 PM, a face-to-face interview was conducted with Employees #3, who was asked how staff communicated with the patient/patient's representative. S/he shared that as far as s/he knew, they understood English. Employee #3 continued explaining that a staff member helped, as a translator. However, in the future, staff will use the language line services to ensure the patient's representative understands the patient's status and plan of care for the patient.


On January 26, 2017 at approximately 10:55 AM, a face-to-face interview was conducted with Employees #47, who was asked to explain his/her interaction with the patient/patient representative. S/he admitted translating for staff and the patient representative, explaining that s/he speaks the same language; however, s/he denied being a certified translator.


Employees #3, 5, 47, and 48 acknowledged and confirmed the findings on the above dates and times.

Based on observation, policy review, and staff interviews, it was determined that facility staff failed to ensure environmental safety, relative to the spread of infection, in three (3) of three (3) observations.


The findings include:


Bridgepoint Hospital policy number IC.13, effective December 2014 stipulates, "1.Contact Precautions ...Perform hand hygiene when entering the room. Don gloves when entering the room ...C. Gowns are also necessary when entering the room since contact with the patient, the patient's items or environment is anticipated. Remove gown before leaving the room. 2.Enteric Precautions ...This sign alerts staff that the patient is suspected of having [Clostridium difficile] or that the [Clostridium difficile] has been confirmed by laboratory testing. Staff should perform hand hygiene by either soap and water or alcohol foam before donning gloves and gown when entering the room ...Droplet Precautions ...B. Yellow isolation masks will be worn when entering the room and removed as the room is exited ...In addition, gloves and gown are recommended for close contact with the patient, patient's items or the environment ..."


A. Patient #14 was admitted for Sepsis and Pneumonia.


During the tour of 3North, on January 23, 2017, at approximately 11:55 AM, in the presence of Employee #33, Employee #68 was observed donning a mask and entering the room of Patient #14. Signs posted outside of the room indicated that the patient was on enteric and droplet precautions. S/he did not don gloves and gown before entering the room. Employee #33 asked Employee #68 to put on the appropriate personal protective equipment (PPE) before entering the patient's room.


The observation failed to provide evidence of hospital staff compliance with transmission-based precaution policies.


A face-to-face interview was conducted with Employee #68 on January 23, 2017, at approximately 12:00 PM, regarding the proper procedure for entering the room of a patient on transmission based precautions. S/he explained that s/he knows the procedure, but Patient #14 was not his/her patient, and s/he did not see the signs posted. Employee #33 acknowledged the findings mentioned above, during the face to face interview.


B. Patient #20 was admitted with End Stage Renal Disease on Dialysis and a past medical history of an Anoxic Brain Injury.


During the tour of 3North, on January 25, 2017, at approximately 10:00 AM, signage observed outside of Patient #20's room indicated that the patient was on transmission based precautions. The surveyor entered the room of Patient #20 with Employee #33 after donning the proper PPE, which included a gown, gloves, and mask. After approximately four (4) minutes in the room, Employee #33 exited the room, without first removing PPE, and held a conversation in the hallway.


The observation failed to provide evidence of hospital staff compliance with transmission-based precaution policies.


A face-to-face interview was conducted with Employee #33 regarding the proper procedure for entering and exiting a patient's room on transmission based precautions. S/he stated that s/he was only stepping into the hallway for a moment.


Employee #33 acknowledged the findings, during the face to face interview as mentioned above.

1. Based on observation, review of the Infection Control Program and staff interviews, it was determined that the Governing Body failed to ensure a mechanism was in place for monitoring semi-critical equipment.


The findings include:


On January 23, 2017 at approximately 3:49 PM, review of the hospital's procedure schedule revealed that two (2) patients underwent EGD [Esophagogastroduodenoscopy] & PEG [Percutaneous Endoscopic Gastrostomy] removal on December 23, 2016.


On January 25, 2017 at approximately 1:40 PM, a review of the Infection Control Program was conducted with Employee #7, who was asked to explain the reprocessing of semi-critical equipment, like the endoscopes. S/he explained the process of high level disinfection and sterilization and presented the associated policies; however, Employee #7 explained that s/he doesn't monitor the reprocessing for endoscopes because the hospital no longer performs procedures that require the use of endoscopes.


The practice lacked evidence that the Governing Body monitored the reprocessing of endoscope equipment used in the hospital to maximize the prevention of infection and communicable disease.


On January 26, 2017 at approximately 9:48 AM, in a subsequent face-to-face interview with Employees #2 and 7, Employee #2 shared the names of staff that reprocessed semi-critical equipment used in the hospital, and communicated that the information is shared in the Safety and Patient Care Committee meetings. However, Employee #7 revealed she had not attended the meetings. Employees #2 and 7 acknowledged the findings during the interviews.

1. Based on medical record, policy review and staff interview, it was determined that the nursing staff failed to establish a care plan based on the patient's identified needs, for 12 of 19 patient records reviewed (Patients #3, 5, 6, 11, 14, 15, 16, 18, 19, 20, 30, and 31).


The findings include:


The BridgePoint Capitol Hill Hospital Policy #PCS.MU. 204.0, effective December, 2014 titled, 'Interdisciplinary Care Plan,' stipulates, " ...POLICY: The policy of BridgePoint Hospital Capitol Hill is to develop both a clinical and multi-disciplinary plan of care that is consistent with the patient's needs."


A. Patient #3 was admitted with diagnoses of Respiratory Failure and End Stage Renal Disease.


On January 25, 2017 at approximately 9:30 AM, review of the 'Admission Order Form' dated January 18, 2017 at 10:00 PM, revealed the physician directed dialysis, three times a week. Additionally, on January 19, 2017, the physician ordered Dakins solution to be applied to the patient's sacrococcygeal area, every 12 hours and Xeroform to the right ankle, daily.


Further record review revealed nursing documentation on the 'Dialysis Treatment Summary' that indicated the patient received hemodialysis on Tuesdays, Thursdays and Saturdays; and review of the 'Wound Assessment' notes revealed the patient had a sacrococcygeal and right ankle wounds. However, the record lacked documented evidence of an individualized care plan that addressed the patient's identified wounds and need for hemodialysis.


On January 25, 2017 at approximately 10:00 AM, a face-to-face interview was conducted with Employee #5, who was asked to provide the care plan that addressed the patient's identified wounds and need for hemodialysis. Employee #5 reviewed the record and confirmed that there was no care plan found.


B. Patient #5 was admitted with diagnoses that included Acute Kidney Injury and Severe Sepsis.


On January 25, 2017 at approximately 10:30 AM, review of the physician orders dated December 28, 2016 at 12:00 PM directed Santyl ointment to be applied to the patient's sacrococcygeal wound, daily.


Further record review revealed nursing documentation on the 'Wound Assessment' notes revealed the patient had a sacrococcygeal wound; however, the record lacked documented evidence of an individualized care plan that addressed the patient's identified wound.


On January 25, 2017 at approximately 10:00 AM, a face-to-face interview was conducted with Employee #5, who was asked to provide the care plan that addressed the patient's identified wound care needs. Employee #5 reviewed the record and confirmed that there was no care plan found.



C. Patient #6 was admitted with diagnoses that included Respiratory Failure and End Stage Renal Disease.


On January 25, 2017 at approximately 9:40 AM, review of the history and physical revealed the patient was receiving hemodialysis three times a week. Additionally, a physician order dated January 13, 2017, directed assessment of the sacrococcygeal wound, every shift.


Further record review revealed nursing documentation on the 'Dialysis Treatment Summary' that indicated the patient received hemodialysis on January 13, 16, and 18, 2017; however, the record lacked documented evidence of an individualized care plan that addressed the patient's identified need for hemodialysis and assessment of the sacrococcygeal wound, every shift.


On January 25, 2017 at approximately 10:00 AM, a face-to-face interview was conducted with Employee #5, who was asked to provide the care plan that addressed the patient's need for hemodialysis and sacrococcygeal wound assessments. Employee #5 reviewed the record and confirmed that there was no care plans found.



D. Patient #11 was admitted with diagnoses that included Multiple Extremity Fractures, status post Motor Vehicle Accident, and Acute Respiratory Failure.



On January 23, 2017 at approximately 2:00 PM, review of the physician order dated January 8, 2017 at 2:11 PM, directed ventilator weaning, per protocol.


Further review of the nursing documentation on the flow sheet revealed the patient was weaning from the ventilator to high flow oxygen; however, the record lacked documented evidence of an individualized care plan that addressed the patient's identified need for high flow oxygen and ventilator weaning.


On January 25, 2017 at approximately 10:00 AM, a face-to-face interview was conducted with Employee #5, who was asked to provide the care plan that addressed the patient's needs for high flow oxygen and ventilator weaning. Employee #5 reviewed the record and confirmed that there was no care plan found.




35226


E. Patient #14 was admitted for the continuation of acute care and a past medical history including Diabetes and multiple wounds.


A review of the medical record conducted on January 24, 2017, at approximately 11:00 AM revealed a Wound Care Assessment dated January 6, 2017, describing multiple unhealed wounds, including three (3) unstageable pressure ulcers.


A review of the Nursing Care Plan initiated on January 4, 2017, revealed that Potential for Skin Breakdown was not indicated as a current problem, and did not address the actual alterations in skin integrity.


The medical record lacked documented evidence the nursing staff established and maintained a care plan for the patient's identified needs.


A face to face interview was conducted on January 23, 2017, at approximately 11:00 AM with Employee #34 regarding the individual needs of the patient, and the care plan. S/he acknowledged the findings mentioned above.



