HospitalInspections.org

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Based on document reviews, record reviews, and interviews, the hospital failed to ensure it was in compliance with applicable Federal laws and regulations related to the health and safety of patients. The hospital failed to ensure "An Important Message From Medicare About Your Rights" was provided to Medicare inpatients at admit and/or discharge for two (Patient #1, Patient #3) of four Medicare inpatient records reviewed for notification of rights at admit and discharge from a sample of 21 patients. This deficient practice had the potential to affect the two inpatients whose records were reviewed and any future Medicare patient admitted for inpatient services.

Findings:

Review of "An Important Message From Medicare About Your Rights," dated 3/31/20, indicated hospital inpatients have there right to, ". . . Receive Medicare covered services. . . If you think you are being discharged too soon: You can talk to the hospital staff, your doctor and your managed care plan (if you belong to one) about your concerns. You also have the right to an appeal, that is, a review of your case by a Quality Improvement Organization (QIO). "

The facility was unable to provide a policy regarding the process for providing "An Important Message From Medicare About Your Rights" to Medicare inpatients at admit and discharge that included whose responsibility it was to review the form with the patient.

Review of the "CMS Manual System,"dated 5/25/07, indicated ". . . Currently, at or about the time of admission, hospitals must deliver the 'Important Message from Medicare' (IM), as required by Section 1866(a)(1)(M) of the Social Security Act (the Act), to all hospital inpatients with Medicare to explain their rights as a hospital in-patient, including their right to an expedited review by a QIO of a discharge. In addition, a hospital must provide a Hospital-Issued Notice of Non-coverage (HINN), as required by Section 1154 of the Act to any beneficiary in original Medicare that expresses dissatisfaction with an impending hospital discharge. . . Beginning July 1, 2007, hospitals must deliver a revised version of the Important Message from Medicare (IM), CMS-R-193, which is an existing statutorily required notice, to explain discharge appeal rights. Hospitals must issue the IM within 2 calendar days of the day of admission, and obtain the signature of the beneficiary or his or her representative to indicate that he or she received and understood the notice. The IM, or a copy of the IM, must also be provided to each beneficiary within 2 calendar days of the day of discharge. Thus, in cases where the delivery of the initial IM occurs more than 2 days before discharge, hospitals will deliver a follow up copy of the signed notice to the beneficiary as soon as possible prior to discharge, but no more than 2 days before. . ."

1. Review of Patient #1's inpatient electronic medical record (EMR) indicated Patient #1 was a Medicare inpatient admitted on 10/28/21 and discharged on 11/9/21. There was no documentation that Patient #1 received "An Important Message From Medicare About Your Rights" at least two days prior to discharge.

In an interview on 11/15/21 at 11:55 am, Health Informatics Analyst #9 confirmed Patient #1's medical record did not have documentation of "An Important Message From Medicare About Your Rights" at the time Patient #1 was discharged.

2. Review of Patient #3's inpatient EMR indicated Patient #3 was a Medicare patient who was admitted on 11/8/21 and discharged on 11/11/21. There was no documentation that Patient #3 received "An Important Message From Medicare About Your Rights" at admit and again at discharge.

In an interview on 11/16/21 at 2:46 PM, Health Informatics Analyst #9 confirmed Patient #3's medical record did not have documentation of "An Important Message From Medicare About Your Rights" at the time Patient #3 was discharged.

In an interview on 11/16/21 at 10:10 AM, Director of Quality Management #3 indicated the hospital does not have a policy for "An Important Message From Medicare About Your Rights."

In an interview on 11/17/21 at 11:03 AM, Licensed Nurse (LN) UR (Utilization Review) #18 stated "An Important Message From Medicare About Your Rights" is put together on admission by the unit clerk who gives it to the admitting nurse. Registered Nurse UR #18 stated the admitting nurse gets the patient to sign the form and does the same thing at discharge.

In an interview on 11/17/21 at 12:38 PM, LN #33 stated he/she was totally unaware of needing a signature for "An Important Message From Medicare About Your Rights." LN #33 stated "it wasn't brought to my attention until a few days ago that the unit clerk made me aware that the forms needed to be signed." LN #33 stated he/she, "Got busy and passed it on to the following shift registered nurse," for Patient #3. LN #33 stated, "I can't say what happened with the papers for [Patient #1]." LN #33 stated he/she had no recollection if he/she was told about the form. He/she stated he/she knows nothing about needing the form signed within two days of discharge. ."
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Based on policy review, record review, and interview, the hospital failed to ensure services were provided in accordance with written policies. The hospital failed to ensure swing-bed patients signed acknowledgement of receipt of patient rights and the "Swing Bed Patient Information" packet as required by hospital policy. This deficient practice was evident for two (Patient #2, Patient #4) of four swing-bed patient records reviewed for receipt of swing-bed packet and notification of patient rights. This deficient practice had the potential to affect the four current swing-bed patients and any future swing-bed patient admitted for services.

