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Based on observations, reviews of policies and procedures, governing body meeting minutes, reports and staff interviews, it was determined the governing body did not monitor the development and implementation of policies and procedures for the hospital's total operation.

Findings include:

(C-276) Provision of Services. The governing body failed to ensure the development, implementation and monitoring of policies and procedures for the provision of Pharmaceutical Services (C-276); Reporting medication errors (C-277); Infection Control (C-278); and Nursing Services (C294).

Failure of the Governing Body to have oversight of the Provision of Services provided by staff of the CAH poses a high potential risk of harm to patients if staff are not following specific requirements for delivery of care.

(C-330) Periodic Evaluation & QA Review. The governing body failed to ensure policies and procedures were followed for identifying and evaluating care and services by all hospital departments with services that affected patient care; which poses a high potential risk of harm for patients if the care delivered is not evaluated and adjusted as needed.

Based on clinical record reviews, review of hospital policies and procedures, and staff interviews, it was determined for patients who had outpatient endoscopic procedures, the hospital's Governing Body:

1. Failed to ensure for 5 of 5 patients, that there was a legible and comprehensive history and physical as defined by the Medical Staff Bylaws/Rules and Regulations completed prior to the procedure; which poses a potential risk that the staff involved in their care will not be aware of the patients current medical condition. (Patients #9, #10, #11, #12, and #17.)

2. Failed to require nursing staff address abnormal vital signs prior to, during and/or after procedures during which the physician administered propofol for conscious sedation; which is a high potential risk of harm for the patient if the physician is not informed of abnormal vital signs. (Patients #9 and #10.)

Findings include:

1. The Medical Staff Rules and Regulations included the following: "The attending physician shall be responsible for the preparation of a complete and legible medical record for each patient. Its content shall be pertinent and current. This record shall include identification; date; complaint; personal history; history of the present illness; physical examination; special reports such as consultation, clinical laboratory and radiology services, and others; provisional diagnosis; medical and surgical treatment; operation report; pathological findings; progress notes; final diagnosis; conditions on discharge; summary or discharge note...All entries shall be dated, timed, and authenticated...Outpatient procedures history and physical examinations may be hand written and may use the H&P short form, and authenticated."

The clinical records of Patients #9, #10, #11, #12, and #17 included preprinted "Surgical Procedure History and Physical Examination" forms completed and signed by Physician #1. The preprinted form included the elements of a standard history and physical. The majority of the elements were not completed and the elements that were completed were illegible.

The above History and Physicals were reviewed by the Director of Nursing and she acknowledged they were incomplete and illegible.

2. Patient # 9

Patient #9 had an Esophagogastroduodenoscopy (EGD) with biopsies on 08/21/2015. Documentation on the "Endoscopy Pre-op Form revealed the patient's blood pressure (BP) was 203/79 at the time of the preoperative assessment. The patient's history included Hypertension, and the RN documented: "BP med unknown."

The patient was taken into the Procedure Room on or around 12:15 p.m. at which time her BP was recorded to be 205/110. The procedure started at 12:20 p.m. and her BP at that time was 195/72. The procedure ended at 12:25 p.m. and her BP at 12:26 p.m. was 190/64. The patient's BP's after her arrival to the post-procedure area were as follows: 12:43 p.m. - 145/53; 12:48 p.m. - 173/58; and 12:53 p.m. - 208/71.

The patient was discharged at 1 p.m. and there was no documentation in the clinical record that the patient's high blood pressure was addressed with the patient at any time.

Patient # 10

Patient #10 had an EGD on 08/21/2015. The patient's preoperative BP and pulse on or around 12:30 p.m. was 177/107 and 114 respectively. The patient's Medication List revealed she took Lisinopril, however, there was no documentation of the dosage or the date and time she last took the medication.

The following BP's and pulses were documented while the patient was in the procedure room: 12:57 p.m. - BP 144/111 and Pulse 117; 1:04 p.m. - BP 130/93 and Pulse 122; 1:06 p.m. BP 161/112 and Pulse 120. The following BP's and Pulses were recorded on the Endoscopy Post-Procedure Flowsheet: 1:20 p.m. BP 158/92 and Pulse 115; 1:25 p.m. BP 138/95 and Pulse 109; 1:30 p.m. BP 127/92 and Pulse 107.