F. Patient #15 admitted with Osteomyelitis and multiple Decubitus Ulcers.


A review of the medical record conducted on January 23, 2017 at approximately 10:45 AM revealed a Wound Care Assessment sheet dated January 16, 2016, which indicated that Patient #15 had multiple wounds, including three (3) Stage four (4) wounds, one (1) unstageable wound, and one (1) Stage two (2) wound.


Further review of the medical record revealed a nursing note dated January 15, 2017, at 3:50 AM indicating that Patient #15 experienced a fall from his/her wheelchair during the day shift. The physician was notified.


Review of the Nursing care plan initiated on January 17, 2017, identified the potential for skin breakdown. However, the care plan did not address the present on admission alterations in skin integrity. Additionally, alteration in mobility/moderate high risk for fall was not initiated in the care plan.


The medical record lacked documented evidence the nursing staff established and maintained a current care plan for the patient's identified needs.


A face to face interview was conducted on January 23, 2017, at approximately 11:00 AM with Employee #34 regarding the individual needs of the patient, and the care plan. S/he acknowledged the findings mentioned above.



G. Patient #16 was admitted with Methicillin-resistant Staphylococcus Aureus in the nares.


During the tour of 3North on January 23, 2017, at approximately 11:30 AM, Patient #16 was observed walking in and out of his/her room. Signs outside of the room indicated that the patient was on enteric and droplet precautions.


Hospital staff failed to ensure that patient's complied with did not comply with the hospital infection control policy regarding proper use of Personal Protective Equipment (PPE) for a patient on transmission based precautions.


A face-to-face interview was conducted on January 23, 2017, at 11:45 AM with Employee #33 regarding Patient
#16's transmission-based precaution status. S/he stated that Patient #16 was asked several times to stay in the room but s/he will not comply.


A face to face interview was conducted on January 23, 2017, at 11:45 AM with Employee #33 regarding Patient
#16's transmission-based precaution status. S/he stated that Patient #16 had been asked several times to stay in the room but s/he won't comply.


A review of the Nursing Care Plan for Patient #16 initiated on January 10, 2017, failed to address the patient's knowledge deficit related to transmission based precautions.



H. Patient #18 was admitted with diagnoses to include End Stage Renal Disease on dialysis.



A review of the medical record conducted on January 23, 2017, at 10:00 AM revealed a History and Physical dated January 11, 2017, indicated Patient #18 was receiving dialysis services three (3) times a week.


A review of the nursing care plan initiated on January 11, 2017, did not identify End Stage Renal Disease or Patient
#18's dependence on Hemodialysis.


The medical record lacked documented evidence that nursing staff established and maintained a current care plan to address the patient's identified needs.


A face to face interview was conducted on January 23, 2017, at approximately 11:00 AM with Employee #34 regarding the individual needs of the patient, and the care plan. S/he acknowledged the findings mentioned above.




I. Patient #19 was admitted with diagnoses to include End Stage Renal Disease requiring dialysis.


A review of the medical record conducted on January 24, 2017, at approximately 10:50 AM, revealed a History and Physical dated January 5, 2017, indicating that Patient #19 received Hemodialysis.


A review of the Nursing care plan initiated on January 11, 2017, did not identify End Stage Renal Disease or Patient #19's dependence on Hemodialysis.


The medical record lacked documented evidence that nursing staff established and maintained a current care plan to address the patient's identified needs.


A face to face interview was conducted on January 23, 2017, at approximately 11:00 AM with Employee #34 regarding the individual needs of the patient, and the care plan. S/he acknowledged the findings mentioned above.


J. Patient #20 was admitted with End Stage Renal Disease on Dialysis.


A review of the medical record conducted on January 23, 2017, at approximately 10:15 AM revealed a physician order dated January 6, 2017 for hemodialysis.


A review of the Nursing Care Plan initiated on October 24, 2016, and last updated on January 12, 2017, did not identify End Stage Renal Disease or Patient #20's dependence on Hemodialysis.


The medical record lacked documented evidence that nursing staff established and maintained a current care plan to address the patient's identified needs.


A face to face interview was conducted on January 23, 2017, at approximately 11:00 AM with Employee #34 regarding the individual needs of the patient, and the care plan. S/he acknowledged the findings mentioned above.




K. Patient #30 was admitted with diagnoses of Respiratory Failure and End Stage Renal Disease.


A review of the medical record conducted on January 25, 2017, at approximately 10:45 AM revealed a History and Physical dated November 7, 2016, that indicated Patient #30 was on Hemodialysis and receive treatment every Monday, Wednesday, and Friday.


Review of the Nursing Care Plan initiated on November 6, 2016, and last updated on November 28, 2016, did not identify End Stage Renal Disease or Patient #30's dependence on Hemodialysis.


The medical record lacked documented evidence that nursing staff established and maintained a current care plan to address the patient's identified needs.


A face to face interview was conducted on January 26, 2016, at approximately 2:00 PM with Employee #4. S/he acknowledged the findings mentioned above.





L. Patient #31 was admitted with diagnoses of Respiratory Failure and End Stage Renal Disease.


Review of the medical record conducted January 25, 2017, at approximately 10:45 AM revealed a History and Physical dated December 1, 2016, indicated that Patient #30 had End Stage Renal Disease, and was dialysis dependent.


Review of the nursing care plan initiated December 1, 2016, did not identify End Stage Renal Disease or Patient
#31's dependence on Hemodialysis.


The medical record lacked documented evidence that nursing staff established and maintained a current care plan to address the patient's identified needs.


A face to face interview was conducted on January 26, 2016, at approximately 2:00 PM with Employee #4. S/he acknowledged then findings mentioned above.

Based on medical record review, policy review and staff interviews, it was determined the nursing staff failed to follow physician orders, relative to medication administration in four (4) of seven (7) records reviewed (Patients #13, 14, 21 and 25).


The findings include:


District of Columbia Municipal Regulations (DCMR) for Registered Nursing Chapter 54. Section 5414 entitled Scope of Practice, regulation 5414.1 stipulates, "The practice of registered nursing means the performance of acts requiring substantial specialized knowledge, judgment, and skill based upon the principles of the biological, physical, behavioral, and social sciences in the following: d) The administration of medications and treatment as prescribed by a legally authorized healthcare professional licensed in the District of Columbia ..."


The Institute for Safe Medication Practice (ISMP) dated 2011, Acute Care Guidelines for Timely Administration of Scheduled Medications, " ...Time-Critical Scheduled Medication" stipulates " ...Hospital-defined time-critical medication*Limited number of drugs when delayed or early administration of more than 30 minutes may cause harm or therapeutic effect. Includes but not limited to: Medication with a dosing schedule more frequent than every four (4) hours. Goals for Timely Administration: Administer at the exact time indicated when necessary (e.g. rapid-acting insulin), otherwise within 30 minutes before or after the scheduled time. Non-Time Critical Scheduled Medications ...Medications prescribed more frequently than daily, but no more frequently than every four (4) hours ... Goals for Timely Administration: Within one (1) hour before or after the scheduled time ..."


Hospital policy # PTS.F. 105 Schedule of Medication Administration dated October 2016, stipulates, II. POLICY: Unless otherwise specified by the physician, medications may be administered according to the following guidelines: Q 6 hours 6:00 AM, 12:00 noon; 6:00 PM; 12:00 midnight ..."


A. Patient #13 was admitted with diagnoses that included Respiratory Failure, Diabetes Mellitus, and End Stage Renal Disease.


On January 26, 2017, at approximately 2:00 PM, a review of the medical record revealed physician orders dated January 13, 2017, for blood glucose monitoring before meals and at bedtime, with medium dose correctional insulin coverage.


The medium dose insulin coverage for blood glucose, milligrams per deciliters (mg/dL), revealed the following: 150-199 - 1 unit; 200-249 - 3 units; 250-299 - 5 units; 300-349 - 7 units; and more than 349 - 8 units.


Review of the blood glucose monitoring flow sheet revealed the nursing staff documented the results and administered insulin as follows: January 14, 2017 at 4:54 PM - 245mg/dL -5 units (2 units more than ordered); January 21, 2017 at 10:24 PM - 248 mg/dL- 5 units (2 units more than ordered); and January 22, 2017 at 9:59 PM - 279 mg/dL - 3 units (2 units less than ordered).


The medical record lacked documented evidence the nursing staff administered insulin, according to the physician orders for the medium dose insulin coverage.


On January 26, 2017, at approximately 2:15 PM, Employee #9 acknowledged and confirmed the findings.




B. Patient #14 was admitted with diagnoses of Diabetic Ketoacidosis and Chronic Obstructive Pulmonary Disease.


Review of the medical record on January 23, 2017, at approximately 2:30 PM revealed the physician ordered Finger Sticks Blood Glucose (FSBG) monitoring before meals and bedtime on January 4, 2017, at 11:00 PM. and low dose correctional insulin coverage with Lispro (Humalog).


The low dose correctional insulin coverage for blood glucose as follows: 150-199- one (1) unit; 200-249- two (2) units; 250-299 -three (3) units; 300-349- four (4) units; greater than 349- five (5) units. The blood glucose results are measured in milligrams per deciliter (mg/dl).


Review of the blood glucose monitoring flow sheet revealed the nursing staff documented the results and administered insulin as follows: January 5, at 7:58 AM- 348 mg/dl- 5 units (one unit more than ordered); January 8, at 7:00 AM- 176 mg/dl (no insulin given) and January 14, 2017-156 mg/dl - (no insulin given).


The medical record lacked documented evidence the nursing staff administered insulin, according to the physician orders for the low dose insulin coverage.