Findings:

1. Review of Patient #2's swing-bed electronic medical record (EMR) indicated Patient #2 was admitted to swing-bed on 11/3/21. Further review indicated there was no document signed by Patient #2 of receipt of the swing-bed packet and notification of patient rights.

In an interview on 11/16/21 at 12:43 PM, Health Informatics Analyst #9 confirmed there was no documentation signed by Patient #2 of receipt of the swing-bed packet and notification of patient rights.

2. Review of Patient #4's swing-bed EMR indicated Patient #4 was admitted to swing-bed on 11/13/21. Further review indicated there was no document signed by Patient #4 of receipt of the swing-bed packet and notification of patient rights.

In an interview on 10/16/21 at 10:23 AM, Health Informatics Analyst #9 confirmed there was no documentation signed by Patient #4 of receipt of the swing-bed packet and notification of patient rights.

In an interview on 11/16/21 at 2:00 PM, Licensed Certified Social #22 stated he/she is responsible for reviewing the "Swing Bed Patient Acknowledgement" form with the patient and putting a copy of the signed acknowledgement page in the physical binder on the unit. Licensed Certified Social #22 offered no explanation of why such a form was not in the medical record of Patient #2 and Patient #4.

Review of the policy titled "Admission to Swing Bed," revised 8/12/16, indicated ". . . The Social Worker will obtain a copy of the Swing bed admission paperwork. They will explain to the patient, family members or guardian the Swing Bed agreement, covered and non-covered costs, and patient's rights. A signature will be obtained from the patient, family or guardian, verifying receipt of Swing Bed Packet, which includes information on Available Services, General Policies, Rights and Privacy Act Statement. Their signature will be on the Acknowledgement Form and placed in the patient's chart. . ."
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Based on policy review, record review, and interview, the hospital failed to ensure:
1.) Physician orders for multiple pain medications and/or multiple strengths of pain medication included parameters for administration for two (Patient #1, Patient #14) of seven patient records reviewed for pain medication administration from a sample of 21 patients. This deficient practice had the potential to affect the current 10 patients admitted to the hospital and any future patient admitted with physician orders for pain medications.
2.) Pain medication administered was assessed for effectiveness in accordance with hospital policy for seven (Patient #1, Patient #3, Patient #6, Patient #11, Patient #12, Patient #14, Patient #15) of seven patient records reviewed for assessment of effectiveness of pain medication from a sample of 21 patients. This deficient practice had the potential to affect the current 10 patients admitted to the hospital and any future patient admitted with physician orders for pain medications.

Findings:

1. Review of the hospital policy titled "Pain Management in the Acute Care Hospital," originated 1/12/18, indicated ". . . 2. Interventions for Pain Management: a) Medication as ordered by physician. . ." There was no documentation that addressed the need to clarify pain medication that was ordered in two strengths and multiple pain medications to obtain parameters that explained when each strength or medication was to be administered, such as using a pain scale.

Review of Patient #1's electronic medical record (EMR), located under the "Order Chronology" tab, indicated the following physician orders for pain medication that had no documentation of parameters for administration:
10/28/21 at 8:50 PM Oxycodone IR (immediate release) 5 milligram (mg) oral tablet PO (by mouth) PRN (as needed) Q3H (every three hours).
10/28/21 at 8:50 PM Oxycodone IR 5 mg oral tablet 10 mg PO PRN Q3H.
10/28/21 at 8:55 PM Acetaminophen 325 mg oral tablet 650 mg PO PRN Q4H

Review of Patient #1's "Pain Assessment Flowsheet," located under the "Documentation" tab, indicated Patient #1 received Oxycodone 5 mg orally on 11/5/21 at 12:52 am and Oxycodone 10 mg orally at 2:44 am (less than three hours between administrations); Oxycodone 5 mg orally on 11/5/21 at 5:30 am (less than three hours than the previous administration) and Oxycodone 10 mg orally at 6:46 am (less than three hours between administrations); Oxycodone 5 mg orally on 11/5/21 at 8:41 am and Oxycodone 10 mg at 10:04 am (less than three hours between administrations); Oxycodone 5 mg on 11/5/21 at 3:07 PM and Oxycodone 10 mg at 4:44 PM (less than three hours between administrations); Oxycodone 5 mg orally on 11/5/21 at 6:23 PM and Oxycodone 10 mg orally at 7:35 PM (less than three hours between administrations).

Review of Patient #14's EMR under the medication and progress note tab, revealed patient #14 received hydrocodone/APAP , the physician ordered "oxycodone/APAP, 5/325, one tablet by mouth (PO) and oxycodone/APAP 5/325, two tablets PO." On 4/6/21 at 1:12 PM the nurse documented one tablet of oxycodone/APAP 5/325 one tablet given. On 4/6/21 at 7:19 PM., two tablets of oxycodone/APAP 3/323/APAP were given There was no clarification of the order to guide the nurse on the administration of when to give the higher strength of medication.

In an interview on 11/15/21 at 3:39 PM, Director Pharmacy #5 stated when to give which pain medication was "a nurses' discretion." Director Pharmacy #5 stated "the pharmacist is supposed to be getting a clarification with the physician, but we aren't doing it."

