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Based on observation, record reviews and interviews, the Hospital failed to ensure that for one of one mechanically ventilated patients (Patient #1), the patient received appropriate medical care consistent with medical protocols for mechanically ventilated patients, in a total sample of 32.

Findings include:

Observation on 10/17/2011 at 9:00 A.M. indicated that Patient #1 was mechanically ventilated and sedated from a intravenous (IV) infused Propofol drip.(Propofol is an sedative/hypnotic drug with anesthetic effects administered intravenously to induce moderate to deep sedation and/or maintain general anesthesia depending on dose and titration.). The patient's respiratory rate was above normal at 26 breaths per minute with the inspiratory/expiratory phases being of equal duration, which is indicative of hyperventilation. Patient #1 had a left femoral triple lumen IV catheter and was receiving Vancomycin, Magnesium, and Normal saline with 20 mEq of Potassium through the IV. Interview with Registered Nurse (RN) #1, assigned to care for Patient #1, said that Patient #1 may be arousing from the sedation, causing the elevation in respiratory rate.

Record review on 10/17/2011 revealed the patient had presented through the emergency room (ER) from the community, nonresponsive, hypothermic and hypoglycemic with a blood sugar of 23. ER records showed Patient #1 received IV Ativan at 9:45 P.M. (Ativan is an anti-anxiety (sedative) also used to treat sustained seizure activity with a rapid onset of five minutes and peak action in one hour, and diminishing effects over the next 1- 6 hours.) Patient #1 was in respiratory distress and noted to have harsh, vibrating respirations and odd movements of the extremities. Review of the ER records indicated the ER physician called the anesthesiologist to intubate the patient. After two failed routine attempts with an endoscope, a glidoscope was required to insert the endotracheal tube (airway) which was secured with good air exchange. The anesthesiologist documented using three doses of short acting paralytics to successfully intubate the patient. The last dose of paralytic was Vecuronium given at 10:25 P.M.

Review of medications given in the ER on 10/16/2011, indicated Patient #1 was given a long acting neuromuscular paralytic, Pavulon, 6 milligrams at 11:05 P.M, well after the successful intubation and without a documented reason. Patient #1 was given a second dose of Pavulon at 12:16 A. M, again without a documented reason. Pavulon paralyzes all the skeletal muscles in the body. Duration of effects last anywhere from one to three hours before return of 75-90% of muscle function depending on the patient's state of health. A patient is not anesthetized/sedated by Pavulon, thus can be awake, but unable to move or breathe on their own. Further record review revealed Patient #1 was not given any further sedation and level of consciousness was not assessed at the time of administration of the Pavulon.

Review of the facility's IV medication list indicated that Pavulon may only be given IV push by RN's in critical care specialities and in the perioperative area. The medication list indicates that for Pavulon competency, nurses must review the medication guidelines in the Lexicomp online system. (Lexicomp is a on line drug reference for nursing.)

Review of the Lexicomp Drug review site with the Director of Quality and Safety on 10/17/2011 at approximately 10:00 A.M. revealed that Pavulon is indicated for ICU paralysis (e.g. facilitate mechanical ventilation) in select adequately sedated patients.

The Lexicomp drug information for nursing also stated the labeled indications for the use of Pavulon are: facilitation of endotracheal intubation, relaxation of skeletal muscles during surgery, facilitation of mechanical ventilation in ICU patients, with a statement that Pavulon does not relieve pain or produce sedation.

There was no evidence in the ER medical record that the patient was adequately sedated as per the ventilator bundle protocols ( facility specific set of care guidelines for patients who are on mechanical ventilation) or the nursing IV medication administration protocols for Pavulon administration. The last sedation the patient had received was IV Ativan 0.5 mg at 9:45 P.M. Patient #1 was intubated at 10:25 P.M. The patient did not transfer out of the ER to the ICU until 12:45 A.M. ER records include an assessment of the patient's level of consciousness or sedation prior to administration of either dose of Pavulon.

On 10/18/2011 at 9:00 A.M., interview with the ER physician who, ordered the Pavulon for this patient, said she ordered the medication, because of "patient safety", to avoid losing the airway. The physician said that the patient was not attempting to remove the airway but because it was such a difficult intubation, the physician said she did not want the airway to come out during transfer to the ICU. The ER physician said that the patient did receive "long acting sedative" early in the ER admission, referring to the Ativan. The physician said that no other other means were tried to protect the airway such as continuous IV sedation and said that sedation should have been started per the ventilator bundle protocol, but added that the Hospitalist usually orders the ventilator bundle which includes the IV sedation upon admission to the ICU. The ER physician said she should have ordered the IV sedation when she paralyzed the patient with Pavulon.

Interview with the Physician Director of the ICU on 10/19/2011 at 9:30 A.M.,said that not providing sedation for patient's who are paralyzed with neuromuscular blockers such as Pavulon and who are mechanically ventilated was poor medical practice. The ICU Physician Director said there are risks of post traumatic stress disorder and psychological trauma for patients who arouse or wake up while paralyzed. The Director stated this issue would be discussed at Quality Counsel which is a meeting of all department chiefs.

Based on observations, staff interviews and record reviews, the governing body failed to ensure that four of twenty-two services performed under contract (Hospitalist Physicians, Pharmacy Services, Behavioral Health and Dialysis) were provided in a safe and effective manner. The findings are:

1. The contracted Pharmacy Service failed to ensure that all areas of drug storage were under pharmacy control. Additionally, there was no system to ensure drugs were returned to the pharmacy. Refer to A 491.

2. The contracted Behavioral Health Service failed to ensure that the patient care areas were maintained in a safe manner. Refer to A 144

3. The contracted Dialysis Service failed to provide safe and effective care to patients. Refer to A 398.

4. The contracted Medical Staff service, "Hospitalists," failed to ensure a medical history and physical examination was completed timely for two patients on the Behavioral Health Service. Refer to A 358.

Based on record reviews, observations and interviews, the Hospital failed to protect and promote patient's rights. The findings are:

1. The Hospital failed to ensure that the designated individual had been contacted regarding the patient's resuscitation status prior to the entry in the medical record of a physician's order for "Do Not Resuscitate." (Refer to A 132).

2. The hospital failed to provide sufficient equipment to ensure patient's privacy would be maintained in the outpatient rehabilitation area. (Refer to A 143.)

3. The hospital failed to ensure that three areas in which patient care was provided (the Behavioral Health Unit, the Pediatric/Adult Medical outpatient satellite, and the inpatient contracted Dialysis Unit), were maintained in a safe manner. (Refer to A 144).

4. The Hospital failed to ensure that the use of physical restraints (siderails) was assessed as essential for the patient's safety and applied following an established plan. (Refer to A 161).

5. The Hospital failed to prohibit the use of standing orders or PRN (Latin abbreviation for pro re nata - as needed; as circumstances requires) orders for the use of medication restraints. (Refer to A 169).

6. The Hospital failed to ensure that, in cases when chemical restraints were used for the management of violent or self destructive behaviors that jeopardized the immediate safety of the patient or others, that the patient was seen face to face, within one hour after the initiation of the interventions by either a physician or other authorized trained practitioner. (Refer to A 178).

7. The Hospital failed to ensure that following the initiation of a chemical restraint, the patient was seen face to face within one hour, to evaluate the patient's immediate situation, the patient's reaction to the intervention, the patient's medical and behavioral condition and the need to continue or terminate the restraint. (Refer to A 179).

Based on clinical record review and staff interview, the Hospital failed to ensure for one patient (#13), who was incapacitated, that the designated individual had been contacted regarding the patient's resuscitation status prior to the entry in the medical record of a physician's order for "Do Not Resuscitate." A total of 32 inpatient records were sampled.

The findings are:

Clinical record review on 10/17/11 at 2 P.M. revealed Patient #13 was admitted to the Hospital on 10/6/11 via the emergency department from a long term care facility after a fall resulting in a left hip fracture. According to the transfer information from the long term care facility, the patient's resuscitation status was a "Full Code."

Review of the 10/6/11 physician's emergency department report, the patient was confused and disoriented. The physician noted that the patient's case was discussed with the primary physician and an orthopedist and was to be admitted to the Hospital with left hip fracture and right lower lobe pneumonia. Further review revealed the emergency department physician on 10/6/11 at 2:25 P.M. had entered a "Do Not Resuscitate" order. There was no evidence in the physician's emergency department report that advanced directives had been discussed with the individual designated to act on the patient's behalf.

The Inpatient/Outpatient registration form reviewed on 10/17/11 at 2 P.M. noted the patient's step-child was the health care proxy. Subsequent clinical record review revealed on 10/7/11, the patient's guardian had signed a consent for blood transfusions. There was no evidence in the medical record of the name of the court appointed guardian. Nurse Manager #3 acknowledged the information was not in the medical record and a copy was faxed to the hospital on 10/17/11 at 3:25 P.M. The guardianship document noted a temporary guardian had been appointed due to the step-child's death in February 2011. The Nurse Manager acknowledged the information was incorrect on the registration form and that nursing staff would use this information to determine who to contact regarding health care decisions.

The Nurse Manager provided a copy of the Medical Staff policy and procedure for "Withholding And Withdrawing Life Support" with an effective date of 6/7/10. The policy noted it was "the responsibility of all physicians and registered professional Nursing staff to be acutely aware of the policy on withdrawing or withholding life-sustaining treatment in its entirety and to monitor compliance." The policy noted that all patients admitted to the hospital would have a signed "In hospital code status order" form and that only legally appropriate surrogate decision makers may act on behalf of an incompetent patient. The physician would initiate an order for a full code or "Do Not Resuscitate" status. The policy was reviewed with the CMO (Chief Medical Officer) on 10/18/11. The CMO acknowledged that the policy was current and due to CPOE (computerized provider order entry) not all physicians were completing the "In-Hospital Code Status" order form and were only entering the order in the electronic medical record.

Based on observation and interview, the hospital failed to ensure privacy during care for patients in the outpatient rehabilitation area was not compromised.

Findings include:

1. On 10/19/2011, at 4:15.P.M. during the initial tour of the outpatient rehabilitation unit, 5 treatment areas were observed. Only 3 privacy curtains were provided for use during care. 2 of the 5 areas where patients were to receive care were not afforded complete privacy.

The rehabilitation director confirmed on 10/19/2011 at 4:20 P.M. that the area was not provided with an adequate number of privacy curtains for the 5 treatment areas. He stated that he was in process of ordering additional curtains for the unit.

Based on observation and staff interviews, it was determined that the hospital failed to ensure that three areas in which patient care was provided (the Behavioral Health Unit, the Pediatric/Adult Medical outpatient satellite, and the inpatient contracted Dialysis Unit), were maintained in a safe manner.

Findings included:

1. The Hospital's elder behavioral unit provided short term, acute, psychiatric, inpatient care

During an initial interview on 10/17/11 at 9:30 AM, the Behavioral Unit Program Director stated that the Elder Behavioral Health Service (EBHS) provided care, treatment and services to persons age 55 and older who have a primary conditions and/or symptoms of mental illness. The Program Director reported the majority of patients were admitted voluntarily. There are also patients admitted on an involuntary basis. The Director added the unit offered a safe environment for patient's who required urgent and acute psychiatric care. The Director stated that to assure safety was a priority certain precautions were implemented to protect potential harmful behavior, both individually and environmentally.

During a tour of the EBHS unit on 10/17/11 at 9:45 AM, and a subsequent tour on 10/18/11 at 9:45 AM, patient environmental safety concerns were observed in areas that had been allocated for treatment of patients. The observed environmental safety concerns particular to the potential for ligature strangulation or hanging included: Goose neck facets with paddle sink handles, in all but one patient bathrooms, activity of daily living kitchen and in all communal bathrooms and shower rooms. All patient beds had two siderails with open slats. The doors of rooms 130, 131, 132, 133, 135, and 136 were noted to have a metal extended door closure that swung into the room, that were accessible to patients.

Patient room doors could be barricaded and inaccessible to staff. Alcohol based hand sanitizers were mounted in the hallways and accessible to the patient population. Trash containers in all patient rooms and communal areas were uncovered. The unit reported cameras and mirror globes were used for observational purposes. On 10/18/11 at 10 AM, it was determined that staff were unable to observe patients at doorways of rooms 130, 136 and 137.

On 10/18/11 at 2 PM an interview with Behavioral Unit Program Director was held. The Program Director stated that he/she had conducted an environmental safety risk assessment in September 2011. She had also identified that the gooseneck faucets, patient room doors, siderails, hand sanitizer and current camera monitoring system did not follow the current standards of practice for patient environmental safety and security. The Director stated that, after identifying the issues, she submitted the report to the Hospital's plant operations department for a cost analysis. Further, the Program Director stated she had educated the unit's staff that areas in the environment were unsafe and that staff were to be vigilant with patient safety. The Director was unaware of other immediate actions the hospital had taken regarding the environmental concerns.

The Surveyors met with the Hospital's Quality and Safety Manager on 10/18/11 immediately following the above interview with the EBHS Program Director. The surveyors reviewed the above concerns, and the Quality and Safety Manager immediately began to address the environmental concerns.

2. The Hospital operated two, outpatient, medical clinics at a satellite located at a school complex (Pediatric Medical and Adult Medical.) The satellite was visited on 10/19/11 at 1:00 PM. It was observed that the satellite was located within a school building; had secure exterior doors and had a secure door between the waiting and the treatment areas. However, the clinic corridor had numerous interior doors, one labeled "school nurse."

Nurse Practitioners #1 and #2 were interviewed on 10/19/11 at 1:30 PM regarding the interior doors. The Nurse Practitioners stated that the doors opened into the school nurse's suite; and that school staff could access the satellite directly via the doors.

The hospital failed to ensure that the satellite clinic was secured to prevent unauthorized access from within the school.

3. During tour of the EBHS unit on 10/18/11 at 2 PM it was noted that a patient bathroom could be locked from the inside and staff could not immediately disarm the lock and open the bathroom door. During a tour of the Pediatric/Adult Medical satellite on 10/19/11 at 1:00 PM, it was also noted that the patient bathroom had a locking mechanism that could not be immediately disarmed by staff in an emergency.

4. On 10/19/11 at 1:30 P.M., Nurse Manager #2 accompanied the surveyor to the hemodialysis room. The dialysis room was observed to be in the surgical suite area. The surgical suite was accessed through unlocked, automatic controlled double doors. The hemodialysis room could be accessed through a single door which was observed to be unlocked. The room was able to accommodate three patients for hemodialysis treatments and stored hemodialysis machines, portable reverse osmosis machines and hemodialysis supplies which included dialysate, bicarbonate solution and hemodialyzers and tubing. Additionally, there were two other doors which provided access to the room which were not secured.
Contracted Hemodialysis Nurse #1 was in the room at the time and confirmed that the entrance door to the room could not be locked.

On 10/20/11 at 9 A.M. the surveyor met with the contracted Hemodialysis Acute Nursing Manager. At this time, it was observed that the hemodialysis room was divided by a fabric curtain. On the other side of the curtain, were shelves with supplies. The Manager stated the supplies were not hemodialysis supplies and were not used by patients receiving hemodialysis treatments in the room.

These findings were reviewed on 10/20/11 at 10 A.M. with Nurse Manager #2 who acknowledged that the room was not secure and was easily accessed by unauthorized personnel.

Review of the Acute Dialysis Services Agreement effective May 2010, revealed that the Hospital would provide sufficient space for the administration of hemodialysis services capable of being locked, that was adjacent to, or in reasonable proximity to the above referenced space for the storage of equipment and supplies used by the hemodialysis nurses.

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Based on record review and staff interview, the Hospital failed to prohibit the use of drugs or medications used to manage the behavior of one patient (#10), out of a sample 32 patients and that was not a standard treatment for the patient's condition.

Findings included:

The Elder Behavioral Health Service (EBHS) unit admitted patients 55 years and older who had a primary mental health diagnoses, and who met the severity of the illness as evident by symptoms. Symptoms may include, but were not limited to suicidal/homicidal ideation, assaultive and destructive behaviors, psychiatric symptoms (agitation, depression, anxiety, etc). The EBHS unit was to provide continuous observation and to control behaviors to protect the patient and others through a comprehensive multi-modal therapy plan and psychoactive medications. The only form of restraint authorized for use on the EBHS was medication restraint.

Patient #10, had recently been admitted to the Elder Behavioral Health Service (EBHS) with diagnoses that included hypertension, seizure disorder and a history of alcohol induced dementia with acute mental status changes, that included threatening, disruptive and assaultive behaviors.

On 10/13/11 at 19:40 the physician documented the patient was extremely agitated and was threatening to assault staff. The physician ordered the antipsychotic medication Abilify, 9.75 ml, IM (intramuscular), one time, to "chemically restrain the patient."

On 10/16/11 at 14:30, the patient became increasingly agitated, escalating aggressiveness and assaultive behavior towards others. After unsuccessful attempts with diversional activities and the administration of the anti-anxiety medication (Ativan), the physician ordered the antipsychotic medication Haldol 4 mg in conjunction with the Ativan be administered every 6 hours as needed to manage the patient's behavior. The Haldol and Ativan remained as PRN orders and were administered on 10/16/11, 10/17/11 and 10/18/11 because the patient exhibited unanticipated aggressive behaviors that posed an imminent danger to self or others.

On 10/20/11 at 10 AM interviews were held with Program Manager of the EBHS, Nurse # 13, the Physician Assistant Director of the EBHS and Human Rights Officer # 1 to discuss the administration of the Haldol as a medication restraint and the ongoing authorization of PRN medications. The surveyors asked the staff if the use of the Haldol (with or without the Ativan) met the definition of a medication used as a restraint during the times they were administered. The staff initially stated that the Haldol was not a medication restraint because it was administered by mouth. Later during the discussion the staff confirmed that it was restraint, as evident by their intent when it was used was as a restriction to manage the patient's behavior and not as part of the clinical treatment plan. In addition, the staff agreed the ongoing authorization of the PRN, not only failed to include administrative guidelines for use, but allowed the potential of improper administration of the medication as a restraint. The physician agreed that psychotropic, and especially antipsychotic, PRN medications required a firm understanding of the indications for there use; and that assessment and judgement may be inconsistent and misunderstood.

Based on record review, observation and interview the Hospital failed to ensure for 1 (#20) of 32 sampled patients that the use of physical restraints (siderails) was assessed as essential for the patient's safety and applied following an established plan.

Findings include the following:

The record review for patient #20 was started on 10/17/11 at 11:00 A.M. The patient was admitted to the Hospital 10/16/11 with medical diagnoses which included hyperkalemia and renal failure.

The initial inpatient nursing note written on 10/16/11 by the staff on the S1 unit indicated that the patient was admitted from the Emergency Room after being transported to the Emergency Room from a local nursing home.

The initial plan of care identified the patient as requiring fall precautions. This was described as including a bed alarm and frequent checks by the nursing staff.

A nursing note written at 10:45 P.M. on 10/16/11 described the patient as confused and disoriented. The note included that the patient had not attempted to get out of bed.

On 10/17/11 this patient was observed by survey staff to be in bed sleeping at 2:00 P.M., 3:00 P.M. and 4:00 P.M.. During each of these observations it was noted that the patient had three of the 1/2 siderails on the bed in the up position.

On 10/18/11 this patient was observed by survey staff to be in bed sleeping at 11:30 A.M., 12:00 noon, and 2:00 P.M.. During each of these observations it was noted that the patient had all four of the 1/2 siderails on the bed in the up position.

A review of the patient's plan of care failed to reveal any assessment or interventions requiring the use of restraints in the form of 4, 1/2 siderails in the up position.

On 10/18/11 at 2:00 P.M. the surveyor met with Nursing Supervisor #1 to discuss the observations related patient #20 being restrained in the bed with the use of the 4, 1/2 siderails in the up position. Nursing Supervisor #1 expressed agreement that placing the 4 siderails on the bed in the up position would be considered a restraint for this patient. Nursing Supervisor #1 was unable to provide any additional information either from the medical record or staff interviews to justify the use of restraints for this patient. Nursing Supervisor #1 did said that the staff informed her that they had not placed the 4, 1/2 siderails in the up position on this patient's bed. However, Nursing Supervisor #1 acknowledged that she had observed the patient in bed with the 4, 1/2 siderails in the up position.

Based on observation, record review and interview, the facility failed to ensure staff followed the facility policies and procedures for the initiation and use of restraints in patients with invasive devices for two of two restrained patients (#1 and #2 ), in a total active sample of 32. Findings include:

According to the facility policy for restraining patients with invasive devices, (last revised on 7/2010), the criteria for use of restraints includes the presence of an invasive device AND at least one of the following: confusion, delirium, disorientation, cognitive impairment, lack of awareness of potential for self harm, AND, at least one of the following: combativeness of sufficient severity to pose an immediate threat that the patient will extubate or remove the invasive devices necessary for medical management, previous successful self extubation or attempt to do so, or previous successful removal a device or attempt to do so. Alternative measures to protect an endotracheal tube or other invasive lines should be tried prior to restraint such as medications for pain or agitation, frequent observation, keep tubing out of visual field, diversion, or use of a sitter or family member. If alternative measures fail, document the patient's behavior and cognitive state that places patient at risk, to ensure patient meets criteria for restraint. Document attempt at alternative measures utilized to manage patient behavior and response if alternatives prove unsuccessful and document how the patient remains at risk. Notify the licensed independent practitioner (LIP)/physician authorized to order restraint and if the LIP/physician is not available to write an order, in an emergency situation, a registered nurse (RN) may initiate restraint and notify the LIP/physician as soon as possible to obtain a telephone order for the restraint application. A RN will reassess the patient at least every 2 hours to determine if the pateint still meets the criteria for restraint.

1. The facility failed to follow the restraint policy for Patient #1 in meeting criteria before application of the restraint.

Patient #1 was admitted to the Intensive Care Unit (ICU) on 10/17/2011, on mechanical ventilation. and was placed on a Propofol drip for sedation at 3:00 A.M. (Propofol is an sedative/hypnotic drug with anesthetic effects administered intravenously to induce moderate to deep sedation and/or maintain general anesthesia depending on dose and titration.) The patient was observed at 9:00 A.M. on 10/17/2011, to be restrained with bilateral wrist restraints, asleep and making no attempt to move.

Review of the medical record indicated a telephone order dated 1017/11 at 8:00 A.M., recorded by a registered nurse, for the use of soft upper limb restraints. The physician cosigned the order at 9:00 A.M. The order was recorded on a consent form that had a preprinted statement that read "I found the patient meets criteria for use of restraint. The patient is interfering with care and is in danger of sudden arousal and unpreventable accidental extubation and /or dislodging of drains, tubes and/or lines, due to disorientation and inability to follow instructions. Alternative measures have been considered and/or attempted and have been found to be unsuccessful in mitigating the patient's physical behavior. The following restraints are ordered."

Review of nursing and physician progress notes lacked documentation of patient assessment or evidence that the patient exhibited any behaviors such as attempted self extubation or severe combativeness. Hourly nursing documentation indicated the patient had been successfully sedated to a RASS ( Richmond Agitation Sedation Scale) score of minus 2 to 3 indicating moderate sedation from 3:00 A.M. through 8:00 A.M. There was no documentation that the Propofol sedation was ineffective in managing the patient's behavior, or that the patient was in danger of sudden arousal or unpreventable accidental extubation because nursing was monitoring the patient's sedation level hourly nor did the documentation specify how the patient remained at risk for self extubation.

2. For Patient #2, the facility failed to follow the restraint policy for obtaining a physician/LIP order for use of restraints.

Patient #2 was admitted to the ICU on 10/5/2011 with respiratory failure, rapid atrial fibrillation and on mechanical ventilation. The patient's diagnosis included end stage renal disease requiring hemodialysis three times a week via an arterial venous fistula in the left arm.

Record review indicated a telephone order recorded by the Registered Nurse (RN) at 12:01 A.M., on 10/7/2011, to apply bilateral soft upper limb restraints, due to the patient being intubated, which was cosigned by the physician on 10/7/2011 at 8:00 A.M.

On 10/13/2011, the patient was extubated. Review of physician orders indicated an order was written to discontinue the limb restraints.

On 10/17/2011 at 9:00 A.M., the patient was observed to be restrained with bilateral wrist restraints while receiving dialysis.

Review of physician orders indicated there was no order to reapply the wrist restraints on 10/17/11.

During interview on 10/19/2011 at approximately 10:00 A.M., the ICU Nurse Manager said there were no physician orders for the use of wrist restraints on 10/17/11.

Based on record review and staff interview, the Hospital failed to prohibit the use of standing orders or PRN (Latin abbreviation for pro re nata - as needed; as circumstances requires) orders for the use of medication restraints for one patient (#10) out of a sample 32 current patient records reviewed.

Findings included:

The Elder Behavioral Health Service (EBHS) unit admitted patients 55 years and older who had a primary mental health diagnoses, and who met the severity of the illness as evident by symptoms. Symptoms may include, but were not limited to suicidal/homicidal ideation, assaultive and destructive behaviors, psychiatric symptoms (agitation, depression, anxiety, etc). The EBHS unit was to provide continuous observation and to control behaviors to protect the patient and others through a comprehensive multi-modal therapy plan and psychoactive medications. The only form of restraint authorized for use on the EBHS was medication restraint.

Patient #10, had recently been admitted to the Elder Behavioral Health Service (EBHS) with diagnoses that included hypertension, seizure disorder and a history of alcohol induced dementia with acute mental status changes, that included threatening, disruptive and assaultive behaviors.