The patient was discharged at 1:30 p.m. and there was no documentation that the patient's high blood pressure and pulse were addressed with the patient.

Based on clinical record reviews, review of policies and procedures, and staff interviews, it was determined the hospital failed to ensure that all services provided were in accordance with written policies and procedures.

Findings include:

(C-276) Pharmaceutical Services: Failure by staff to notify the physician that a medication ordered was not available through their formulary. (Patient #19) Failure to notify the physician that medication doses are not available poses a high potential health risk that the intended patient plan of care needs will not be met resulting in a potential negative outcome for the patient; and

Failure to ensure policies and procedures were followed for nursing access to the pharmacy. Failure by the hospital staff to follow specific policies and procedures related to services provided by the Pharmacy department poses a potential safety risk if a person not approved to access medications is allowed to do so.

(C-277) Medication Errors: Failure of the hospital to have effective procedures in place to report medication errors in 3 of 8 inpatient records. (Patients #5, #7 and #19.) This poses a high potential risk for patient safety if medication errors are not identified and addressed to correct ongoing errors.

(C-278) Infection Control: Failure of the hospital to maintain a clean and sanitary environment in all areas of the hospital, which poses a potential risk for the spread of infection; and


(C-294) Nursing Services: Failure of the nursing staff to 1. notify the physician of abnormal vital signs prior to, during and/or after an endoscopic procedure for Patients #9, #10, and #12.

2. to document current medications and when they were last taken on pre-operative nursing assessments for five of five patients scheduled for endoscopic procedures with conscious sedation. (Patients #9, #10, #11, #12, and #17.)

3. to check blood sugars for two diabetic patients prior to outpatient endoscopic procedures. (Patients #11 and #12.)

4. to ensure the documentation of nursing assessments and care provided to patients after endoscopic procedures was performed at the time of or shortly after the assessments and care and not prior to. (Patients #9, #10, #11, #12, and #17.)

5. to ensure insulin was administered following physician orders for Patients #5 and #7 and failed to consistently document the number of units of insulin administered to Patient #5.

6. to develop and implement policies and procedures of identifying patients at risk for skin breakdown including interventions to prevent breakdown and protocols for measuring and documenting skin breakdown (Patients #4, #20); and

7. to notify the physician that a medication ordered was not available from the Pharmacy for administration for seven doses. (Patient #19)

Failure by the nursing staff to document nursing assessments and the patients current medications, follow physician orders, develop and implement policies and procedures of identifying patients at risk for skin breakdown , and communicate with the medical staff regarding patient related issues poses a high potential health and safety risk that the needs of the patient will not be met.

The cumulative effect of these systemic problems resulted in the Critical Access Hospital's inability to ensure the provision of quality health care in a safe environment.

Based on clinical record reviews, review of hospital policies and procedures, and staff interviews, it was determined the hospital Pharmacy staff:

1. Failed to notify the physician that a medication ordered was not available through their formulary. (Patient #19) Failure to notify the physician medication doses not available poses a high potential health risk that the intended patient plan of care needs will not be met resulting in a potential negative outcome for the patient.

2. Failed to ensure policies and procedures were followed for nursing access to the pharmacy. Failure by the hospital staff to follow specific policies and procedures related to services provided by the Pharmacy department poses a potential safety risk if a person not approved to access medications is allowed to do so.

Findings include:

1. The hospital's Pharmacy policy PHARM-POL-02302 on the subject of "Assessment of Patient Medications" included: "Pharmacists at Northern Cochise Community Hospital will assess all medication orders for new patients within four (4) hours of the patient's or pharmacist's arrival in the hospital...Pharmacy will continue to monitor therapy during the duration of admission."

The hospital's Pharmacy policy PHARM-POL-063 on the subject of "Quality Assurance and Improvement" included: "Medication profiles shall be reviewed by a pharmacist daily for such problems as allergies, appropriate dosage, and drug interactions. All problems should be documented and reported to the attending physician and nursing services."