In an interview on 11/16/21 at 12:00 PM, Licensed Nurse #25 stated he/she uses the "1-10 scale" if the patient can speak, and if non-verbal, he/she uses the facial scale. Licensed Nurse #25 stated he/she doesn't get clarification orders when no parameters are given for pain medication. Licensed Nurse #25 stated he/she gives the Oxycodone as ordered, such as 5 mg every three hours and 10 mg every three hours which may be result in the patient getting Oxycodone sooner than every three hours.

In an interview on 11/17/21 at 11:05 am, Chief Nursing Officer #2, when informed that record reviews indicated the nurses weren't getting clarification orders when physicians ordered multiple pain medication without parameters, Chief Nursing Officer #2 offered no explanation or reason to explain this occurrence.

2. Review of the hospital policy titled "Pain Management in the Acute Care Hospital," originated 1/12/18, indicated ". . . 3. Reassessment related to pain/interventions attempted: a) Pain will be reassessed within 30 minutes of an intervention involving the administration of an IV [intravenous] medication, and within 60 minutes for oral or IM [intramuscular] medication administration. . . b) Reassessment will include patient level of pain as indicated on the Wong-Baker Faces/Numerical Scale, patient's level of sedation and adverse reactions and any continued pain characteristics. . . 4. Documentation . . . b) Documentation of pain assessment will be completed in the Plan of Care (POC) to include Status: Addressed, Intervention and/or Evaluation completed Wong-Baker numerical value of pain scale Location and character of pain c) Nursing will document and act upon any adverse reactions that may occur from the patient's current pain management therapies. . ."

a. Review of Patient #1's EMR, located under the "Order Chronology" tab, indicated the following physician orders for pain medication that had no documentation of parameters for administration:
10/28/21 at 8:50 PM Oxycodone IR (immediate release) 5 milligram (mg) oral tablet PO (by mouth) PRN (as needed) Q3H (every three hours).
10/28/21 at 8:50 PM Oxycodone IR 5 mg oral tablet 10 mg PO PRN Q3H.

Review of Patient #1's "Pain Assessment Flowsheet," located under the "Documentation" tab, indicated Patient #1 received Oxycodone 5 mg orally without documentation of an assessment for the effectiveness of the pain medication within 60 minutes after administration on the following days and times: 11/4/21 at 4:50 PM and 8:03 PM; 11/5/21 at 12:52 am, 5:30 am, 8:41 am, 11:54 am, 3:07 PM, 6:23 PM, and 9:55 PM; 11/6/21 at 2:01 PM. Further review indicated Patient #1 received Oxycodone 10 mg orally without documentation of an assessment for the effectiveness of the pain medication within 60 minutes after administration on the following days and times: 10/29/21 at 12:00 am, 3:54 am, 9:36 am, 9:52 PM; 10/31/21 at 10:03 am; 10/31/21 at 2:22 am, 6:40 am, 12:23 PM, 3:34 PM, 8:36 PM; 11/1/21 at 1:34 am, 9:58 am, 3:32 PM, 9:12 PM; 11/2/21 at 12:18 am, 3:47 am, 7:05 am.

In an interview on 11/16/21 at 12:00 PM, Licensed Nurse #25 stated he/she evaluates the patient 30 to 60 minutes after administration of pain medication. Licensed Nurse #25 offered no explanation for not documenting an assessment of pain medication effectiveness within 60 minutes after each administration of pain medication.

In an interview on 11/17/21 at 11:05 am, Chief Nursing Officer #2, when informed that record reviews indicated the nurses weren't documenting the effectiveness of pain medication, Chief Nursing Officer #2 offered no explanation or reason to explain this occurrence.

b. Review of Patient #3's EMR, located under the "Order Chronology" tab, indicated an order on 11/6/21 at 7:03 PM for Tramadol 50 mg oral tablet PRN every six hours.

Review of Patient #3's "Pain Assessment Flowsheet," located under the "Documentation" tab, indicated Patient #3 received Tramadol 50 mg orally on 11/9/21 at 2:01 am and at 8:19 PM without documentation within 60 minutes after administration of the effectiveness of the pain medication.

c. Review of Patient #6 electronic medical record (EMR), under the medication and progress note tab, revealed documentation that Patient #1 received, lorazepam 1 milligram (mg) by injection (a medication given for anxiety) on 5/9/21, at 7:45 PM , and on 5/10/21 at 8:36 am. There was no documented reassessment of the effectiveness of the medication after administration.

d. Review of Patient #11's EMR under the medication and progress note tab, revealed patient #12 received hydrocodone/APAP (opioid and acetaminophen medication given for pain), 2 tablets by mouth (PO) on 3/9/21 at 7:19 PM, 11/14/21 at 3:15 and 13/15/21 at 11:05 am. There was no documented reassessment of the effectiveness of the pain medication after administration.