On 10/13/11 at 19:40 the physician documented the patient was extremely agitated and was threatening to assault staff. The physician ordered the antipsychotic medication Abilify, 9.75 ml, IM (intramuscular), one time, to "chemically restrain the patient."

On 10/16/11 at 14:30, the patient became increasingly agitated, escalating aggressiveness and assaultive behavior towards others. After unsuccessful attempts with diversional activities and the administration of the anti-anxiety medication (Ativan), the physician ordered the antipsychotic medication Haldol 4 mg in conjunction with the Ativan be administered every 6 hours as needed to manage the patient's behavior. The Haldol and Ativan remained as PRN orders and were administered on 10/16/11, 10/17/11 and 10/18/11 because the patient exhibited unanticipated aggressive behaviors that posed an imminent danger to self or others.

On 10/20/11 at 10 AM interviews were held with Program Manager of the EBHS, Nurse # 13, the Physician Assistant Director of the EBHS and Human Rights Officer # 1 to discuss the administration of the Haldol as a medication restraint and the ongoing authorization of PRN medications. The surveyors asked the staff if the use of the Haldol (with or without the Ativan) met the definition of a medication used as a restraint during the times they were administered. The staff initially stated that the Haldol was not a medication restraint because it was administered by mouth. Later during the discussion the staff confirmed that it was restraint, as evident by their intent when it was used was as a restriction to manage the patient's behavior and not as part of the clinical treatment plan. In addition, the staff agreed the ongoing authorization of the PRN, not only failed to include administrative guidelines for use, but allowed the potential of improper administration of the medication as a restraint. The physician agreed that psychotropic, and especially antipsychotic, PRN medications required a firm understanding of the indications for there use; and that assessment and judgement may be inconsistent and misunderstood.

Based on documentation review and staff interview, the Hospital failed to ensure that in cases when chemical restraints were used for the management of violent or self destructive behaviors that jeopardized the immediate safety of the patient or others, that the patient was seen face to face, within one hour after the initiation of the interventions by either a physician or other authorized trained practitioner for one sampled patient (#10) of 32 current in-patient records reviewed and two additionally non-sampled patients (C and D).

Findings included:

1. Patient #10 was administered the antipsychotic medication Abilify as a chemical restraint. The physician assessed the patient and ordered the medication on 10/13/11 at 19:40. Following the administration of the chemical restraint no face to face evaluation was conducted.

2. On 10/19/11 at 12 PM, a review of the restraint log book on the Elder Behavioral Health Service (EBHS) revealed that two non-sampled patients (Patient C and Patient D) were both administered chemical restraints on 9/24/11 at 20:30. Although the medication restraint progress note documented that the face to face would be done; there was no evidence that the authorized, trained practitioner or physician had completed one.

3. The Elder Behavioral Health Service (EBHS) had a policy that addressed the face to face within one hour after the initiation of a chemical restraint. Per review, the policy stated that an authorized physician would conduct a face to face evaluation of the patient as soon as possible; but no later than one hour of the initiation of the restraint, only if the restraint was authorized by telephone.

On 10/19/11 at 12 PM interview with RN # 13 reported that the face to face evaluation only occurred if the the order for the chemical restraint was obtained by telephone.

See F179.

Based on record review and staff interview, the Hospital failed to ensure that following the initiation of a chemical restraint, the patient was seen face to face within one hour, to evaluate the patient's immediate situation, the patient's reaction to the intervention, the patient's medical and behavioral condition and the need to continue or terminate the restraint for one sampled patient (Patient #10) of 32 patient records reviewed and two non-sampled patients (C and D).

Findings included:

1. Patient #10 was administered the antipsychotic medication Abilify as a chemical restraint. The physician assessed the patient and ordered the medication on 10/13/11 at 19:40. Following the administration of the chemical restraint, no face to face evaluation was conducted. No documentation was evident in the medical record of the patient's condition following the administration of the restraint that included all the elements of this requirement.

2. On 10/19/11 at 12 PM, a review of the Elder Behavioral Health Service (EBHS) restraint log book revealed that Patient C and Patient D were both administered chemical restraints on 9/24/11 at 20:30. Although the medication restraint progress note documented the face to face would be done; there was no evidence that the authorized trained practitioner or physicians had completed one. There was no documented evaluation of the patient's reaction, condition or need to to continue or terminate the restraint.

See F178.

Based on record review and staff interview, the facility's quality improvement program failed to identify opportunity for improvement and implement timely changes that would lead to improvement. Findings include

1. The facility failed to identify the need for performance improvement activities in the area of timeliness in reporting deaths to the OPO.

The OPO policy and procedure required the facility staff to report all deaths to the OPO within one hour of the patient being found asystolic (without heart beat).

Review of audit reports revealed the OPO program tracked and trended the timeliness of the death reporting to the OPO by unit, lateness of the report and the person who made the call to the OPO. Review of the this data from 11/2010 through September 2011, revealed an average of 3-7 late calls per month, most occurring on the intensive care unit (ICU) emergency room (ER) and progressive care unit (PCU). Many repeat staff names occurred each month as not reporting deaths in a timely manner.

Interview with the Performance Improvement Manager (PIM) who managed the OPO program, on 10/18/2011 at 2:30 P.M., revealed that the reports are shared with each unit manager each month so that the managers can address the timeliness issue with identified staff. Further interview revealed that the PIM did not receive feedback from the managers on the interventions provided.

After discussion with surveyor, the PIM confirmed that since 11/2010, the rate of late reports had not improved and that a performance improvement plan should have been implemented.


07338

2. For the incident reporting system, the Hospital failed to implement in a timely manner a plan of action which would result in changes that would lead to improvement.

Non-Sampled Patient # A was admitted to the hospital on 9/25/2011 with diagnosis including polymorphic tachycardia. While in the progressive care unit on 9/26/2011, the patient had an episodes of unsustained ventricular tachycardia. The Hospitalist physician was notified and requested to see the patient. The physician stated that he had already seen the patient in the emergency department, and was aware of these irregularities in the heartbeat. The nursing supervisor then notified the physician and stated his/her concern and desire to have the patient seen. Later that morning, the patient became unresponsive and a rapid response was called by the nursing staff. The MD responded to the rapid response and ordered the patient sent to the intensive care unit where he saw the patient.

The QUANTROS system of reporting incidents which is utilized by the hospital, entered this event into the system on 9/26/2011. The medical director did not indicate that a plan of action was formulated and implemented until 10/15/2011 which would improve communication and develop effective actions to prevent this event from recurring.

Based on record review and staff interview, the Hospital failed to ensure that a medical history and physical examination was completed and documented within twenty-four hours for two patients (#9 and #11) from a sample of 32 current patients reviewed

The findings included:

1. Patient #9 was admitted to the Elder Behavioral Health Service (EBHS) unit on 10/13/11 with diagnoses that included Chronic Lung Disease, Coronary Artery Disease, Depression and Suicidal Ideation's. The patient had been living in an independent setting and after falling was hospitalized. The patient was then discharged to a long term care facility. The long term care facility reported the patient was having a poor adjustment to the facility and his/her decline, was depressed and threatened to harm self. In addition, the patient was noted with weight loss and anxiety. The long term care facility transferred the patient back to the hospital for in-patient care.

Record review on 10/18/11 revealed that although the patient was admitted to the hospital on 10/13/11 and a psychiatric initial assessment was completed, no history or physical had been completed by the medical physician. On 10/18/11 the physician assistant (PA) evaluated the patient and noted worsening leukocytosis, an increase in his/her white blood cells potassium and BUN. The PA ordered treatment and documented there would be discussion with the supervising physician. The patient was discharged from the EBHS unit to a medical unit on 10/18/11. (Refer to A 385.)

2. Patient #11 was admitted to the EBHS unit on 9/30/11. Record review revealed that no history or physical had been completed by the medical physician until 10/5/11. Following the assessment, the patient was transferred to the hospital's medical unit for hyponatremia.

3. Interviews with RN #13 on 10/20/11 at 12 PM revealed that completion of a patient history and physical examination by a medical physician for patients admitted to the EBHS unit had been identified as a problem. The Nurse stated that following an admission to the unit the Hospitalists were notified of the admission. Per Hospital policy, the Hospitalists were to complete the history and physical examination within 24 hours. However, RN #13 stated that an admission log was implemented as frequently the examinations did not get done. The log tracked the patient's date of admission, date and time the physician was called and the date the physician saw the patient. RN #13 confirmed that the issue remained a problem as evident by Patient #11 and #9.

4. Per 10/21/11 at 10 A.M. review of documents provided by Hospital Administration, both the Elder Behavioral Health Service (EBHS) and the "Hospitalist" physicians were contracted services in the hospital.

The "Hospitalist" contract, signed 12/12/2006, indicated the "performance expectations" for the Hospitalist physicians included the following criteria:

#6. Patients on the EBHS will be managed per DMH (Department of Mental Health) requirements.
#7. Comply with bylaws for Medical Records completion.

The Medical Staff Bylaws for the Hospital, dated September 2011, Section 9.4 specified:

"A medical history and physical examination (H&P) must be performed and documented by a Physician, Oral Surgeon, or other qualified licensed individual (as identified in the Medical Staff Policies), no more than thirty days before or twenty-four hours after admission or registration, but in all cases prior to surgery or a procedure requiring anesthesia services (as described in the Medical Staff Policies)."

The Hospital failed to ensure a medical history and physical examination were completed and documented for Patients #9 and #11 as per the Hospitalist contract and Medical Staff By-laws.

Based on record reviews, observations and interviews the Hospital failed to provide an organized nursing service that ensured adequate delivery of nursing care to patients.

1. The Hospital nursing service failed to ensure that the care provided to patients was adequate to meet the specific needs of each patient. Patients # 9, 15, 18 & non-sampled patient B did not have plans of care to ensure services were provided for the maintenance of intravenous devices. (Refer to A 396)

2. The Hospital nursing service failed to ensure the emergency "code cart" equipment was ready for immediate use. (Refer to A 395.)

3. The Hospital nursing service failed to ensure that adequate nursing care plans were developed and implemented for patients. (Refer to A 396.)

4. The Hospital nursing service failed to ensure that the Registered Nurse assigned and directed the care provided by the nursing assistants. (Refer to A 397.)

5. The Hospital nursing service failed to ensure that contracted nursing staff adhered to Hospital policies. (Refer to A 398.)

6. The Hospital nursing service failed to adhere to established policies for medication administration. (Refer to A 405.)

7. The Hospital nursing service failed to adhere to policies and procedures for administration of blood and blood products. (Refer to A 409.)

Based on observation and interview the Hospital failed to ensure that the registered nurse supervising the care and services provided to the patients on the S1 medical/surgical unit maintained the emergency equipment required to provide immediate emergent care.

Findings include the following:

On 10/17/11 at 3:40 P.M. survey staff reviewed the contents of the emergency cart with Nursing Supervisor #1. The emergency "code cart" was located in the hallway of the S1 unit. This cart would be used by the nursing staff in the event of a cardio-pulmonary event on the unit. There was no suction machine located on top of the code cart.

During the review of the code cart, the surveyor reviewed a form with the title: "monthly code cart checklist." One of the areas listed on this checklist was "test suction 10-15 seconds." This was to be done on a daily basis. The recording in this column from 10/1/ to 10/13/11 indicated that the suction machine was located in the locked code cart. On 10/14/11 it was recorded as n/a. On 10/15 and 10/16/11, the suction machine was recorded as being inside the locked cart. On 10/17/11 it was recorded as n/a.

Nursing Supervisor #1 said that the suction machine is stored in the bottom drawer of the locked code cart.

On 10/18/11 at 8:10 A.M. Nursing Supervisor #1 informed the surveyor that she had opened the code cart on the S1 unit, and that there was no suction machine stored inside of the cart. She indicated that she had to obtain a portable suction machine from the Hospital central supply area and had placed it on top of the code cart.

When observed by the surveyor on 10/18/11 at 8:10 A.M. the portable suction machine was on top of the code cart; however, the staff had not prepared the device for immediate use by attaching the necessary tubing.

Based on observation, record reviews and staff interviews, for six of 32 inpatients reviewed, (Patients # 2, 9, 15, 18, 27 and 32) and 1 non-sampled patient B, the Hospital failed to ensure that the nursing staff developed and implemented an adequate, current nursing care plan for each patient.

For Patients # 9, 15, 18 & non-sampled patient B (# NSB), plans of care were not developed and implemented to ensure nursing services were provided for the maintenance of intravenous devices


For Patient #32, who staff knew from previous admissions to the hospital, the nursing staff failed to develop a plan to address the patient's urinary tract infection and behaviors.

For Patients #2 and #27, the nursing staff failed to monitor and assess weight changes to ensure appropriate nutrition and medical interventions would be provided.


1. The medical record review for Patient #18 was started on 10/19/11 at 8:15 A.M. After treatment in the Hospital's Emergency Department on 10/10/11, the patient was admitted as an inpatient to the Hospital's Intensive Care Unit at 7 P.M. on 10/10/11. The patient was admitted with a central line catheter in the right chest that was used for hemodialysis. There was no evidence in the medical record that the staff of the hospital provided ongoing assessment and care to the central line from the time of admission to the time of surveyor record review on 10/19/11.

Specific findings follow:

The patient was transported to the Hospital's Emergency Department by paramedics. The patient had been found by dialysis transport employees sitting on the bathroom floor at her home.

There was a notation on the Emergency Department's report that the physician in the Emergency Department called the patient's nephrologist. The subsequent notation by the Emergency Department physician indicated that after discussing the case with the nephrologist, the nephrologist "would prefer that the patient be dialyzed less urgently since no CHF, Hyperkalemia, AG Acidosis."

The Emergency Department report also indicated that the patient had a "right dialysis catheter."

The patient was transferred from the Emergency Department to the Intensive Care Unit with the clinical impression of Dehydration and Hyperglycemia.

The initial nurse's note written on 10/10/11 at 11:57 P.M. by the nurse in the Intensive Care Unit indicated that the patient arrived at approximately 7:00 P.M. and that a "dialysis catheter is seen in the right chest. This is intact with a DSD in place." This was the only entry related to the central line catheter by the nursing staff while the patient was being cared for in the Intensive Care Unit.

The nurse's note of 10/11/11 at 2:19 P.M. recorded that the patient was transferred to the PCU (Progressive Care Unit.)

The initial nurse's note by the staff in the PCU was written on 10/11/11 at 5:17 P.M. The note failed to make any mention of the patient having a central line in her right chest.

The next note by the PCU nursing staff was on 10/11/11 at 10:35 P.M. This nurse wrote that the patient had a "tesio (central line) to (the) right chest wall, new dialysis pt.." There was no additional information related to the status of the catheter including dressing appearance, drainage, the last time the dressing was changed or the last time the catheter/ports were flushed to maintain patency.

On 10/12/11 at 3:02 A.M. the nurse caring for the patient in the PCU wrote that there was a "Tesio cath to R chest, dsg C/D/I." (dressing clean, dry, intact.) There was no additional information in this nursing note related to the care of this central line.

On 10/13/11 at 7:14 A.M. the nurse in the PCU noted that the patient had "Tesio to right chest. Drsg C/D/I"

The patient was transferred to the S1 unit on 10/13/11 at 12:52 P.M.. The first entry by the nursing staff on S1 related to the patient having a central line catheter was on 10/14/11 at 2:18 A.M. The nurse wrote: "pt aware of dialysis in A.M." and "drsg. to rt. chest dialysis catheter intact."

On 10/14/11 at 2:28 P.M., the nurse wrote that the patient indicated that, "I am ready to go home. I will go to my own dialysis center."

A review of the nephrologist's note in the patient's medical record dated 10/13/11 indicated, "some recovery of renal function, to defer dialysis, to observe as outpatient."

It was unclear why the night nurse on 10/14/11 indicated that the patient was going to be dialyzed in the morning when the nephrologist had determined on 10/13/11 that dialysis was being deferred.

It was determined through interview with the contracted dialysis staff that this patient had not been dialyzed in this hospital during this admission.

The next nursing entry related to the care of this patient's central line was on 10/18/11 at 3:14 A.M. when the nurse wrote, "dialysis cath dressing needs changing - Pt refused at present. Would let R.N. secure with tape."

On 10/19/11 at 2:06 A.M. the nurse indicated in the nursing entry, "Drsg to dialysis catheter intact."

On 10/19/11 at 10:00 A.M. the patient's medical record was reviewed and discussed with Nursing Supervisor #1. The surveyor initially discussed the lack of care provided to the patient's central line. Nursing Supervisor #1 immediately responded: "We do not touch Tesio catheters here." The surveyor asked for a hospital policy related to this statement and was told that it was understood by nursing staff that they do not provide care to Tesio catheters. Nursing Supervisor #1 indicated that it has been a long standing hospital policy that the nursing staff does not care for central lines designated for use in the patient's dialysis treatment.

The surveyor explained to Nursing Supervisor #1 that this patient was admitted to the hospital on 10/10/11, had been cared for in the Intensive Care Unit, the Progressive Care Unit and on S1 (a medical/surgical unit), and there was no evidence in the patient's medical record that the nursing staff had provided care to this device and/or arranged to have care provided to this device. It was also explained that there was no indication that the patient had been dialyzed while hospitalized; therefore, there had been no assessment or care provided to the central line by the contracted dialysis staff.

The hospital utilized an electronic medical record system. Survey staff asked Nursing Supervisor #1 to locate any information in the patient's medical record related to the care of the patient's central line that may have been overlooked by the surveyor. Nursing Supervisor #1 asked the Nursing Informatics Manager to assist in the search of the electronic medical record. There was no additional information regarding the assessment and care provided to this patient's central line that was brought to the attention of the surveyor by either of these two individuals.

Nursing Supervisor #1 was asked if the nurse assigned to the patient's care that day (10/19/11 on the day shift) had any plan regarding the care she would be providing to the patient's central line. Nursing Supervisor #1 located R.N. #14 who was caring for Patient #18 during that shift. When asked about the Patient's central line, R.N.#14 indicated that she was aware that this patient had a central line in place for dialysis. R.N. #14 was asked by the surveyor what the plan was for providing care to this central line. R.N. #14 offered that she thought that "was a good question." R.N. #14 also indicated that the insertion site of the central line could not be assessed because the dressing covering the area was not transparent.

Following the conversation with R.N.#14, Nursing Supervisor #1 indicated that she was going to direct R.N. #14 to contact the Patient's nephrologist regarding direction for the care of the central line.

The surveyor requested to be informed of the orders obtained from the nephrologist. In the event that the nephrologist ordered that the dressing to the central line site was to be changed and the lines of the device were to be flushed, survey staff requested to be present for these procedures. Nursing Supervisor #1 indicated that she understood the request and would contact the surveyor prior to any care being provided to the central line.

The surveyor returned to the S1 unit at 1 P.M. on 10/19/11. R.N. #14 was asked about the status of the patient's central line care. R.N. #14 indicated that the covering nephrologist had written medical orders for the dressing change at the site of the central line and for the flushing of the line. R.N. #14 indicated that she had to contact the nephrologist for clarification of the frequency these procedures were to be done. The surveyor was told that following this clarification, the dressing change and line flushing would be done. R.N. #14 would contact the surveyor prior to the care to the central line being done.

Approximately 3 minutes later, R.N. #14 approached the surveyor and indicated that the care of the central line for this patient had already been done. R.N. #14 indicated that she had just been informed that the contracted dialysis nurse had changed the central line dressing, flushed the lines and instilled heparin into the ports. R.N. #14 indicated that the contracted dialysis nurse had not communicated with any staff on the unit, including R.N.#14, regarding the patient's condition, the indication for the patient to be on contact precautions (positive for methicillin resistant staph aureus), obtaining supplies needed to perform the dressing change and flushing procedures, the condition of the insertion site, the status of the ports of the catheter, the patient's acceptance of the procedure and any reaction the patient may have experienced.

The patient's medical record was then reviewed with Nursing Supervisor #1 and Nurse Manager #2 in an effort to determine if the contracted dialysis nurse had entered any information in the patient's medical record regarding the procedures she had just completed. As the contracted dialysis staff cannot enter information in the electronic medical record, the paper record was reviewed. It was confirmed that the contracted dialysis nurse had not made any entries in the patient's medical record regarding the procedures that she performed related to the central line.

It was then determined that the Nurse Manager would accompany the surveyor to the three station dialysis unit the Hospital operated through a contract with a provider of hemodialysis services. (Please refer to A-398)

Following the surveyors visit to the dialysis room on 10/19/11 at 3:00 P.M., a discussion was held with the CNO (Chief Nursing Officer) and Nursing Supervisor #1 to review the lack of care provided to Patient #18's central line, and the multiple issues regarding the contracted dialysis services. The CNO indicated that she had been informed of the issue of the Hospital nursing staff not providing care to the patient's central line, and the contracted dialysis nurse inappropriately providing care to the patient. The surveyor informed the CNO and Nursing Supervisor #1 of the supply of Heparin that had been found in the dialysis room. They both expressed their understanding of the issues and did not offer any additional information other than indicating that the Hospital had a policy and procedure for the care of central lines which they would supply to the survey team.

2. Clinical record review on 10/19/11 at 10 A.M. revealed Patient #15 was admitted to the Hospital on 10/15/11. According to the initial nursing assessment completed on 10/15/11 at 11:43 P.M., the patient had a past medical history of lymphoma and had received chemotherapy.

On 10/17/11 at 11:37 P.M. nursing documentation in the electronic medical record revealed the patient had a portacath (implanted small medical appliance installed beneath the skin, used for chemotherapy) in the left upper arm. There was no mention of this device in the initial nursing assessment of 10/15/11.

The above findings were reviewed with Nurse Manager #3 on 10/19/11 at approximately 2 P.M. The Nurse Manager acknowledged there were no other entries prior to 10/17/11 regarding the portacath. Nurse Manager #3 reviewed the electronic medical record with the nurse assigned to the patient for a nursing plan of care for the portacath. There was no plan; nor alerts for the nursing staff to not use this arm for blood pressure or obtaining blood samples. When asked how this information would be communicated to the nursing staff including the CNA's assigned to the unit, the Nurse Manager stated the information should be noted on the dry/erase board in the patient's room. (These were boards mounted on the wall of patients' rooms that were visible to other patients as well as visitors and were not an appropriate forum for communicating personal care needs.) Nurse Manager #3 accompanied the surveyor to the patient's room. It was noted on the dry/erase board not to use the patient's left arm for these procedures. Nurse Manager #3 acknowledged that the nursing plan of care should have identified the presence of this device and care interventions needed to be in the plan.

3. The Elder Behavioral Health Unit was a unit the Hospital operated through a contract with a provider of acute behavioral health services. On 10/18/11 at approximately 4:45 P.M., RN survey staff went to the Elder Behavioral Health Services (EBHS) unit to assess two patients, Patient #9 and non-sampled Patient B who had intravenous devices, at the request of Social Work survey staff.

Upon arriving on the Unit, non-sampled Patient B was observed sitting in the day room. The patient was observed with an intravenous saline lock in his right hand. The nurse, RN #19 from the Behavioral Health contract company, stated that the patient had returned to the unit on 10/17/11 at 2:15 P.M. after surgery with the device and it would need to be flushed every shift. RN #19 also stated the device would be left in for approximately 24 hours post-operatively and if the patient was tolerating food and liquids it would be discontinued. RN #19 stated that "it could probably be pulled now."

RN #19 accessed the electronic medication administration record to obtain information regarding the flushing of the device. RN #19 stated there was no evidence that the device had been flushed since the patient returned to unit nor physician's orders for the maintenance of the device.

At 5 P.M., Patient #9 was observed lying in bed, with oxygen via a nasal cannula, and had an intravenous device in his left hand. According to RN #19 the patient had pneumonia and was receiving intravenous antibiotics and intravenous fluids. When asked by survey staff as to the amount of fluids the patient had received since the initiation of the intravenous, the nurse was unable to locate the information in the electronic medical record or in the written medical record. RN #19 stated she would look at the time tape which was affixed to the intravenous solution bag for the amount infused and brought the time tape to survey staff to see. RN #19 acknowledged there should be a way to retrieve this information from the clinical record.

At 6 P.M. RN #15, also from the Behavioral Health contractor, provided survey staff with a nurse's note from 10/18/11 1:51 P.M. written by RN #16 (also from the Behavioral Health contractor.) According to the note, RN #16 documented that the intravenous was started by another RN, not RN #16. Documentation from the electronic medical record revealed an entry by RN#16 in the intravenous insertion section of the record that she had inserted the intravenous device. There was no documentation that the nursing staff could provide or locate by the nurse identified as inserting the intravenous as noted by RN#16 in the nurse's note. Additionally, record review on 10/18/11 revealed that although the patient was admitted to the hospital on 10/13/11 and a psychiatric initial assessment had been completed, no history or physical had been completed by the medical physician. (Refer to A 358).

At 6:15 P.M., survey staff met with the CNO to discuss the above findings,observations and concerns regarding Patient #9's medical condition. The CNO stated that based on the patient's current condition, the patient would be evaluated to see if his medical condition was stable so he could remain on the EBHS unit or be transferred to to a medical unit in the Hospital. On 10/19/11, the CNO informed survey staff that Patient #9 had been transferred to a medical unit later in the evening on 10/18/11.



