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29800


Based on observation and interview the facility failed to provide patients in the emergency room "Fast Track" area a safe environment to receive care and treatment. The facility also failed to assure linen was handled in a manner that would avoid cross contamination with soiled linens.

The findings include:

1. During tour of a free standing building with signage of "Fast Track" on 2/21/11 at 12:30 p.m., observation was made that no wall oxygen or wall suction is available in the patient treatment area.

There was no visible sign of a fire sprinkler system in the free standing "Fast Track" building.

On 2/24/11 at 10:20 a.m. during tour of the exterior area of the hospital with Fire Life Safety personnel and the Director of Maintenance, the building designated as the emergency room Fast Track area was again visited and noted not to have a fire sprinkler system or fire alarm system connected to the main building/hospital. The Director of Maintenance confirmed the building is free standing and does not have connection to the main hospital building. Furthermore, it was confirmed that staff working in this area did not have call light access to the emergency department in the event of an emergent situation. The building did not have any patients or staff at the time of the visit.

Interview with the CEO and the Director of Maintenance at 10:50 a.m., on 2/24/11 confirmed the above findings. The Director of Maintenance also provided correspondence from Agency for Healthcare Administration (AHCA) Plans and Construction division which stated the free standing building was not healthcare construction.

During the 2/24/11 visit with Fire Life Safety staff, it was noted the posted hours of operation were 11:00 a.m., to 9:00 p.m., daily. The CEO and emergency room staff were in the process of removing all equipment from the building and changing the signage to have all patients screened and treated in the main emergency department of the hospital. The "Fast Track" building would be closed.

2. During the initial tour of the facility on 2/21/11 at 9:30 a.m., on the 3rd floor, an aide was observed gathering clean linen from the clean linen storage closet. The aide collected sheets and towels from the shelves and clutched them against her chest to exit the closet. Out in the corridor, the aide placed the clean linen on top of the soiled line bin and wheeled the bin to room 332. By the time the surveyor arrived at the room the aide had taken the clean linen from the top of the soiled linen bin into the patient room.

Based on staff interview, patient record review, and review of the hospital staffing grid and assignment records, the hospital failed to ensure the Intensive Care Unit (ICU) was staffed to meet the needs of 1 (Patient #9) 36 sampled patients.

The findings include:

1. Clinical record review for Patient #9 shows the patient was admitted to the hospital with diagnoses of rectal bleeding. The patient was admitted through the Emergency Department and subsequently transferred to the ICU due to a critically low Hemoglobin blood level.

After review of the record for Patient #9 on 2/22/11, a request was made for the staffing pattern for the Intensive Care Unit. Review of the staffing ICU staffing grid shows that, for a census of seven (7) or eight (8) patients, the unit is to be staffed with four (4) nurses and 0.5 Certified Nursing Assistants (CNA's).

On 12/26/10, Patient #9 had a physician order for a blood transfusion written at 1915 (7:15 p.m.) and the patient did not receive the transfusion until 2300 (11:00 p.m.). Review of the ICU staff assignments for 12/26/10 shows the patient census was eight (8) and three (3) nurses were assigned to the ICU. The assignment sheet showed that no CNA was assigned to the unit. Review of the hospital staffing grid showed that four (4) nurses and one half -time CNA should have been assigned to the unit.

On 12/28/10, the nursing assignment sheet shows three (3) nurses were assigned to care for eight (8) patients and no CNA is documented as being assigned to the unit. Clinical record reviews show that Patient #9 had another physician order to receive a blood transfusion. The physician order is dated 12/28/10 and timed as written at 12:30. On 12/28/10, Patient #9 did not receive the blood transfusion until 3:30 p.m. This was verified with laboratory staff on 2/24/11 at approximately 4:00 p.m.

2. During two separate interviews with hospital staff physicians, it was revealed that both physicians made comments related to short staffing of the units. One interview was with the chief of staff and the other was with a physician who also sits on the board.

Interview with the chief of staff on 2/24/11 revealed there are so many issues he has every day that he takes to the CEO's office. "Most of the issues could be avoided with adequate staffing." "Since this new crew has taken over, this seems to have been handled, I have fewer things on my list each day. Adequate staffing has been quite an issue."

Based on patient record review, a registered nurse did not properly supervise the accuchecks and failed to administer medication as prescribed by the physician in 4 (Patients #19, #20, #21, and #36) of 36 records reviewed.

The findings include:

Reviewing the medical records from 2/22/11 through 2/24/11 for Patients #19, #20, #21 and #36 revealed the accuchecks were either conducted at the wrong time or not at the time prescribed by the physician; thus the accuchecks and insulin were not administered in accordance to the patient meal time; and insulin doses were not given as prescribed by the physician.

It was also determined that for Patient #36, the wrong value was used to administer insulin on 2/17/11 at 9:51 p.m. The MAR (Medication Administration Record) records a BS (Blood Sugar) value of 243 with 6 units of insulin given. The glucometer printout in the lab records a BS value of 274 for 2/17/11 at 8:43 p.m. According to the sliding scale the patient should have received 8 units of insulin.