e. Review of Patient #12's EMR under the medication and progress note tab, revealed patient #12 received tramadol 50 mg (narcotic medication given for pain), given PO on 03/09/21 at 7:19 PM, on 11/14/21 at 1:21 PM, and on 11/15/21 at 11:05 am. There was no documented reassessment of the effectiveness of the pain medication after administration.

f. Review of Patient #14's EMR under the medication and progress note tab, revealed patient #14 received hydrocodone/APAP , the physician ordered "oxycodone/APAP, 5/325, one tablet by mouth (PO) and oxycodone/APAP 5/325, two tablets PO." On 4/6/21 at 1:12 PM the nurse documented one tablet of oxycodone/APAP 5/325 one tablet given. On 4/6/21 at 7:19 PM., two tablets of oxycodone/APAP 3/323/APAP were given. There was no documented reassessment of the effectiveness of the pain medication after administration.

g. Review of Patient #15's EMR under the medication and progress note tab, revealed patient #15 received hydrocodone/APAP , 1 tablet PO on 05/10/21 at 7:24 PM, on 5/10/21 at 2:41 PM, on 5/10/21 at 7:17 PM, on 5/11/21 at 1:46 am, and on 5/11/21 at 8:36 am. There was no documented reassessment of the effectiveness of the pain medication after administration.

In an interview with Staff #4, Unit Based Educator Licensed Nurse on 11/16/21 at 2:30 PM, confirmed the staff failed to document the effectiveness of the medication given for pain and anxiety for Patient #6, Patient #11, Patient #12, Patient #14, and Patient #15.

In an interview on 11/17/21 at 11:05 AM, Chief Nursing Officer #2, when informed that record reviews indicated the nurses weren't documenting the effectiveness of pain medication, Chief Nursing Officer #2 offered no explanation or reason to explain this occurrence.
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Based on record review, and interview, and policy review, the hospital failed to ensure occupational therapy (OT) services were provided as ordered and in accordance with the hospital's policy and the patient's plan of care established during the evaluation for two (Patient #1, Patient #2) of four patient records reviewed for OT services from a sample of 21 patients. This deficient practice had the potential to affect the four patients receiving OT services and any future patient admitted with orders for OT services.

Findings:

1. Review of Patient #1's electronic medical record (EMR) indicated Patient #1 was discharged from inpatient on 11/9/21 and admitted to swing-bed on 11/9/21. Review of the physician orders, located under the "Order Chronology" tab, indicated an order on 11/8/21 for "OT Eval [evaluate] And Treat 1x [one time]."

Review of Patient #1's EMR, under the "Notes" tab, indicated Occupational Therapist #24 evaluated Patient #1 on 11/10/21 with a frequency of visits established as two to five times a week. Further review indicated OT visits were conducted on 11/15/21 and 11/16/21. There was no documentation that a second visit was conducted 11/11/21, 11/12/21, or 11/13/21 to meet the plan that was established.

2. Review of Patient #2's EMR indicated Patient #2 was discharged from inpatient on 11/3/21 and admitted to swing-bed on 11/3/21. Review of the physician orders, located under the "Order Chronology" tab, indicated an order on 11/3/21 for "OT Eval And Treat."

Review of Patient #2's EMR, under the "Notes" tab, indicated Occupational Therapist #24 evaluated Patient #2 on 11/3/21 with a frequency of visits established for three to five times a week. Further review indicated OT visits were conducted on 11/04/21, 11/8/21, and 11/9/21. There was no documentation that an OT was made on 11/5/21 or 11/6/21, which would have been the third visit in accordance with the established plan, and there was no documentation that a third visit was made the week of 11/7/21.

In an interview on 11/17/21 at 10:11 am, Occupational Therapist #24 stated Patient #1's evaluation was done and had a frequency of two to five times a week Occupational Therapist #24 stated the frequency established in the plan was not met, because Occupational Therapist #24 was on vacation starting 11/11/21 through 11/16/21, and the relief occupational therapist should have seen Patient #1 on 11/12/21.

In an interview on 11/17/21 at 1:20 PM, Occupational Therapist Registered #34 stated he/she went to see Patient #1 on 11/12/21, and Patient #1 was busy with physical therapy. Occupational Therapist Registered #34 stated he/she didn't go back to see Patient #1, because "I was out of time." Occupational Therapist Registered #34 stated he/she has his/her own practice and comes to help in the hospital, because they don't have enough occupational therapists right now.

Review of the policy titled, "Provision of Care," approved 8/20/15, indicated ". . . Rehabilitative Services 1. A functional assessment is performed for each patient referred for rehabilitation services (PT [physical therapy], OT, and SLP [speech and language pathology]). Based on assessment of the patient's physical, cognitive, emotional, and social status, a written treatment plan is developed that identifies the patient's needs. . . 2. The rehabilitation department's assessment is completed within 24 hours of notification during the regular work week. . ."