00421

4. Per 10/26/2011 at 10:30 AM review of the medical record, Patient #32 was an elderly patient who was re-admitted to the Hospital via the Emergency Room (ER) on 10/17/11. The Patient had arrived at the Hospital ER via ambulance at 7:22 AM. Twenty minutes later, at 7:42 AM, the nurse documented that the patient was "consistently" complaining of left sided abdominal pain, was stating she was confused and anxious, and was unable to state her birthday.

Patient #32 was seen by the physician at 7:54 AM. The physician documented that the Patient had been seen in the ER three days prior, was diagnosed with a urinary tract infection at that time; however, had not taken any medication. The physician also wrote that the Patient was complaining of abdominal pain then and presently, that the patient had a history of Bipolar-Mood Disorder, Dementia and below the knee amputations.

The ER nurse documented that the patient voided a large amount in the bedpan at 11:30 AM., and that at 1 PM the patient was medicated with the antibiotic medication, Rocephin, for a "UTI" (urinary tract infection.) At 1:38 PM the physician ordered Sodium Cl 0.9% IV (NS 0.9% IV) at a rate of 100 mls per hour for parenteral fluid replacement. Patient #32 was transferred and admitted to the S1 inpatient unit at 2:40 PM.

The initial assessment by the nursing staff on the S1 unit was recorded at 5:29 PM and noted that Patient #32 had a bilateral, below the knee amputation, had an IV/Saline/Heparin Lock, had frequency of urination, was confused, disoriented and required toileting every two hours. Additionally, the assessment noted the patient was a high fall risk and required assistance of two with mobility.

The nursing plan of care developed on 10/17/2011 indicated Patient #32 was "on bed rest with bathroom privileges." The plan of care noted the patient was a fall risk and the "fall prevention care plan" would be implemented.

The Hospital's Falls Prevention and Management Protocol, effective 10/7/11, directed staff to complete the following:

- Assess coordination and balance before transferring or mobility activities
- Provide frequent toileting to decrease urgency and incontinence
- Use rubber sole shoes, slippers or traction socks
- Lock all moveable equipment before transferring patients
- Individualize assistive devices to patient needs
- Place patient care articles within reach
- Provide physically safe environment
- Provide adequate lighting
- Review medications for potential impact on fall risk
- Actively engage patient and family in fall prevention

Additionally, for patients' assessed to be at high risk (including Patient #32) staff were directed to:

- Post a falling star on the door
- The patient was to wear yellow socks and a yellow arm band
- Low beds would be provided where available
- Bed and Chair alarms
- Move the patient closer to the nursing station
- Consider an observation attendant if above interventions not effective.

However, the nursing plan of care developed on 10/17/2011 for Patient #32 did not address nor plan interventions for the patient's known urinary tract infection, confusion, disorientation, diagnosed mood disorder nor dementia.

Continued medical record review revealed that at 9:18 PM on 10/17/11 the nurse documented that Patient #32 had voided on the bedpan on two occasions.

The following morning, on 10/18/11 at 7:53 AM, the nurse documented the patient had complained about pain during the night shift, the doctor had been called and had ordered "Morphine 1 - 2 milligrams IV;" however, the morphine was not available in Pyxis. Also, that the patient was receiving her second bag of normal saline via an intravenous device that was infusing at 100 milliliters an hour. At 9:09 AM the nurse documented "morphine given for pain."

At 1:00 PM the nurse documented that Patient #32 was found sitting on the floor. Subsequent radiographs revealed the patient, who was a bilateral amputee, had a supracondylar fracture of the right femur.

RN #22, who had cared for Patient #32 at the time of the fall, was interviewed on 10/26/11 at 2 PM. The nurse stated that she knew Patient #32 from previous admissions. The nurse said that Patient #32 was on medication for a urinary tract infection and had used the bedpan earlier in the morning without incident. The nurse stated that, to her knowledge, Patient #32 had never attempted to get out of bed in the past. However, Patient #32 had "difficulty waiting for care," and "would yell rather than use the call bell." Also, that Patient #32 would refuse to take her medication at times, stating: "I no take them." The nurse acknowledged that the patient was a high fall risk and stated: "we had implemented all the fall interventions in the protocol." The nurse stated that the "falling star" was on the door. However, as the patient was a bilateral amputee and had no feet, the nurse stated that the staff were uncertain how to implement the use of the non-skid "yellow slippers" required in the Hospital's fall protocol . The nurse stated that (in an attempt to adhere to the Hospital's protocol,) staff had placed yellow slippers over the top of the posts at the end of the patient's bed. It was unclear how the nurse determined that action would prevent a fall.

Nursing Assistant #1 (NA #1) who was caring for Patient #32 at the time of the fall was interviewed on 10/27/11 at 7:30 AM. The Nursing Assistant said she knew (Patient #32) "by heart as he/she has been on my floor many times." NA #1 stated the patient could be "combative" if she didn't get what she wanted immediately, so if her buzzer went on, the NA responded quickly. NA #1 said she offered the patient the bedpan; however, the patient "was screaming and yelling no." The NA stated the nurse had been in the room; however, had been called to the desk at that time. The NA stated she offered the commode and the patient pushed it against her hands, stating "banyo" (bathroom.) The NA stated she knew the patient had no legs so she left to get the wheelchair.

RN #22, confirmed on 10/26/11 at 2 PM that she had told the NA "maybe we could get her into a wheelchair." The nurse stated that she had heard a commotion in the room and entered to find the patient on the floor. The nurse stated the NA arrived moments later with the commode. The NA stated she had arrived moments later with a wheelchair.

Observation of the S1 unit's physical layout, on 10/26/11 at 8:30 AM, revealed that Patient #32's assigned room was located at one end of the unit and at a significant distance from the equipment storage area. Accessing the equipment storage closet required walking the length of the corridor, turning around a corner and traveling down an adjacent corridor. At the request of surveyors, the CNO had the distance from Patient #32's room to the storage closet measured. The hospital CNO reported on 10/26/11 at 11:15 AM that the distance from Patient #32's room to the equipment closet was 156 feet each way (312 feet round trip.)

The Nursing Staff failed to ensure that necessary patient care equipment (including commode and/or wheelchair) for Patient #32 was readily available. The nursing staff rigidly adhered to a generic falls protocol that was not appropriate to the needs of Patient #32 who was a bilateral amputee ("yellow slippers"), and failed to develop an adequate plan of care to address Patient #32's impulsive behavior and urinary tract infection. Failure to develop an adequate plan of care for Patient #32 resulted in the patient's fall and resulting fracture.


00446


5. The medical record of Patient #27, including both the written and electronic recordings, was reviewed on 10/18/11.

Record review revealed the patient was admitted on 10/12/11 after treatment in the emergency room for a recent fall, with question of early dementia or hypoglycemia. The patient was admitted to the S1 unit for mild dehydration and anemia, with plans for neuropsychological, dermatology and ophthalmology consultations. Admission data noted the patient's height was 5' 4" and weight was 144 pounds; with presence of a stage II skin area to buttock. Additionally, the patient had medication orders for insulin and a 75 gram Carbohydrate, 1800 calorie diet. The diet was subsequently changed to a No Concentrated Sweets diet on 10/13/11.

The 10/14/11 nutrition progress note by the dietitian indicated the resident's Ideal Body Weight was approximately 130 lbs. Laboratory values included a blood urea nitrogen level (BUN) of 25 (slight elevation) and iron (Fe) level at 34 (low abnormal). Blood glucose levels were followed before meals and at night with sliding scale insulin coverage. Recorded meal intakes for this patient ranged from 50 to 100 %. The nutrition goal read to monitor intake, blood sugar levels and weight. This patient was transferred from the S1 unit to the Elder Behavioral Health Services (EBHS) unit. On 10/17/11 the patient's weight was documented as 134.4 pounds; a 9.6 pound loss.

On 10/19/11, at 9:30 A.M., the surveyor interviewed the EBHS Program Manager about the resident's weight changes. According to the Program Manager, the patient's 134.4 pounds was the only recorded weight available for review. The program manger proceeded to search the electronic medical record for nursing documentation from the S1 unit where this patient was first admitted and could not access the nursing documentation. The EBHS Nurse Program Manger's explanation as to why the admission nursing documentation from the S1 unit could not be reviewed by the staff on EBHS caring for the patient was due to security limits of patient information on the EBHS unit. However, the patient's admission weight was recorded on the dietary report listing for hospital patient census; with pertinent patient nutritional information such as diet order, height, weight, allergies, etc.

Further interview with the EBHS Program Manager indicated that the weight method used on the EBHS unit was a chair scale. The EBHS Program Manager was not aware of the patent's admission weight of 144 pounds. There was no way to determine if the patient's weight variance was due to the difference in equipment (bed scale), an actual weight loss, or a combination of both factors.

Per interview on 10/18/11, the Clinical Dietitian Manager was not aware of the 9 to 10 pound weight (loss) change since the patient's 10/12/11 admission weight. According to clinical nutrition assessment criteria, this patient was not due to for a follow-up review until 10/20/11. Per interview with the RN#13 on 10/18/11 at 2 P.M., the RN was not aware of a hospital nursing/weight assessment policy.

An outdated policy dated 5/09 for Patient Care Services/Nutrition Services was provided at 2:30 P.M. on 10/18/11,. The policy stated that the admission nurse was responsible for obtaining a patient's weight. Additionally, the weights and patient reweighs were to be done on the same scale and documented accordingly.

Patient #27's weight change went unnoted and the data recording for patient weight information was limited..

6. Patient # 2 was reviewed on 10/18/11. Patient #2 was admitted to the hospital for acute intervention with multiple medical conditions which included aspiration with esophageal impaction, respiratory failure, congestive heart failure, diabetes, atrial fibrillation and end stage renal disease with dialysis treatments.

Admission data for this patient included height of 5' 11" and weight at 180.39 pounds. The initial nutritional assessment reported this patient at risk due to a clear liquid diet, poor protein stores and high risk due to skin breakdown. Speech therapy determined the patient was unable to swallow safely and remained NPO (fed nothing by mouth). Tolerance and risk of fluid/metabolic imbalances and gastric residuals limited the advancement of enteral feedings. The patient's condition evidenced extreme low albumin levels and edematous extremities despite dialysis treatments. The dietician's nutritional assessment calculated the patient's estimated caloric and nutrient needs could be met with the formula administration at 55 ml/hour. The patient received intravenous fluids, and was determined unable to safely swallow foods; therefore, a nasogastric tube provided the nutrition formula at a slow rate.

The patient's weight measurements were recorded in the medical record and included significant variances of 20 to 22 pounds on two occasions; without evidence of nursing assessment or reweigh according to hospital policy.

Review of printed medical record information identified this patient's weight on 9/30/11 and 10/1/11, data from a previous hospital stay, at 180.34 pounds. On the date of admission, 10/5/11, the patient's documented weight was reported as 180.34, which was recorded for 10/7/11. On 10/8/11, the patients weight was reported at 182 pounds. It was difficult to determine if the admission weight was accurate, and whether the current weight was valid.

Review of weight documentation noted the patient was weighed on a bed scale on 10/9/11, at 203 pounds (an increase of 22 pounds). The patient received dialysis while in the intensive care unit (ICU) with pre and post treatment weight measurements recorded in kilograms with the dialysis services documentation, separate from the electronic medical record.

During 10/18/11 at 12:30 P.M. interview, RN #1 reviewed the documentation and could only correlate the increase with intravenous fluids received on 10/7/11 and 10/8 /11 respectively (3 plus liters and 4 liter intakes via intravenous/enteral fluids with little to no output.) Discussion with RN #1 revealed that weight inaccuracies would be likely if the patient's bed contained additional items that were not accounted for, or that the bed scale weight was not obtained correctly.

A nutrition progress note dated 10/10/11 had questioned the patient's weight difference of 20 pounds in two days. Also, the nutrition progress note noted concern with the laboratory blood value for the patient's albumin (1.9) as extremely low and questioned possible fluid overload status/anasarca. However, there was no nursing documentation that indicated the increased weight was reassessed at that time.

On 10/13/11, the patient's weight was noted at 224 pounds (21 pound increase). These weights were obtained via bed scale within the patient's ICU bed. The nutrition progress notes of 10/16 and 10/17/11 recommended protein repletion was needed and questioned whether the patient's weight gain was related to fluid. The recommendation was to resume enteral feeding as soon as possible and/or consider gastrostomy placement or total parenteral nutrition. Although this patient was followed by dialysis services, the patient' dialysis pre and post weights were not documented in the weight data collection area of the electronic record; comprehensive review of data collection was limited.

Discussion with RN #13 on 10/18/11 at 2:30 P.M. revealed that the hospital had provided education/competency for bed scale weight measurements during November 2010 for licensed and certified nurse aide staff. The information directed staff to compare the previous weight in electronic medical documentation to the current day's weight. There was no evidence that patients' weights were reviewed by nursing at the time of recording in the electronic medical record with comparison with the previously documented weight to address the significant variances.

The Hospital failed to ensure that the weight monitoring system in use was effective and implemented correctly for these two patients.

Based upon record reviews and staff interviews, the Hospital failed to ensure that a Registered Nurse supervised the care of each patient by directing the assignments and care provided by the nursing assistants. The findings are:

On the first day of survey, 10/17/11 during the initial tour, the surveyor was informed by RN #6 that the "charge nurse" on the S1 unit takes a full patient assignment. During the initial tour on the S2 unit on 10/17/11 at 9 AM, the "charge nurse" had a three patient assignment. On 10/18/11 at 8 AM, the "charge nurse" on S2 unit had a three patient assignment.

Review of the S2 assignment/roster sheet used by the nursing assistants on 10/18/11 at 9 AM revealed 7 of the 28 patients on the S2 unit had no information documented on the roster sheet to direct the nursing assistants other than the name of the nurse assigned to the patient.

Review of the S1 assignment/roster sheet used by the nursing assistants on 10/20/11 at 9 AM revealed 13 of the 19 patients on the S1 unit had no information documented on the roster sheet to direct the nursing assistants other than the name of the nurse assigned to the patient.

On 10/26/11 at 9:30 AM, Nurse Manager #3 was interviewed and asked to explain the process for communicating nursing assistants' assignments. The Nurse Manager stated that the on-coming day shift nursing assistants met with the out-going night shift nursing assistants to "update each other" on the patients. This nurse aide to nurse aide meeting occurred at the same time the Registered Nurses were meeting. On the unit where Nurse Manager #3 worked, there were three nursing assistants on the day shift; and according to Nurse Manager #3, the nursing assistants did not have a specific assignment. According to Nurse Manager #3, the three nurse aides "work together." Nurse Manager #3 stated that the nurse was responsible to "touch base" with the assistant, and would write specific instructions for individual patients on a daily bed roster. Also, the nurse would write information on the "white board" located in each patients' room. (These were boards mounted on the wall of patients' rooms that were visible to other patients as well as visitors and were not an appropriate forum for communicating personal care needs.) The surveyors requested to view a nurse aide roster sheet. The surveyors were provided with a copy of the sheet being used by Nurse Aide #3 to direct her care at approximately 9:45 AM on 10/26/11. The sheet listed all of the patients on the unit on 10/26/11; and, next to each patient's name were initials of the nurse assigned to the patient. It was approximately three hours into the shift at the time of review and there was no additional documented information to guide/direct the nurse aide in the care of the patients on the roster sheet.

On 10/26/11 at 11:25 AM, staff nurse (RN #20) was interviewed. RN #20 was asked to explain the process for communicating patients' care needs to the nursing assistants. RN #20 stated the day shift nursing assistants "pass along" information directly to the evening shift nursing assistants. RN #20 also stated the nursing assistants are not assigned to specific patients.

On 10/26/11 at 1:00 PM, staff nurse (RN #21) was interviewed. RN #21 stated there are usually two nursing assistants on her unit. RN #21 stated the nursing assistants talk before the start of the shift with the out-going night aide "for direction."

Staff Nurse (RN #22) was interviewed on 10/26/11 at 2 PM and stated her unit has two nursing assistants and each assistant takes "a side, typically ten patients each." RN #22 said she would personally direct the nurse assistants assigned to her patients; however, RN #22 was only responsible for four of the patients.

On 10/27/11 at 7:30 AM, Nursing Assistant (NA #1) was interviewed. NA #1 stated she would receive a list of the patients from the nurse and would "try to get a report the best I can from the night aide." NA #1 went on to explain that there is only one nursing assistant on the night shift, and that person is very busy so it is difficult to obtain a report at times. NA #1 stated her assignment at times is 13 patients. "I know I don't do medications or assessments, but some nurses want me to."

Nursing Assistant (NA #2) was interviewed on 10/27/11 at 9:05 AM. NA #2 stated she received report from the night shift nursing assistants, and that the nursing assistants decided how to divide the work load amongst themselves. The assistant was asked how they would know what patients needed feeding assistance? NA #2 stated: "that's a tough one, because there is no meal on 11 to 7, so the night aides don't always know." NA #2 went on to explain that sometimes information is passed along from the 3 to 11 shift nursing assistants; and other times the nurse aide just observes the patient to decide if they need assistance to eat.

Nursing Assistant (NA#3) was interviewed on 10/27/11 at 10:15 AM. NA #3 stated she met with the night aides to receive report and the nurse would tell her anything else she needed to know. (As noted above, the surveyors had reviewed the roster used by NA #3 on 10/26/11 and it contained no specific directions from the nursing staff.)

NA #3 stated her usual tasks included application of immobilizers. When asked how she would know the plan for a specific patient included application of an immobilizer, NA #3 stated: "if I find one in the room, then I know to apply it." "There are white ones and there's another one." "The other ones have a setting, but it would already be set." NA #3 stated she was familiar with Femoral Blocks. When asked what her responsibility would be, NA #3 stated: "it's just a matter of rearranging the furniture in the room." When asked how she would know to do that, NA #3 stated: "Because it is a different IV Pole and the liquid in the tube is yellow."

The above findings were reviewed with the Chief Nursing Officer (CNO) on 10/27/11 at 12:15 PM. The CNO confirmed that the charge nurses have a full patient assignment and the Nurse Managers have responsibility for multiple areas. The CNO confirmed the S1 Nurse Manager position was vacant. The CNO stated she had wanted to create a "true" charge nurse/resource nurse position to provide direction for staff on each unit; however, the Hospital had been unable to fund that position within the budget.

The Hospital failed to implement an adequate system to ensure that a Registered Nurse was directing the care provided by nursing assistants.

Based on record review and interview the Hospital failed to ensure that the professional nursing staff providing hemodialysis as a contracted service within the Hospital were providing care in accordance with Hospital policies and procedures and were adequately supervised.

Findings include the following:

The medical record review for Patient #18 was started on 10/19/11 at 8:15 A.M. After treatment in the Hospital's Emergency Department on 10/10/11 the patient was admitted as an inpatient to the Hospital's Intensive Care Unit at 7 P.M. on 10/10/11. The patient was admitted with a central line catheter in the right chest that was used for hemodialysis. There was no evidence in the medical record that the staff of the hospital provided ongoing assessment and care to the central line from the time of admission to the time of surveyor record review on 10/19/11.

On 10/19/11 Nursing Supervisor #1 directed the nurse (R.N. #14) assigned to the patient to contact the patient's nephrologist for medical orders for the care of the patient's central line.

The surveyor requested to be informed of the orders obtained from the nephrologist. In the event that the nephrologist ordered that the dressing to the central line site was to be changed and the lines of the device were to be flushed survey staff requested to be present for these procedures. Nursing Supervisor #1 indicated that she understood the request and would contact the surveyor prior to any care being provided to the patient's central line.

The surveyor returned to the S1 unit at 1 P.M. on 10/19/11. R.N. #14 was asked about the status of the patient's central line care. R.N. #14 indicated that the covering nephrologist had written medical orders for the dressing change at the site of the central line and for the flushing of the line. R.N. #14 indicated that she had to contact the nephrologist for clarification of the frequency these procedures were to be done. The surveyor was told that following this clarification the dressing change and line flushing would be done. R.N. #14 would contact the surveyor prior to the care to the central line being done.

Approximately 3 minutes later R.N. #14 approached the surveyor and indicated that the care of the central line for this patient had already been done. R.N. #14 indicated that she had just been informed that the contracted dialysis nurse had changed the central line dressing and flushed the lines and instilled heparin into the ports. R.N. #14 indicated that the contracted dialysis nurse had not communicated with any staff on the unit, including R.N.#14, regarding the patient's condition at the time of the dressing change. It was unclear how the dialysis nurse would be aware that the patient was on contact precautions (positive for methicillin resistant staph aureus), where to obtain supplies needed to perform the dressing change and flushing procedures without communicating with the S1 nursing staff. Additionally, the contracted hemodialysis nurse failed to report to the S1 nursing staff the condition of the patient's central line insertion site, the status of the ports of the catheter, the patient's acceptance of the procedure and any reaction the patient may have experienced.

The patient's medical record was then reviewed with Nursing Supervisor #1 and Nurse Manager #2 in an effort to determine if the contracted dialysis nurse had entered any information in the patient's medical record regarding the procedures she had just completed. As the contracted dialysis staff cannot enter information in the electronic medical record the paper record was reviewed. It was confirmed that the contracted dialysis nurse had not made any entries in the patient's medical record regarding the procedures that she performed related to the central line.

It was then determined that Nurse Manager would accompany the surveyor to the three station dialysis room operated through a contract with a provider of hemodialysis services. This occurred at 1:30 P.M..

At the time the surveyor entered the dialysis room, contracted dialysis nurse (RN #17) was in the unit caring for the one patient on hemodialysis. The surveyor inquired of contracted dialysis nurse (RN #17) if she had provided care to patient #18 who was a patient on S1. She indicated that she had not provided any care to patient #18; but, was aware that contracted dialysis nurse (RN #18) had left the dialysis unit and gone to S1 to provide care to a patient's central line. She indicated that there had been a call to the dialysis unit from a physician requesting that a dialysis nurse change the central line dressing, flush the line and instill heparin into the ports. Contracted dialysis nurse (RN #17) indicated that contracted dialysis nurse (RN #18) had left for the day; however, she could page contracted dialysis nurse (RN #18) and have her call the dialysis unit. The surveyor indicated that contracted dialysis nurse (RN #17) should page contracted nurse (RN #18.)

While waiting for the call to be returned the surveyor asked contracted dialysis nurse (RN #17) if she was aware of where contracted dialysis nurse (RN #18) obtained the Heparin to instill into the ports of the central line. Contracted dialysis nurse (RN #17) explained that the staff order medications from the pharmacy for each dialysis treatment provided to each patient therefore they have no stock supplies.

Contracted dialysis nurse (RN #18) returned the call and the surveyor was able to briefly interview the nurse via telephone. Contracted nurse (RN #18) confirmed that, at the request of a nephrologist RN #18 had provided care to the central line of patient #18. The nurse indicated that she had changed the dressing to the central line, flushed the line and instilled heparin into each of the ports. Contracted dialysis nurse (RN #18) confirmed that she did not talk to any of the staff on the S1 unit including the nurse assigned to care for the patient during the day shift on 10/19/11. Contracted dialysis nurse (RN #18) confirmed that she made no entries in the patient's medical record regarding the care that was provided and any observations made of the site or the external line/ports. She confirmed that her documentation was limited to noting the day and her initials on the physician's hand written order sheet. The surveyor asked contracted dialysis nurse (RN #18) where she had obtained the Heparin solution used to instill into the ports of the central line. Contracted nurse (RN #18) indicated that they had a stock of Heparin in the dialysis unit which she had used.

Following the telephone interview with contracted dialysis nurse (RN #18), the surveyor informed contracted dialysis (RN #17) that contracted dialysis nurse (RN #18) indicated that there was a stock of Heparin located in the dialysis unit. Contracted dialysis nurse (RN #17) stated that she would look in the locked medication cabinet for Heparin. Contracted dialysis nurse (RN #17) unlocked the medication cabinet, briefly looked around the open shelf in the cabinet and then reached for another key. Leaving the medication cabinet, contracted dialysis nurse (RN #17) then used the key to open a two drawer metal filing cabinet, Contracted dialysis nurse (RN #17) opened and then reached into the bottom drawer and removed a clear plastic bag containing approximately 15 vials of Heparin.

Contracted dialysis nurse (RN #17) was unable/unwilling to explain how the vials of Heparin ended up being stored in the bottom drawer of the filing cabinet.

On 10/21/11 at 9:00 A.M. the surveyor returned to the dialysis room. The contracted acute dialysis nursing manager (Nurse Manager #4) was present in the unit. Contracted Nurse Manager #4 indicated to the surveyor that she had talked with contracted dialysis nurse (RN #18) regarding the care provided to patient #18. The contracted acute dialysis nursing manager (Nurse Manager #4) indicated that she was in agreement that contracted dialysis nurse (RN #18) had no authority to enter the patient's room, change the central line dressing, flush the line and instill Heparin into the ports. The contracted acute dialysis nursing manager (Nurse Manager #4) stated she had been told of the Heparin supply located in the file cabinet in the dialysis room and confirmed that this was where contracted dialysis nurse (RN #18) had obtained the medication.

Based on record review and staff interviews, for one patient (Patient #31) from a total sample of thirty-two patients reviewed, the Hospital failed to ensure that analgesic medications were administered in accordance with the physician's orders and according to accepted standards of practice for medication administration by the Registered Nurse.