Patient #19 was admitted on 10/19/2015, with diagnoses including seizure disorder and was discharged home on 10/26/2015. Documentation in the clinical record revealed the patient's home medications included the anticonvulsant medications, Keppra and Primidone, and the physician wrote orders to continue the medications during her admission. Primidone 100mg by mouth was scheduled to be administered every night at 9 p.m.

A review of the Medication Administration Records (MARs) revealed the medication was not administered during her entire admission, a total of seven missed doses. There was no documentation that the physician was notified that the medication was not available and not administered during her admission. There was no documentation in the physician's daily progress notes that he was aware of the medication not available for administration.

An interview was conducted on 10/26/2015, with the hospital's Pharmacy Manager at which time he was asked what the policy was if a physician ordered a medication that was not available for administration. The Pharmacist responded that he reviewed all medication orders and would notify the physician and ask whether another medication could be substituted or if the physician wanted the patient to bring the medication in from home, if applicable. The Pharmacist was then asked to review Patient #19's physician orders and MARs which he did. He stated he did not know why the patient did not receive the medication because it was stocked in the pharmacy. One of the pharmacy technicians who was present told the pharmacist that this medication was not stocked in the pharmacy. The pharmacist stated, "I missed this."

2. The hospital's Pharmacy policy, PHARM-POL-050-1, on the subject of "Nursing Access to the Pharmacy" included: "When the pharmacist is not on duty at North Cochise Community Hospital, the charge nurses or other nurse designees may obtain medications from the pharmacy...This will be done in a legal, safe and secure manner...The charge nurse and nurse designee shall assure that they adhere to the procedures for obtaining medications in the absence of the pharmacist."

The Pharmacy Manager stated during an interview on 10/26/2015, that the prior policy was that only Charge Nurses had access to the pharmacy area when the pharmacist was not on duty, however, the current policy included all of the nurses in the Emergency Department (ED) in addition to Charge Nurses. When questioned why all ED nurses had access to the pharmacy, he responded it was at the direction of the Director of Nursing.

A review of the After Hours Pharmacy Sign Out Log revealed an entry dated 10/21/2015 at 6 p.m. by a Respiratory Therapist who signed out Symbicort. The Pharmacy Manager was asked how and why the RT had access to the pharmacy, and he responded that he did not know who that person was but that it was "probably" authorized by the Director of Nursing (DON).

The Director of Nursing acknowledged during a subsequent interview on 10/26/2015, that she wanted all of the ED nurses to have access to pharmacy. A list of all staff who currently had access to the pharmacy was provided to the surveyor. There were sixteen ED nurses, ten medical/surgical staff nurses, and four nursing administration staff for a total of thirty nurses who had known access to the pharmacy. The DON stated she did not know who the RT was and that the person should not have had access. The DON contacted the Charge Nurse who was on duty at the time the RT was in the pharmacy. The DON stated the Charge Nurse authorized the RT to be in the pharmacy which should not have happened.

The policies and procedures for access to the pharmacy were not being followed and were being directed by the DON rather than the Pharmacist.

Based on clinical record reviews, review of hospital policies and procedures, and staff interviews, it was determined for 3 of 8 inpatient record reviews, the hospital failed to have effective procedures in place to report medication errors. (Patients #5, #7 and #19.) This poses a high potential risk for patient safety if medication errors are not identified and addressed to correct ongoing errors.

Findings include:

The Pharmacy policy on the subject of Medication Error Definitions, PHARM-POL-044-1, included: "Policy: The pharmacist will evaluate, classify, and track medication errors...Purpose: Provide a continual quality improvement process designed to identify causes of errors, error trends, and implement corrective actions to prevent future errors...Medication errors are defined as the following: 1. Missed dose: Failure to administer an ordered dose before the next scheduled dose...Wrong time: Failure to administer an ordered dose within 60 minutes of the scheduled administration time."