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Based on record review, interview, and policy review, the facility failed to have a signed, dated, and timed patient "Consent for Treatment" form for inpatient admission for seven (Patient #1, Patient #2, Patient #6, Patient #7, Patient #8, Patient #12 and Patient #21) out of 12 inpatient medical records reviewed. In addition, the facility failed to have a signed consent for admission to a swing bed (a hospital room that can switch from in-patient acute care status to skilled care status) for two (Patient #1 and Patient #3) out of four swing bed patients' medical records reviewed. The facility also failed to ensure a blood transfusion consent was signed, prior to administration of blood for one (Patient #21) out of three patient records reviewed for blood transfusions administered. These findings had the potential for the facility to provide treatments and blood administration prior to obtaining the patients' or guardians' consent.

Findings:

1. Review of Patient #1's swing-bed electronic medical record (EMR) indicated Patient #1 was admitted to swing-bed on 11/9/21. Further review indicated there was no documentation of a signed consent when Patient #1 was admitted for swing-bed services.

In an interview on 11/15/21 at 2:27 PM, Health Informatics Analyst #9 confirmed there was no signed consent by Patient #1 when Patient #1 was admitted for swing-bed services.

2. Review of Patient #2's inpatient EMR indicated Patient #2 was admitted on 10/26/21 and discharged on 11/3/21. Review of the swing-bed record indicated Patient #2 was admitted on 11/3/21. There was no documentation of a signed consent by Patient #2 for inpatient and swing-bed services.

In an interview on 11/16/21 at 11:20 am, Health Informatics Analyst #9 confirmed there was no signed consent by Patient #2 when Patient #2 was admitted for inpatient and swing-bed services.

3. Review of Patient #3's swing-bed EMR indicated Patient #3 was admitted to swing-bed on 11/11/21. Further review indicated there was no documentation of a signed consent when Patient #3 was admitted for swing-bed services.

In an interview on 11/15/21 at 3:30 PM, Health Informatics Analyst #9 confirmed there was no signed consent by Patient #3 when Patient #3 was admitted for swing-bed services.

4. Review of Patient #4's inpatient EMR indicated Patient #4 was admitted as an inpatient on 11/11/21 and discharged on 11/13/21. Review of the swing-bed record indicated Patient #4 was admitted to swing bed status on 11/13/21. There was no documentation of a signed consent by Patient #4 for inpatient and swing-bed services.

In an interview on 11/16/21 at 10:30 am, Health Informatics Analyst #9 confirmed there was no signed consent by Patient #4 when Patient #4 was admitted for inpatient and swing-bed services.

In an interview on 11/16/21 at 2:52 PM, Registration #21 states his/her department is responsible for getting patient consents signed. Registration #21 stated he/she was notified this morning that there were records without consents. When told the patients without consent were not patients under suspicion of COVID-19, Registration #21 stated he/she could not explain or give a reason why the consents were not signed, and the surveyor would need to speak with the staff who registered the patient. Registration #21 stated his/her department does not get consents for admission to swing bed. Registration #21 presented the names of the unit clerks (Registration Clerk #31 and registration Clerk #36) who did the registration on the patient unit.

In an interview on 11/17/21 at 11:05 am, Chief Nursing Officer #2 Registration Clerk #31 was out sick and not available to be interviewed. Chief Nursing Officer #2 stated Registration Clerk #36 was not available to be interviewed as Registration Clerk #36 is working for another employer today.

5. Review of Patient #1's EMR revealed he/she did not sign the admission consent on 11/14/21. The consent was found under the scanned documents tab, but the consent for medical treatment was not signed, dated and timed. The consents all had a blank line for both the patient signature, time, and date.

6. Review of Patient #6's EMR revealed the consent form, located under the scanned documents tab, indicated the staff obtained verbal consent. There was no notation of who provided the verbal consent or why the patient could not sign. The nurses documented in the emergency department record that the patient was alert and oriented to person, place, and time.

7. Review of Patient #7's EMR revealed he/she did not sign the admission consent on 11/8/21, The consent was found under the scanned documents tab, but the consent for medical treatment was not signed, dated and timed. The consents all had a blank line for both the patient signature, time, and date.

8. Review of Patient #8's EMR revealed he/she did not sign the admission consent on 11/14/21, The consent was found under the scanned documents tab, but the consent for medical treatment was not signed, dated and timed. The consents all had a blank line for both the patient signature, time, and date.

9. Review of Patient #12 EMR revealed the patient was born on 2/28/21, but parental consent for medical treatment was not signed until 3/1/21 at 3:00 am. The consent was found under the scanned tab.

11. Review of Patient #21's EMR revealed he/she did not sign the admission consent on 11/14/21, The consent was found under the scanned documents tab, but the consent for medical treatment was not signed, dated and timed. The consents all had a blank line for both the patient signature, time, and date.

12. Review of patient #21's EMR revealed the patient was transfused four units of blood on 10/2/21. The EMR did not contain a consent for the Blood Transfusion, although the patient was later able to sign a surgical consent. The nursing documentation indicated the patient was alert and oriented.