The findings were reviewed and acknowledged by Employee #33 on January 23, 2017, at approximately 3:00 PM.


C. Patient #21 was admitted with diagnoses of Sepsis and status post Laminectomy for Spinal Abscess.


Reviews of the medical record on January 23, 2017, at approximately 11:05 AM revealed the physician ordered the transfusion of three (3) units of red blood cells on January 20, 2017; and administer Lasix 20 milligrams (mg) by mouth after the second unit of blood had transfused.


Review of the Blood Component Transfusion Record indicated that the second unit of blood was completed on January 22, 2017, at 6:00 AM.


Further review of the Medication Administration Record (MAR), nursing progress notes and physician's orders sheet revealed the medical record lacked documented that Lasix 20 milligrams (mg) were administered or a reason for the omission.


The medical record lacked documented evidence that the nursing staff followed the physician's order about the administration of Lasix.


On January 23, 2017, at approximately 11:30 AM, the findings were reviewed and discussed with Employee #33. S/he searched the medical record to locate information; however, information supporting the administration of Lasix would not be found. Employee #33 acknowledged the findings.



D. Patient #25 was admitted with diagnoses of Right Ankle Fracture post fall and Diabetes Mellitus.


Reviews of the medical record on January 25, 2017, at approximately 11:30 AM revealed the physician ordered "Fingerstick Blood Glucose Monitoring" every six (6) hours on November 23, 2016, at 1:00 PM; and Lispro (Humalog) low dose correctional coverage.


The low dose correctional insulin coverage was as follows: 150-199- one (1) unit; 200-249- two (2) units; 250-299- three (3) units; 300-349- four (4) units; greater than 349- five (5) units. The blood glucose results are measured in milligrams per deciliter (mg/dl).


During the medical record, Employee #21 was queried about the timeframe for every six (6) hours medication administration. Employee #21 stated the medication administration times for every six-hour orders are 6:00 AM, 12:00 PM, 6:00 PM and 12:00 AM.


Review of the Glucose Monitoring Flow Sheet January 14 through January 24, 2017, revealed the following results: the fingersticks were not completed on the every six (6) hour frequency and insulin coverage not administered every six (6) hours per physician's orders on the following dates and times:


Review of the blood glucose monitoring flow sheet revealed the nursing staff documented the results and administered insulin as follows: January 15, 2016 at 3:42 PM- 180 one (1) unit; January 18, 2017 at 3:55 PM 147 mg/dl (finger stick not completed timely); January 19, 2017, at 4:24 PM- 217 two (2) units ( fingerstick not completed timely); and on January 20, 2017, at 4:36 PM (finger stick not completed timely).


The medical record lacked documented evidence that the nursing staff consistently completed finger sticks and administered insulin every six (6) hours, according to the hospital's medication administration time policy, thereby administering rapid-acting insulin off schedule.


The findings were reviewed, discussed and acknowledged by Employee #21 on January 25, 2017, at approximately 12:15 PM.




33152


2. Based on the review of facility documents to include Med-Dispense [Automated Dispensing Machine (ADM)] - Transactions by Patient report of Schedule II, III, IV, and V Controlled Substances, physicians' orders, and the Medication Administration Record [MAR], it was determined that hospital staff failed to administer medications in a timely manner in four (4) of nine (9) records reviewed (Patients #11, 16, 47, and 59).



The findings include:


Institute for Safe Medication Practices (ISMP) Acute Care Guidelines for Timely Administration of Scheduled Medications (2011) stipulates, " ...time-critical scheduled medications at the exact time indicated when necessary or within 30 minutes before or 30 minutes after the scheduled time ...non-critical scheduled medications ...daily, weekly, or monthly medications administered within two (2) hours before or after the scheduled time ...medications administered more frequently than daily but not more frequently than every 4 hours ...administer these medications within 1 hour before or after the scheduled time ..."


On January 24, 2017, at approximately 9:00 AM, the surveyor requested copies of a seventy-two (72) hour report generated by the facilities Med-Dispense Automated Dispensing Machine (ADM) for controlled substances schedule II-V for all patients receiving a controlled substance, from January 20, 2017, to January 22, 2017.


On January 25, 2017, at approximately 1:00 PM, the surveyor conducted a review of randomly selected medical records from the reports provided on January 24, 2017. Deficient practices related to the timeliness of the administration of controlled substances and wrong strength of medication administered as follows:


A. On January 2, 2017, Patient # 11 on Patient Care unit 2North was ordered Methadone 20 mg (milligrams) at bedtime. The MAR is initialed by the preprinted 22:00 as being the time of administration of Methadone; the actual time of the administration of the Methadone is unknown.


B. On January 11, 2017, at 11:30, Patient #16 on patient care unit 3North was ordered Methadone 20 mg by mouth daily for pain. On January 20, 2017, at 12:30 PM, two (2) Methadone 10 mg tablets were removed from the ADM; the MAR shows that 20 mg of Methadone was administered at 10:00 AM (administered two and one-half hours before medication removed from the ADM). Additionally, on January 22, 2017, the MAR indicated that Methadone was administered to the patient at 10:00 AM; however, Methadone was not removed from the ADM until 10:28 AM (almost half an hour after the documented administration time).


C. On January 7, 2017, at 09:10, Patient # 47 on patient care unit 3North was ordered Alprazolam 0.5 mg every eight (8) hours around the clock. On January 20 and 21, 2017, the MAR was initialed by the scheduled times indicating administration of Alprazolam. These times do not reflect the actual times of administration, when compared to the ADM record for the removal of Alprazolam. Also, on January 18, 2017, at 9:00 AM, Patient # 47 was ordered Hydromorphone 1 mg intravenous push every 2 hours as needed. On January 22, 2017, the MAR indicates that 1 mg Hydromorphone was administered at 9:05 PM; however, Hydromorphone was not removed from the ADM until 21:36 (actual time of administration unknown).



On January 21, 2017, at 9:10 AM, Patient #47 on patient care unit 3North was ordered Alprazolam 0.5 mg every eight hours as needed for anxiety. The MAR from "01/22/17 00:00 to 01/22/17 23:59, Page 2 of 4" indicates that Alprazolam 1 mg by mouth every eight hours (as needed for anxiety was left off the order).


On January 22, 2017, at 05:19 two (2) tablets of Alprazolam 0.5 mg were removed from the ADM and administered at 06:00 (approximately 40 minutes late).


On January 22, 2017, at 14:00 MAR states "not available pharmacy aware." Alprazolam 1 mg not administered. Employee #51 informed the inspector that the hospital never stocked Alprazolam 1mg and that two tablets of Alprazolam 0.5 mg should have been given. Alprazolam 0.5 mg was available to administer the dose.


D. On January 16, 2017, at 09:30, Patient #57, on Patient Care Unit 2 North was ordered Clonazepam 0.25 mg at bedtime. On January 21, 2017, at 23:04 Clonazepam 0.5 mg was removed from the ADM; 0.25 mg Clonazepam wasted, and 0.25 mg Clonazepam administered to the patient at 22:00 (administered 1 hour before medication was removed from the ADM).


The Medication Administration Records for the above patients were initialed, at the preprinted schedule times. However, the actual times of medication administration were not documented.


The findings were reviewed, discussed, and acknowledged by Employee #12 at the time of record review.

Based on medical record review, policy review, and staff confirmation, it was determined the nursing staff failed to ensure orders for drugs were documented and signed by a practitioner, in one (1) of five (5) records reviewed (Patient# 47).


The findings include:


The BridgePoint Capitol Hill Hospital Medical Staff Rules and Regulations stipulates, " ...E. Treatment 1. Orders a. All orders for treatment shall be in writing, written clearly, legibly and completely ... d. Members of the Respiratory Therapy Department who are licensed respiratory therapists may accept verbal and/or telephone orders pertaining to respiratory therapy procedures ..."


On January 25, 2017, at approximately 1:00 PM, the surveyor conducted a review of randomly selected medical records from the reports provided on January 24, 2017. Deficient practices related to actual medication administration times as follows:


On January 21, 2017, at 9:10 AM, Patient # 47 on patient care unit 3North was ordered Alprazolam 0.5 mg (milligrams) every eight hours as needed for anxiety. MAR From "01/22/17 00:00 to 01/22/17 23:59 Page 2 of 4" indicates that Alprazolam 1 mg by mouth every eight hours (as needed for anxiety was left off order). On January 22, 2017, at 5:19 AM two (2) tablets of Alprazolam 0.5 mg were removed from ADM and administered at 6:00 AM (approximately 40 minutes late).



The medical record lacked documented evidence of a signed physician order for Alprazolam 1 mg by mouth every eight hours, as documented on the MAR.


The findings were reviewed, discussed, and acknowledge by Employee #12 at the time of record review.

Based on the review of records (Glucose Monitoring Flow Sheets, Fingerstick Glucose logs and uploaded fingerstick glucose results) and by staff interview conducted on January 26, 2017 at approximately 5:00 PM, the hospital failed to ensure that all finger stick glucose results performed at point of care were accurately documented in each patient's medical record for three (3) of the six (6) patients that require fingerstick glucose monitoring and were randomly selected for review (Patients #4, #21 and #25).





The findings included:


A. According to the review of uploaded results from the glucometer and the review of Glucose log completed by the Patient Care Technicians, Patient #4's glucose was 104 milligrams per deciliter (mg/dl) on January 20, 2017 at 6:29 AM. However, review of the patient's medical record failed to document this fingerstick glucose value. The Glucose Monitoring Flow Sheet in the patient's medical record was left blank.