Pursuant to Massachusetts General Law (M.G.L.), chapter 112, individuals are given the designation of registered nurse and practical nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a registered nurse and Practical nurse respectively. The regulations stipulate that both the registered nurse and practical nurse bear full responsibility for systematically assessing health status and recording the related health data. They also stipulate that both the registered nurse and practical nurse incorporate into the plan of care, and implement prescribed medical regimens. The rules and regulations 9.03 define standards of Conduct for Nurses where it is stipulated that a "nurse licensed by the Board shall engage in the practice of nursing in accordance with accepted standards of practice."

The findings are:

1. Per 10/26/2011 at 10:30 AM review of the medical record, Patient #31 was an elderly patient who was admitted to the Hospital on 10/17/11 following a total arthroplasty of the right knee at approximately 8 AM that morning.

According to the anesthesia record, at 7:42 AM on 10/17/11 anesthesia was started. At 10:00 AM it stopped. The anesthesia record also indicated that the patient had an ultrasound guided, Femoral Nerve Catheter Nerve Block placed prior to the procedure. The Post-operative Anesthesia Continuous Peripheral Nerve Block Order indicated the catheter was placed at the right femoral nerve and the medication was Bupivacaine 0.125 % (B1/8) in 100 milliliters (ml) of normal saline and was to infuse a 6 milliliters per hour for 48 hours and then to be discontinued on 10/19/11 at 6:00 AM. The post anesthesia evaluation note, completed at 11:45 AM on 10/17/11, noted that the patient was "receiving a long-acting regional anesthesia: full recovery had not occurred and is not expected within the 48 hour timeframe."

The Chief of Anesthesia was interviewed on 10/26/11 at 1:50 PM and explained that, although the Femoral Nerve Block provided excellent pain relief, the quadriceps muscle can be weakened for 6 to 24 hours following removal of the catheter. The Chief of Anesthesia stated that all nurses had been trained on Femoral Nerve Catheter Blocks prior to the Anesthesia Department's initiation of their use for that reason.

Further clinical record review revealed that, at 11:10 AM on 10/17/11 the physician ordered a PCA (Patient Controlled Anesthesia) Pump for Patient #31. The PCA is a device that allows the patient to self-administer pain medication with built-in limits. The order for Patient #31's PCA indicated that the pump would be loaded with IV Morphine at a concentration of 5 milligrams per milliliter. The pump would be set to dose the Morphine at 1 milligram intravenously, every 7 minutes, with a maximum of 8 injections in an hour. These settings reflected that, no matter how often the patient pushed the button on the pump, the maximum dose of Morphine the patient could receive would be 8 milligrams an hour.

Patient #31 was transferred out of the post anesthesia care unit and to the S2 nursing unit on 10/17/11. The nurses noted that the patient had a Femoral Nerve Block Catheter in the upper right thigh/groin that was infusing at 6 cubic centimeters an hour. Additionally, the patient had a CPM (Continuous Passive Motion) Machine that had been applied in the "recovery room." The plan was for the nurses to remove the CPM machine when required.

An initial nursing assessment, documented on 10/17/11 at 2:09 PM, indicated the patient had neither chronic nor acute pain. The plan of care, developed at 2:23 on the 10/17 noted a problem with alteration in comfort, and a plan to complete a pain assessment, initiate and maintain a PCA pump, medicate as ordered and evaluate effect.

At approximately 8:00 PM, Patient #31 complained of fever, shaking and chills. The nurse documented that the patient had a temperature of 102.7, that she administered 650 milligrams of Tylenol, and would "recheck temp. in 1 hr." At 9:45 the patient's temperature was 102.1, but the patient denied shaking or chills. The nurse encouraged the patient to cough/deep breathe. At 1:30 AM the patient's temperature was 100.7. The physician's assistant was notified but gave no new orders.

The following morning, 10/18/11 at 8:23 AM, the nurse documented that the patient was on and off the bedpan, complaining of a full bladder and the Femoral Nerve Block Catheter was found in the bed. The physician assistant was notified and ordered a Foley catheter be inserted. On 10/18 at 10:35 AM the nurse documented an assessment of the patient's pain as "N" (none). At 10:41 AM the nurse documented that Anesthesia came to see the patient as the Femoral Nerve Block was "out" and that the Femoral Nerve Block had been discontinued. There was no documentation to indicate how much of the nerve block was received. Also the nurse wrote that the patient "uses PCA morphine sparingly - 1/7/8", the settings ordered by the physician.

At 1:21 PM on 10/18/11 the physician's assistant ordered the analgesic medication, Percocet 5/325 (oxycodone 5 milligrams/ acetaminophen 325 milligrams) 1 to 2 tablets, by mouth, every four hours as needed for pain.

On 10/18/11 at 1:25 PM, the nurse assessed the patient's pain and documented "N" (none.)

According to the medication administration records in the clinical record, at 2:41 PM, the nurse administered two Percocet 5/325 tablets to the patient.

At 3:24 PM the physical therapist visited the patient and applied the CPM machine. The machine was scheduled to shut off at 5 PM.

At 3:30 PM on 10/18/11, Patient #31 was found sitting on the floor by the nursing assistant who initiated a staff emergency. The patient was "confused," and unable to recall the circumstances of the fall.

RN #20 was interviewed on 10/26/11 at 11:25 AM stated she had responded to the staff emergency. The RN stated the patient had removed her leg from the CPM machine herself. The RN stated the patient's wound had "totally dehisced" and was bleeding. The RN stated that the patient "denied pain throughout the fall." The RN stated that the patient was unable to state what happened or why.

The physician assistant (PA #1) who cared for patient #31 was interviewed on 10/26/11 at 12:30 PM. PA #1 stated he had responded to the emergency call from the nurses and determined "it was a running stitch. The whole thing broke open." He contacted MD #3 who stated the patient needed to return to the OR. When asked regarding the discontinuation of the PCA pump and the order for the Percocet, PA #1 stated he could not recall why he had ordered the Percocet.

The patient's surgeon, MD #3, was interviewed on 10/26/11 at 12:05 PM. MD #3 stated the patient had previously had the same procedure on the other knee and was the "model patient." When asked, MD #3 stated that although the CPM device can be challenging to apply/remove; the patient was familiar with the device from her previous surgery.

RN #21, who cared for the patient on the day-shift of 10/18/11 was interviewed on 10/26/11 at 1 PM. RN #21 stated that Patient #31 "didn't like the PCA - made her loopy." Further, that Patient #31 told the Physician Assistant that she wanted Percocet. RN #21 stated that when the Physician Assistant came to see the patient he discontinued the PCA and ordered Percocet. When asked about the Percocet administered at 2:41 PM, RN #21 stated that it was administered because the patient wanted it. RN #21 was asked how much PCA Morphine the patient had self-administered on her shift. RN #21 answered: "the PCA was discontinued." The RN was asked again, and continued to state the PCA was discontinued.

The Physical Therapist (PT #1) who had cared for Patient #31 was interviewed on 10/26/11 at 3:15 PM. PT #1 said that although the patient's Femoral Nerve Block had "fallen out," she was not complaining of pain. He stated she was unusual, stating: "she never complained of pain greater than 3." He assisted her back to bed and found she required "moderate assistance" adding, she was putting weight on her leg, and tolerating it, so I was happy." She was placed on the machine at 3 PM, "was awake, alert, talking to me."

There was no further documentation in the clinical record regarding the amount of morphine self-administered by Patient #31 while utilizing the PCA pump. The Nursing Infomatics Manager was interviewed at 9:15 AM and reviewed Patient #31's electronic and written clinical record together with the surveyors. Following this review, the Infomatics Manager stated that although "initiate and maintain" forms existed in the Hospital's electronic medical record for both the PCA pump and Femoral Nerve Block Catheters, the Manager confirmed that neither form had been completed for Patient #31. Therefore there was no documentation to indicate the amount and timing of self-administered morphine used by Patient #31 and or that the morphine was tracked and evaluated, and there was no documentation of the monitoring of the Femoral Nerve Block as required by Hospital policies and procedures.

At 11:30 AM on 10/27/11 the surveyors interviewed the Director of Pharmacy, Director of Nursing Education and the Chief Nursing Officer regarding the above. The Director of Pharmacy stated that the pharmacy could track the total amount of morphine used during the time the patient had the pump and reported it was a total of 26 milligrams over 26 hours. However, as nursing staff had not completed the tracking forms, neither pharmacy nor nursing could determine when during those 26 hours the patient had received the morphine.

The nurse administered the maximum ordered dose of Percocet at 2:41 PM, with no evidence the patient was in pain nor that the dose and timing of morphine was assessed/documented and there was no assessment of sensory and motor function from the femoral nerve catheter before the Percocet tablets were administered. The patient fell from her bed at 3:30 PM and sustained a dehiscence of her surgical wound.

Based on observation, record review and interview, the facility failed to ensure that one sampled patient (#1), in a total sample of 32, was administered medications by nursing staff in accordance with approved staff policies and procedures. Findings include:

Observation on 10/17/2011 at 9:00 A.M. indicated that Patient #1 was mechanically ventilated and sedated from a intravenous (IV) infused Propofol drip.(Propofol is an sedative/hypnotic drug with anesthetic effects administered intravenously to induce moderate to deep sedation and/or maintain general anesthesia depending on dose and titration.). The patient's respiratory rate was above normal at 26 breaths per minute with the inspiratory/expiratory phases being of equal duration, which is indicative of hyperventilation. Patient #1 had a left femoral triple lumen IV catheter and was receiving Vancomycin, Magnesium, and Normal saline with 20 mEq of Potassium through the IV. Interview with Registered Nurse (RN) #1, assigned to care for Patient #1, said that the patient may be arousing from the sedation, causing the elevation in respiratory rate.

Review of the Emergency Room (ER) records indicated the patient had presented via the emergency room (ER) from the community, nonresponsive, hypothermic and hypoglycemic with a blood sugar of 23. ER records indicated the patient received IV Ativan at 9:45 P.M. (Ativan is an anti-anxiety (sedative) also used to treat sustained seizure activity with a rapid onset of five minutes and peak action in one hour, and diminishing effects over the next 1 -6 hours.) Patient #1 was in respiratory distress and noted to have stridorous respirations and odd movements of the extremities. Review of the ER records indicated that the ER physician called anesthesiologist to intubate the patient. After two failed attempts, a glidoscope was required to insert the endotracheal tube (airway) which was secured with good air exchange. The anesthesiologist documented using three doses of short acting paralytics in order to successfully intubate the patient.

Review of medications administered in the ER indicated Patient #1 was given a long acting neuromuscular paralytic, Pavulon 6 milligrams at 11:05 P.M, by nursing staff, well after the successful intubation and without documented reason. The patient was given a second dose of Pavulon at 12:16 A.M.. Pavulon paralyzes all the skeletal muscles in the body. Duration of effects last anywhere from one to three hours before return of 75-90% of muscle function depending on the patient's state of health. A patient is not anesthetized or sedated by Pavulon, thus can be awake, but unable to move or breathe on their own. Further record review confirmed the patient was not given any further sedation.

Review of the facility's IV medication list which specifies which IV medications can be given by which classification of nurses indicated that Pavulon may only be given IV push by RN's in critical care specialities and in the perioperative area. The medication list indicates that for Pavulon nurses must review for competency the medication guidelines in the Lexicomp online system. Lexicomp is a on line drug reference for nursing. Review of the Lexicomp Drug review site with the Director of Quality and Safety on 10/17/2011 at approximately 10:00 A.M. revealed that Pavulon is indicated for ICU paralysis (e.g. facilitate mechanical ventilation) in select adequately sedated patients.

The Lexicomp drug information for nursing also stated the labeled indications for the use of Pavulon are: facilitation of endotracheal intubation, relaxation of skeletal muscles during surgery, facilitation of mechanical ventilation in ICU patients, with a statement that Pavulon does not relieve pain or produce sedation.

There was no evidence in the ER medical record that the patient was adequately sedated as per the ventilator bundle protocols or the nursing IV medication administration protocols for Pavulon administration. The last sedation the patient had received was IV ativan 0.5 mg at 9:45 P.M. The patient did not transfer out of the ER to the ICU until 12:45 A.M. ER records did not have an assessment of the patient's level of consciousness or sedation prior to administration of either dose of Pavulon.

Interview with the Quality and Safety Manager on 10/17/2011 at approximately 10:00 A.M. confirmed that the Pavulon was not given by nursing according to stated guidelines in Lexicomp drug reference that nursing staff is to be familiar with prior to administering Pavulon in the speciality areas.

Based on clinical record review, review of Nursing policies and procedures for administration of blood/blood products, review of the Blood Bank transfusion reaction protocols and staff interview, the Hospital failed to ensure that for 2 patients (#13 & 16) nursing staff followed the procedures and process for verification of the right blood product for the right patient; and identification and treatment of transfusion reactions. A total sample of 32 in-patients were reviewed.

The findings are:

1. The clinical record of Patient #13 was reviewed on 10/17/11 at 2 P.M. The record revealed the patient had received a transfusion of packed cells on 10/15/11. According to the transfusion record, the nurse started the packed cells at 3 P.M. At this time the patient's temperature was 98.7 degrees F (Fahrenheit.) At 3:15 P.M., the patient's temperature was 98.5 degrees F. At 4:20 P.M., the patient's temperature was taken axillary and was 100.2 degrees F. The nurse noted on the transfusion record that Tylenol was administered and the transfusion was completed at 6:20 P.M. At this time the patient's temperature was 98.3 degrees F.

The 10/15/11 transfusion record noted instructions for the nursing staff to follow for a Grade 1 or Grade 2 transfusion reaction. Grade 1 was defined as a temperature rise of less than 2 degrees Fahrenheit, itching and urticaria. If a reaction occurred the transfusion was to be stopped and the physician and blood bank were to be notified. The nurse checked the block on the transfusion record that a Grade 1 reaction had occurred due to the temperature rise of less than 2 degrees. There was no corresponding nurse's note regarding the reaction; however according to the electronic record, the nurse initiated a call to the physician for a Tylenol suppository order.

On 10/18/11 at 11:25 A.M. Nurse Manager #3 provided a copy of the 10/15/10 Nursing policy and procedure for administration of blood/blood products. According to the policy, the nurse was to document significant events related to blood product administration in the patient's record. Nurse Manager #3 also informed the surveyor that she had spoken to the Chief Medical Officer who had confirmed that she had spoken to the nurse and had ordered a Tylenol suppository.

Nurse Manager #3 acknowledged there was no entry by the nurse regarding the transfusion events, the condition of the patient at the time of the call to the physician, or if additional instructions had been communicated to the nurse by the physician.

2. Clinical record review on 10/18/11 at 11 A.M. of Patient #16 revealed the patient was admitted to the Hospital on 10/14/11 with diagnosis of anemia. Review of the clinical record revealed the patient had received blood/blood products on three different days, 10/14, 10/15 and 10/16/11.

According to the "Unit Transfusion Card," on 10/14/11 the patient received a unit of packed cells which had been initiated at 9:15 P.M. Instructions on the card noted that prior to initiation of the transfusion, staff were to check each box noting that the information was reviewed and confirmed as correct. The transfusionist and a second RN/LPN would also sign indicating that all of the following were confirmed as exact matches at the patient bedside:

-type of blood product to be transfused against the physician's order
-patient's name, date of birth, and medical record number on the patient's ID band against the Unit Issue Card for exact match
-the blood group and blood type on the patient's current hospital chart against the same information on the Unit Crossmatch Card attached to the blood tag, the blood tag itself, and against the Unit Issue/Transfusion form.
-Donor number and expiration date on the Blood Bag against the cross match card and the Unit Issue/Transfusion form

Review of the transfusion card revealed that although there were two signatures, none of the boxes had been checked indicating that all the above information had been reviewed by the two nurses and had been confirmed as correct.

On 10/15/11, the patient received a unit of fresh frozen plasma. According to the Unit Transfusion Card, the transfusion was initiated at 4:25 A.M. However, there was no date and time the transfusion was completed. Additionally, the transfusionist signature had no date or time and none of the boxes were checked indicating that all the required information had been reviewed and was confirmed to be correct.

Clinical record review revealed that on 10/16/11, the patient had received two units of packed cells. The first unit was initiated at 12 P.M. and the second unit was initiated at 5 P.M. Review of the Unit Transfusion Card for the packed cells initiated at 12 P.M., revealed that the nurses had checked each box as the information was reviewed and confirmed it was correct for the first unit. However, the second unit of packed cells initiated at 5 P.M. lacked evidence that the information had been reviewed and confirmed correct as the boxes were not checked.

These findings were reviewed with Nurse Manager #3 who acknowledged the transfusion records were not complete, lacked evidence that all of the information had been verified and matched exactly indicating there were no discrepancies which would require the nursing staff not to initiate the transfusion and to notify the Blood Bank.

Based on observation and interview, the hospital failed to ensure that the medical records were secure and safe from unauthorized access at all times and in all locations.

Findings include:

1. For patients receiving care at the outpatient rehabilitation unit at the Northwood facility, the hospital failed to ensure all medical records were kept in a secure area.

On 10/19/11 during a tour of the outpatient rehab unit, the metal cabinet used to store patient care records was observed to have the bottom drawer of this unit dislodged from the hindges. This drawer could not be closed and locked securely. This room was in a public area in which patients and visitors had access.

Interview with the director of rehabilitation on 10/19/2011 at 5:10 P.M confirmed that the drawer could not be closed completely to secure the medical records. This drawer contained recent discharges from the outpatient unit.

Based on record review, observation and interview the facility failed to assure that the Pharmacy Department adhered to pharmacy administration principles involving control over pharmaceuticals in the facility. Specifically the Pharmacy Department failed to have an adequate system to return unused pharmaceuticals to the department and that the department ' s control of drug storage covered all areas of the hospital. Evidence includes:

1. Review of QUANTROS incident reporting system Event ID: JTV5476821, documented a medication incident which occurred on September 7, 2011, on the Maternal Child Health Department. The reporter stated that a 1.0 ml syringe of 0.4mg/ml morphine solution was obtained from the unit pyxis station. This syringe did not contain the full amount of 1.0ml but a lesser amount 0.91ml. A second syringe of morphine was obtained, which also contained less than labeled (0.85ml vs. 1.0ml). The contents of both syringes were wasted and documented on the unit.

When interviewed about this incident on 10/20/11 at approximately 10:30 AM the Director of Pharmacy stated that the two syringes in question should have been returned to pharmacy to facilitate the investigation of this incident. However this was not done because there is no secure system to store items for return to pharmacy from the patient units.

2. During an investigation of patient care on the dialysis unit, a nurse surveyor observed the staff access a bag containing several single dose vials of 5000unit/ml Heparin from a filing cabinet in the administrative area of the unit. During an Interview on 10/21/11 at 8:45 AM the Contracted Acute Dialysis unit Nurse Manager (Nurse Manager #4) acknowledged the Heparin had been in the filing cabinet and that it was removed shortly after the observation. The nurse manager stated that dialysis nurses do not have access to pyxis stations for access to medications and speculated the heparin had accumulated as unused leftover from patient treatments. The nurse manager stated there was no system for returning unused items to pharmacy.

At 9:00 on 10/21/11, the Director of Pharmacy acknowledged that the storage of medications on the dialysis unit was unauthorized and the pharmacy had no knowledge that heparin was stored on the unit. The Director also acknowledged the need for a system to return unused items to pharmacy.

3. On 10/19/11 at 10:10 AM the Director of Pharmacy disclosed that the Materials Management department stored and maintained a stock of pharmaceutical items outside of the Pharmacy Departments administrative control. Pharmacy does not inspect or monitor the storage conditions of these items until they are requisitioned to a hospital care area. In those areas the items fall under the jurisdiction of pharmacy.

Observation in the Materials Management storage area on 10/18/11 at 2:50 PM revealed several pharmaceutical items including various IV solutions, Fleet Enemas, and irrigation solutions stored in significant quantities. At that time the Purchasing Officer confirmed that the Pharmacy Department did not monitor storage of or conduct inspections of these items while in the Materials Management Department.

Based on record review and interview, the facility failed to ensure that all patient care staff, to include medical staff, received training on donation issues such as consent process, using discretion and sensitivity, role of designated requestor, transplantation and donation, quality improvement activities and role of the organ procurement organization (OPO). Findings include:

1. Review of the agreement between the hospital and the OPO, dated 2/1/2010 and in effect, clearly states it is the donor hospital's responsibility to train the members of its medical staff with all relevant Donor Hospital policies and procedures. The OPO per the agreement would also provide periodic in-service education programs on organ, tissue and eye donation.

2. Interview on 10/18/11 at 2:30 P.M. with the Performance Improvement Manager (PIM) assigned to oversee the OPO program, revealed that the OPO does an annual nursing competency on donation in November. In July, the OPO does a second in-service at which it is mandatory that one member of the medical staff attend. The PIM confirmed there is no process to confirm medical staff are aware of the policies and procedures involved in organ donation.

3. Review of three of three physician credentialing files ( MD #1, MD #2 and MD #3), revealed no evidence of any training or acknowledgement of understanding of the facility's policies and procedures for organ donation.

4. On 10/19/2011 at 2:00 P.M., the Chief Medical Officer stated that it was not hospital policy that medical staff attend training on organ donation.

5. Interview with MD #2, on 10/13/11 at approximately 10:00 A.M., confirmed the MD had not received any training in organ donation policies in the five years of practice at the hospital. MD #2 stated that if there was to be a donation, they would just call the OPO for directions on what to do.

Based on record review and interview, the facility failed to ensure that one patient (#4) in a total sample of 32, had a pre-anesthesia evaluation before having a procedure under anesthesia. Findings include;

1. For Patient #4, admitted 10/2/2011, record review on 10/18/2011, revealed the patient had a cystoscopy with a retrograde pyelogram on 10/2/2011 under general anesthesia.

Search of the electronic and hard copy of the medical record revealed no pre-anesthesia evaluation as required. Another search of both medical records by the Intensive Care unit secretary on 10/19/2011 also confirmed there was no pre-anesthesia evaluation.

Based on staff interviews, for three of five outpatient service satellites visited (Pediatric Medical, Adult Medical and Physical/Occupational Therapy,) the outpatient medical records were not fully integrated with the inpatient service medical records. The findings are:

1. The Hospital operated two outpatient medical clinics at a satellite located at a school complex (Pediatric Medical and Adult Medical.) The satellite was visited on 10/19/11 at 1:00 PM. The satellite used a paper medical record. These medical records were stored at the satellite.

Nurse Practitioners #1 and #2 were interviewed on 10/19/11 at 1:30 PM regarding the process for communicating patient information with the main hospital campus. The Nurse Practitioners stated that the hospital staff would have to call them for information. The satellite's hours of operation were:

Pediatric Medical: Monday through Friday, morning and early afternoon.
Adult Medical: Monday and Wednesday, late afternoon.

If a patient who had been seen at the satellite visited the emergency room or was admitted, during the evening or night, there was no method for hospital staff to promptly obtain medical record information. The Nurse Practitioners both confirmed there was no process for the hospital staff to access medical record information at times the satellite was closed.


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2. For patients receiving care at the outpatient rehabilitation unit, the hospital failed to integrate the medical records of patients receiving care at the outpatient unit with the hospital. Patient care information at the outpatient units was entirely on paper. If a patient who had received care at the outpatient unit required care at the hospital during off hours, the staff at the hospital would be unable to access patient information.

The outpatient clinic hours of operation were Monday through Friday 8:00 A.M. through 6 :00 P.M.

This lack of integration of medical information for patients receiving care at the outpatient unit was confirmed by the Rehabilitation Director on 10/19/2011 at 5:15 P.M.

Based on review of policies and procedures currently in use, and interview with the Respiratory Care Director, the hospital failed to ensure that its policies were developed and approved by the medical staff and were appropriate to the scope of services provided.

Findings included:

Upon review of the Respiratory Care Service policies and procedures on 10/20/11, it was noted that many of the policies and procedures presently in use, were either outdated and no longer appropriate, or, were awaiting development, revision, review, and/or approval by the medical staff.

For example: The current hospital practice used by medical providers to enter respiratory care orders, required that the medical provider utilize the CPOE (Computerized Physician Order Entry) system. This system required that respiratory care orders for patients be entered into the CPOE system. Computerized physician order entry facilitated communication between physicians and other medical providers, nursing, and pharmacy, to effectuate implementation of the treatment ordered by the provider.

On 10/20/11 at 10:00, the Respiratory Care Services Department policies and procedures for physician orders were reviewed. Review of the policy revealed no provision for medical providers, nurses, respiratory service staff, or the pharmacy, to process orders through the CPOE system.

Review of the hospital's current policy for physician orders was effective on 8/11/97, and last reviewed by the previous head of the Respiratory Care Department on 2/9/2004. This policy gave no provision or direction to medical providers to enter respiratory care orders into the CPOE system as is the hospital's current practice.

Interview with the Respiratory Care Department Director on 10/20/11 at 11:30 AM, acknowledged that many of the departments' polices and procedures were in need of revision or review. The Director acknowledged that the current departmental physician order policy was obsolete, and that the CPOE system had been in effect for quite some time. The Respiratory Care Director and the Medical Director for Respiratory Care, both acknowledged the need to re-write or revise the current policies and procedures for the respiratory care department. They provided the surveyor on 10/20/11 at 11:30 AM, with a plan that included revising or re-writing their departmental policies by December 31, 2011. The plan also included in-servicing staff of any changes or revisions made to the hospital respiratory care policies by January 31, 2012.