In an interview with Staff #4, Unit Based Educator Licensed Nurse (LN) on 11/16/21 at 2:30 PM, confirmed the consents for medical treatments noted above were not signed dated and timed for Patient #1, Patient #7, Patient #8, and Patient #21. The Unit Based Educator LN also confirmed that patient #6 verbal consent indicted it was a verbal consent obtained without indicating who gave the verbal consent. He/She also confirmed Patient # 21 did not sign a blood administration consent.

Review of the policy titled "Consent For Treatment," revised 7/9/10, indicated ". . . A "Permission for Medical Treatment and Billing" form (which includes general consent for treatment), must be signed by the patient or qualified representative. The RN [registered nurse] shall ensure consent is obtained at the time of registration or as soon as possible thereafter. If the form is not signed before treatment begins, the reason (i.e. [that is] patient unconscious or representative not available) must be noted on the form, and the form signed as soon as possible. Each episode of treatment will require a new general consent form. . ."
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Based on policy review, record reviews, and interviews, the hospital failed to ensure patient medical records contained documentation of the administration of blood transfusions, diabetes education, and daily weights in accordance with physician orders and/or hospital policy for one (Patient #1) of two patient records reviewed for blood transfusion, for one (Patient #1) of two patient records reviewed with physician orders for diabetes education, and for one (Patient #3) of one patient record reviewed with physician orders for daily weights from a sample of 21 patients. These deficient practices had the potential to affect the 10 current patients and any future patient admitted to the hospital for services.

Findings:

1. Review of the policy titled "Blood Transfusion," revised 10/28/16, indicated ". . . Obtain a set of pre-transfusion vital signs, and document on the blood transfusion flow sheet in electronic health record. Vital signs will be repeated after the first 15 minutes then hourly until the unit is completed. Vital signs will be taken at the completion of the unit. Visual checks will be done on the patient every 30 min. [minutes] for S/S [signs and sym[ptoms] of transfusion reaction, vital signs will be checked as needed if the patient's condition changes or suspected reaction at any time during the transfusion. . . Begin the transfusion at a rate of 30ml/hr [milliliters per hour] for the first 15 minutes. If there are no signs and symptoms of a reaction, the transfusion can then be infused at the ordered rate or as patient tolerates. . . Documentation of the patient's response to the transfusion will be recorded in the nursing record no less than every 30 minutes. . ." There was no documentation in the policy of how long the patient's response had to be recorded every 30 minutes post-transfusion.

Review of Patient #1's medical record, located under "Order Chronology" tab, indicated a physician's order to give packed red blood cells on 10/31/21 at 4:50 am with no documentation of the rate at which the blood was to be administered. Further review indicated a physician's order on 10/31/21 at 9:10 am to give packed red blood cells with no documentation of the rate at which the blood was to be administered.

Review of the "Blood Transfusion Flow Chart" and the "Physical Assessment" documentation, located under the "Notes" tab, indicated Licensed Nurse (LN) #26 initiated the blood transfusion on 10/31/21 at 4:56 am at 50 ml per hour. Further review indicated LN #26 assessed Patient #1's vital signs at 4:56 am. There was no documentation that vital signs were assessed prior to LN #26 initiating the transfusion and that LN #26 began the transfusion at 30 ml per hour as required by hospital policy. Review indicated the blood transfusion was completed at 7:23 am, and vital signs were assessed at 7:50 am. There was no documentation that vital signs were assessed 30 minutes after the blood transfusion was completed.

Review of the "Physical Assessment" documentation, located under the "Notes" tab, indicated LN #16 assessed Patient #1's vital signs on 10/31/21 at 9:13 am and initiated the blood transfusion at 9:15 am at 50 ml per hour. Further review indicated the blood transfusion was completed at 11:20 am, and LN #16 assessed Patient #1's vital signs at 11:30 am. There was no documentation that LN #16 initiated the blood at 30 ml per hour as required by hospital policy, and that vital signs were assessed at least 30 minutes after the blood was completed.

In an interview on 11/16/21 at 8:20 am, LN #26 stated when administering blood, he/she "reviews the order, ensure there's a consent, and pulls out the quality assessment sheet that has all the things they're supposed to do." LN #26 stated he/she instructs the patient on what she's doing and gets the patient "hooked up" to the blood tubing. LN #26 stated he/she does the initial set of vital signs and assesses the patient. LN #26 stated he/she takes the blood request and "checks the blood out from the lab after checking it with lab personnel." LN #26 stated he/she then double checks the blood against the patient and the blood label with another nurse. LN #26 stated he/she does vital sign assessments every 15 minutes during the administration and for about an hour after the administration of the last unit. LN #26 stated he/she starts the blood at 50 ml per hour for about 30 minutes and then increases by 50 ml per hour as long as the patient tolerates it. LN #26 confirmed after reviewing Patient #1's medical record that he/she didn't document a set of vital signs prior to administration and that he/she started the blood at 30 ml per hour. LN #26 stated he/she didn't know why the vital signs "weren't in there [meaning in the medical record], and maybe [he/she] hadn't seen the policy, but [he/she] always started it at 50 ml per hour."