B. According to the review of uploaded results from the glucometer and the review of Glucose log completed by the Patient Care Technicians Patient # 21's fingerstick glucose was 238 mg/dl on January 20, 2017 at 9:57 PM. However, review of the Glucose Monitoring Flow Sheet in the patient's medical record revealed a glucose of 237 mg/dl instead of 238 mg/dl. In addition, it was documented as being done at 10:30 PM instead of 9:57 PM.


C. According to the review of uploaded results from the glucometer and the review of Glucose log completed by the Patient Care Technicians Patient #25's fingerstick glucose was 178 mg/dl on January 23, 2017 at 5:34 AM. However, review of the Glucose Monitoring Flow Sheet in the patient's medical record revealed a glucose value of 186 mg/dl instead of 178 mg/dl.


D. The hospital's Point of Care manager was informed of the documentation errors.

1. Based on medical record review, policy review and staff confirmation, it was determined that the nursing staff failed to ensure complete documentation on the 'Comprehensive Assessment', in three (3) of nine (9) records reviewed (Patients #2, 4, and 6).


The findings include:


The BridgePoint Capitol Hill Hospital Policy # PCS.083, effective December 2014, titled, 'Guidelines For Completing Nursing Flow Sheet,' stipulates, "F. PHYSICAL ASSESSMENT 1. The RN/LPN [Registered nurse/Licensed Practical Nurse] is responsible for performing a complete physical assessment each shift and documenting any changes that have occurred during the shift ..."


A. Patient #2 was admitted with diagnoses that included Acute Respiratory Failure that required ventilator services.


On January 24, 2017 at approximately 12:00 PM, review of the nursing flowsheet revealed the allotted areas to document the assessment of the patient's respirations, breath sounds, and rate were left blank on January 21, 22, 23, 2017, on the day and night shifts.


The record lacked evidence that the nursing staff ensured a comprehensive assessment was documented to describe the patient's response to care and treatment.


On January 24, 2017 at approximately 12:30 PM, a face-to-face interview was conducted with Employee #5, regarding the lack of documentation. Employee #5 reviewed the record and explained that staff is expected to document a complete and comprehensive assessment, every shift. S/he confirmed the findings.


B. Patient #4 was admitted with diagnoses that included Respiratory Failure.


On January 24, 2017 at approximately 11:00 AM, a review of the nursing flowsheet revealed the allotted areas to document the assessment of the patient's respirations, breath sounds, and rate were left blank on January 21 and 22, 2017, on the day and night shifts. The allotted areas to document the assessment of the patient's heart rate and rhythm were also left blank on January 21, 2017, on the day shift and January 22, 2017, on the day and night shifts.


The record lacked evidence that the nursing staff ensured a comprehensive assessment was documented to describe the patient's response to care and treatment.


On January 24, 2017 at approximately 12:30 PM, a face-to-face interview was conducted with Employee #5, regarding the lack of documentation. Employee #5 reviewed the record and explained that staff is expected to document a complete and comprehensive assessment, every shift. S/he confirmed the findings.


C. Patient #6 was admitted with diagnoses that included Respiratory Failure and End Stage Renal Disease.


On January 23, 2017 at approximately 11:00 AM, a review of the nursing flowsheet revealed the allotted areas to document the assessment of the patient's respirations, breath sounds, and rate were left blank on January 19, 20, 21, and 22, 2017, on the day and night shifts. The allotted areas to document the assessment of the patient's heart rate and rhythm were also left blank on January 21 and 22, 2017, on the day and night shifts.


The record lacked evidence that the nursing staff ensured a comprehensive assessment was documented to describe the patient's response to care and treatment.


On January 24, 2017 at approximately 12:30 PM, a face-to-face interview was conducted with Employee #5, regarding the lack of documentation. Employee #5 reviewed the record and explained that staff is expected to document a complete and comprehensive assessment, every shift. S/he confirmed the findings.


35226

2. Based on record review, and staff interview, it was determined that medical staff failed to document the evaluation and plan for patients with wounds, in three (2) of four (4) records reviewed. (Patient #14 and 19).


The findings include:


Patient #14 was admitted for the continuation of acute care and past medical history, included Diabetes and multiple wounds.


A review of the medical record conducted on January 24, 2017 at approximately 11:00 AM revealed a Wound Care Assessment dated January 6, 2017, describing multiple unhealed wounds including: A sacral pressure ulcer, an unstageable left elbow pressure ulcer, a right knee pressure ulcer, a right hip unstageable pressure ulcer, an unstageable right distal hip pressure ulcer, and a Stage 2 bilateral buttock pressure ulcer.


Review of the physician progress notes from January 5 - 21, 2017 revealed an evaluation of the sacral wound only.


The medical record lacked documented evidence of an evaluation and plan for all identified wounds.


A face to face interview was conducted on January 24, 2017, at approximately 11:15 AM with Employee #33. S/he acknowledged and confirmed the findings.



B. Patient #19 was admitted with Osteomyelitis, End Stage Renal Disease requiring dialysis, and Pressure Ulcers.


A review of the medical record conducted on January 24, 2017, at approximately 10:50 AM, revealed a wound care sheet dated January 6, 2017, describing multiple wounds including sacral pressure ulcer, left elbow pressure ulcer, right elbow Stage 4 pressure ulcer, left heel pressure ulcer, left hip unstageable pressure ulcer, and a right heel deep tissue injury.


Review of the physician progress notes from January 21 - 23, 2017 revealed evaluation of the sacral wound only.


The medical record lacked documented evidence of an evaluation and plan for all identified wounds.


A face to face interview was conducted on January 24, 2017, at approximately 11:15 AM with Employee #33. S/he acknowledged and confirmed the findings.

1. Based on medical record review, policy review and staff confirmation, it was determined that the hospital staff failed to ensure documentation in the medical record was complete, legible, dated, timed and/or authenticated, in six (6) of 37 patient records reviewed (Patients #4, 5, 11, 13, 40 and 42).


The findings include:


The BridgePoint Capitol Hill Hospital Medical Staff Rules and Regulation, approved May 25, 2016, stipulates, "...D. MEDICAL RECORDS 6. All clinical entries in the patient's medical record shall be written clearly, legibly and completely, accurately signed, dated, and timed ..."


The BridgePoint Capitol Hill Hospital Policy Number HIM 07-001, effective December, 2014 titled, 'Medical Record Content' stipulates, "... POLICY: F. Every medical record entry, including orders, is dated and timed, its author documented, and as required, authenticated."


BridgePoint Hospital Bylaws of the Medical Staff approved March 25, 2016 stipulates, "A complete admission history and physical examination shall be recorded within twenty-four (24) hours of admission and prior to any invasive procedure being performed ...In the event of a transcription delay or if a history and physical is dictated late in the 24 hour period a handwritten note must be written by the attending physician or his/her designee, or designee of the Hospital containing the reason for admission and pertinent findings giving enough information for clinicians to manage the patient and guide the plan of care."



A. Patient #4 was admitted with diagnoses that included Respiratory Failure.


On January 26, 2017, at approximately 11:40 AM, a review of the 'Interdisciplinary Team Meeting' note dated January 17, 2017 revealed the 'Case Management/UR [utilization review] Narrative Note' lacked evidence of a timed entry.


The practices lacked evidence that staff followed the hospital policies to ensure all entries were timed.


Employee #19 acknowledged and confirmed the findings, during the record review.


B. Patient #5 was admitted with diagnoses that included Acute Kidney Injury and Severe Sepsis.


On January 25, 2017, at approximately 10:30 AM, a review of the 'Case Management/UR [Utilization Review] Narrative Note' dated December 21, 2016, lacked evidence of a timed entry.


The practices lacked evidence that staff followed the hospital policies to ensure all entries were timed.


Employees #5 and 19 acknowledged and confirmed the findings, during the record review.


C. Patient #11 was admitted with diagnoses that included Multiple Extremity Fractures, status post, Motor Vehicle Accident and Acute Respiratory Failure.


On January 23, 2017, at approximately 2:00 PM, review of the Speech- Language Pathology note and the 'Case Management/UR [utilization review] Narrative Notes' dated December 19 and 23, 2016 and January 3 and 12, 2017, lacked evidence of timed entries.


The practices lacked evidence that staff followed the hospital policies to ensure that all entries were timed.


Employee #20 acknowledged and confirmed the findings, during the record review.


D. Patient #13 was admitted with diagnoses that included Respiratory Failure, Diabetes Mellitus, and End Stage Renal Disease.


On January 26, 2017, at approximately 12:00 PM, review of the 'Case Management/UR [utilization review] Narrative Note' date January 6, 2017, lacked evidence of a timed entry.


The practices lacked evidence that staff followed the hospital policies to ensure that all entries were timed.


Employee #19 acknowledged and confirmed the findings, during the record review.



E. Patient #40 was admitted with diagnoses to include Chronic Obstructive Pulmonary Disease and Atrial Fibrillation.


Medical record review conducted on January 26, 2017, at 9:15 AM revealed Patient #40 was discharged on December 25, 2016.


On December 7, 2016 at 10:24 PM, the medical staff dictated the Admission History and Physician Examination. Review of the dictated document revealed multiple blank lines where the relevant data was not captured through dictation. Examples of the missing data are as follows:


1. "The patient is ...with recent laparoscopic appendectomy because of_____ [TIME: 00:44]..."
2 "The patient was transferred to ICU after_______ [TIME: 02:45]..."
3. "The patient should_____ [TIME: 09:06] to prevent aspiration."


The medical staff authenticated the History and Physical as evidenced by the presence of a signature. However, medical staff failed to make the necessary corrections to address blanks, prior to authentication.