Based on observation, record reviews and interviews, the Hospital failed to ensure that for one of one mechanically ventilated patients (Patient #1), the patient received appropriate medical care consistent with medical protocols for mechanically ventilated patients, in a total sample of 32.

Findings include:

Observation on 10/17/2011 at 9:00 A.M. indicated that Patient #1 was mechanically ventilated and sedated from a intravenous (IV) infused Propofol drip.(Propofol is an sedative/hypnotic drug with anesthetic effects administered intravenously to induce moderate to deep sedation and/or maintain general anesthesia depending on dose and titration.). The patient's respiratory rate was above normal at 26 breaths per minute with the inspiratory/expiratory phases being of equal duration, which is indicative of hyperventilation. Patient #1 had a left femoral triple lumen IV catheter and was receiving Vancomycin, Magnesium, and Normal saline with 20 mEq of Potassium through the IV. Interview with Registered Nurse (RN) #1, assigned to care for Patient #1, said that Patient #1 may be arousing from the sedation, causing the elevation in respiratory rate.

Record review on 10/17/2011 revealed the patient had presented through the emergency room (ER) from the community, nonresponsive, hypothermic and hypoglycemic with a blood sugar of 23. ER records showed Patient #1 received IV Ativan at 9:45 P.M. (Ativan is an anti-anxiety (sedative) also used to treat sustained seizure activity with a rapid onset of five minutes and peak action in one hour, and diminishing effects over the next 1- 6 hours.) Patient #1 was in respiratory distress and noted to have harsh, vibrating respirations and odd movements of the extremities. Review of the ER records indicated the ER physician called the anesthesiologist to intubate the patient. After two failed routine attempts with an endoscope, a glidoscope was required to insert the endotracheal tube (airway) which was secured with good air exchange. The anesthesiologist documented using three doses of short acting paralytics to successfully intubate the patient. The last dose of paralytic was Vecuronium given at 10:25 P.M.

Review of medications given in the ER on 10/16/2011, indicated Patient #1 was given a long acting neuromuscular paralytic, Pavulon, 6 milligrams at 11:05 P.M, well after the successful intubation and without a documented reason. Patient #1 was given a second dose of Pavulon at 12:16 A. M, again without a documented reason. Pavulon paralyzes all the skeletal muscles in the body. Duration of effects last anywhere from one to three hours before return of 75-90% of muscle function depending on the patient's state of health. A patient is not anesthetized/sedated by Pavulon, thus can be awake, but unable to move or breathe on their own. Further record review revealed Patient #1 was not given any further sedation and level of consciousness was not assessed at the time of administration of the Pavulon.

Review of the facility's IV medication list indicated that Pavulon may only be given IV push by RN's in critical care specialities and in the perioperative area. The medication list indicates that for Pavulon competency, nurses must review the medication guidelines in the Lexicomp online system. (Lexicomp is a on line drug reference for nursing.)

Review of the Lexicomp Drug review site with the Director of Quality and Safety on 10/17/2011 at approximately 10:00 A.M. revealed that Pavulon is indicated for ICU paralysis (e.g. facilitate mechanical ventilation) in select adequately sedated patients.

The Lexicomp drug information for nursing also stated the labeled indications for the use of Pavulon are: facilitation of endotracheal intubation, relaxation of skeletal muscles during surgery, facilitation of mechanical ventilation in ICU patients, with a statement that Pavulon does not relieve pain or produce sedation.

There was no evidence in the ER medical record that the patient was adequately sedated as per the ventilator bundle protocols ( facility specific set of care guidelines for patients who are on mechanical ventilation) or the nursing IV medication administration protocols for Pavulon administration. The last sedation the patient had received was IV Ativan 0.5 mg at 9:45 P.M. Patient #1 was intubated at 10:25 P.M. The patient did not transfer out of the ER to the ICU until 12:45 A.M. ER records include an assessment of the patient's level of consciousness or sedation prior to administration of either dose of Pavulon.

On 10/18/2011 at 9:00 A.M., interview with the ER physician who, ordered the Pavulon for this patient, said she ordered the medication, because of "patient safety", to avoid losing the airway. The physician said that the patient was not attempting to remove the airway but because it was such a difficult intubation, the physician said she did not want the airway to come out during transfer to the ICU. The ER physician said that the patient did receive "long acting sedative" early in the ER admission, referring to the Ativan. The physician said that no other other means were tried to protect the airway such as continuous IV sedation and said that sedation should have been started per the ventilator bundle protocol, but added that the Hospitalist usually orders the ventilator bundle which includes the IV sedation upon admission to the ICU. The ER physician said she should have ordered the IV sedation when she paralyzed the patient with Pavulon.

Interview with the Physician Director of the ICU on 10/19/2011 at 9:30 A.M.,said that not providing sedation for patient's who are paralyzed with neuromuscular blockers such as Pavulon and who are mechanically ventilated was poor medical practice. The ICU Physician Director said there are risks of post traumatic stress disorder and psychological trauma for patients who arouse or wake up while paralyzed. The Director stated this issue would be discussed at Quality Counsel which is a meeting of all department chiefs.

Based on observations, staff interviews and record reviews, the governing body failed to ensure that four of twenty-two services performed under contract (Hospitalist Physicians, Pharmacy Services, Behavioral Health and Dialysis) were provided in a safe and effective manner. The findings are:

1. The contracted Pharmacy Service failed to ensure that all areas of drug storage were under pharmacy control. Additionally, there was no system to ensure drugs were returned to the pharmacy. Refer to A 491.

2. The contracted Behavioral Health Service failed to ensure that the patient care areas were maintained in a safe manner. Refer to A 144

3. The contracted Dialysis Service failed to provide safe and effective care to patients. Refer to A 398.

4. The contracted Medical Staff service, "Hospitalists," failed to ensure a medical history and physical examination was completed timely for two patients on the Behavioral Health Service. Refer to A 358.

Based on record reviews, observations and interviews, the Hospital failed to protect and promote patient's rights. The findings are:

1. The Hospital failed to ensure that the designated individual had been contacted regarding the patient's resuscitation status prior to the entry in the medical record of a physician's order for "Do Not Resuscitate." (Refer to A 132).

2. The hospital failed to provide sufficient equipment to ensure patient's privacy would be maintained in the outpatient rehabilitation area. (Refer to A 143.)

3. The hospital failed to ensure that three areas in which patient care was provided (the Behavioral Health Unit, the Pediatric/Adult Medical outpatient satellite, and the inpatient contracted Dialysis Unit), were maintained in a safe manner. (Refer to A 144).

4. The Hospital failed to ensure that the use of physical restraints (siderails) was assessed as essential for the patient's safety and applied following an established plan. (Refer to A 161).

5. The Hospital failed to prohibit the use of standing orders or PRN (Latin abbreviation for pro re nata - as needed; as circumstances requires) orders for the use of medication restraints. (Refer to A 169).

6. The Hospital failed to ensure that, in cases when chemical restraints were used for the management of violent or self destructive behaviors that jeopardized the immediate safety of the patient or others, that the patient was seen face to face, within one hour after the initiation of the interventions by either a physician or other authorized trained practitioner. (Refer to A 178).

7. The Hospital failed to ensure that following the initiation of a chemical restraint, the patient was seen face to face within one hour, to evaluate the patient's immediate situation, the patient's reaction to the intervention, the patient's medical and behavioral condition and the need to continue or terminate the restraint. (Refer to A 179).

Based on clinical record review and staff interview, the Hospital failed to ensure for one patient (#13), who was incapacitated, that the designated individual had been contacted regarding the patient's resuscitation status prior to the entry in the medical record of a physician's order for "Do Not Resuscitate." A total of 32 inpatient records were sampled.

The findings are:

Clinical record review on 10/17/11 at 2 P.M. revealed Patient #13 was admitted to the Hospital on 10/6/11 via the emergency department from a long term care facility after a fall resulting in a left hip fracture. According to the transfer information from the long term care facility, the patient's resuscitation status was a "Full Code."

Review of the 10/6/11 physician's emergency department report, the patient was confused and disoriented. The physician noted that the patient's case was discussed with the primary physician and an orthopedist and was to be admitted to the Hospital with left hip fracture and right lower lobe pneumonia. Further review revealed the emergency department physician on 10/6/11 at 2:25 P.M. had entered a "Do Not Resuscitate" order. There was no evidence in the physician's emergency department report that advanced directives had been discussed with the individual designated to act on the patient's behalf.

The Inpatient/Outpatient registration form reviewed on 10/17/11 at 2 P.M. noted the patient's step-child was the health care proxy. Subsequent clinical record review revealed on 10/7/11, the patient's guardian had signed a consent for blood transfusions. There was no evidence in the medical record of the name of the court appointed guardian. Nurse Manager #3 acknowledged the information was not in the medical record and a copy was faxed to the hospital on 10/17/11 at 3:25 P.M. The guardianship document noted a temporary guardian had been appointed due to the step-child's death in February 2011. The Nurse Manager acknowledged the information was incorrect on the registration form and that nursing staff would use this information to determine who to contact regarding health care decisions.

The Nurse Manager provided a copy of the Medical Staff policy and procedure for "Withholding And Withdrawing Life Support" with an effective date of 6/7/10. The policy noted it was "the responsibility of all physicians and registered professional Nursing staff to be acutely aware of the policy on withdrawing or withholding life-sustaining treatment in its entirety and to monitor compliance." The policy noted that all patients admitted to the hospital would have a signed "In hospital code status order" form and that only legally appropriate surrogate decision makers may act on behalf of an incompetent patient. The physician would initiate an order for a full code or "Do Not Resuscitate" status. The policy was reviewed with the CMO (Chief Medical Officer) on 10/18/11. The CMO acknowledged that the policy was current and due to CPOE (computerized provider order entry) not all physicians were completing the "In-Hospital Code Status" order form and were only entering the order in the electronic medical record.

Based on observation and interview, the hospital failed to ensure privacy during care for patients in the outpatient rehabilitation area was not compromised.

Findings include:

1. On 10/19/2011, at 4:15.P.M. during the initial tour of the outpatient rehabilitation unit, 5 treatment areas were observed. Only 3 privacy curtains were provided for use during care. 2 of the 5 areas where patients were to receive care were not afforded complete privacy.

The rehabilitation director confirmed on 10/19/2011 at 4:20 P.M. that the area was not provided with an adequate number of privacy curtains for the 5 treatment areas. He stated that he was in process of ordering additional curtains for the unit.

Based on observation and staff interviews, it was determined that the hospital failed to ensure that three areas in which patient care was provided (the Behavioral Health Unit, the Pediatric/Adult Medical outpatient satellite, and the inpatient contracted Dialysis Unit), were maintained in a safe manner.

Findings included:

1. The Hospital's elder behavioral unit provided short term, acute, psychiatric, inpatient care

During an initial interview on 10/17/11 at 9:30 AM, the Behavioral Unit Program Director stated that the Elder Behavioral Health Service (EBHS) provided care, treatment and services to persons age 55 and older who have a primary conditions and/or symptoms of mental illness. The Program Director reported the majority of patients were admitted voluntarily. There are also patients admitted on an involuntary basis. The Director added the unit offered a safe environment for patient's who required urgent and acute psychiatric care. The Director stated that to assure safety was a priority certain precautions were implemented to protect potential harmful behavior, both individually and environmentally.

During a tour of the EBHS unit on 10/17/11 at 9:45 AM, and a subsequent tour on 10/18/11 at 9:45 AM, patient environmental safety concerns were observed in areas that had been allocated for treatment of patients. The observed environmental safety concerns particular to the potential for ligature strangulation or hanging included: Goose neck facets with paddle sink handles, in all but one patient bathrooms, activity of daily living kitchen and in all communal bathrooms and shower rooms. All patient beds had two siderails with open slats. The doors of rooms 130, 131, 132, 133, 135, and 136 were noted to have a metal extended door closure that swung into the room, that were accessible to patients.

Patient room doors could be barricaded and inaccessible to staff. Alcohol based hand sanitizers were mounted in the hallways and accessible to the patient population. Trash containers in all patient rooms and communal areas were uncovered. The unit reported cameras and mirror globes were used for observational purposes. On 10/18/11 at 10 AM, it was determined that staff were unable to observe patients at doorways of rooms 130, 136 and 137.

On 10/18/11 at 2 PM an interview with Behavioral Unit Program Director was held. The Program Director stated that he/she had conducted an environmental safety risk assessment in September 2011. She had also identified that the gooseneck faucets, patient room doors, siderails, hand sanitizer and current camera monitoring system did not follow the current standards of practice for patient environmental safety and security. The Director stated that, after identifying the issues, she submitted the report to the Hospital's plant operations department for a cost analysis. Further, the Program Director stated she had educated the unit's staff that areas in the environment were unsafe and that staff were to be vigilant with patient safety. The Director was unaware of other immediate actions the hospital had taken regarding the environmental concerns.

The Surveyors met with the Hospital's Quality and Safety Manager on 10/18/11 immediately following the above interview with the EBHS Program Director. The surveyors reviewed the above concerns, and the Quality and Safety Manager immediately began to address the environmental concerns.

2. The Hospital operated two, outpatient, medical clinics at a satellite located at a school complex (Pediatric Medical and Adult Medical.) The satellite was visited on 10/19/11 at 1:00 PM. It was observed that the satellite was located within a school building; had secure exterior doors and had a secure door between the waiting and the treatment areas. However, the clinic corridor had numerous interior doors, one labeled "school nurse."

Nurse Practitioners #1 and #2 were interviewed on 10/19/11 at 1:30 PM regarding the interior doors. The Nurse Practitioners stated that the doors opened into the school nurse's suite; and that school staff could access the satellite directly via the doors.

The hospital failed to ensure that the satellite clinic was secured to prevent unauthorized access from within the school.

3. During tour of the EBHS unit on 10/18/11 at 2 PM it was noted that a patient bathroom could be locked from the inside and staff could not immediately disarm the lock and open the bathroom door. During a tour of the Pediatric/Adult Medical satellite on 10/19/11 at 1:00 PM, it was also noted that the patient bathroom had a locking mechanism that could not be immediately disarmed by staff in an emergency.

4. On 10/19/11 at 1:30 P.M., Nurse Manager #2 accompanied the surveyor to the hemodialysis room. The dialysis room was observed to be in the surgical suite area. The surgical suite was accessed through unlocked, automatic controlled double doors. The hemodialysis room could be accessed through a single door which was observed to be unlocked. The room was able to accommodate three patients for hemodialysis treatments and stored hemodialysis machines, portable reverse osmosis machines and hemodialysis supplies which included dialysate, bicarbonate solution and hemodialyzers and tubing. Additionally, there were two other doors which provided access to the room which were not secured.
Contracted Hemodialysis Nurse #1 was in the room at the time and confirmed that the entrance door to the room could not be locked.

On 10/20/11 at 9 A.M. the surveyor met with the contracted Hemodialysis Acute Nursing Manager. At this time, it was observed that the hemodialysis room was divided by a fabric curtain. On the other side of the curtain, were shelves with supplies. The Manager stated the supplies were not hemodialysis supplies and were not used by patients receiving hemodialysis treatments in the room.

These findings were reviewed on 10/20/11 at 10 A.M. with Nurse Manager #2 who acknowledged that the room was not secure and was easily accessed by unauthorized personnel.

Review of the Acute Dialysis Services Agreement effective May 2010, revealed that the Hospital would provide sufficient space for the administration of hemodialysis services capable of being locked, that was adjacent to, or in reasonable proximity to the above referenced space for the storage of equipment and supplies used by the hemodialysis nurses.

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Based on record review and staff interview, the Hospital failed to prohibit the use of drugs or medications used to manage the behavior of one patient (#10), out of a sample 32 patients and that was not a standard treatment for the patient's condition.

Findings included:

The Elder Behavioral Health Service (EBHS) unit admitted patients 55 years and older who had a primary mental health diagnoses, and who met the severity of the illness as evident by symptoms. Symptoms may include, but were not limited to suicidal/homicidal ideation, assaultive and destructive behaviors, psychiatric symptoms (agitation, depression, anxiety, etc). The EBHS unit was to provide continuous observation and to control behaviors to protect the patient and others through a comprehensive multi-modal therapy plan and psychoactive medications. The only form of restraint authorized for use on the EBHS was medication restraint.

Patient #10, had recently been admitted to the Elder Behavioral Health Service (EBHS) with diagnoses that included hypertension, seizure disorder and a history of alcohol induced dementia with acute mental status changes, that included threatening, disruptive and assaultive behaviors.

On 10/13/11 at 19:40 the physician documented the patient was extremely agitated and was threatening to assault staff. The physician ordered the antipsychotic medication Abilify, 9.75 ml, IM (intramuscular), one time, to "chemically restrain the patient."

On 10/16/11 at 14:30, the patient became increasingly agitated, escalating aggressiveness and assaultive behavior towards others. After unsuccessful attempts with diversional activities and the administration of the anti-anxiety medication (Ativan), the physician ordered the antipsychotic medication Haldol 4 mg in conjunction with the Ativan be administered every 6 hours as needed to manage the patient's behavior. The Haldol and Ativan remained as PRN orders and were administered on 10/16/11, 10/17/11 and 10/18/11 because the patient exhibited unanticipated aggressive behaviors that posed an imminent danger to self or others.

On 10/20/11 at 10 AM interviews were held with Program Manager of the EBHS, Nurse # 13, the Physician Assistant Director of the EBHS and Human Rights Officer # 1 to discuss the administration of the Haldol as a medication restraint and the ongoing authorization of PRN medications. The surveyors asked the staff if the use of the Haldol (with or without the Ativan) met the definition of a medication used as a restraint during the times they were administered. The staff initially stated that the Haldol was not a medication restraint because it was administered by mouth. Later during the discussion the staff confirmed that it was restraint, as evident by their intent when it was used was as a restriction to manage the patient's behavior and not as part of the clinical treatment plan. In addition, the staff agreed the ongoing authorization of the PRN, not only failed to include administrative guidelines for use, but allowed the potential of improper administration of the medication as a restraint. The physician agreed that psychotropic, and especially antipsychotic, PRN medications required a firm understanding of the indications for there use; and that assessment and judgement may be inconsistent and misunderstood.

Based on record review, observation and interview the Hospital failed to ensure for 1 (#20) of 32 sampled patients that the use of physical restraints (siderails) was assessed as essential for the patient's safety and applied following an established plan.

Findings include the following:

The record review for patient #20 was started on 10/17/11 at 11:00 A.M. The patient was admitted to the Hospital 10/16/11 with medical diagnoses which included hyperkalemia and renal failure.

The initial inpatient nursing note written on 10/16/11 by the staff on the S1 unit indicated that the patient was admitted from the Emergency Room after being transported to the Emergency Room from a local nursing home.

The initial plan of care identified the patient as requiring fall precautions. This was described as including a bed alarm and frequent checks by the nursing staff.

A nursing note written at 10:45 P.M. on 10/16/11 described the patient as confused and disoriented. The note included that the patient had not attempted to get out of bed.

On 10/17/11 this patient was observed by survey staff to be in bed sleeping at 2:00 P.M., 3:00 P.M. and 4:00 P.M.. During each of these observations it was noted that the patient had three of the 1/2 siderails on the bed in the up position.

On 10/18/11 this patient was observed by survey staff to be in bed sleeping at 11:30 A.M., 12:00 noon, and 2:00 P.M.. During each of these observations it was noted that the patient had all four of the 1/2 siderails on the bed in the up position.

A review of the patient's plan of care failed to reveal any assessment or interventions requiring the use of restraints in the form of 4, 1/2 siderails in the up position.

On 10/18/11 at 2:00 P.M. the surveyor met with Nursing Supervisor #1 to discuss the observations related patient #20 being restrained in the bed with the use of the 4, 1/2 siderails in the up position. Nursing Supervisor #1 expressed agreement that placing the 4 siderails on the bed in the up position would be considered a restraint for this patient. Nursing Supervisor #1 was unable to provide any additional information either from the medical record or staff interviews to justify the use of restraints for this patient. Nursing Supervisor #1 did said that the staff informed her that they had not placed the 4, 1/2 siderails in the up position on this patient's bed. However, Nursing Supervisor #1 acknowledged that she had observed the patient in bed with the 4, 1/2 siderails in the up position.

Based on observation, record review and interview, the facility failed to ensure staff followed the facility policies and procedures for the initiation and use of restraints in patients with invasive devices for two of two restrained patients (#1 and #2 ), in a total active sample of 32. Findings include:

According to the facility policy for restraining patients with invasive devices, (last revised on 7/2010), the criteria for use of restraints includes the presence of an invasive device AND at least one of the following: confusion, delirium, disorientation, cognitive impairment, lack of awareness of potential for self harm, AND, at least one of the following: combativeness of sufficient severity to pose an immediate threat that the patient will extubate or remove the invasive devices necessary for medical management, previous successful self extubation or attempt to do so, or previous successful removal a device or attempt to do so. Alternative measures to protect an endotracheal tube or other invasive lines should be tried prior to restraint such as medications for pain or agitation, frequent observation, keep tubing out of visual field, diversion, or use of a sitter or family member. If alternative measures fail, document the patient's behavior and cognitive state that places patient at risk, to ensure patient meets criteria for restraint. Document attempt at alternative measures utilized to manage patient behavior and response if alternatives prove unsuccessful and document how the patient remains at risk. Notify the licensed independent practitioner (LIP)/physician authorized to order restraint and if the LIP/physician is not available to write an order, in an emergency situation, a registered nurse (RN) may initiate restraint and notify the LIP/physician as soon as possible to obtain a telephone order for the restraint application. A RN will reassess the patient at least every 2 hours to determine if the pateint still meets the criteria for restraint.

1. The facility failed to follow the restraint policy for Patient #1 in meeting criteria before application of the restraint.

Patient #1 was admitted to the Intensive Care Unit (ICU) on 10/17/2011, on mechanical ventilation. and was placed on a Propofol drip for sedation at 3:00 A.M. (Propofol is an sedative/hypnotic drug with anesthetic effects administered intravenously to induce moderate to deep sedation and/or maintain general anesthesia depending on dose and titration.) The patient was observed at 9:00 A.M. on 10/17/2011, to be restrained with bilateral wrist restraints, asleep and making no attempt to move.

Review of the medical record indicated a telephone order dated 1017/11 at 8:00 A.M., recorded by a registered nurse, for the use of soft upper limb restraints. The physician cosigned the order at 9:00 A.M. The order was recorded on a consent form that had a preprinted statement that read "I found the patient meets criteria for use of restraint. The patient is interfering with care and is in danger of sudden arousal and unpreventable accidental extubation and /or dislodging of drains, tubes and/or lines, due to disorientation and inability to follow instructions. Alternative measures have been considered and/or attempted and have been found to be unsuccessful in mitigating the patient's physical behavior. The following restraints are ordered."

Review of nursing and physician progress notes lacked documentation of patient assessment or evidence that the patient exhibited any behaviors such as attempted self extubation or severe combativeness. Hourly nursing documentation indicated the patient had been successfully sedated to a RASS ( Richmond Agitation Sedation Scale) score of minus 2 to 3 indicating moderate sedation from 3:00 A.M. through 8:00 A.M. There was no documentation that the Propofol sedation was ineffective in managing the patient's behavior, or that the patient was in danger of sudden arousal or unpreventable accidental extubation because nursing was monitoring the patient's sedation level hourly nor did the documentation specify how the patient remained at risk for self extubation.

2. For Patient #2, the facility failed to follow the restraint policy for obtaining a physician/LIP order for use of restraints.

Patient #2 was admitted to the ICU on 10/5/2011 with respiratory failure, rapid atrial fibrillation and on mechanical ventilation. The patient's diagnosis included end stage renal disease requiring hemodialysis three times a week via an arterial venous fistula in the left arm.

Record review indicated a telephone order recorded by the Registered Nurse (RN) at 12:01 A.M., on 10/7/2011, to apply bilateral soft upper limb restraints, due to the patient being intubated, which was cosigned by the physician on 10/7/2011 at 8:00 A.M.

On 10/13/2011, the patient was extubated. Review of physician orders indicated an order was written to discontinue the limb restraints.

On 10/17/2011 at 9:00 A.M., the patient was observed to be restrained with bilateral wrist restraints while receiving dialysis.

Review of physician orders indicated there was no order to reapply the wrist restraints on 10/17/11.

During interview on 10/19/2011 at approximately 10:00 A.M., the ICU Nurse Manager said there were no physician orders for the use of wrist restraints on 10/17/11.

Based on record review and staff interview, the Hospital failed to prohibit the use of standing orders or PRN (Latin abbreviation for pro re nata - as needed; as circumstances requires) orders for the use of medication restraints for one patient (#10) out of a sample 32 current patient records reviewed.

Findings included:

The Elder Behavioral Health Service (EBHS) unit admitted patients 55 years and older who had a primary mental health diagnoses, and who met the severity of the illness as evident by symptoms. Symptoms may include, but were not limited to suicidal/homicidal ideation, assaultive and destructive behaviors, psychiatric symptoms (agitation, depression, anxiety, etc). The EBHS unit was to provide continuous observation and to control behaviors to protect the patient and others through a comprehensive multi-modal therapy plan and psychoactive medications. The only form of restraint authorized for use on the EBHS was medication restraint.

Patient #10, had recently been admitted to the Elder Behavioral Health Service (EBHS) with diagnoses that included hypertension, seizure disorder and a history of alcohol induced dementia with acute mental status changes, that included threatening, disruptive and assaultive behaviors.