In an interview on 11/16/21 at 4:24 PM, LN #16 stated they have a checklist for blood transfusions, and "[he/she] goes down it." LN #16 stated vital signs need to be taken prior to initiation of the blood, at the 15 minute point, at 30 minutes, and then every hour afterwards. LN #16 stated after the transfusion is complete, one more set of vital signs need to be documented at least one to two hours after administration is complete. LN #16 stated the rate of infusion is 50 ml per hour to start. LN #16 stated he/she probably knew at some point that the rate should be 30 ml per hour but forgot. LN #16 stated regarding the post transfusion vital signs being done 10 minutes after completion and not until more than four hours later is "probably due to miscommunication with the certified nursing assistant, meaning it's standard that the certified nursing assistant does vital signs around noon, and while [LN #16] had been doing vital signs during administration of blood, [he/she] should have specifically told the certified nursing assistant to be sure to do the vital signs one hour after the transfusion was complete. LN #16 confirmed vital signs were not assessed at least 30 minutes after the blood was completed. LN #16 stated the policy for assessment after transfusion is open-ended and should be clarified.

2. Review of Patient #1's medical record, located under "Order Chronology" tab, indicated a physician's order on 10/29/21 at 1:53 am for "Inpatient Diabetes Education consult."

Review of documentation located under the "Notes" tab indicated no documentation that inpatient diabetes education had been performed.

In an interview on 11/17/21 at 10:30 am, LN #23 stated he/she gets an auto-generated referral for diabetes education from the nurse of patients who self-identify as having diabetes or hypoglycemia, but LN #23 "doesn't always see those patients unless [he/she] gets a further referral from the doctor or [he/she looks] through the chart and sees that it makes sense for [him/her] to see the patient." LN #23 stated "if a patient is at end of life, a home health patient, or a long term care patient, [LN #23] doesn't always see them unless the nurse or doctor asks [LN #23] to get involved. LN #23 confirmed he/she did not provide education as ordered for Patient #1. LN #23 stated he/she doesn't notify the physician on a regular basis that he/she won't see the patient and the reason why and doesn't document the notification.

3. Review of Patient #3's medical record, located under the "Order Chronology" tab, indicated a physician's order on 11/6/21 at 6:55 PM for "Daily weights."

Review of Patient #3's "Vital Signs" located under the "Notes" tab indicated no documentation of Patient #3's weight on 11/7/21, 11/9/21, 11/10/21, and 11/11/21 as ordered.

In an interview on 11/15/21 at 3:14 PM, Health Informatics Analyst #9 confirmed there was no documentation of Patient #3's weight on 11/7/21, 11/9/21, 11/10/21, and 11/11/21 as ordered.

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Based on observation, interview, and document review, the facility staff failed to screen visitors for COVID-19 as directed in the Center for Disease Control and Prevention (CDC) guidelines. Failure to follow recommendations from the CDC could result in patient's, staff, and visitors being exposed to COVID-19. This deficient practice had the potential to affect all patients, staff, and visitors.

Findings:

On 11/16/21 at 8:00 am, the facility staff failed to screen the surveyors and one visitor who entered, for COVID-19, prior to the surveyors and visitor entering the facility through the Emergency Department entry. Upon entering there was no one sitting at the desk. There was a staff member coming down the hall who asked where we were going, and we responded we were surveyors and going to Administration. He/She stated for us to go on up. The visitor was seen at the registration area and the staff did not screen the visitor.

During an interview on 11/16/21 at 3:45 PM, Staff # 6, Infection Prevention stated that facility staff are required to screen all visitors entering the facility. She/he stated the staff probably thought since were came the day before that we did not need to be screened. He/She agreed we still needed to be screen as well as the visitor who entered as were entering.

Review of CDC's "Interim Additional Guidance for Infection Prevention and Control" dated 09/17/20 revealed, "Recommendations ...all visitors should be assessed before entering the healthcare facility for symptoms of acute respiratory illness consistent with covid 19 guidelines, and they should not be allowed to enter the facility ...Placing a staff member near all entrances (outdoors if weather and facility layout permit,) or in the waiting room area, to ensure everyone (patients, HCP (health care personnel,) visitors) is screened for symptoms consistent with COVID-19 or close contact with someone with SARS-CoV-2 (the virus that causes coronavirus disease (COVID-19) infection before they enter the treatment area and ensure they are practicing source control."

Review of the facility's policy titled, "Lobby Screening Protocol," updated 5/12/21, revealed, "Ask, 'What brings you here?' AND Screening Questions 1. Have you been tested for COVID including pre-procedural testing? Do you have results yet? * If pending, restrict entry for non-urgent visits or ask Manager/Charge RN (Registered Nurse)/Provider/Ops (Operations) team for guidance. Encourage to stay home & minimize contact until results known. If previously tested positive, have you been cleared from isolation by Public Health? *If asymptomatic and fully vaccinated (at least two weeks following the last dose in series) entry not restricted. Pending SPH [sic} staff VOLUNTARY or MANDATORY LTC [sic]test does not restrict entry."
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Based on review of facility documents and interview, the hospital failed to ensure the swing-bed patient notification of discharge or transfer included the reason for the move in writing and in a language and manner they understand. The facility also failed to ensure a copy of the notice was sent to a representative of the Office of the State Long-Term Care Ombudsman, and the name, address, and telephone number of the Office of the State Long-Term Care Ombudsman. This deficient practice had the potential to affect the current four swing-bed patients (Patient #1, Patient #2, Patient #3, Patient #4) and any future patient admitted for swing-bed services.