The medical record lacked documented evidence the medical staff ensured a complete history and physical, to include all information relevant to the patient's plan of care.


A face to face interview was conducted on January 26, 2017, at approximately 9:30 AM with Employee #48. When queried about the completion of the history and physical s/he explained that it is the expectation of the medical staff to review the dictated document and make necessary correction or addition, prior to authenticating and placing in the medical record. The findings were reviewed, discussed, and acknowledged during a face to face conversation on January 26, 2017, at approximately 2:16 PM with Employees# 2, 4, 10, and 48.


F. Patient #42 was admitted with diagnoses of underwent placement of Percutaneous Endoscopic Gastrostomy (PEG) during hospitalization. December 23, 2016.


Review of the medical record on January 25, 2017, at approximately 2:30 PM revealed that Patient #42 underwent PEG placement on December 23, 2016. The Time Out form dated December 23, 2016, was signed, dated, and timed by the nursing staff.


The medical staff authenticated the Time Out form on December 27, 2016; however, the time of authentication was not documented.


The medical staff failed to include the time of authentication, on the 'Time Out' form.


The findings were acknowledged by Employee #2 on January 25, 2017, at approximately 3:00 PM.



34093


2. Based on medical record review, policy review and staff confirmation, it was determined that the nursing staff failed to document the restraint type on the 'Comprehensive Assessment', in two (2) of three (3) records reviewed (Patients #4 and 11).


The findings include:


The BridgePoint Capitol Hill Hospital Policy #PCS.083, effective December, 2014, titled, 'Guidelines for Completing Nursing Flow Sheet', stipulates, "...Part One: Complete Restraint/Seclusion Interventions (RN/LPN)...5. Document type and location of restraint being used."


The BridgePoint Capitol Hill Hospital Policy #PCS.0904, effective December, 2014, titled, 'Restraint Use With Non-Violent/Non-Self-Destructive Patients & Violent/Self Destructive Patients' stipulates, "...E. Documentation: 4. The type of restraints/and part (s) restrained..."


A. Patient #4 was admitted with diagnoses that included Respiratory Failure.


On January 24, 2017, at approximately 11:00 AM, review of the 'Non Violent Restraint Orders' dated January 21, 22, and 23, 2017, directed soft limb restraints to the right and left upper extremities.


Further review of the nursing documentation on the nursing flowsheet on January 21-23, 2017, under restraint interventions, lacked documented evidence of the restraint locations.


The practice lacked evidence that staff followed the hospital policies to ensure documentation of locations of the restraints being used to justify continued treatment.


Employee #5 reviewed the record and confirmed during the time of the record review.


B. Patient #11 was admitted with diagnoses that included Fractures, status post Motor Vehicle Accident, and Acute Respiratory Failure.


On January 23, 2017, at approximately 2:00 PM, review of the 'Non Violent Restraint Orders' dated January 18, 19, and 20, 2017, directed soft limb restraints to the right upper and left lower extremities.


Review of the nursing documentation on the nursing flowsheet, on January 18, 19, and 20, 2017, under restraint interventions, lacked documented evidence of the restraint locations.


The practice lacked evidence that staff followed the hospital policies to ensure documentation of locations of the restraints.


Employee #5 reviewed the record and confirmed the findings during the time of the record review.



3. Based on observation, medical record and staff interview, it was determined that the pharmacy staff failed to ensure a complete order for wound care was documented on the Medication Administration Record, in three (3) of nine (9) records reviewed (Patients #3, 4, and 5).


The findings include:


The BridgePoint Capitol Hill Hospital Policy # HIM 07-001, effective December 2014, revised May 2016, titled, 'Medical Record Content,' stipulates, "...B ...Therefore each inpatient medical record shall consist of at least the following items...16. Every medication prescribed and dispensed during inpatient admissions, emergency visits or ambulatory care. The route of administration and site of injections must be recorded if medication is administered by other than oral route..."




A. Patient #3 was admitted with diagnoses of Respiratory Failure and End Stage Renal Disease.


On January 25, 2017, at approximately 9:30 AM, review of the 'Admission Order Form' dated January 19, 2017, revealed the physician ordered Dakins ½ strength solution to be applied to the patient's sacrococcygeal wound, every 12 hours and one gauze of Xeroform to the right ankle, daily.


Further record review revealed the transcribed orders on the Medication Administration Record (MAR) failed to specify the sacrococcygeal and right ankle locations.


The practice lacked evidence that pharmacy staff documented complete wound care orders, as prescribed by the physician.


On January 26, 2017, at approximately 11:00 AM, a face-to-face interview was conducted with Employee #5, regarding the incomplete orders. Employee #5 explained that staff receives the MAR from the pharmacy and have to attach a copy of the physician's original wound care order to the MAR so that the nurse knows where to apply the medication and treatment. S/he acknowledged the findings, explaining the challenges during the interview.



B. Patient #4 was admitted with diagnoses that included Respiratory Failure.


On January 25, 2017 at approximately 10:30 AM, review of the 'Admission Order Form' dated January 8, 2017, revealed the physician ordered Dakins ½ strength solution to be applied to the patient's sacrococcygeal wound, every 12 hours and one gauze of Aquacel to the percutaneous endoscopic gastrostomy (peg) site, daily.


Further record review revealed the transcribed orders on the Medication Administration Record (MAR) failed to specify the sacrococcygeal and peg site locations.


The practice lacked evidence that pharmacy staff documented complete wound care orders, as prescribed by the physician.


On January 26, 2017 at approximately 11:00 AM, a face-to-face interview was conducted with Employee #5, regarding the incomplete orders. Employee #5 explained that staff receives the MAR from pharmacy and have to attach a copy of the physician's original wound care order to the MAR so that the nurse knows where to apply the medication and treatment. S/he acknowledged the findings, explaining the challenges during the interview.



C. Patient #5 was admitted with diagnoses that included Acute Kidney Injury and Severe Sepsis.


On January 25, 2017, at approximately 10:40 AM, review of the 'Admission Order Form' dated December 28, 2016, revealed the physician ordered Santyl Ointment, nickel thick, to be applied to the patient's sacrococcygeal wound, every day.


Further record review revealed the transcribed orders on the Medication Administration Record (MAR) failed to specify the sacrococcygeal location.


The practice lacked evidence that pharmacy staff documented a complete wound care order, as prescribed by the physician.


On January 26, 2017, at approximately 11:00 AM, a face-to-face interview was conducted with Employee #5, regarding the incomplete order. Employee #5 explained that staff receives the MAR from the pharmacy and have to attach a copy of the physician's original wound care order to the MAR so that the nurse knows where to apply the medication and treatment. S/he acknowledged the findings, explaining the challenges during the interview.

1. Based on medical record review, policy review and staff confirmation, it was determined that the medical staff failed to date and time all orders in the medical record in four (4) of 39 records reviewed (Patients #14, 21, 29, and 31).


The findings include:


Bridgepoint Medical Staff Rules and Regulation, approved March 25, 2016 section E. Treatment, subsection one (1) Orders. stipulates: " ... a. All orders for treatment shall be in writing, written clearly, legibly and completely and shall be dated, timed and signed by a physician. Orders which are illegible or improperly written will not be carried out until rewritten or understood. All orders shall be authenticated by the physician according to state specific guidelines. b. Verbal physician order are only acceptable in an emergency code blue situation when the practitioner who is giving the order is at the bedside ... c. All orders dictated over the telephone shall be accepted by such duly authorized heath professional. All telephone orders must be authenticated based upon Federal and State law. If there is no State law that designates a specific timeframe for the authentication of telephone orders, then they must be authenticated within seven (7) days or the state mandated time requirement ..."


Bridgepoint Hospital policy number PCS.100 entitled "Physician Orders" effective December 2014, stipulates, "Telephone orders must be authenticated (verified) and countersigned by the prescribing practitioner or other responsible practitioner within seven days of receipt ..."


A. Patient #14 was admitted with diagnoses of Diabetic Ketoacidosis and Chronic Obstructive Pulmonary Disease.


Review of the medical record on January 23, 2017, at approximately 2:30 PM revealed the nursing staff documented telephone orders on January 6, 2017, at 1:00 PM and 2:55 PM and January 10, 2017, at 12:45 PM.


The medical record lacked documented evidence the medical staff documented the time of authentication for January 6, 2017, at 12:45 PM and 1:00 PM orders. Also, the medical lacked documented evidence the medical staff authenticated January 6, 2017, 2:55 PM order with date, time, and signature.


The findings were reviewed, discussed and acknowledged by Employee #33 on January 23, 2017, at approximately 2:45 PM.


B. Patient #21 was admitted with diagnoses of Sepsis and status post Laminectomy for Spinal Abscess and Debridement of Right Foot.


Review of the medical record on January 23, 2017, at approximately 11:05 AM revealed the clinical staff documented telephone orders from the medical staff on January 20, 2017, at 9:00 AM, 11:21 AM and 12:17 PM.


The medical record lacked documented evidence that the medical staff authenticated the telephone orders with date and time.


The medical record was reviewed by Employee #33 and acknowledged the findings on January 23, 2017, at approximately 1:15 PM.


C. Patient #29 was admitted for respiratory distress.


A review of the medical record conducted on January 26, 2017, at approximately 11:00 AM revealed a physician telephone order dated December 14, 2016, at 3:20 PM for transfusion of two units of packed red blood cells. The order was authenticated by the medical staff on January 23, 2017.


The medical record lacked documented evidence the medical staff authenticated all verbal/telephone orders promptly.