On 10/13/11 at 19:40 the physician documented the patient was extremely agitated and was threatening to assault staff. The physician ordered the antipsychotic medication Abilify, 9.75 ml, IM (intramuscular), one time, to "chemically restrain the patient."

On 10/16/11 at 14:30, the patient became increasingly agitated, escalating aggressiveness and assaultive behavior towards others. After unsuccessful attempts with diversional activities and the administration of the anti-anxiety medication (Ativan), the physician ordered the antipsychotic medication Haldol 4 mg in conjunction with the Ativan be administered every 6 hours as needed to manage the patient's behavior. The Haldol and Ativan remained as PRN orders and were administered on 10/16/11, 10/17/11 and 10/18/11 because the patient exhibited unanticipated aggressive behaviors that posed an imminent danger to self or others.

On 10/20/11 at 10 AM interviews were held with Program Manager of the EBHS, Nurse # 13, the Physician Assistant Director of the EBHS and Human Rights Officer # 1 to discuss the administration of the Haldol as a medication restraint and the ongoing authorization of PRN medications. The surveyors asked the staff if the use of the Haldol (with or without the Ativan) met the definition of a medication used as a restraint during the times they were administered. The staff initially stated that the Haldol was not a medication restraint because it was administered by mouth. Later during the discussion the staff confirmed that it was restraint, as evident by their intent when it was used was as a restriction to manage the patient's behavior and not as part of the clinical treatment plan. In addition, the staff agreed the ongoing authorization of the PRN, not only failed to include administrative guidelines for use, but allowed the potential of improper administration of the medication as a restraint. The physician agreed that psychotropic, and especially antipsychotic, PRN medications required a firm understanding of the indications for there use; and that assessment and judgement may be inconsistent and misunderstood.

Based on documentation review and staff interview, the Hospital failed to ensure that in cases when chemical restraints were used for the management of violent or self destructive behaviors that jeopardized the immediate safety of the patient or others, that the patient was seen face to face, within one hour after the initiation of the interventions by either a physician or other authorized trained practitioner for one sampled patient (#10) of 32 current in-patient records reviewed and two additionally non-sampled patients (C and D).

Findings included:

1. Patient #10 was administered the antipsychotic medication Abilify as a chemical restraint. The physician assessed the patient and ordered the medication on 10/13/11 at 19:40. Following the administration of the chemical restraint no face to face evaluation was conducted.

2. On 10/19/11 at 12 PM, a review of the restraint log book on the Elder Behavioral Health Service (EBHS) revealed that two non-sampled patients (Patient C and Patient D) were both administered chemical restraints on 9/24/11 at 20:30. Although the medication restraint progress note documented that the face to face would be done; there was no evidence that the authorized, trained practitioner or physician had completed one.

3. The Elder Behavioral Health Service (EBHS) had a policy that addressed the face to face within one hour after the initiation of a chemical restraint. Per review, the policy stated that an authorized physician would conduct a face to face evaluation of the patient as soon as possible; but no later than one hour of the initiation of the restraint, only if the restraint was authorized by telephone.

On 10/19/11 at 12 PM interview with RN # 13 reported that the face to face evaluation only occurred if the the order for the chemical restraint was obtained by telephone.

See F179.

Based on record review and staff interview, the Hospital failed to ensure that following the initiation of a chemical restraint, the patient was seen face to face within one hour, to evaluate the patient's immediate situation, the patient's reaction to the intervention, the patient's medical and behavioral condition and the need to continue or terminate the restraint for one sampled patient (Patient #10) of 32 patient records reviewed and two non-sampled patients (C and D).

Findings included:

1. Patient #10 was administered the antipsychotic medication Abilify as a chemical restraint. The physician assessed the patient and ordered the medication on 10/13/11 at 19:40. Following the administration of the chemical restraint, no face to face evaluation was conducted. No documentation was evident in the medical record of the patient's condition following the administration of the restraint that included all the elements of this requirement.

2. On 10/19/11 at 12 PM, a review of the Elder Behavioral Health Service (EBHS) restraint log book revealed that Patient C and Patient D were both administered chemical restraints on 9/24/11 at 20:30. Although the medication restraint progress note documented the face to face would be done; there was no evidence that the authorized trained practitioner or physicians had completed one. There was no documented evaluation of the patient's reaction, condition or need to to continue or terminate the restraint.

See F178.

Based on record review and staff interview, the facility's quality improvement program failed to identify opportunity for improvement and implement timely changes that would lead to improvement. Findings include

1. The facility failed to identify the need for performance improvement activities in the area of timeliness in reporting deaths to the OPO.

The OPO policy and procedure required the facility staff to report all deaths to the OPO within one hour of the patient being found asystolic (without heart beat).

Review of audit reports revealed the OPO program tracked and trended the timeliness of the death reporting to the OPO by unit, lateness of the report and the person who made the call to the OPO. Review of the this data from 11/2010 through September 2011, revealed an average of 3-7 late calls per month, most occurring on the intensive care unit (ICU) emergency room (ER) and progressive care unit (PCU). Many repeat staff names occurred each month as not reporting deaths in a timely manner.

Interview with the Performance Improvement Manager (PIM) who managed the OPO program, on 10/18/2011 at 2:30 P.M., revealed that the reports are shared with each unit manager each month so that the managers can address the timeliness issue with identified staff. Further interview revealed that the PIM did not receive feedback from the managers on the interventions provided.

After discussion with surveyor, the PIM confirmed that since 11/2010, the rate of late reports had not improved and that a performance improvement plan should have been implemented.


07338

2. For the incident reporting system, the Hospital failed to implement in a timely manner a plan of action which would result in changes that would lead to improvement.

Non-Sampled Patient # A was admitted to the hospital on 9/25/2011 with diagnosis including polymorphic tachycardia. While in the progressive care unit on 9/26/2011, the patient had an episodes of unsustained ventricular tachycardia. The Hospitalist physician was notified and requested to see the patient. The physician stated that he had already seen the patient in the emergency department, and was aware of these irregularities in the heartbeat. The nursing supervisor then notified the physician and stated his/her concern and desire to have the patient seen. Later that morning, the patient became unresponsive and a rapid response was called by the nursing staff. The MD responded to the rapid response and ordered the patient sent to the intensive care unit where he saw the patient.

The QUANTROS system of reporting incidents which is utilized by the hospital, entered this event into the system on 9/26/2011. The medical director did not indicate that a plan of action was formulated and implemented until 10/15/2011 which would improve communication and develop effective actions to prevent this event from recurring.

Based on record review and staff interview, the Hospital failed to ensure that a medical history and physical examination was completed and documented within twenty-four hours for two patients (#9 and #11) from a sample of 32 current patients reviewed

The findings included:

1. Patient #9 was admitted to the Elder Behavioral Health Service (EBHS) unit on 10/13/11 with diagnoses that included Chronic Lung Disease, Coronary Artery Disease, Depression and Suicidal Ideation's. The patient had been living in an independent setting and after falling was hospitalized. The patient was then discharged to a long term care facility. The long term care facility reported the patient was having a poor adjustment to the facility and his/her decline, was depressed and threatened to harm self. In addition, the patient was noted with weight loss and anxiety. The long term care facility transferred the patient back to the hospital for in-patient care.

Record review on 10/18/11 revealed that although the patient was admitted to the hospital on 10/13/11 and a psychiatric initial assessment was completed, no history or physical had been completed by the medical physician. On 10/18/11 the physician assistant (PA) evaluated the patient and noted worsening leukocytosis, an increase in his/her white blood cells potassium and BUN. The PA ordered treatment and documented there would be discussion with the supervising physician. The patient was discharged from the EBHS unit to a medical unit on 10/18/11. (Refer to A 385.)

2. Patient #11 was admitted to the EBHS unit on 9/30/11. Record review revealed that no history or physical had been completed by the medical physician until 10/5/11. Following the assessment, the patient was transferred to the hospital's medical unit for hyponatremia.

3. Interviews with RN #13 on 10/20/11 at 12 PM revealed that completion of a patient history and physical examination by a medical physician for patients admitted to the EBHS unit had been identified as a problem. The Nurse stated that following an admission to the unit the Hospitalists were notified of the admission. Per Hospital policy, the Hospitalists were to complete the history and physical examination within 24 hours. However, RN #13 stated that an admission log was implemented as frequently the examinations did not get done. The log tracked the patient's date of admission, date and time the physician was called and the date the physician saw the patient. RN #13 confirmed that the issue remained a problem as evident by Patient #11 and #9.

4. Per 10/21/11 at 10 A.M. review of documents provided by Hospital Administration, both the Elder Behavioral Health Service (EBHS) and the "Hospitalist" physicians were contracted services in the hospital.

The "Hospitalist" contract, signed 12/12/2006, indicated the "performance expectations" for the Hospitalist physicians included the following criteria:

#6. Patients on the EBHS will be managed per DMH (Department of Mental Health) requirements.
#7. Comply with bylaws for Medical Records completion.

The Medical Staff Bylaws for the Hospital, dated September 2011, Section 9.4 specified:

"A medical history and physical examination (H&P) must be performed and documented by a Physician, Oral Surgeon, or other qualified licensed individual (as identified in the Medical Staff Policies), no more than thirty days before or twenty-four hours after admission or registration, but in all cases prior to surgery or a procedure requiring anesthesia services (as described in the Medical Staff Policies)."

The Hospital failed to ensure a medical history and physical examination were completed and documented for Patients #9 and #11 as per the Hospitalist contract and Medical Staff By-laws.

Based on record reviews, observations and interviews the Hospital failed to provide an organized nursing service that ensured adequate delivery of nursing care to patients.

1. The Hospital nursing service failed to ensure that the care provided to patients was adequate to meet the specific needs of each patient. Patients # 9, 15, 18 & non-sampled patient B did not have plans of care to ensure services were provided for the maintenance of intravenous devices. (Refer to A 396)

2. The Hospital nursing service failed to ensure the emergency "code cart" equipment was ready for immediate use. (Refer to A 395.)

3. The Hospital nursing service failed to ensure that adequate nursing care plans were developed and implemented for patients. (Refer to A 396.)

4. The Hospital nursing service failed to ensure that the Registered Nurse assigned and directed the care provided by the nursing assistants. (Refer to A 397.)

5. The Hospital nursing service failed to ensure that contracted nursing staff adhered to Hospital policies. (Refer to A 398.)

6. The Hospital nursing service failed to adhere to established policies for medication administration. (Refer to A 405.)

7. The Hospital nursing service failed to adhere to policies and procedures for administration of blood and blood products. (Refer to A 409.)

Based on observation and interview the Hospital failed to ensure that the registered nurse supervising the care and services provided to the patients on the S1 medical/surgical unit maintained the emergency equipment required to provide immediate emergent care.

Findings include the following:

On 10/17/11 at 3:40 P.M. survey staff reviewed the contents of the emergency cart with Nursing Supervisor #1. The emergency "code cart" was located in the hallway of the S1 unit. This cart would be used by the nursing staff in the event of a cardio-pulmonary event on the unit. There was no suction machine located on top of the code cart.

During the review of the code cart, the surveyor reviewed a form with the title: "monthly code cart checklist." One of the areas listed on this checklist was "test suction 10-15 seconds." This was to be done on a daily basis. The recording in this column from 10/1/ to 10/13/11 indicated that the suction machine was located in the locked code cart. On 10/14/11 it was recorded as n/a. On 10/15 and 10/16/11, the suction machine was recorded as being inside the locked cart. On 10/17/11 it was recorded as n/a.

Nursing Supervisor #1 said that the suction machine is stored in the bottom drawer of the locked code cart.

On 10/18/11 at 8:10 A.M. Nursing Supervisor #1 informed the surveyor that she had opened the code cart on the S1 unit, and that there was no suction machine stored inside of the cart. She indicated that she had to obtain a portable suction machine from the Hospital central supply area and had placed it on top of the code cart.

When observed by the surveyor on 10/18/11 at 8:10 A.M. the portable suction machine was on top of the code cart; however, the staff had not prepared the device for immediate use by attaching the necessary tubing.

Based on observation, record reviews and staff interviews, for six of 32 inpatients reviewed, (Patients # 2, 9, 15, 18, 27 and 32) and 1 non-sampled patient B, the Hospital failed to ensure that the nursing staff developed and implemented an adequate, current nursing care plan for each patient.

For Patients # 9, 15, 18 & non-sampled patient B (# NSB), plans of care were not developed and implemented to ensure nursing services were provided for the maintenance of intravenous devices


For Patient #32, who staff knew from previous admissions to the hospital, the nursing staff failed to develop a plan to address the patient's urinary tract infection and behaviors.

For Patients #2 and #27, the nursing staff failed to monitor and assess weight changes to ensure appropriate nutrition and medical interventions would be provided.


1. The medical record review for Patient #18 was started on 10/19/11 at 8:15 A.M. After treatment in the Hospital's Emergency Department on 10/10/11, the patient was admitted as an inpatient to the Hospital's Intensive Care Unit at 7 P.M. on 10/10/11. The patient was admitted with a central line catheter in the right chest that was used for hemodialysis. There was no evidence in the medical record that the staff of the hospital provided ongoing assessment and care to the central line from the time of admission to the time of surveyor record review on 10/19/11.

Specific findings follow:

The patient was transported to the Hospital's Emergency Department by paramedics. The patient had been found by dialysis transport employees sitting on the bathroom floor at her home.

There was a notation on the Emergency Department's report that the physician in the Emergency Department called the patient's nephrologist. The subsequent notation by the Emergency Department physician indicated that after discussing the case with the nephrologist, the nephrologist "would prefer that the patient be dialyzed less urgently since no CHF, Hyperkalemia, AG Acidosis."

The Emergency Department report also indicated that the patient had a "right dialysis catheter."

The patient was transferred from the Emergency Department to the Intensive Care Unit with the clinical impression of Dehydration and Hyperglycemia.

The initial nurse's note written on 10/10/11 at 11:57 P.M. by the nurse in the Intensive Care Unit indicated that the patient arrived at approximately 7:00 P.M. and that a "dialysis catheter is seen in the right chest. This is intact with a DSD in place." This was the only entry related to the central line catheter by the nursing staff while the patient was being cared for in the Intensive Care Unit.

The nurse's note of 10/11/11 at 2:19 P.M. recorded that the patient was transferred to the PCU (Progressive Care Unit.)

The initial nurse's note by the staff in the PCU was written on 10/11/11 at 5:17 P.M. The note failed to make any mention of the patient having a central line in her right chest.

The next note by the PCU nursing staff was on 10/11/11 at 10:35 P.M. This nurse wrote that the patient had a "tesio (central line) to (the) right chest wall, new dialysis pt.." There was no additional information related to the status of the catheter including dressing appearance, drainage, the last time the dressing was changed or the last time the catheter/ports were flushed to maintain patency.

On 10/12/11 at 3:02 A.M. the nurse caring for the patient in the PCU wrote that there was a "Tesio cath to R chest, dsg C/D/I." (dressing clean, dry, intact.) There was no additional information in this nursing note related to the care of this central line.

On 10/13/11 at 7:14 A.M. the nurse in the PCU noted that the patient had "Tesio to right chest. Drsg C/D/I"

The patient was transferred to the S1 unit on 10/13/11 at 12:52 P.M.. The first entry by the nursing staff on S1 related to the patient having a central line catheter was on 10/14/11 at 2:18 A.M. The nurse wrote: "pt aware of dialysis in A.M." and "drsg. to rt. chest dialysis catheter intact."

On 10/14/11 at 2:28 P.M., the nurse wrote that the patient indicated that, "I am ready to go home. I will go to my own dialysis center."

A review of the nephrologist's note in the patient's medical record dated 10/13/11 indicated, "some recovery of renal function, to defer dialysis, to observe as outpatient."

It was unclear why the night nurse on 10/14/11 indicated that the patient was going to be dialyzed in the morning when the nephrologist had determined on 10/13/11 that dialysis was being deferred.

It was determined through interview with the contracted dialysis staff that this patient had not been dialyzed in this hospital during this admission.

The next nursing entry related to the care of this patient's central line was on 10/18/11 at 3:14 A.M. when the nurse wrote, "dialysis cath dressing needs changing - Pt refused at present. Would let R.N. secure with tape."

On 10/19/11 at 2:06 A.M. the nurse indicated in the nursing entry, "Drsg to dialysis catheter intact."

On 10/19/11 at 10:00 A.M. the patient's medical record was reviewed and discussed with Nursing Supervisor #1. The surveyor initially discussed the lack of care provided to the patient's central line. Nursing Supervisor #1 immediately responded: "We do not touch Tesio catheters here." The surveyor asked for a hospital policy related to this statement and was told that it was understood by nursing staff that they do not provide care to Tesio catheters. Nursing Supervisor #1 indicated that it has been a long standing hospital policy that the nursing staff does not care for central lines designated for use in the patient's dialysis treatment.

The surveyor explained to Nursing Supervisor #1 that this patient was admitted to the hospital on 10/10/11, had been cared for in the Intensive Care Unit, the Progressive Care Unit and on S1 (a medical/surgical unit), and there was no evidence in the patient's medical record that the nursing staff had provided care to this device and/or arranged to have care provided to this device. It was also explained that there was no indication that the patient had been dialyzed while hospitalized; therefore, there had been no assessment or care provided to the central line by the contracted dialysis staff.

The hospital utilized an electronic medical record system. Survey staff asked Nursing Supervisor #1 to locate any information in the patient's medical record related to the care of the patient's central line that may have been overlooked by the surveyor. Nursing Supervisor #1 asked the Nursing Informatics Manager to assist in the search of the electronic medical record. There was no additional information regarding the assessment and care provided to this patient's central line that was brought to the attention of the surveyor by either of these two individuals.

Nursing Supervisor #1 was asked if the nurse assigned to the patient's care that day (10/19/11 on the day shift) had any plan regarding the care she would be providing to the patient's central line. Nursing Supervisor #1 located R.N. #14 who was caring for Patient #18 during that shift. When asked about the Patient's central line, R.N.#14 indicated that she was aware that this patient had a central line in place for dialysis. R.N. #14 was asked by the surveyor what the plan was for providing care to this central line. R.N. #14 offered that she thought that "was a good question." R.N. #14 also indicated that the insertion site of the central line could not be assessed because the dressing covering the area was not transparent.

Following the conversation with R.N.#14, Nursing Supervisor #1 indicated that she was going to direct R.N. #14 to contact the Patient's nephrologist regarding direction for the care of the central line.

The surveyor requested to be informed of the orders obtained from the nephrologist. In the event that the nephrologist ordered that the dressing to the central line site was to be changed and the lines of the device were to be flushed, survey staff requested to be present for these procedures. Nursing Supervisor #1 indicated that she understood the request and would contact the surveyor prior to any care being provided to the central line.

The surveyor returned to the S1 unit at 1 P.M. on 10/19/11. R.N. #14 was asked about the status of the patient's central line care. R.N. #14 indicated that the covering nephrologist had written medical orders for the dressing change at the site of the central line and for the flushing of the line. R.N. #14 indicated that she had to contact the nephrologist for clarification of the frequency these procedures were to be done. The surveyor was told that following this clarification, the dressing change and line flushing would be done. R.N. #14 would contact the surveyor prior to the care to the central line being done.

Approximately 3 minutes later, R.N. #14 approached the surveyor and indicated that the care of the central line for this patient had already been done. R.N. #14 indicated that she had just been informed that the contracted dialysis nurse had changed the central line dressing, flushed the lines and instilled heparin into the ports. R.N. #14 indicated that the contracted dialysis nurse had not communicated with any staff on the unit, including R.N.#14, regarding the patient's condition, the indication for the patient to be on contact precautions (positive for methicillin resistant staph aureus), obtaining supplies needed to perform the dressing change and flushing procedures, the condition of the insertion site, the status of the ports of the catheter, the patient's acceptance of the procedure and any reaction the patient may have experienced.

The patient's medical record was then reviewed with Nursing Supervisor #1 and Nurse Manager #2 in an effort to determine if the contracted dialysis nurse had entered any information in the patient's medical record regarding the procedures she had just completed. As the contracted dialysis staff cannot enter information in the electronic medical record, the paper record was reviewed. It was confirmed that the contracted dialysis nurse had not made any entries in the patient's medical record regarding the procedures that she performed related to the central line.

It was then determined that the Nurse Manager would accompany the surveyor to the three station dialysis unit the Hospital operated through a contract with a provider of hemodialysis services. (Please refer to A-398)

Following the surveyors visit to the dialysis room on 10/19/11 at 3:00 P.M., a discussion was held with the CNO (Chief Nursing Officer) and Nursing Supervisor #1 to review the lack of care provided to Patient #18's central line, and the multiple issues regarding the contracted dialysis services. The CNO indicated that she had been informed of the issue of the Hospital nursing staff not providing care to the patient's central line, and the contracted dialysis nurse inappropriately providing care to the patient. The surveyor informed the CNO and Nursing Supervisor #1 of the supply of Heparin that had been found in the dialysis room. They both expressed their understanding of the issues and did not offer any additional information other than indicating that the Hospital had a policy and procedure for the care of central lines which they would supply to the survey team.

2. Clinical record review on 10/19/11 at 10 A.M. revealed Patient #15 was admitted to the Hospital on 10/15/11. According to the initial nursing assessment completed on 10/15/11 at 11:43 P.M., the patient had a past medical history of lymphoma and had received chemotherapy.

On 10/17/11 at 11:37 P.M. nursing documentation in the electronic medical record revealed the patient had a portacath (implanted small medical appliance installed beneath the skin, used for chemotherapy) in the left upper arm. There was no mention of this device in the initial nursing assessment of 10/15/11.

The above findings were reviewed with Nurse Manager #3 on 10/19/11 at approximately 2 P.M. The Nurse Manager acknowledged there were no other entries prior to 10/17/11 regarding the portacath. Nurse Manager #3 reviewed the electronic medical record with the nurse assigned to the patient for a nursing plan of care for the portacath. There was no plan; nor alerts for the nursing staff to not use this arm for blood pressure or obtaining blood samples. When asked how this information would be communicated to the nursing staff including the CNA's assigned to the unit, the Nurse Manager stated the information should be noted on the dry/erase board in the patient's room. (These were boards mounted on the wall of patients' rooms that were visible to other patients as well as visitors and were not an appropriate forum for communicating personal care needs.) Nurse Manager #3 accompanied the surveyor to the patient's room. It was noted on the dry/erase board not to use the patient's left arm for these procedures. Nurse Manager #3 acknowledged that the nursing plan of care should have identified the presence of this device and care interventions needed to be in the plan.

3. The Elder Behavioral Health Unit was a unit the Hospital operated through a contract with a provider of acute behavioral health services. On 10/18/11 at approximately 4:45 P.M., RN survey staff went to the Elder Behavioral Health Services (EBHS) unit to assess two patients, Patient #9 and non-sampled Patient B who had intravenous devices, at the request of Social Work survey staff.

Upon arriving on the Unit, non-sampled Patient B was observed sitting in the day room. The patient was observed with an intravenous saline lock in his right hand. The nurse, RN #19 from the Behavioral Health contract company, stated that the patient had returned to the unit on 10/17/11 at 2:15 P.M. after surgery with the device and it would need to be flushed every shift. RN #19 also stated the device would be left in for approximately 24 hours post-operatively and if the patient was tolerating food and liquids it would be discontinued. RN #19 stated that "it could probably be pulled now."

RN #19 accessed the electronic medication administration record to obtain information regarding the flushing of the device. RN #19 stated there was no evidence that the device had been flushed since the patient returned to unit nor physician's orders for the maintenance of the device.

At 5 P.M., Patient #9 was observed lying in bed, with oxygen via a nasal cannula, and had an intravenous device in his left hand. According to RN #19 the patient had pneumonia and was receiving intravenous antibiotics and intravenous fluids. When asked by survey staff as to the amount of fluids the patient had received since the initiation of the intravenous, the nurse was unable to locate the information in the electronic medical record or in the written medical record. RN #19 stated she would look at the time tape which was affixed to the intravenous solution bag for the amount infused and brought the time tape to survey staff to see. RN #19 acknowledged there should be a way to retrieve this information from the clinical record.

At 6 P.M. RN #15, also from the Behavioral Health contractor, provided survey staff with a nurse's note from 10/18/11 1:51 P.M. written by RN #16 (also from the Behavioral Health contractor.) According to the note, RN #16 documented that the intravenous was started by another RN, not RN #16. Documentation from the electronic medical record revealed an entry by RN#16 in the intravenous insertion section of the record that she had inserted the intravenous device. There was no documentation that the nursing staff could provide or locate by the nurse identified as inserting the intravenous as noted by RN#16 in the nurse's note. Additionally, record review on 10/18/11 revealed that although the patient was admitted to the hospital on 10/13/11 and a psychiatric initial assessment had been completed, no history or physical had been completed by the medical physician. (Refer to A 358).

At 6:15 P.M., survey staff met with the CNO to discuss the above findings,observations and concerns regarding Patient #9's medical condition. The CNO stated that based on the patient's current condition, the patient would be evaluated to see if his medical condition was stable so he could remain on the EBHS unit or be transferred to to a medical unit in the Hospital. On 10/19/11, the CNO informed survey staff that Patient #9 had been transferred to a medical unit later in the evening on 10/18/11.