Findings:

Review of the "Notice of Medicare Non-Coverage" form, approved 12/31/11, indicated the form did not include an area for documentation of the reason for the discharge or transfer in writing and in a language and manner the patient understands and the name, address, and telephone number of the Office of the State Long-Term Care Ombudsman.

No policy was presented during the survey for use of the "Notice of Medicare Non-Coverage" form that included instructions for completing the form, such as the need to provide a copy of the notice to the representative of the Office of the State Long-Term Care Ombudsman.

In an interview on 11/16/21 at 1:30 PM, Registered Nurse UR (utilization review) #18 confirmed the "Notice of Medicare Non-Coverage" form does not include the reason for transfer or discharge, the location to which the patient is transferred or discharged, and the name, address, and telephone number of the State long-term care ombudsman. Registered Nurse UR #18 confirmed the hospital does not have a policy for use of the form that the need to provide a copy of the notice to the representative of the Office of the State Long-Term Care Ombudsman.
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Based on document review, policy review, and interview, the hospital failed to ensure the swing-bed patient rights included the patient's right to be free from misappropriation of resident property, exploitation, verbal abuse, corporal punishment, and involuntary seclusion. This deficient practice had the potential to affect the current four swing-bed patients (Patient #1, Patient #2, Patient #3, Patient #4) and any future swing-bed patient admitted for services.

Findings:

Review of the "Swing Bed Patient Information" packet presented to swing-bed patients upon admission to swing-bed services indicated "Swing Bed Patient Rights" did not include the right to be free from misappropriation of resident property, exploitation, verbal abuse, corporal punishment, and involuntary seclusion.

Review of the policy titled, "Admission to Swing Bed," revised 8/12/16, indicated, ". . . The Social Worker will obtain a copy of the Swing bed admission paperwork. They will explain to the patient, family members or guardian the Swing Bed agreement, covered and non-covered costs, and patient's rights. A signature will be obtained from the patient, family or guardian, verifying receipt of Swing Bed Packet, which includes information on Available Services, General Policies, Rights and Privacy Act Statement. Their signature will be on the Acknowledgement Form and placed in the patient's chart. . ."

In an interview on 11/16/21 at 2:00 PM, Licensed Certified Social #22 stated he/she is responsible for reviewing the "Swing Bed Patient Acknowledgement" form with the patient and putting a copy of the signed acknowledgement page in the physical binder on the unit. Licensed Certified Social #22 stated he/she gives the "Swing Bed Patient Information" packet to the patient. Licensed Certified Social #22 confirmed swing-bed patient rights do not include the right to be free from misappropriation of resident property, exploitation, verbal abuse, corporal punishment, and involuntary seclusion.

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Based on document review and interview, the hospital failed to ensure the emergency preparedness (EP) plan addressed the system of medical documentation during a disaster that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records. This deficient practice had the potential to affect the 10 current inpatients and staff and any future patient admitted for services and future staff employed to provide services.

Findings:

Review of the policy titled "Health Information Management," originated 3/8/07 and revised in 2017 (no specific date documented), and the "Notifications and Communications" section of the "Emergency Operations Plan," dated 2020, indicated the policy and the section in the plan did not address a system for medical documentation during a disaster and how patient information would be preserved, how confidentiality would be maintained, and the means to be used to secure and maintain the availability of records.

In an interview on 11/17/21 at 9:05 AM, Security and Safety Manager #27 and Regulatory Compliance #28, along with Support Services Director #29 by telephone, confirmed the "Health Information Management" policy and the section of the EP plan titled "Notifications and Communications" did not included a system of medical documentation during a disaster that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records.

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Based on document review and interview, the hospital failed to ensure the emergency preparedness (EP) plan addressed the role the hospital would take in providing care and treatment at an alternate care site identified by emergency management officials under a waiver declared by the Secretary, in accordance with section 1135 of the Act. This deficient practice had the potential to affect the 10 current inpatients and staff and any future patient admitted for services and future staff employed to provide services.

Findings:

Review of the hospital's EP plan, dated 2020, indicated no documentation of the role the hospital would take in providing care and treatment at an alternate site under a waiver declared by the Secretary.

In an interview on 11/17/21 at 9:48 AM with Security and Safety Manager #27 and Regulatory Compliance #28 present and Support Services Director #29 participating by telephone, Support Services Director #29 stated the hospital made the decision that they would not man an alternate care site, because they don't have the employee numbers to staff an alternate location. Support Services Director #29 confirmed the hospital's EP plan did not include this decision and whether the decision was approved by emergency management officials.
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