A face to face interview was conducted with Employee #6 on January 25, 2017, at 11:45 AM. S/he confirmed the findings mentioned above.


D. Patient #31 was admitted for intravenous therapy, rehabilitation and pain management.


A review of the medical record conducted on January 25, 2017 at approximately 2:00 PM revealed a physician telephones orders on December 7, 2016, at 3:28 PM, for physical therapy order clarification; December 8, 2016, at 1: 16 PM for physical therapy order clarification; and December 10, 2016, at 7:40 PM to restart a Dopamine drip.


These orders were authenticated on January 22, 2017, at 8:00 AM.


The medical record lacked documented evidence the medical staff authenticated all verbal/telephone orders promptly.


A face to face interview was conducted with Employee #6 on January 25, 2017, at 11:45 AM. S/he confirmed the findings mentioned above.





35226

Based on medical record review, bylaws and policy review, and staff confirmation, it was determined the medical staff failed to complete and document a medical history and physical examination no more than twenty-four hours after admission in three (3) of eleven (11) records reviewed (Patients# 32, 37, and 40).


The findings include:


BridgePoint Hospital Bylaws for Medical Staff approved March 25, 2016 stipulates "13.5.1 Completion of the H&P- A complete admission history and physical shall be recorded within twenty-four (24) hours of admission and prior to an invasive procedure being performed. The report shall include all pertinent findings resulting from an assessment of all systems of the body. In the event of a transcription delay or if a history and physical is dictated late in the 24-hour period a handwritten note must be written by the attending physician or his/her designee of the Hospital containing the reason for admission and pertinent findings giving enough information for clinicians to manage the patient and guide the plan of care."


Bridge Point Hospital Policy Number: HIM 07-001 titled "Medical Record Content" last revised and reviewed May 2016 stipulates, "The medical history should be completed within 24 hours of admission and include the chief complaints, details of the present illness (including, when appropriate, reflection of the patient's emotional, behavioral, and social status), relevant past, social, and family histories, and a historical inventory by body systems ...The physical examination should reflect a comprehensive, current physical assessment completed within 24 hours of admission and prior to the performance of any surgery."


A. Patient #32 was admitted with diagnoses to include Respiratory Failure and Cerebrovascular Accident.


A medical record review conducted on January 25, 2017, at approximately 2:20 PM, revealed Patient #32's History and Physical was dictated as evidenced by the handwritten noted; "H&P dictated #34170010". Further review of the medical record failed to reveal the presence of the History and Physical.




The medical record lacked documented evidence the medical staff ensured a medical history and physical was completed and documented in the medical record to ensure that all relevant information was available to clinicians within twenty-four hours of admission.


On January 25, 2017, at approximately 3:45 PM Employee #6 reviewed the medical record and confirmed the absence of the dictated History and Physical. S/he was unable to provide further explanation related to the missing dictated history and physical. According to Employee #6, it is the hospital's expectation that all dictated report be placed in the medical record as soon as practical.


B. Patient #37 was admitted with diagnoses to include Left Planter Ulcer and Depression.


The medical record review conducted on January 25, 2017, at approximately 2:30 PM, revealed Patient #37's History and Physical was dictated as evidenced by the handwritten note "H&P dictated #34172845". Further review of the medical record failed to reveal the presence of the History and Physical.


The medical record lacked documented evidence the medical staff ensured a medical history and physical was completed and documented in the medical record within twenty-four hours of admission.


On January 25, 2017, at approximately 3:45 PM Employee #6 reviewed the medical record and confirmed the absence of the dictated History and Physical. S/he was unable to provide further explanation related to the missing dictated history and physical. According to Employee #6, it is the hospital's expectation that all dictated report be placed in the medical record as soon as practical.




C. Patient #40 was admitted with diagnoses to include Chronic Obstructive Pulmonary Disease and Atrial Fibrillation.


Medical record review conducted on January 26, 2017, at 9:15 AM revealed Patient #40 was discharged on December 25, 2016.


On December 7, 2016, at 10:24 PM, the medical staff dictated the Admission History and Physician Examination. Review of the dictated document revealed multiple blank lines where the relevant data was not captured through dictation. Examples of the missing data are as follows:


1. "The patient is ...with recent laparoscopic appendectomy because of_____ [TIME: 00:44]..."
2. "The patient was transferred to ICU after_______ [TIME: 02:45]..."
3. "The patient should_____ [TIME: 09:06] to prevent aspiration."




The medical staff authenticated the History and Physical as evidenced by the presence of a signature. However, medical staff failed to make the necessary corrections to address blanks, prior to authentication.


The medical record lacked documented evidence the medical staff ensures a complete history and physical, to include all information relevant to the patient's plan of care.


A face to face interview was conducted on January 26, 2017, at approximately 9:30 AM with Employee #48. When queried about the completion of the history and physical s/he explained that it is the expectation of the medical staff to review the dictated document and make necessary correction or addition, prior to authenticating and placing in the medical record. The findings were reviewed, discussed, and acknowledged during a face to face conversation on January 26, 2017, at approximately 2:16 PM with Employees #2, 4, 10, and 48.

Based on medical record review and staff confirmation, it was determined the hospital staff failed to ensure that the medical record contained all consultative evaluations to assist providers with making assessments and revisions to the plan of care, in one (1) of 39 records reviewed (Patient #39).


The findings include:


Bridge Point Hospital Policy Number: HIM 07-001 titled, "Medical Record Content," last revised and reviewed May 2016 stipulates, "Each record will contain sufficient information to identify the patient, support the diagnosis, justify the treatment, document the course and results accurately, and facilitate continuity of care. Only authorized individuals may make entries in BridgePoint medical records. Therefore each inpatient medical record shall consist of at least the following items ...A report containing the written (and/or authenticated report of) opinion of any physician or other health care provider who sees the patient in consultation that reflects actual examination of the medical record and the patient whenever appropriate."


Patient #39 was admitted with diagnoses to Microcytic Anemia, Chronic Sacral Ulcer, and Spina Bifida.


The medical record review conducted on January 25, 2017, at approximately 3:00 PM revealed a "Suicidal Evaluation" dated October 19, 2016 at 3:21 PM, with a "Recommendation: Referral for Psychiatric Consultation." Further review of the medical record revealed the medical staff ordered a psychiatric consult on October 19, 2016.


The medical record lacked documented evidence the psychiatric consult was completed.


On January 25, 2017, at approximately 3:45 PM the findings were reviewed, discussed and acknowledged by Employee #6.

1. Based on the review of patients' transfusion records and confirmation by staff interview conducted on January 25, 2017 at approximately 3:30 PM, the hospital failed to ensure that all post-transfusion laboratory test results are filed in each patient's chart for one (1) of the eleven (11) patients with post-transfusion laboratory test that were randomly selected for review (Patient #29).

The findings included:

A. Review of Patient #29's medical record revealed on December 15, 2016, the patient had an order for transfusion of two (2) units of packed Red Packed Cells (RBC). In addition, the patient had a telephone order dated December 16, 2016 for post - transfusion Complete Blood Count (CBC) test.

B. Further review of the records revealed that Patient #29 was transfused with two units of packed RBC on December 15, 2016. However, the patient's medical record on January 26, 2017 failed to provide evidence of a post - transfusion laboratory test result for CBC.

C. Upon the surveyor's inquiry, the hospital staff obtained the post- transfusion CBC result from the hospital's reference laboratory. Review of the result revealed that the test was performed on December 16, 2015 as ordered but the results were not filed in the patient's medical record.

D. Interview with the nursing staff confirmed that the post transfusion CBC result was never filed in the patient's medical record.



34093



2. Based on medical record review, policy review, and staff interview, it was determined that the medical staff failed to write a complete order for ventilator services, in one (1) of six (6) patient records reviewed (Patient #3).


The findings include:


The BridgePoint Capitol Hill Hospital Medical Staff Rules and Regulations stipulates, "...E. Treatment 1. Orders a. All orders for treatment shall be in writing, written clearly, legibly and completely and shall be dated, timed and signed by a physician..."


On January 24, 2017, at approximately 10:25 AM, Patient #3 was observed on mechanical ventilation at a continuous mandatory mode, with a rate of 16, tidal volume 300, fraction of inspired oxygen of 30%, and positive end expiratory pressure of 5.


Review of the medical record on January 24, 2017, at approximately 10:30 AM revealed a
physician order on January 18, 2017 at 10:00 PM for mechanical ventilation at a continuous mandatory mode, with a rate of 16, tidal volume 350, and fraction of inspired oxygen of 30%. A subsequent order on January 20, 2017 at 8:25 AM revealed a tidal volume of 300. There was no positive end expiratory pressure (PEEP) indicated on either order.


Further review of the ventilator flow sheets and the physician progress notes revealed the patient was ventilated with PEEP of 5 on January 18, 2017 to January 24, 2017.


The medical record lacked documented evidence that the medical staff wrote a complete order for the ventilator services to include the PEEP of 5.


On January 24, 2017, at approximately 1:15 PM, a face-to-face interview was conducted with Employee #27, who was queried about the order. S/he explained that the patient was admitted to the hospital on PEEP of 5 and the respiratory staff continued the setting. However, the physician didn't document it on the order form and it was an oversight by the respiratory staff. Employee #27 could provide no order for the complete ventilator settings.


Employees #5 and 27 acknowledged and confirmed the findings during the face to face interview.

Based on medical record review, policy and bylaw review and staff confirmation, it was determined the hospital staff failed to ensure the final diagnosis and completion of medical record within thirty (30) days following discharge in four (4) of 39 records reviewed (Patients #30, 31, 34 and 40).