The Pharmacy policy on the subject of Medication Errors and Monitoring, PHARM-POL-090, included: "The Pharmacy shall establish a CQA program to monitor and reduce medication related incidents recording the number of incidents; develop strategies to reduce those incidents and reassess, on a routine basis....The pharmacist shall review with the staff the errors and intervention strategies implemented on a annual basis."

Patient # 5

Documentation in the clinical record for Patient #5 revealed physician ordered insulin was not administered on 10/15/2015 at 7 p.m. and again on 10/16/2015 at 11:30 a.m. In addition, the number of units of insulin administered to the patient was not documented on 10/13/2015 at 9 p.m.; 10/16/2015 at 2 p.m. and 7 p.m.; and on 10/17/2015 at 6 a.m.

The Director of Nursing and the Director of Quality reported the medication errors were not reported through their computer system.

Patient # 7

Patient #7 had a physician's order dated 10/01/2015 at 12:30 p.m. for 10 units of Lantus insulin to be administered "NOW." Documentation in the patient's Medication Administration Record (MAR) revealed the medication was not given until 2:20 p.m., almost two hours later. There was no documentation as to why it was administered late and no occurrence report generated.

Patient # 19

Patient #19 had physician orders dated 10/19/2015 for Primidone (antiseizure medication) 100 mg to be administered every night. Documentation in the clinical record revealed the patient did not receive the medication during her entire admission (seven nights) because the medication was "not available." There was no documentation that the nursing staff or the pharmacy staff notified the physician.

The Director of Nursing and the Director of Pharmacy both acknowledged the medication omission and stated no medication error report was generated.

Based on observations, review of hospital policies and procedures, and staff interviews, it was determined the hospital failed to maintain a clean and sanitary environment in all areas of the hospital, which poses a potential risk for the spread of infection.

Findings include:

The hospital's Infection Control policy IC-POL-066-3 on the subject of "Care of Environment, Housekeeping" included: "POLICY: NCCH will use processes and take actions to lower and prevent the risks of healthcare-associated infections (HAI) in residents, employees and visitors. PURPOSE: Routine, daily, effective environmental cleaning and sanitation lessen the hazards of exposure to contaminated air, dust, furnishing, equipment and other fomites that may contribute to the risk of HAIs in most situations. SCOPE/RESPONSIBILITIES/PROCEDURES: The Infection Control Manager and Director of Plan Operations will monitor the Environmental Services cleaning routines for appropriateness and applicability. The Director of Plan Operations will establish daily written cleaning routines and schedules, assure knowledge and adherence by housekeeping staff, and submit current process for ICC review annually. Housekeeping staff will demonstrate knowledge and adherence to established process by maintaining a clean and safe environment."

A general tour of the hospital was made on 10/14/2015 with the Director of Nursing at which time the following observations were made:

-A clean storage room on the medical surgical unit included patient care supplies and an ice machine. The doors underneath the sink had been removed and there were non-patient care items stored in there. The floors and surface areas in the room were visibly dirty with dust, dirt and debris.

-The floor in the medication room was dirty with a build-up of dirt and debris. Surface areas of shelves and bins that contained patient care supplies were dirty.

-The nurses station in the Emergency Department was cluttered with items not necessary or used for patient care including a refrigerator for employees, stacks of paper, and employee personal items. The floor was dirty and shelves, cabinets, and bins containing patient care supplies were visibly dirty.

-One of the storage rooms in the ED used for storage of patient care supplies and equipment contained a microwave and coffee pot for staff use. The floor, cabinets, shelves were visibly dirty.

The surveyor requested documentation of a cleaning schedule for the various areas of the hospital after the above observations were made, however, it was not provided.

On 10/15/2015 at 8:30 a.m. observation was made with the Director of Nursing of another storage room in the hospital. The room included patient x-ray files with film which were scattered throughout the room in no seemingly order. They were in cardboard boxes and plastic crate containers on the floor, stacked on counter tops and in and on top of shelves against the wall. There were eight large plastic barrels in the room, two of which were about three-quarters full of discarded x-ray film. The room also contained four portable privacy screens, a cardiac treadmill, a large plastic respiratory therapy enclosed chamber with attached equipment and another tall piece of equipment with a monitor.