00421

4. Per 10/26/2011 at 10:30 AM review of the medical record, Patient #32 was an elderly patient who was re-admitted to the Hospital via the Emergency Room (ER) on 10/17/11. The Patient had arrived at the Hospital ER via ambulance at 7:22 AM. Twenty minutes later, at 7:42 AM, the nurse documented that the patient was "consistently" complaining of left sided abdominal pain, was stating she was confused and anxious, and was unable to state her birthday.

Patient #32 was seen by the physician at 7:54 AM. The physician documented that the Patient had been seen in the ER three days prior, was diagnosed with a urinary tract infection at that time; however, had not taken any medication. The physician also wrote that the Patient was complaining of abdominal pain then and presently, that the patient had a history of Bipolar-Mood Disorder, Dementia and below the knee amputations.

The ER nurse documented that the patient voided a large amount in the bedpan at 11:30 AM., and that at 1 PM the patient was medicated with the antibiotic medication, Rocephin, for a "UTI" (urinary tract infection.) At 1:38 PM the physician ordered Sodium Cl 0.9% IV (NS 0.9% IV) at a rate of 100 mls per hour for parenteral fluid replacement. Patient #32 was transferred and admitted to the S1 inpatient unit at 2:40 PM.

The initial assessment by the nursing staff on the S1 unit was recorded at 5:29 PM and noted that Patient #32 had a bilateral, below the knee amputation, had an IV/Saline/Heparin Lock, had frequency of urination, was confused, disoriented and required toileting every two hours. Additionally, the assessment noted the patient was a high fall risk and required assistance of two with mobility.

The nursing plan of care developed on 10/17/2011 indicated Patient #32 was "on bed rest with bathroom privileges." The plan of care noted the patient was a fall risk and the "fall prevention care plan" would be implemented.

The Hospital's Falls Prevention and Management Protocol, effective 10/7/11, directed staff to complete the following:

- Assess coordination and balance before transferring or mobility activities
- Provide frequent toileting to decrease urgency and incontinence
- Use rubber sole shoes, slippers or traction socks
- Lock all moveable equipment before transferring patients
- Individualize assistive devices to patient needs
- Place patient care articles within reach
- Provide physically safe environment
- Provide adequate lighting
- Review medications for potential impact on fall risk
- Actively engage patient and family in fall prevention

Additionally, for patients' assessed to be at high risk (including Patient #32) staff were directed to:

- Post a falling star on the door
- The patient was to wear yellow socks and a yellow arm band
- Low beds would be provided where available
- Bed and Chair alarms
- Move the patient closer to the nursing station
- Consider an observation attendant if above interventions not effective.

However, the nursing plan of care developed on 10/17/2011 for Patient #32 did not address nor plan interventions for the patient's known urinary tract infection, confusion, disorientation, diagnosed mood disorder nor dementia.

Continued medical record review revealed that at 9:18 PM on 10/17/11 the nurse documented that Patient #32 had voided on the bedpan on two occasions.

The following morning, on 10/18/11 at 7:53 AM, the nurse documented the patient had complained about pain during the night shift, the doctor had been called and had ordered "Morphine 1 - 2 milligrams IV;" however, the morphine was not available in Pyxis. Also, that the patient was receiving her second bag of normal saline via an intravenous device that was infusing at 100 milliliters an hour. At 9:09 AM the nurse documented "morphine given for pain."

At 1:00 PM the nurse documented that Patient #32 was found sitting on the floor. Subsequent radiographs revealed the patient, who was a bilateral amputee, had a supracondylar fracture of the right femur.

RN #22, who had cared for Patient #32 at the time of the fall, was interviewed on 10/26/11 at 2 PM. The nurse stated that she knew Patient #32 from previous admissions. The nurse said that Patient #32 was on medication for a urinary tract infection and had used the bedpan earlier in the morning without incident. The nurse stated that, to her knowledge, Patient #32 had never attempted to get out of bed in the past. However, Patient #32 had "difficulty waiting for care," and "would yell rather than use the call bell." Also, that Patient #32 would refuse to take her medication at times, stating: "I no take them." The nurse acknowledged that the patient was a high fall risk and stated: "we had implemented all the fall interventions in the protocol." The nurse stated that the "falling star" was on the door. However, as the patient was a bilateral amputee and had no feet, the nurse stated that the staff were uncertain how to implement the use of the non-skid "yellow slippers" required in the Hospital's fall protocol . The nurse stated that (in an attempt to adhere to the Hospital's protocol,) staff had placed yellow slippers over the top of the posts at the end of the patient's bed. It was unclear how the nurse determined that action would prevent a fall.

Nursing Assistant #1 (NA #1) who was caring for Patient #32 at the time of the fall was interviewed on 10/27/11 at 7:30 AM. The Nursing Assistant said she knew (Patient #32) "by heart as he/she has been on my floor many times." NA #1 stated the patient could be "combative" if she didn't get what she wanted immediately, so if her buzzer went on, the NA responded quickly. NA #1 said she offered the patient the bedpan; however, the patient "was screaming and yelling no." The NA stated the nurse had been in the room; however, had been called to the desk at that time. The NA stated she offered the commode and the patient pushed it against her hands, stating "banyo" (bathroom.) The NA stated she knew the patient had no legs so she left to get the wheelchair.

RN #22, confirmed on 10/26/11 at 2 PM that she had told the NA "maybe we could get her into a wheelchair." The nurse stated that she had heard a commotion in the room and entered to find the patient on the floor. The nurse stated the NA arrived moments later with the commode. The NA stated she had arrived moments later with a wheelchair.

Observation of the S1 unit's physical layout, on 10/26/11 at 8:30 AM, revealed that Patient #32's assigned room was located at one end of the unit and at a significant distance from the equipment storage area. Accessing the equipment storage closet required walking the length of the corridor, turning around a corner and traveling down an adjacent corridor. At the request of surveyors, the CNO had the distance from Patient #32's room to the storage closet measured. The hospital CNO reported on 10/26/11 at 11:15 AM that the distance from Patient #32's room to the equipment closet was 156 feet each way (312 feet round trip.)

The Nursing Staff failed to ensure that necessary patient care equipment (including commode and/or wheelchair) for Patient #32 was readily available. The nursing staff rigidly adhered to a generic falls protocol that was not appropriate to the needs of Patient #32 who was a bilateral amputee ("yellow slippers"), and failed to develop an adequate plan of care to address Patient #32's impulsive behavior and urinary tract infection. Failure to develop an adequate plan of care for Patient #32 resulted in the patient's fall and resulting fracture.


00446


5. The medical record of Patient #27, including both the written and electronic recordings, was reviewed on 10/18/11.

Record review revealed the patient was admitted on 10/12/11 after treatment in the emergency room for a recent fall, with question of early dementia or hypoglycemia. The patient was admitted to the S1 unit for mild dehydration and anemia, with plans for neuropsychological, dermatology and ophthalmology consultations. Admission data noted the patient's height was 5' 4" and weight was 144 pounds; with presence of a stage II skin area to buttock. Additionally, the patient had medication orders for insulin and a 75 gram Carbohydrate, 1800 calorie diet. The diet was subsequently changed to a No Concentrated Sweets diet on 10/13/11.

The 10/14/11 nutrition progress note by the dietitian indicated the resident's Ideal Body Weight was approximately 130 lbs. Laboratory values included a blood urea nitrogen level (BUN) of 25 (slight elevation) and iron (Fe) level at 34 (low abnormal). Blood glucose levels were followed before meals and at night with sliding scale insulin coverage. Recorded meal intakes for this patient ranged from 50 to 100 %. The nutrition goal read to monitor intake, blood sugar levels and weight. This patient was transferred from the S1 unit to the Elder Behavioral Health Services (EBHS) unit. On 10/17/11 the patient's weight was documented as 134.4 pounds; a 9.6 pound loss.

On 10/19/11, at 9:30 A.M., the surveyor interviewed the EBHS Program Manager about the resident's weight changes. According to the Program Manager, the patient's 134.4 pounds was the only recorded weight available for review. The program manger proceeded to search the electronic medical record for nursing documentation from the S1 unit where this patient was first admitted and could not access the nursing documentation. The EBHS Nurse Program Manger's explanation as to why the admission nursing documentation from the S1 unit could not be reviewed by the staff on EBHS caring for the patient was due to security limits of patient information on the EBHS unit. However, the patient's admission weight was recorded on the dietary report listing for hospital patient census; with pertinent patient nutritional information such as diet order, height, weight, allergies, etc.

Further interview with the EBHS Program Manager indicated that the weight method used on the EBHS unit was a chair scale. The EBHS Program Manager was not aware of the patent's admission weight of 144 pounds. There was no way to determine if the patient's weight variance was due to the difference in equipment (bed scale), an actual weight loss, or a combination of both factors.

Per interview on 10/18/11, the Clinical Dietitian Manager was not aware of the 9 to 10 pound weight (loss) change since the patient's 10/12/11 admission weight. According to clinical nutrition assessment criteria, this patient was not due to for a follow-up review until 10/20/11. Per interview with the RN#13 on 10/18/11 at 2 P.M., the RN was not aware of a hospital nursing/weight assessment policy.

An outdated policy dated 5/09 for Patient Care Services/Nutrition Services was provided at 2:30 P.M. on 10/18/11,. The policy stated that the admission nurse was responsible for obtaining a patient's weight. Additionally, the weights and patient reweighs were to be done on the same scale and documented accordingly.

Patient #27's weight change went unnoted and the data recording for patient weight information was limited..

6. Patient # 2 was reviewed on 10/18/11. Patient #2 was admitted to the hospital for acute intervention with multiple medical conditions which included aspiration with esophageal impaction, respiratory failure, congestive heart failure, diabetes, atrial fibrillation and end stage renal disease with dialysis treatments.

Admission data for this patient included height of 5' 11" and weight at 180.39 pounds. The initial nutritional assessment reported this patient at risk due to a clear liquid diet, poor protein stores and high risk due to skin breakdown. Speech therapy determined the patient was unable to swallow safely and remained NPO (fed nothing by mouth). Tolerance and risk of fluid/metabolic imbalances and gastric residuals limited the advancement of enteral feedings. The patient's condition evidenced extreme low albumin levels and edematous extremities despite dialysis treatments. The dietician's nutritional assessment calculated the patient's estimated caloric and nutrient needs could be met with the formula administration at 55 ml/hour. The patient received intravenous fluids, and was determined unable to safely swallow foods; therefore, a nasogastric tube provided the nutrition formula at a slow rate.

The patient's weight measurements were recorded in the medical record and included significant variances of 20 to 22 pounds on two occasions; without evidence of nursing assessment or reweigh according to hospital policy.

Review of printed medical record information identified this patient's weight on 9/30/11 and 10/1/11, data from a previous hospital stay, at 180.34 pounds. On the date of admission, 10/5/11, the patient's documented weight was reported as 180.34, which was recorded for 10/7/11. On 10/8/11, the patients weight was reported at 182 pounds. It was difficult to determine if the admission weight was accurate, and whether the current weight was valid.

Review of weight documentation noted the patient was weighed on a bed scale on 10/9/11, at 203 pounds (an increase of 22 pounds). The patient received dialysis while in the intensive care unit (ICU) with pre and post treatment weight measurements recorded in kilograms with the dialysis services documentation, separate from the electronic medical record.

During 10/18/11 at 12:30 P.M. interview, RN #1 reviewed the documentation and could only correlate the increase with intravenous fluids received on 10/7/11 and 10/8 /11 respectively (3 plus liters and 4 liter intakes via intravenous/enteral fluids with little to no output.) Discussion with RN #1 revealed that weight inaccuracies would be likely if the patient's bed contained additional items that were not accounted for, or that the bed scale weight was not obtained correctly.

A nutrition progress note dated 10/10/11 had questioned the patient's weight difference of 20 pounds in two days. Also, the nutrition progress note noted concern with the laboratory blood value for the patient's albumin (1.9) as extremely low and questioned possible fluid overload status/anasarca. However, there was no nursing documentation that indicated the increased weight was reassessed at that time.

On 10/13/11, the patient's weight was noted at 224 pounds (21 pound increase). These weights were obtained via bed scale within the patient's ICU bed. The nutrition progress notes of 10/16 and 10/17/11 recommended protein repletion was needed and questioned whether the patient's weight gain was related to fluid. The recommendation was to resume enteral feeding as soon as possible and/or consider gastrostomy placement or total parenteral nutrition. Although this patient was followed by dialysis services, the patient' dialysis pre and post weights were not documented in the weight data collection area of the electronic record; comprehensive review of data collection was limited.

Discussion with RN #13 on 10/18/11 at 2:30 P.M. revealed that the hospital had provided education/competency for bed scale weight measurements during November 2010 for licensed and certified nurse aide staff. The information directed staff to compare the previous weight in electronic medical documentation to the current day's weight. There was no evidence that patients' weights were reviewed by nursing at the time of recording in the electronic medical record with comparison with the previously documented weight to address the significant variances.

The Hospital failed to ensure that the weight monitoring system in use was effective and implemented correctly for these two patients.

Based upon record reviews and staff interviews, the Hospital failed to ensure that a Registered Nurse supervised the care of each patient by directing the assignments and care provided by the nursing assistants. The findings are:

On the first day of survey, 10/17/11 during the initial tour, the surveyor was informed by RN #6 that the "charge nurse" on the S1 unit takes a full patient assignment. During the initial tour on the S2 unit on 10/17/11 at 9 AM, the "charge nurse" had a three patient assignment. On 10/18/11 at 8 AM, the "charge nurse" on S2 unit had a three patient assignment.

Review of the S2 assignment/roster sheet used by the nursing assistants on 10/18/11 at 9 AM revealed 7 of the 28 patients on the S2 unit had no information documented on the roster sheet to direct the nursing assistants other than the name of the nurse assigned to the patient.

Review of the S1 assignment/roster sheet used by the nursing assistants on 10/20/11 at 9 AM revealed 13 of the 19 patients on the S1 unit had no information documented on the roster sheet to direct the nursing assistants other than the name of the nurse assigned to the patient.

On 10/26/11 at 9:30 AM, Nurse Manager #3 was interviewed and asked to explain the process for communicating nursing assistants' assignments. The Nurse Manager stated that the on-coming day shift nursing assistants met with the out-going night shift nursing assistants to "update each other" on the patients. This nurse aide to nurse aide meeting occurred at the same time the Registered Nurses were meeting. On the unit where Nurse Manager #3 worked, there were three nursing assistants on the day shift; and according to Nurse Manager #3, the nursing assistants did not have a specific assignment. According to Nurse Manager #3, the three nurse aides "work together." Nurse Manager #3 stated that the nurse was responsible to "touch base" with the assistant, and would write specific instructions for individual patients on a daily bed roster. Also, the nurse would write information on the "white board" located in each patients' room. (These were boards mounted on the wall of patients' rooms that were visible to other patients as well as visitors and were not an appropriate forum for communicating personal care needs.) The surveyors requested to view a nurse aide roster sheet. The surveyors were provided with a copy of the sheet being used by Nurse Aide #3 to direct her care at approximately 9:45 AM on 10/26/11. The sheet listed all of the patients on the unit on 10/26/11; and, next to each patient's name were initials of the nurse assigned to the patient. It was approximately three hours into the shift at the time of review and there was no additional documented information to guide/direct the nurse aide in the care of the patients on the roster sheet.

On 10/26/11 at 11:25 AM, staff nurse (RN #20) was interviewed. RN #20 was asked to explain the process for communicating patients' care needs to the nursing assistants. RN #20 stated the day shift nursing assistants "pass along" information directly to the evening shift nursing assistants. RN #20 also stated the nursing assistants are not assigned to specific patients.

On 10/26/11 at 1:00 PM, staff nurse (RN #21) was interviewed. RN #21 stated there are usually two nursing assistants on her unit. RN #21 stated the nursing assistants talk before the start of the shift with the out-going night aide "for direction."

Staff Nurse (RN #22) was interviewed on 10/26/11 at 2 PM and stated her unit has two nursing assistants and each assistant takes "a side, typically ten patients each." RN #22 said she would personally direct the nurse assistants assigned to her patients; however, RN #22 was only responsible for four of the patients.

On 10/27/11 at 7:30 AM, Nursing Assistant (NA #1) was interviewed. NA #1 stated she would receive a list of the patients from the nurse and would "try to get a report the best I can from the night aide." NA #1 went on to explain that there is only one nursing assistant on the night shift, and that person is very busy so it is difficult to obtain a report at times. NA #1 stated her assignment at times is 13 patients. "I know I don't do medications or assessments, but some nurses want me to."

Nursing Assistant (NA #2) was interviewed on 10/27/11 at 9:05 AM. NA #2 stated she received report from the night shift nursing assistants, and that the nursing assistants decided how to divide the work load amongst themselves. The assistant was asked how they would know what patients needed feeding assistance? NA #2 stated: "that's a tough one, because there is no meal on 11 to 7, so the night aides don't always know." NA #2 went on to explain that sometimes information is passed along from the 3 to 11 shift nursing assistants; and other times the nurse aide just observes the patient to decide if they need assistance to eat.

Nursing Assistant (NA#3) was interviewed on 10/27/11 at 10:15 AM. NA #3 stated she met with the night aides to receive report and the nurse would tell her anything else she needed to know. (As noted above, the surveyors had reviewed the roster used by NA #3 on 10/26/11 and it contained no specific directions from the nursing staff.)

NA #3 stated her usual tasks included application of immobilizers. When asked how she would know the plan for a specific patient included application of an immobilizer, NA #3 stated: "if I find one in the room, then I know to apply it." "There are white ones and there's another one." "The other ones have a setting, but it would already be set." NA #3 stated she was familiar with Femoral Blocks. When asked what her responsibility would be, NA #3 stated: "it's just a matter of rearranging the furniture in the room." When asked how she would know to do that, NA #3 stated: "Because it is a different IV Pole and the liquid in the tube is yellow."

The above findings were reviewed with the Chief Nursing Officer (CNO) on 10/27/11 at 12:15 PM. The CNO confirmed that the charge nurses have a full patient assignment and the Nurse Managers have responsibility for multiple areas. The CNO confirmed the S1 Nurse Manager position was vacant. The CNO stated she had wanted to create a "true" charge nurse/resource nurse position to provide direction for staff on each unit; however, the Hospital had been unable to fund that position within the budget.

The Hospital failed to implement an adequate system to ensure that a Registered Nurse was directing the care provided by nursing assistants.

Based on record review and interview the Hospital failed to ensure that the professional nursing staff providing hemodialysis as a contracted service within the Hospital were providing care in accordance with Hospital policies and procedures and were adequately supervised.

Findings include the following:

The medical record review for Patient #18 was started on 10/19/11 at 8:15 A.M. After treatment in the Hospital's Emergency Department on 10/10/11 the patient was admitted as an inpatient to the Hospital's Intensive Care Unit at 7 P.M. on 10/10/11. The patient was admitted with a central line catheter in the right chest that was used for hemodialysis. There was no evidence in the medical record that the staff of the hospital provided ongoing assessment and care to the central line from the time of admission to the time of surveyor record review on 10/19/11.

On 10/19/11 Nursing Supervisor #1 directed the nurse (R.N. #14) assigned to the patient to contact the patient's nephrologist for medical orders for the care of the patient's central line.

The surveyor requested to be informed of the orders obtained from the nephrologist. In the event that the nephrologist ordered that the dressing to the central line site was to be changed and the lines of the device were to be flushed survey staff requested to be present for these procedures. Nursing Supervisor #1 indicated that she understood the request and would contact the surveyor prior to any care being provided to the patient's central line.

The surveyor returned to the S1 unit at 1 P.M. on 10/19/11. R.N. #14 was asked about the status of the patient's central line care. R.N. #14 indicated that the covering nephrologist had written medical orders for the dressing change at the site of the central line and for the flushing of the line. R.N. #14 indicated that she had to contact the nephrologist for clarification of the frequency these procedures were to be done. The surveyor was told that following this clarification the dressing change and line flushing would be done. R.N. #14 would contact the surveyor prior to the care to the central line being done.

Approximately 3 minutes later R.N. #14 approached the surveyor and indicated that the care of the central line for this patient had already been done. R.N. #14 indicated that she had just been informed that the contracted dialysis nurse had changed the central line dressing and flushed the lines and instilled heparin into the ports. R.N. #14 indicated that the contracted dialysis nurse had not communicated with any staff on the unit, including R.N.#14, regarding the patient's condition at the time of the dressing change. It was unclear how the dialysis nurse would be aware that the patient was on contact precautions (positive for methicillin resistant staph aureus), where to obtain supplies needed to perform the dressing change and flushing procedures without communicating with the S1 nursing staff. Additionally, the contracted hemodialysis nurse failed to report to the S1 nursing staff the condition of the patient's central line insertion site, the status of the ports of the catheter, the patient's acceptance of the procedure and any reaction the patient may have experienced.

The patient's medical record was then reviewed with Nursing Supervisor #1 and Nurse Manager #2 in an effort to determine if the contracted dialysis nurse had entered any information in the patient's medical record regarding the procedures she had just completed. As the contracted dialysis staff cannot enter information in the electronic medical record the paper record was reviewed. It was confirmed that the contracted dialysis nurse had not made any entries in the patient's medical record regarding the procedures that she performed related to the central line.

It was then determined that Nurse Manager would accompany the surveyor to the three station dialysis room operated through a contract with a provider of hemodialysis services. This occurred at 1:30 P.M..

At the time the surveyor entered the dialysis room, contracted dialysis nurse (RN #17) was in the unit caring for the one patient on hemodialysis. The surveyor inquired of contracted dialysis nurse (RN #17) if she had provided care to patient #18 who was a patient on S1. She indicated that she had not provided any care to patient #18; but, was aware that contracted dialysis nurse (RN #18) had left the dialysis unit and gone to S1 to provide care to a patient's central line. She indicated that there had been a call to the dialysis unit from a physician requesting that a dialysis nurse change the central line dressing, flush the line and instill heparin into the ports. Contracted dialysis nurse (RN #17) indicated that contracted dialysis nurse (RN #18) had left for the day; however, she could page contracted dialysis nurse (RN #18) and have her call the dialysis unit. The surveyor indicated that contracted dialysis nurse (RN #17) should page contracted nurse (RN #18.)

While waiting for the call to be returned the surveyor asked contracted dialysis nurse (RN #17) if she was aware of where contracted dialysis nurse (RN #18) obtained the Heparin to instill into the ports of the central line. Contracted dialysis nurse (RN #17) explained that the staff order medications from the pharmacy for each dialysis treatment provided to each patient therefore they have no stock supplies.

Contracted dialysis nurse (RN #18) returned the call and the surveyor was able to briefly interview the nurse via telephone. Contracted nurse (RN #18) confirmed that, at the request of a nephrologist RN #18 had provided care to the central line of patient #18. The nurse indicated that she had changed the dressing to the central line, flushed the line and instilled heparin into each of the ports. Contracted dialysis nurse (RN #18) confirmed that she did not talk to any of the staff on the S1 unit including the nurse assigned to care for the patient during the day shift on 10/19/11. Contracted dialysis nurse (RN #18) confirmed that she made no entries in the patient's medical record regarding the care that was provided and any observations made of the site or the external line/ports. She confirmed that her documentation was limited to noting the day and her initials on the physician's hand written order sheet. The surveyor asked contracted dialysis nurse (RN #18) where she had obtained the Heparin solution used to instill into the ports of the central line. Contracted nurse (RN #18) indicated that they had a stock of Heparin in the dialysis unit which she had used.

Following the telephone interview with contracted dialysis nurse (RN #18), the surveyor informed contracted dialysis (RN #17) that contracted dialysis nurse (RN #18) indicated that there was a stock of Heparin located in the dialysis unit. Contracted dialysis nurse (RN #17) stated that she would look in the locked medication cabinet for Heparin. Contracted dialysis nurse (RN #17) unlocked the medication cabinet, briefly looked around the open shelf in the cabinet and then reached for another key. Leaving the medication cabinet, contracted dialysis nurse (RN #17) then used the key to open a two drawer metal filing cabinet, Contracted dialysis nurse (RN #17) opened and then reached into the bottom drawer and removed a clear plastic bag containing approximately 15 vials of Heparin.

Contracted dialysis nurse (RN #17) was unable/unwilling to explain how the vials of Heparin ended up being stored in the bottom drawer of the filing cabinet.

On 10/21/11 at 9:00 A.M. the surveyor returned to the dialysis room. The contracted acute dialysis nursing manager (Nurse Manager #4) was present in the unit. Contracted Nurse Manager #4 indicated to the surveyor that she had talked with contracted dialysis nurse (RN #18) regarding the care provided to patient #18. The contracted acute dialysis nursing manager (Nurse Manager #4) indicated that she was in agreement that contracted dialysis nurse (RN #18) had no authority to enter the patient's room, change the central line dressing, flush the line and instill Heparin into the ports. The contracted acute dialysis nursing manager (Nurse Manager #4) stated she had been told of the Heparin supply located in the file cabinet in the dialysis room and confirmed that this was where contracted dialysis nurse (RN #18) had obtained the medication.

Based on record review and staff interviews, for one patient (Patient #31) from a total sample of thirty-two patients reviewed, the Hospital failed to ensure that analgesic medications were administered in accordance with the physician's orders and according to accepted standards of practice for medication administration by the Registered Nurse.