The findings include:


BridgePoint Hospital Bylaws for Medical Staff approved March 25, 2016 stipulates, "13.5.2 Medical Records upon Discharge- Medical records must be completed and authenticated by the appropriate physician, dentist, or podiatrist within thirty (30) days following a patient's discharge from the Hospital."


BridgePoint Hospital Policy Number HIM 07-001, entitled, "Medical Record Content," effective May 2016 stipulates, "Upon discharge, the medical record will be completed as soon as possible, not to exceed 30 days."


A. Patient #30 was admitted with Respiratory Failure and End Stage Renal Disease on dialysis.


A review of the medical record conducted on January 25, 2017, at 1:45 PM revealed that Patient #30 expired on December 6, 2016.


The medical record lacked documented evidence of a death summary completed within 30 days of discharge.


A face to face interview was conducted with Employee #6 on January 25, 2017, at approximately 1:50 PM. The findings were reviewed, discussed, and acknowledged.


B. Patient #31 was admitted for Intravenous Therapy, Rehabilitation and Pain Management.


A review of the medical record conducted on January 25, 2017, at approximately 2:00 PM revealed that Patient #31 was discharged from the facility on December 16, 2016.


The medical record lacked documented evidence of a discharge summary completed within 30 days of discharge.


A face to face interview was conducted with Employee #6 on January 25, 2017, at approximately 2:05 PM. The findings were reviewed, discussed, and acknowledged.


C. Patient #34 was admitted with diagnoses to include Perforated Duodenal Ulcer, Hypertension, and Cardiac Mass.


Medical record review conducted on January 25, 2017, at approximately 2:20 PM revealed Patient #34 was discharged on December 20, 2016.


The medical record lacked documented evidence of a discharge summary.


The medical staff failed to ensure a discharge summary was documented within 30 days of Patient #34's discharge.


A face to face interview was conducted on January 25, 2017, at approximately 3:45 AM with Employee #6. According to Employee #6, it is the expectation that the medical record be complete to include the discharge summary within 30 days of discharge from the facility. The findings were reviewed, discussed, and acknowledged by the Employee #6.


D. Patient #40 was admitted with diagnoses to include Chronic Obstructive Pulmonary Disease and Atrial Fibrillation.


Medical record review conducted on January 26, 2017, at 9:15 AM revealed Patient #40 was discharged on December 25, 2016.


The medical record lacked documented evidence of a discharge summary or the final diagnoses for Patient #40.


The hospital staff failed to ensure a complete medical record within thirty days of discharge to include a discharge summary or final diagnoses.


A face to face interview was conducted on January 26, 2017, at approximately 9:30 AM, with Employee #48. When queried about the completion of the history and physical and discharge. S/he explained that it is the expectation of the medical staff to review the dictated document and make necessary correction or addition prior to singing and placing in the medical record. The findings were reviewed, discussed, and acknowledged during a face to face conversation on January 26, 2017 at approximately 2:16 PM with Employees #2, 4, 10, and 48.




35226

Based on observation and staff interviews, it was determined that the hospital staff failed to ensure mislabeled medications were not stored and available for use, in one (1) of four (4) observations made (Patient #3).


The findings include:


Patient #3 was admitted with diagnosis a of Respiratory Failure.


On January 24, 2017, at approximately 9:30 AM, during a tour of the Medication Room, in the Intensive Care Unit, a bag of Vancomycin 750 milligrams labeled, "Hang by 1/23/2017, 10:00 every day" was observed hanging with other bags of medications, available for use for Patient #3.The observation was conducted in the presence of Employee
#5.


Review of the Medication Administration Record (MAR) revealed an order transcribed by pharmacy staff that indicated the patient was to receive Vancomycin 750 mg every 48 hours, intravenously, based on the Vancomycin dosing protocol, per physician order, which would indicate the patient would receive a dose of medication January 24, 2017, instead of January 23, 2017.


The practice lacked evidence that staff ensured that mislabeled medication was not stored and available for patient use.


On January 25, 2017, at approximately 9:40 AM, a face-to-face interview was conducted with Employee #5 regarding the finding. S/he explained that typically staff would remove the mislabeled medication, place it in the bin to return to pharmacy; and request the correctly labeled medication. At 10:15 AM, a face-to-face interview was conducted with Employees #32 who acknowledged and confirmed the finding.

Based on observations, it was determined that Dietary Services were not adequate to ensure that foods are always served and prepared in a safe and sanitary manner. These findings were observed in the presence of the Employee #16.


The findings include:


1. Foods, such as tomatoes, Pineapple and Cantaloupe were improperly disposed of, in trash receptacles, near the Pot and Pan Wash Area, in one (1) of one (1) of one (1) observation at 11:30 AM on January 23, 2017.


2. The interior and bottom surfaces of hotel pans washed in the Pot and Pan Wash Ares were soiled on the interior and bottom surfaces and grease was on the bottom and interior surfaces.


A. Six (6) of 11- 1/8" inch pans were observed to have leftover food and grease on the inner surfaces.


B. One (1) Large Cooking (Soup Pot) had burned food residue on the inner and bottom surfaces, in one (1) of one (1) observation at 10:45 AM on January 23, 2017.


C. Sheet pans were soiled with leftover food residue on the inner and corner surfaces, after washing in the Pot and Pan Wash Area, in 11 of 12 observations at 11:50 AM on January 23, 2017.


D. Six (6) of 11- 2" X 24" X 12" inch pans were soiled with food particles and a thin film of grease, on the inner and bottom surfaces at 10:55 AM on January 18, 2017.


3. Sprinkler head and shaft surfaces were soiled with dust over the steam table; sprinklers were dark in appearance in the back hallway outside of the Main Kitchen, in three (3) of four (4) observations at 11:15 AM on January 23, 2017; and water supply lines over the serving line were soiled with dust, in three (3) of four (4) observations at 11:17 AM on January 23, 2017.


4. Ceiling surfaces were soiled and stained; floor tiles were soiled, stained and damaged in the Men's and Ladies Bathrooms, in two (2) of two (2) observations at 12:15 PM on January 23, 2017.


5. The backsplash area of the sink in the Ladies Restroom was damaged and separated from the wall and a large opening was present in the wall of stall three, in two (2) of two (2) observations at 12:20 PM on January 23, 2017.


6. Entrance doors and doors within the Main Kitchen were marred and soiled throughout, in three (3) of three (3) observations between 9:45 AM 3:30 PM on January 23, 2017.


7. Floor surfaces were discolored; uneven and damaged and beyond repair, in the cook's preparation area, under the counter of the soda machine dispensers in the cafeteria serving area, in front of the double door refrigerators (adjacent to the tray line) and in front of the walk-in refrigerators, in the main kitchen and production areas, in six (6) of six (6) observations between 10:00 AM and 2:00 PM on January 23, 2017.


8. Threshold surfaces located at the entrances to walk in refrigerators were soiled with debris, in two (2) of to (2) observations; wall surfaces were soiled and baseboards were separated in the rear of the steamer and flat skillet, in two (2) of two (2) observations in the Main Kitchen, behind equipment at 9:50 AM on January 23, 2017.

Based on observation, a review of the 'Weekly Kitchen Staffing Schedule' from January 15, 2017 through January 21, 2017 and staff confirmation, it was determined that the dietary staff failed to ensure that Certified Food Service Managers were on duty during all shifts to ensure that foods were prepared and served in a safe manner.


The findings include:


On January 23, 2017, at approximately 2:00PM, a review of the 'Weekly Kitchen Staff Schedule' revealed that licensed Food Service Managers were not on duty during the following shifts; day and evening shifts between 6:30 AM and 8:00 PM on January 15, 2017; day and evening shifts between 6:30 AM and 8:00 PM on January 16, 2017; early shift between 6:30 AM and 11:30 AM on January 17, 18 and 19th, 2017 and early and late shifts on January 20, 2017; and evening shift on January 21, 2017, in seven (7) of seven (7) observations on January 23, 2017. The observations were in the presence of Employee #16.


The observations failed to provide evidence that Certified Food Service Managers were on duty during all shifts to ensure that foods were prepared and served in a safe manner.


The findings were reviewed and acknowledged by Employee #16.

Based on observations during the survey, it was determined that housekeeping and maintenance services were not adequate to ensure that the facility is maintained in a safe and sanitary manner. These findings were observed in the presence of the Employee #14.


The findings include:


1. The following findings were observed during a tour of the Second Floor at 11:45 AM on January 24th, 2017.


A. The second-floor elevator, on the south side, failed to align properly with the floor when the elevator doors opened, creating a potential for accidental trips or falls; and the frontal surfaces of the elevator were marred, in two (2) of two (2) observations.


2. The following findings were observed, during a tour of the Intensive Care Unit, between 1:35 PM and 2:45 PM on January 24, 2017.


A. Floor surfaces, in the rear of the toilet, were damaged; the exhaust vent was soiled on the interior and exterior surfaces; hot water temperatures were 82 degrees Fahrenheit, which is below the 105 degree Fahrenheit minimum; dust accumulation was observed on top of headboard and wall panel surfaces; and door and jamb were marred and damaged, in Room 2002 in six (6) of six (6) observations.


B. Baseboard surfaces under the sink were soiled and damaged; floor tiles in the toilet room were stained; the nightstand lacked a drawer; exhaust vents were soiled and stained; the toilet dispenser holder was damaged; baseboards behind the toilet were damaged; window sill surfaces were soiled with dust; the toilet flush valve was leaking water continuously; and a small penetration was observed in wall surfaces, in Room 2007, in eight (8) of eight (8) observations.