There was no organization to the room that would allow for adequate cleaning of the floor and surface areas both of which had a visible build up of dirt and debris.

The Director of Nursing acknowledged the above. She was not able to say whether or not all of the pieces of equipment were functional, why they were stored there or how long they had been stored there.

The Director of Infection Control acknowledged during a later interview that she was aware of areas in the hospital that were cluttered and dirty.

Based on clinical record review, review of hospital policies and procedures, and staff interviews, it was determined the nursing staff:

1. Failed to notify the physician of abnormal vital signs prior to, during and/or after an endoscopic procedure for Patients #9, #10, and #12.

2. Failed to document current medications and when they were last taken on pre-operative nursing assessments for five of five patients scheduled for endoscopic procedures with conscious sedation. (Patients #9, #10, #11, #12, and #17)

3. Failed to check blood sugars for two diabetic patients prior to outpatient endoscopic procedures. (Patients #11 and #12)

4. Failed to ensure the documentation of nursing assessments and care provided to patients after endoscopic procedures was performed at the time of or shortly after the assessments and care and not prior to. (Patients #9, #10, #11, #12, and #17)

5. Failed to ensure insulin was administered following physician orders for Patients #5 and #7, and failed to consistently document the number of units of insulin administered to Patient #5.

6. Failed to develop and implement policies and procedures of identifying patients at risk for skin breakdown including interventions to prevent breakdown and protocols for measuring and documenting skin breakdown. (Patients #4, #20)

7. Failed to notify the physician that a medication ordered was not available from the Pharmacy for administration for seven doses. (Patient #19)

Failure by the nursing staff to document nursing assessments and the patients current medications, follow physician orders, develop and implement policies and procedures of identifying patients at risk for skin breakdown , and communicate with the medical staff regarding patient related issues poses a high potential health and safety risk that the needs of the patient will not be met.

Findings include:

The hospital's Outpatient Ambulatory Services policy on the subject of Conscious Sedation included: "Pre-Sedation Activities..."Obtain vital signs, pulse oximetry reading, height and weight...List current medications and when last taken...Information obtained may significantly affect the subsequent management of patients/residents undergoing conscious sedation.

1. Patient # 9

Patient #9 had an Esophagogastroduodenoscopy (EGD) with biopsies on 08/21/2015. Documentation on the "Endoscopy Pre-op Form revealed the patient's blood pressure (BP) was 203/79 at the time of the preoperative assessment. The patient's history included Hypertension, and the RN documented: "BP med unknown." There was no documentation that the physician was notified of the high blood pressure prior to the procedure.

The patient was taken into the Procedure Room on or around 12:15 p.m. at which time her BP was recorded to be 205/110. The procedure started at 12:20 p.m. and her BP at that time was 195/72. The procedure ended at 12:25 p.m. and her BP at 12:26 p.m. was 190/64. There was no documentation that the RN monitoring the patient notified the physician of the high BP's.

The patient's BP's after her arrival to the post-procedure area were as follows: 12:43 p.m. - 145/53; 12:48 p.m. - 173/58; and 12:53 p.m. - 208/71. There was no documentation that the RN notified the physician of the high blood pressure obtained at 12:53 p.m.

The patient was discharged at 1 p.m. and there was no documentation in the clinical record that the patient's high blood pressure was addressed with the patient at any time.

Patient # 10

Patient #10 had an EGD on 08/21/2015. The patient's preoperative BP and pulse on or around 12:30 p.m. was 177/107 and 114 respectively. The patient's Medication List revealed she took Lisinopril, however, there was no documentation of the dosage or the date and time she last took the medication. There was no documentation that the physician was notified.

The following BP's and pulses were documented while the patient was in the procedure room: 12:57 p.m. - BP 144/111 and Pulse 117; 1:04 p.m. - BP 130/93 and Pulse 122; 1:06 p.m. BP 161/112 and Pulse 120. There was no documentation that the physician was made aware of the patient's high BP's and Pulses. The following BP's and Pulses were recorded on the Endoscopy Post-Procedure Flowsheet: 1:20 p.m. BP 158/92 and Pulse 115; 1:25 p.m. BP 138/95 and Pulse 109; 1:30 p.m. BP 127/92 and Pulse 107. The patient was discharged at 1:30 p.m. and there was no documentation that the patient's high blood pressure and pulse were addressed with the patient.