Pursuant to Massachusetts General Law (M.G.L.), chapter 112, individuals are given the designation of registered nurse and practical nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a registered nurse and Practical nurse respectively. The regulations stipulate that both the registered nurse and practical nurse bear full responsibility for systematically assessing health status and recording the related health data. They also stipulate that both the registered nurse and practical nurse incorporate into the plan of care, and implement prescribed medical regimens. The rules and regulations 9.03 define standards of Conduct for Nurses where it is stipulated that a "nurse licensed by the Board shall engage in the practice of nursing in accordance with accepted standards of practice."

The findings are:

1. Per 10/26/2011 at 10:30 AM review of the medical record, Patient #31 was an elderly patient who was admitted to the Hospital on 10/17/11 following a total arthroplasty of the right knee at approximately 8 AM that morning.

According to the anesthesia record, at 7:42 AM on 10/17/11 anesthesia was started. At 10:00 AM it stopped. The anesthesia record also indicated that the patient had an ultrasound guided, Femoral Nerve Catheter Nerve Block placed prior to the procedure. The Post-operative Anesthesia Continuous Peripheral Nerve Block Order indicated the catheter was placed at the right femoral nerve and the medication was Bupivacaine 0.125 % (B1/8) in 100 milliliters (ml) of normal saline and was to infuse a 6 milliliters per hour for 48 hours and then to be discontinued on 10/19/11 at 6:00 AM. The post anesthesia evaluation note, completed at 11:45 AM on 10/17/11, noted that the patient was "receiving a long-acting regional anesthesia: full recovery had not occurred and is not expected within the 48 hour timeframe."

The Chief of Anesthesia was interviewed on 10/26/11 at 1:50 PM and explained that, although the Femoral Nerve Block provided excellent pain relief, the quadriceps muscle can be weakened for 6 to 24 hours following removal of the catheter. The Chief of Anesthesia stated that all nurses had been trained on Femoral Nerve Catheter Blocks prior to the Anesthesia Department's initiation of their use for that reason.

Further clinical record review revealed that, at 11:10 AM on 10/17/11 the physician ordered a PCA (Patient Controlled Anesthesia) Pump for Patient #31. The PCA is a device that allows the patient to self-administer pain medication with built-in limits. The order for Patient #31's PCA indicated that the pump would be loaded with IV Morphine at a concentration of 5 milligrams per milliliter. The pump would be set to dose the Morphine at 1 milligram intravenously, every 7 minutes, with a maximum of 8 injections in an hour. These settings reflected that, no matter how often the patient pushed the button on the pump, the maximum dose of Morphine the patient could receive would be 8 milligrams an hour.

Patient #31 was transferred out of the post anesthesia care unit and to the S2 nursing unit on 10/17/11. The nurses noted that the patient had a Femoral Nerve Block Catheter in the upper right thigh/groin that was infusing at 6 cubic centimeters an hour. Additionally, the patient had a CPM (Continuous Passive Motion) Machine that had been applied in the "recovery room." The plan was for the nurses to remove the CPM machine when required.

An initial nursing assessment, documented on 10/17/11 at 2:09 PM, indicated the patient had neither chronic nor acute pain. The plan of care, developed at 2:23 on the 10/17 noted a problem with alteration in comfort, and a plan to complete a pain assessment, initiate and maintain a PCA pump, medicate as ordered and evaluate effect.

At approximately 8:00 PM, Patient #31 complained of fever, shaking and chills. The nurse documented that the patient had a temperature of 102.7, that she administered 650 milligrams of Tylenol, and would "recheck temp. in 1 hr." At 9:45 the patient's temperature was 102.1, but the patient denied shaking or chills. The nurse encouraged the patient to cough/deep breathe. At 1:30 AM the patient's temperature was 100.7. The physician's assistant was notified but gave no new orders.

The following morning, 10/18/11 at 8:23 AM, the nurse documented that the patient was on and off the bedpan, complaining of a full bladder and the Femoral Nerve Block Catheter was found in the bed. The physician assistant was notified and ordered a Foley catheter be inserted. On 10/18 at 10:35 AM the nurse documented an assessment of the patient's pain as "N" (none). At 10:41 AM the nurse documented that Anesthesia came to see the patient as the Femoral Nerve Block was "out" and that the Femoral Nerve Block had been discontinued. There was no documentation to indicate how much of the nerve block was received. Also the nurse wrote that the patient "uses PCA morphine sparingly - 1/7/8", the settings ordered by the physician.

At 1:21 PM on 10/18/11 the physician's assistant ordered the analgesic medication, Percocet 5/325 (oxycodone 5 milligrams/ acetaminophen 325 milligrams) 1 to 2 tablets, by mouth, every four hours as needed for pain.

On 10/18/11 at 1:25 PM, the nurse assessed the patient's pain and documented "N" (none.)

According to the medication administration records in the clinical record, at 2:41 PM, the nurse administered two Percocet 5/325 tablets to the patient.

At 3:24 PM the physical therapist visited the patient and applied the CPM machine. The machine was scheduled to shut off at 5 PM.

At 3:30 PM on 10/18/11, Patient #31 was found sitting on the floor by the nursing assistant who initiated a staff emergency. The patient was "confused," and unable to recall the circumstances of the fall.

RN #20 was interviewed on 10/26/11 at 11:25 AM stated she had responded to the staff emergency. The RN stated the patient had removed her leg from the CPM machine herself. The RN stated the patient's wound had "totally dehisced" and was bleeding. The RN stated that the patient "denied pain throughout the fall." The RN stated that the patient was unable to state what happened or why.

The physician assistant (PA #1) who cared for patient #31 was interviewed on 10/26/11 at 12:30 PM. PA #1 stated he had responded to the emergency call from the nurses and determined "it was a running stitch. The whole thing broke open." He contacted MD #3 who stated the patient needed to return to the OR. When asked regarding the discontinuation of the PCA pump and the order for the Percocet, PA #1 stated he could not recall why he had ordered the Percocet.

The patient's surgeon, MD #3, was interviewed on 10/26/11 at 12:05 PM. MD #3 stated the patient had previously had the same procedure on the other knee and was the "model patient." When asked, MD #3 stated that although the CPM device can be challenging to apply/remove; the patient was familiar with the device from her previous surgery.

RN #21, who cared for the patient on the day-shift of 10/18/11 was interviewed on 10/26/11 at 1 PM. RN #21 stated that Patient #31 "didn't like the PCA - made her loopy." Further, that Patient #31 told the Physician Assistant that she wanted Percocet. RN #21 stated that when the Physician Assistant came to see the patient he discontinued the PCA and ordered Percocet. When asked about the Percocet administered at 2:41 PM, RN #21 stated that it was administered because the patient wanted it. RN #21 was asked how much PCA Morphine the patient had self-administered on her shift. RN #21 answered: "the PCA was discontinued." The RN was asked again, and continued to state the PCA was discontinued.

The Physical Therapist (PT #1) who had cared for Patient #31 was interviewed on 10/26/11 at 3:15 PM. PT #1 said that although the patient's Femoral Nerve Block had "fallen out," she was not complaining of pain. He stated she was unusual, stating: "she never complained of pain greater than 3." He assisted her back to bed and found she required "moderate assistance" adding, she was putting weight on her leg, and tolerating it, so I was happy." She was placed on the machine at 3 PM, "was awake, alert, talking to me."

There was no further documentation in the clinical record regarding the amount of morphine self-administered by Patient #31 while utilizing the PCA pump. The Nursing Infomatics Manager was interviewed at 9:15 AM and reviewed Patient #31's electronic and written clinical record together with the surveyors. Following this review, the Infomatics Manager stated that although "initiate and maintain" forms existed in the Hospital's electronic medical record for both the PCA pump and Femoral Nerve Block Catheters, the Manager confirmed that neither form had been completed for Patient #31. Therefore there was no documentation to indicate the amount and timing of self-administered morphine used by Patient #31 and or that the morphine was tracked and evaluated, and there was no documentation of the monitoring of the Femoral Nerve Block as required by Hospital policies and procedures.

At 11:30 AM on 10/27/11 the surveyors interviewed the Director of Pharmacy, Director of Nursing Education and the Chief Nursing Officer regarding the above. The Director of Pharmacy stated that the pharmacy could track the total amount of morphine used during the time the patient had the pump and reported it was a total of 26 milligrams over 26 hours. However, as nursing staff had not completed the tracking forms, neither pharmacy nor nursing could determine when during those 26 hours the patient had received the morphine.

The nurse administered the maximum ordered dose of Percocet at 2:41 PM, with no evidence the patient was in pain nor that the dose and timing of morphine was assessed/documented and there was no assessment of sensory and motor function from the femoral nerve catheter before the Percocet tablets were administered. The patient fell from her bed at 3:30 PM and sustained a dehiscence of her surgical wound.

Based on observation, record review and interview, the facility failed to ensure that one sampled patient (#1), in a total sample of 32, was administered medications by nursing staff in accordance with approved staff policies and procedures. Findings include:

Observation on 10/17/2011 at 9:00 A.M. indicated that Patient #1 was mechanically ventilated and sedated from a intravenous (IV) infused Propofol drip.(Propofol is an sedative/hypnotic drug with anesthetic effects administered intravenously to induce moderate to deep sedation and/or maintain general anesthesia depending on dose and titration.). The patient's respiratory rate was above normal at 26 breaths per minute with the inspiratory/expiratory phases being of equal duration, which is indicative of hyperventilation. Patient #1 had a left femoral triple lumen IV catheter and was receiving Vancomycin, Magnesium, and Normal saline with 20 mEq of Potassium through the IV. Interview with Registered Nurse (RN) #1, assigned to care for Patient #1, said that the patient may be arousing from the sedation, causing the elevation in respiratory rate.

Review of the Emergency Room (ER) records indicated the patient had presented via the emergency room (ER) from the community, nonresponsive, hypothermic and hypoglycemic with a blood sugar of 23. ER records indicated the patient received IV Ativan at 9:45 P.M. (Ativan is an anti-anxiety (sedative) also used to treat sustained seizure activity with a rapid onset of five minutes and peak action in one hour, and diminishing effects over the next 1 -6 hours.) Patient #1 was in respiratory distress and noted to have stridorous respirations and odd movements of the extremities. Review of the ER records indicated that the ER physician called anesthesiologist to intubate the patient. After two failed attempts, a glidoscope was required to insert the endotracheal tube (airway) which was secured with good air exchange. The anesthesiologist documented using three doses of short acting paralytics in order to successfully intubate the patient.

Review of medications administered in the ER indicated Patient #1 was given a long acting neuromuscular paralytic, Pavulon 6 milligrams at 11:05 P.M, by nursing staff, well after the successful intubation and without documented reason. The patient was given a second dose of Pavulon at 12:16 A.M.. Pavulon paralyzes all the skeletal muscles in the body. Duration of effects last anywhere from one to three hours before return of 75-90% of muscle function depending on the patient's state of health. A patient is not anesthetized or sedated by Pavulon, thus can be awake, but unable to move or breathe on their own. Further record review confirmed the patient was not given any further sedation.

Review of the facility's IV medication list which specifies which IV medications can be given by which classification of nurses indicated that Pavulon may only be given IV push by RN's in critical care specialities and in the perioperative area. The medication list indicates that for Pavulon nurses must review for competency the medication guidelines in the Lexicomp online system. Lexicomp is a on line drug reference for nursing. Review of the Lexicomp Drug review site with the Director of Quality and Safety on 10/17/2011 at approximately 10:00 A.M. revealed that Pavulon is indicated for ICU paralysis (e.g. facilitate mechanical ventilation) in select adequately sedated patients.

The Lexicomp drug information for nursing also stated the labeled indications for the use of Pavulon are: facilitation of endotracheal intubation, relaxation of skeletal muscles during surgery, facilitation of mechanical ventilation in ICU patients, with a statement that Pavulon does not relieve pain or produce sedation.

There was no evidence in the ER medical record that the patient was adequately sedated as per the ventilator bundle protocols or the nursing IV medication administration protocols for Pavulon administration. The last sedation the patient had received was IV ativan 0.5 mg at 9:45 P.M. The patient did not transfer out of the ER to the ICU until 12:45 A.M. ER records did not have an assessment of the patient's level of consciousness or sedation prior to administration of either dose of Pavulon.

Interview with the Quality and Safety Manager on 10/17/2011 at approximately 10:00 A.M. confirmed that the Pavulon was not given by nursing according to stated guidelines in Lexicomp drug reference that nursing staff is to be familiar with prior to administering Pavulon in the speciality areas.

Based on clinical record review, review of Nursing policies and procedures for administration of blood/blood products, review of the Blood Bank transfusion reaction protocols and staff interview, the Hospital failed to ensure that for 2 patients (#13 & 16) nursing staff followed the procedures and process for verification of the right blood product for the right patient; and identification and treatment of transfusion reactions. A total sample of 32 in-patients were reviewed.

The findings are:

1. The clinical record of Patient #13 was reviewed on 10/17/11 at 2 P.M. The record revealed the patient had received a transfusion of packed cells on 10/15/11. According to the transfusion record, the nurse started the packed cells at 3 P.M. At this time the patient's temperature was 98.7 degrees F (Fahrenheit.) At 3:15 P.M., the patient's temperature was 98.5 degrees F. At 4:20 P.M., the patient's temperature was taken axillary and was 100.2 degrees F. The nurse noted on the transfusion record that Tylenol was administered and the transfusion was completed at 6:20 P.M. At this time the patient's temperature was 98.3 degrees F.

The 10/15/11 transfusion record noted instructions for the nursing staff to follow for a Grade 1 or Grade 2 transfusion reaction. Grade 1 was defined as a temperature rise of less than 2 degrees Fahrenheit, itching and urticaria. If a reaction occurred the transfusion was to be stopped and the physician and blood bank were to be notified. The nurse checked the block on the transfusion record that a Grade 1 reaction had occurred due to the temperature rise of less than 2 degrees. There was no corresponding nurse's note regarding the reaction; however according to the electronic record, the nurse initiated a call to the physician for a Tylenol suppository order.

On 10/18/11 at 11:25 A.M. Nurse Manager #3 provided a copy of the 10/15/10 Nursing policy and procedure for administration of blood/blood products. According to the policy, the nurse was to document significant events related to blood product administration in the patient's record. Nurse Manager #3 also informed the surveyor that she had spoken to the Chief Medical Officer who had confirmed that she had spoken to the nurse and had ordered a Tylenol suppository.

Nurse Manager #3 acknowledged there was no entry by the nurse regarding the transfusion events, the condition of the patient at the time of the call to the physician, or if additional instructions had been communicated to the nurse by the physician.

2. Clinical record review on 10/18/11 at 11 A.M. of Patient #16 revealed the patient was admitted to the Hospital on 10/14/11 with diagnosis of anemia. Review of the clinical record revealed the patient had received blood/blood products on three different days, 10/14, 10/15 and 10/16/11.

According to the "Unit Transfusion Card," on 10/14/11 the patient received a unit of packed cells which had been initiated at 9:15 P.M. Instructions on the card noted that prior to initiation of the transfusion, staff were to check each box noting that the information was reviewed and confirmed as correct. The transfusionist and a second RN/LPN would also sign indicating that all of the following were confirmed as exact matches at the patient bedside:

-type of blood product to be transfused against the physician's order
-patient's name, date of birth, and medical record number on the patient's ID band against the Unit Issue Card for exact match
-the blood group and blood type on the patient's current hospital chart against the same information on the Unit Crossmatch Card attached to the blood tag, the blood tag itself, and against the Unit Issue/Transfusion form.
-Donor number and expiration date on the Blood Bag against the cross match card and the Unit Issue/Transfusion form

Review of the transfusion card revealed that although there were two signatures, none of the boxes had been checked indicating that all the above information had been reviewed by the two nurses and had been confirmed as correct.

On 10/15/11, the patient received a unit of fresh frozen plasma. According to the Unit Transfusion Card, the transfusion was initiated at 4:25 A.M. However, there was no date and time the transfusion was completed. Additionally, the transfusionist signature had no date or time and none of the boxes were checked indicating that all the required information had been reviewed and was confirmed to be correct.

Clinical record review revealed that on 10/16/11, the patient had received two units of packed cells. The first unit was initiated at 12 P.M. and the second unit was initiated at 5 P.M. Review of the Unit Transfusion Card for the packed cells initiated at 12 P.M., revealed that the nurses had checked each box as the information was reviewed and confirmed it was correct for the first unit. However, the second unit of packed cells initiated at 5 P.M. lacked evidence that the information had been reviewed and confirmed correct as the boxes were not checked.

These findings were reviewed with Nurse Manager #3 who acknowledged the transfusion records were not complete, lacked evidence that all of the information had been verified and matched exactly indicating there were no discrepancies which would require the nursing staff not to initiate the transfusion and to notify the Blood Bank.

Based on observation and interview, the hospital failed to ensure that the medical records were secure and safe from unauthorized access at all times and in all locations.

Findings include:

1. For patients receiving care at the outpatient rehabilitation unit at the Northwood facility, the hospital failed to ensure all medical records were kept in a secure area.

On 10/19/11 during a tour of the outpatient rehab unit, the metal cabinet used to store patient care records was observed to have the bottom drawer of this unit dislodged from the hindges. This drawer could not be closed and locked securely. This room was in a public area in which patients and visitors had access.

Interview with the director of rehabilitation on 10/19/2011 at 5:10 P.M confirmed that the drawer could not be closed completely to secure the medical records. This drawer contained recent discharges from the outpatient unit.

Based on record review, observation and interview the facility failed to assure that the Pharmacy Department adhered to pharmacy administration principles involving control over pharmaceuticals in the facility. Specifically the Pharmacy Department failed to have an adequate system to return unused pharmaceuticals to the department and that the department ' s control of drug storage covered all areas of the hospital. Evidence includes:

1. Review of QUANTROS incident reporting system Event ID: JTV5476821, documented a medication incident which occurred on September 7, 2011, on the Maternal Child Health Department. The reporter stated that a 1.0 ml syringe of 0.4mg/ml morphine solution was obtained from the unit pyxis station. This syringe did not contain the full amount of 1.0ml but a lesser amount 0.91ml. A second syringe of morphine was obtained, which also contained less than labeled (0.85ml vs. 1.0ml). The contents of both syringes were wasted and documented on the unit.

When interviewed about this incident on 10/20/11 at approximately 10:30 AM the Director of Pharmacy stated that the two syringes in question should have been returned to pharmacy to facilitate the investigation of this incident. However this was not done because there is no secure system to store items for return to pharmacy from the patient units.

2. During an investigation of patient care on the dialysis unit, a nurse surveyor observed the staff access a bag containing several single dose vials of 5000unit/ml Heparin from a filing cabinet in the administrative area of the unit. During an Interview on 10/21/11 at 8:45 AM the Contracted Acute Dialysis unit Nurse Manager (Nurse Manager #4) acknowledged the Heparin had been in the filing cabinet and that it was removed shortly after the observation. The nurse manager stated that dialysis nurses do not have access to pyxis stations for access to medications and speculated the heparin had accumulated as unused leftover from patient treatments. The nurse manager stated there was no system for returning unused items to pharmacy.

At 9:00 on 10/21/11, the Director of Pharmacy acknowledged that the storage of medications on the dialysis unit was unauthorized and the pharmacy had no knowledge that heparin was stored on the unit. The Director also acknowledged the need for a system to return unused items to pharmacy.

3. On 10/19/11 at 10:10 AM the Director of Pharmacy disclosed that the Materials Management department stored and maintained a stock of pharmaceutical items outside of the Pharmacy Departments administrative control. Pharmacy does not inspect or monitor the storage conditions of these items until they are requisitioned to a hospital care area. In those areas the items fall under the jurisdiction of pharmacy.

Observation in the Materials Management storage area on 10/18/11 at 2:50 PM revealed several pharmaceutical items including various IV solutions, Fleet Enemas, and irrigation solutions stored in significant quantities. At that time the Purchasing Officer confirmed that the Pharmacy Department did not monitor storage of or conduct inspections of these items while in the Materials Management Department.

Based on record review and interview, the facility failed to ensure that all patient care staff, to include medical staff, received training on donation issues such as consent process, using discretion and sensitivity, role of designated requestor, transplantation and donation, quality improvement activities and role of the organ procurement organization (OPO). Findings include:

1. Review of the agreement between the hospital and the OPO, dated 2/1/2010 and in effect, clearly states it is the donor hospital's responsibility to train the members of its medical staff with all relevant Donor Hospital policies and procedures. The OPO per the agreement would also provide periodic in-service education programs on organ, tissue and eye donation.

2. Interview on 10/18/11 at 2:30 P.M. with the Performance Improvement Manager (PIM) assigned to oversee the OPO program, revealed that the OPO does an annual nursing competency on donation in November. In July, the OPO does a second in-service at which it is mandatory that one member of the medical staff attend. The PIM confirmed there is no process to confirm medical staff are aware of the policies and procedures involved in organ donation.

3. Review of three of three physician credentialing files ( MD #1, MD #2 and MD #3), revealed no evidence of any training or acknowledgement of understanding of the facility's policies and procedures for organ donation.

4. On 10/19/2011 at 2:00 P.M., the Chief Medical Officer stated that it was not hospital policy that medical staff attend training on organ donation.

5. Interview with MD #2, on 10/13/11 at approximately 10:00 A.M., confirmed the MD had not received any training in organ donation policies in the five years of practice at the hospital. MD #2 stated that if there was to be a donation, they would just call the OPO for directions on what to do.

Based on record review and interview, the facility failed to ensure that one patient (#4) in a total sample of 32, had a pre-anesthesia evaluation before having a procedure under anesthesia. Findings include;

1. For Patient #4, admitted 10/2/2011, record review on 10/18/2011, revealed the patient had a cystoscopy with a retrograde pyelogram on 10/2/2011 under general anesthesia.

Search of the electronic and hard copy of the medical record revealed no pre-anesthesia evaluation as required. Another search of both medical records by the Intensive Care unit secretary on 10/19/2011 also confirmed there was no pre-anesthesia evaluation.

Based on staff interviews, for three of five outpatient service satellites visited (Pediatric Medical, Adult Medical and Physical/Occupational Therapy,) the outpatient medical records were not fully integrated with the inpatient service medical records. The findings are:

1. The Hospital operated two outpatient medical clinics at a satellite located at a school complex (Pediatric Medical and Adult Medical.) The satellite was visited on 10/19/11 at 1:00 PM. The satellite used a paper medical record. These medical records were stored at the satellite.

Nurse Practitioners #1 and #2 were interviewed on 10/19/11 at 1:30 PM regarding the process for communicating patient information with the main hospital campus. The Nurse Practitioners stated that the hospital staff would have to call them for information. The satellite's hours of operation were:

Pediatric Medical: Monday through Friday, morning and early afternoon.
Adult Medical: Monday and Wednesday, late afternoon.

If a patient who had been seen at the satellite visited the emergency room or was admitted, during the evening or night, there was no method for hospital staff to promptly obtain medical record information. The Nurse Practitioners both confirmed there was no process for the hospital staff to access medical record information at times the satellite was closed.


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2. For patients receiving care at the outpatient rehabilitation unit, the hospital failed to integrate the medical records of patients receiving care at the outpatient unit with the hospital. Patient care information at the outpatient units was entirely on paper. If a patient who had received care at the outpatient unit required care at the hospital during off hours, the staff at the hospital would be unable to access patient information.

The outpatient clinic hours of operation were Monday through Friday 8:00 A.M. through 6 :00 P.M.

This lack of integration of medical information for patients receiving care at the outpatient unit was confirmed by the Rehabilitation Director on 10/19/2011 at 5:15 P.M.

Based on review of policies and procedures currently in use, and interview with the Respiratory Care Director, the hospital failed to ensure that its policies were developed and approved by the medical staff and were appropriate to the scope of services provided.

Findings included:

Upon review of the Respiratory Care Service policies and procedures on 10/20/11, it was noted that many of the policies and procedures presently in use, were either outdated and no longer appropriate, or, were awaiting development, revision, review, and/or approval by the medical staff.

For example: The current hospital practice used by medical providers to enter respiratory care orders, required that the medical provider utilize the CPOE (Computerized Physician Order Entry) system. This system required that respiratory care orders for patients be entered into the CPOE system. Computerized physician order entry facilitated communication between physicians and other medical providers, nursing, and pharmacy, to effectuate implementation of the treatment ordered by the provider.

On 10/20/11 at 10:00, the Respiratory Care Services Department policies and procedures for physician orders were reviewed. Review of the policy revealed no provision for medical providers, nurses, respiratory service staff, or the pharmacy, to process orders through the CPOE system.

Review of the hospital's current policy for physician orders was effective on 8/11/97, and last reviewed by the previous head of the Respiratory Care Department on 2/9/2004. This policy gave no provision or direction to medical providers to enter respiratory care orders into the CPOE system as is the hospital's current practice.

Interview with the Respiratory Care Department Director on 10/20/11 at 11:30 AM, acknowledged that many of the departments' polices and procedures were in need of revision or review. The Director acknowledged that the current departmental physician order policy was obsolete, and that the CPOE system had been in effect for quite some time. The Respiratory Care Director and the Medical Director for Respiratory Care, both acknowledged the need to re-write or revise the current policies and procedures for the respiratory care department. They provided the surveyor on 10/20/11 at 11:30 AM, with a plan that included revising or re-writing their departmental policies by December 31, 2011. The plan also included in-servicing staff of any changes or revisions made to the hospital respiratory care policies by January 31, 2012.