C. The horizontal surfaces of the bed frame were soiled with dust; the bath exhaust vent was soiled with dust; floor surfaces in front of the sink were stained and the front area of door surfaces were marred, in Room 2010, in four (4) of four (4) observations.


D. Counter top edge surfaces and cabinets doors were worn and damaged at the Nurses' Station, in the Intensive Care Unit, in two (2) of two (2) observations.


E. Baseboards were separated from wall; wall surfaces were damaged; ceiling tiles near supply vent were damaged; the base surfaces of the pole supporting the monitor were soiled; the toilet exhaust vent and a wall heater were soiled with dust; the vertical flush pipe in the toilet was corroded with mineral deposits; and the entrance door and door jambs were married and damaged, in room 2012, in four (4) of four (4) observations.


F. The toilet room in the hallway near Room 2019 lacked signage; baseboard surfaces, under the toilet and around the perimeter of the room, were damaged.


G. Entrance door surfaces and toilet room door surfaces were marred in room 2019.


H. Door edge surfaces were marred; the (HVAC) Heating Ventilation and Air Conditioning Unit condenser were soiled with dust on the interior, and baseboard surfaces were soiled, in three (3) of three (3) observations, in Room 2020.


I. Closet doors failed to close or remained latched, in rooms 2020, and 2023, in two (2) of two (2) observations.


J. The interior areas of the Heating Ventilation Unit were soiled with dust; Venetian blinds were dusty; walls and the bathroom door were marred in room 2021, in three (3) of three (3) observations.


K. The frontal surfaces of the ice machine, near the Nurses' Station, on 2North were soiled and stained with mineral deposits; and the chute surfaces were soiled with mineral deposits on the interior, in two (2) of two (2) observations.


L. The interior and shelf surfaces of the patient's refrigerator were soiled and sticky.


M. Floors and baseboards were soiled in the toilet room; door surfaces were marred; the exhaust vent in the toilet room was soiled, on the interior; the horizontal surfaces of the bed frame were soiled with dust, in Room 2005, in five (5) of five (5) observations.


N. The entrance door made contact with the floor and was difficult to open and close, when examined; the baseboard surfaces of floors were soiled; the overhead lamp lacks a pull cord; ceiling tile surfaces were soiled; the horizontal surfaces of the bed frame were soiled with dust, and window sill surfaces were marred, in Room 2006.


3. The following findings were observed during a tour of 3 North, between 2:35 PM and 3:30 PM on January 24, 2017.


A. The interior surfaces of the Heating Ventilation and Air Conditioning Unit (HVAC) Unit was dust and paper was observed below the interior louvers; hot water temperatures were 72 degrees Fahrenheit, which is below the minimum temperature of 105 degrees Fahrenheit, in three (3) of three (3) observations, in 3154.


B. Ceiling tiles were soiled and stained; the ceiling lamp lacked a cover; three (3) of 14 locker doors were missing, in the female staff Locker Room, in three (3) of three (3) observations.


C. Wall surfaces were marred and damaged, behind the 3 North Pantry door.


D. Floor tiles surfaces were soiled and stained in Men's Restroom.


E. The horizontal surfaces of the bed frames and behind the headboard were soiled with dust, in room 3116, in two (2) of two (2) observations.


F. The lower cabinet drawer on the nightstand was broken; wall surfaces were marred; and tiles were damaged near the door in two (2) of two (2) observations.


G. Floor tiles were missing in front of the Heating Ventilation Air Conditioning Unit; the horizontal surfaces of the bed frame were soiled with dust; walls were marred and damaged, adjacent to the bed, in Room 3103.




H. Chair armrests and finish was worn in Room 3147.


I. The Clean and Soiled linen rooms lacked signage, in two (2) of two (2) observations.

J. Lamp covers were soiled; floor and baseboard surfaces were soiled marred and damaged and the rear surfaces of the entrance door were marred, in the Soiled Linen Room, in four (4) of four (4) observations.


K. Wall surfaces were marred and damaged; floor surfaces around the perimeter of the room and the rear of the toilet were soiled; and wall surfaces were damaged with penetrations, in room 3142.


L. Paint was peeling on the wall, near the window; wall surfaces were marred near the bed; the horizontal surfaces of the bed frame were soiled with dust; and floor tiles were damaged in the toilet, in Room 3139.


M. Floor tiles and baseboards were soiled in the Linen Room.


4. The following observations were made during a tour of the Rehabilitation Department at 10:55 AM on January 25, 2017.




A. Floor surfaces were very soiled in the rear of the room; numerous boxes of supplies and trash and paper products were improperly stored on the floor; and ceiling tiles were stained, in three (3) of three (3) observations.


5. The following finding was observed during a tour of the boiler room beginning at 11:45 AM on January 25, 2017.

Numerous boxes and other equipment were improperly stored on floor surfaces in the Boiler Room.


6. The following findings were observed during a tour of the Dialysis Area on January 26, 2017.


A. Floor surfaces were heavily stained adjacent to the sink; the water outlet housing lacked a cover, and the drainage outlet cabinet was soiled.


B. Penetrations were observed in wall surfaces in the Clean Storage Area.


C. The interior and exterior surfaces of exhaust vents in the toilet room were soiled with dust and faucet handles and base surfaces had mineral deposits.


7. The following findings were observed during a tour of Laboratory Services 10:30 AM on January 25, 2017.


A. Ceiling grid surfaces were soiled; floor surfaces were soiled in corners; the inner areas of the cabinet under the sink were soiled with debris.


8. The following findings were observed during a tour of the X-Ray Department at 11:15 AM on January 25, 2017.


Wall surfaces in the X-Ray Room and X-Ray Office were damaged and crumbling on the lower surfaces, and air supply vents were soiled, in three (3) of three (3) observations.


9. The following findings were observed during a tour of the Rehabilitation Area at 10:45 Am on January 25, 2017.


A. The floor surfaces of parallel bars were marred and the side adjustable rails were scarred.


B. Privacy curtain hooks were detached and not connected to tracks; baseboards were missing and separated around the wall, in the treatment areas; ceiling tiles were soiled and stained; floors under work stations, in the rear of the room, were soiled with debris, in four (4) of four (4) observations.


C. Exhaust vents were soiled in the toilet room.

Based on policy review, temperature log reviews, and staff interview, it was determined that the pharmacy staff failed to ensure that refrigerator temperatures were maintained, between 36 degrees Fahrenheit (ºF) and 46 ºF, for adequate drug storage in four (4) out of four (4) months reviewed.


The findings include:


On January 24, 2017, at approximately 10:30 AM, during the tour of 2North unit, the 'Medication Refrigerator Temperature Log(s)' were observed to have documentation indicating that the medication refrigerator's temperatures were out of range as follows:


1. In October 2016, the refrigerator temperatures were recorded as above 46 ºF on the 1st, 2nd, 3rd, 5th, 8th, 9th, 11th, 19th, 20th, 24th, 29th, and 30th. Additionally, on October 27, 2016, the refrigerator temperature was recorded as below 36ºF (Fahrenheit).


2. In November 2016, the refrigerator temperatures were recorded as above 46ºF on November 10th and 11th.


3. In December 2016, the refrigerator temperatures were recorded as above 46ºF on the 9th, 10th, 14th, 18th, 20th, 21st, and 22nd.

4. In January 2017, the refrigerator temperatures were recorded as above 46ºF on the 5th, 15th, 21st, and 22nd.


The "Medication Refrigerator Temperature Log" indicated that the refrigerator temperatures acceptable range of 36 ºF to 46 ºF, with instructions for corrective action and repeat temperature be taken. The "Corrective Action Legend" provides the following corrective actions: A= Engineering notified, B= Cleaning, C= Adjusted by Dietary Staff; and D= None Taken.


The record lacked documented evidence of the corrective actions taken to address the incidents of out of range temperatures.


On January 24, 2017, at approximately 12:00 PM, Employees #32 and 51 were questioned about the medication refrigerator temperatures and process for correction. The inspector could not ascertain what action was taken to assure the safety and potency of the medications in the refrigerator.

Based on observation, policy review and staff confirmation, it was determined that the staff failed to follow the hospital hand hygiene policy and recommendations to prevent the spread of infection, in two (2) of four (4), observations (Patients #1 and 12).


The findings include:


The BridgePoint Capitol Hill Hospital Policy Number IC.7, effective December 2014, titled, 'Hand Hygiene,' stipulates, "1. When To Perform Hand Hygiene ...C. Decontaminate hands before having direct contact with patients ...F. Decontaminate hands after contact with a patient's intact skin ...H. Decontaminate hands after contact with inanimate objects in the immediate vicinity of the patient ..."


A. Patient #1 was admitted with diagnoses that included Respiratory Failure.


On January 23, 2017, at approximately 2:10 PM, during a tour in the Intensive Care Unit, Employee #25 was observed, in the presence of Employee #20, exiting Patient #1's room, without first removing gloves and sanitizing, after providing patient care.




The observation failed to provide evidence to support that the nurse followed the hospital's hand hygiene policy to prevent the spread of infection.


Employees #20 and 25 acknowledged and confirmed the findings.


B. Patient #12 was admitted with diagnoses to include Respiratory Failure.


On January 23, 2017, at approximately 10:30 AM, during a tour in the Intensive Care Unit, Employee #22 was observed, in the presence of Employee #20, exiting and re-entering Patient #9's room, without first sanitizing, applying gloves, and providing patient care.


The observation failed to provide evidence to support that the nurse followed the hospital's hand hygiene policy to prevent the spread of infection.


Employees #20 and 22 acknowledged and confirmed the findings.