Patient # 12

Patient #12 was over the age of 80 and had a colonoscopy in October 2015. The RN documented in the Intra-op Form: "Patient did have an episode of vomitus yellow colored bile. Pt suctioned & no more occurred." The RN did not document what time that happened. The first set of vital signs obtained in the Post-Procedure area was at 2:50 p.m. and her blood pressure was 133/77 and her pulse 88. At 2:55 p.m. her blood increased to 159/109 and her pulse increased to 104. At 3 p.m. her blood pressure dropped significantly to 86/30 and her pulse was 100. There was no documentation that the patient's blood pressure was checked again prior to her discharge. The line after "Time of outpatient discharge" was blank.

2. A review of clinical records for Patients #9, #10, #11, #12, and #17 revealed they had outpatient endoscopic procedures. The preoperative nursing assessments did not include a complete list of all of the patients' current medications including the times they were last taken by the patients.

3. Patient # 11

Patient #11 had a colonoscopy on 09/04/2015. Documentation on the preop form revealed the patient had a history of diabetes for which she took two oral medications: Metformin and Glipizide. The patient reported having fluids at 5 a.m. that morning but had not eaten solid food for two days. The nurse's assessment did not include checking her blood sugars to establish a baseline.

Patient # 12

Patient #12 had a colonoscopy on 10/02/2015. Documentation on the preop form revealed the patient had a history of diabetes for which she took Metformin. There was no documentation that the RN checked her blood sugar to establish a baseline.

4. A review of the Endoscopy Post-Procedure Flowsheets for Patients #9, #10, #11, #12, and #17 revealed the following handwritten entry in the Nurses Notes section of the form: "Pt arrived via stretcher. Report received (sic) from intra RN. IV d/c'd (with) tip intact, pressure dressing applied. LOC x 3 - PO fluids taken (with*) difficulty. No crepitus noted." The rest of this line was blank in addition to the line after. The preprinted documentation continued on the next line: "Report given to vested adult, ambulated to restroom (with*) difficulty. Pt taken to POV (with*) difficulty. (Signature and title of RN.)" *It was noted that the RN used the symbol "c" with a line over it meaning "with" in areas of the documentation rather than the symbol "s" with a line over it meaning without.

For Patients #9, #10, #12, and #17 the RN documented on the blank lines in a darker color ink: "Pt shows no sign of distress and respirations even unlabored." There was no documentation on the blank lines for Patient #11.

The above records were reviewed with the Director of Nursing on 10/23/2015 and she acknowledged the above documentation had been preprinted which was not the hospital's standard of practice.

5. The Pharmacy policy on the subject of Medication Error Definitions included: "Medication errors are defined as the following: Wrong time: Failure to administer an ordered dose within 60 minutes of the scheduled administration time."

Patient # 5

Patient #5 had a physician's order dated 10/13/2015 for accuchecks (blood sugar testing) before each meal and at night and administration of Humalog insulin based on a sliding scale. A review of the MAR revealed no documentation of how much insulin the patient received based on the following fingersticks (FS):

-10/13/2015 at 9 p.m. the patient's FS was "299." The patient should have received 6 units of insulin.
-10/16/2015 at 2 p.m. the patient's FS was "288." The patient should have received 6 units of insulin.
-10/16/2015 at 7 p.m. the patient's FS was "202." The patient should have received 4 units of insulin.
-10/17/2015 at 6 a.m. the patient's FS was "198." The patient should have received 2 units of insulin.

A physician's order dated 10/15/2015 at 6:57 a.m., identified the patient was to receive 8 units of Humalog insulin before each meal. Documentation in the record revealed the patient did not receive that dose on 10/16/2015 at 11 a.m.

The physician orders on 10/15/2015 at 6:57 a.m. included checking the patient's blood sugars two hours after each meal. Documentation in the clinical record revealed the patient's blood sugar was checked at 7:14 p.m. after the supper meal, and it was "293" and the patient should have received 6 units of Humalog insulin at that time. However documentation in the MAR revealed the patient did not receive 6 units of insulin at that time. The RN documented over two hours later at 9:52 p.m. that the patient was given 4 units of insulin based on a second blood sugar of "221" obtained at that time. The reason for the late administration was not documented.

Patient # 7

Patient #7 had a physician's order dated 10/01/2015 at 12:30 p.m. for 10 units of Lantus insulin to be administered "NOW." Documentation in the patient's Medication Administration Record (MAR) revealed the medication was not given until 2:20 p.m., almost two hours later. There was no documentation as to why it was administered late.

The above clinical records were reviewed with the Director of Nursing who acknowledged the above medication errors.

6. Patient # 4

Patient #4 was admitted on 10/11/2015. A nursing Patient Anatomical Assessment Report dated 10/11/2015 at 1:05 a.m. revealed the patient had a "Stage 2 Ulcer" on his coccyx which measured "1-2-5 cm (centimeters)." The assessment dated 10/12/2015 at 7:29 a.m. revealed the measurement of the Stage 2 ulcer on the coccyx was "2-5-10 cm" which was twice the size as the first assessment. This assessment also revealed an "abrasion" on the patient's spine which measured "1-2-5 cm." There was no documentation of which part of the spine the "abrasion" was. The nursing staff continued to document the same measurements of the areas for the remainder of the patient's admission. The only change was the development of serous drainage to the area on the patient's spine that was documented in the assessment dated 10/13/2015 at 7:50 a.m.

The physician documented in the Admission History and Physical dated 10/11/2015 at 8:52 a.m. that the patient had a "Stage II on the coccyx, stage II on the mid back." The physician ordered "optifoam to mid back and bottom" daily.

There was a photograph of the patient's pressure ulcer which showed the location of the area to be the left sacrum rather than over his coccyx. The page had the patient's label with the admission date of 10/11/2015. There was no documentation of who took the photograph. There was no photograph of the area on the patient's spine.

The Director of Nursing stated during interviews that the hospital had no policies and procedures for wound care including identification, measuring, treating and documenting. She acknowledged the initial nursing assessment did not identify the area on the patient's spine and the discrepancy between the nursing staff documenting an "abrasion" on the patient's spine and the physician documenting a Stage II on the patient's spine. She also acknowledged the second measurement of the area on the patient's "coccyx" was twice the size of the first measurement.

Patient # 20

Patient #20 was admitted on 09/15/2015. A nursing note dated 09/15/2015 at 7:44 p.m. included: "Pt has nickel sized open area to L upper buttock, no drainage noted, appears to be stage 1 ulcer."

The nursing note dated 9/16/2015 at 8:48 p.m. included: ""Also noted to have breakdown to left buttock. Turned frequently and optifoam placed over breakdown."

The nursing documentation dated 9/10/2015 at 4:30 p.m. included: "Calmoseptine has been put on patients bottom."

A review of the physician orders revealed an order dated 09/20/2015 at 7:15 for Calmoseptine ointment to be applied topically as needed. The physician's order did not include where the ointment was to be applied. There was another physician's order dated 9/22/2015 at 4:52 p.m. for Nystop (Nystatin) powder to be applied topically three times a day, however, the order did not include where the powder was to be applied.

Documentation in the Medication Administration Record revealed the Nystop was applied three times a day on 9/22 and 9/23/2015, however, there was no documentation where or why the powder was being applied. There were no physician's order for the care and treatment of the patient's pressure sore.

Nursing Patient Anatomical Assessment Reports dated 9/16/2015 through 9/24/2015 referred to a Stage 2 ulcer on the patient's left buttock which measured "2-2-5 cm." There was no documented change to that measurement during that time. There was no documentation that the physician was made aware of the pressure ulcer, as the physician documented in his daily progress notes: "intact skin" and/or "skin appearance normal."

7. Patient #19 was admitted on 10/19/2015, with a diagnoses including seizure disorder and was discharged home on 10/26/2015. Documentation in the clinical record revealed the patient's home medications included the anticonvulsant medications, Keppra and Primidone, and the physician wrote orders to continue the medications during her admission. Primidone 100mg by mouth was scheduled to be administered every night at 9 p.m.

A review of the Medication Administration Records (MARs) revealed the medication was not administered during her entire admission, a total of seven missed doses. There was no documentation that the physician was notified that the medication was not available and not administered during her admission.

There was no documentation in the physician's daily progress notes that he was made aware of the medication not available for administration. The physician's daily progress notes included the following:

-10/20/2015: "Seizure...Controlled on medications."
-10/21/2015: "On medications continue to be seizure free."
-10/22/2015: "Continue to be seizure free, will resume medications, most likely the patients (sic) having the seizures at home secondary to noncompliant with medications."
-10/23, 24, 25/2015: "Continue to be seizure free with medications."

The physician's original Discharge Summary electronically signed at 9:37 a.m. on 10/26/2015 included: "Continue to be seizure free throughout the hospital course, as long as the patient on her antiseizure medications she will do well, we had a lengthy discussion with the (family member) for him to provide her with her medications, we also arranged for home health for medication management."

The patient's medical record was reviewed with the Director of Nursing (DON) on 10/26/2015 at approximately 8:30 a.m. The Director of Nursing acknowledged the patient did not receive the Primidone 100 mg during her admission and that there was no documentation that the physician was notified at any time during the admission that the medication was not available for administration.

Based on clinical record reviews, review of hospital policies and procedures and reports, and staff interviews, it was determined the hospital failed to ensure a periodic evaluation and quality assurance review was completed; which is a high potential risk of harm for patients if all negative outcomes and adverse occurrences related to patient care that have occurred are not addressed, and plans of care/processes revised when necessary.

Findings include

(C-337) Failure of the hospital to maintain a quality assurance program that evaluated care and services by hospital departments with services that affected patient care including Nursing Services and Pharmaceutical Services.

The cummulative effect of the systemic problem resulted in the hospital's inability to ensure the provision of quality heatlh care in a safe environment.

Based on clinical record reviews, review of policies and procedures, and staff interviews, it was determined the hospital failed to maintain a quality assurance program that evaluated care and services by hospital departments with services that affected patient care; which is a high potential risk of harm for patients if all negative outcomes and adverse occurrences related to patient care that have occurred are not addressed, and plans of care/processes revised when necessary.

Findings include:

The hospital's Quality Assurance and Quality Improvement Plan for 2015-12016 included: "Since patient care is a coordinated and collaborative effort, the approach to improving quality involves multiple departments and disciplines in developing, reviewing and revising the plans, processes and mechanisms that comprise the QA/QI activities at NCCH. The Quality Director, with support and approval from Administration, the Corporate Board of Directors, and Medical Staff, has the responsibility for monitoring every aspect of patient care in order to identify and resolve any breakdowns in systems that may result in sub-optimal care and safety, while striving to continuously improve and facilitate positive patient outcomes. Quality patient care is an expectation of all departments and managers are held accountable for improving the processes necessary to create a culture of quality.

A review of the hospital's 2015 Quality Assurance Indicators included indicators from each Department. There were numerous Departments that had not submitted their data for the past three or more months including: Facilities; Health Information Management; Human Resources; Plant Operations; and Materials Management.

The Director of Quality acknowledged her concern with missing data and stated she reminded the Departments but was not able to do any more than that.

The indicators for the Medical/Surgical Department (nursing) from January to current were "Refrigerator Temp Compliance" and "Code Cart Checks" for both shifts. There were no quality indicators that addressed the findings identified during this survey.

The Director of Quality was asked if she conducted any chart audits and she responded that she did not, as she did not understand that was part of her role as the Director of Quality. She reported she collected and reported data.

The Director of Nursing stated during an interview that she delegated chart audits on the medical/surgical unit to to the nursing supervisors. She stated the audits had not been done for the past few months because the clipboard with the audit tool had been lost.