In summary, the nurse did not supervise the nursing care delivered to Patients #19, #20, #21 and #36.

Based on record review of Patient #36's Medication Administration Record (MAR) and nursing interview on 2/23/11, the patient was given an incorrect units of insulin in accordance to the prescribed insulin sliding scale.

The findings include:

On 2/17/11 at approximately 10:51 p.m., Patient #36 had a blood glucose (means the amount of sugar in the patient's blood) of 243 and was given 6 units of insulin. The printout from the lab established from the glucometer being 'docked' on the medical unit, indicates Patient #36 on 2/17/11 at 8:43 p.m., had a blood sugar of 274 indicating she received 8 units of insulin.

On 2/21/11 at approximately 9:27 p.m., Patient #36 had a blood glucose (means the amount of sugar in the patient's blood) of 260 and was given 6 units of insulin. The printout from the lab established from the glucometer being 'docked' on the medical unit, indicates Patient #36 on 2/21/11 at 7:56 p.m., had a blood sugar of 260 indicating she received 8 units of insulin.

In summary, on 2/17/11 and 2/21/11, Patient #36 did not receive the correct units of insulin in accordance to the prescribed insulin sliding scale.

On 2/23/11 at approximately 10:00 a.m., the registered nurse was interviewed and stated, "the time on the MAR is the time I gave the patient the insulin."

Based on medical record review and staff interview the facility failed to verify physician orders to ensure the correct drugs, dosages, and routes of administration are identified and delivered appropriately in accordance with regulations for 1 (Patient #27) of 36 patients sampled.

The findings include:

On 2/24/11 at 9:00 a.m., a joint review of Patient #27's medical record was conducted with the Chief Nursing Officer (CNO). The record review included the physician orders for 2/21/11. The physician order review revealed multiple orders for Potassium Chloride (KCL). The verbal physician orders revealed the potassium (K+) orders lacked the specified type of intervenous (IV) solution and some orders were not signed by the physician. The CNO verified the facility had not verified the incomplete orders by stating "Yes these should identify the type of solution and required clarification by pharmacy and nursing." The CNO continued by stating, "These orders should be signed by the physician." The following physician orders are documented in the physician order section of the medical record:

Patient #27 was admitted to the facility on 2/21/11 for diagnoses including (but not limited to) Diabetic Ketoacidosis, Shortness of Breath, and Acute Respiratory failure. The review of the documentation in the medical record reveals the patient is unable to maintain a stable Potassium (electrolyte) level, due to his diabetic status. The review of the medical record reveals the Standard Electrolyte Replacement Protocols dated 2/21/11 was signed by the physician on 2/22/11.

An interview with the Intensive Care Unit (ICU) nurse director was conducted on 2/24/11 at 10:00 a.m. To verify the protocol was crossed out, the nurse director was asked what the "X" through the components meant. The nurse stated, "I do not know why this is crossed out like this" (the potassium protocol orders).

The following physician orders are documented in the physician order section of the medical record:

2/21/11- 8:30 a.m.- KCL (Potassium Chloride) 20 meqs (Miliequivilants) / 100 cc (Milliliters) NSS (Normal Saline Solution X (times) 2 doses start now pt (patient) has CVP (Central Venous Pressure).

This indicates the patient has a central venous access line to measure central venous pressure. This order is not clear if the KCL is ordered to be delivered through this line.
2/21/11- 1240 (12:40 p.m.) - For K+ < 4.0 (Potassium level less than 4.0) give 2 runs /bags of KCL 20 meq in 100 ml (milliliter) 0.9 over 1 hour.

This order is documented as scanned to the pharmacy at 1410 (2:10 p.m.)
2/21/11- 1345 (1:45 p.m.) - For K+ of 2.6 give 2 runs of 20 meq KCL in 100 ml per previous K+ replacement order.
This verbal physician order is noted as faxed/scanned to the pharmacy at 1800 (6:00 p.m.) On 2/24/11 the physician order remained unsigned. This is over the 48 hour limit for physician order signature. The order does not identify the solution for dilution of the Potassium.
2/21/11 - 1625 (4:25 p.m.) For K+ of 2.5 give 2 runs of KCL 20 meq in 100 ml previous K+ replacement order.
This was scanned to pharmacy at 1700 (5:00 p.m.)
A review of the medical record on 2/24/11 at 10:00 a.m., reveals the physician had not signed this order.
The order refers to the previous K+ replacement order. During the nurse director interview the nurse commented that the 2/21/11 order at 08:30 a.m., noted normal saline solution, but the 1420 order documents may be in sterile water for injection. The nurse commented this could be confusing with the multiple potassium orders for this patient. The nurse continued by commenting this would be sent to the floor by the pharmacy and would be administered in the solution provided by pharmacy.

2/21/11-1825 (6:25 p.m.) For K+ of 3.6 give 2 runs of 20 meq KCL in 100 ml per previous order.
This verbal order was scanned to the pharmacy at 1825.
This order reviewed on 2/24/11 at 10:00 a.m. was not signed by the physician within 48 hours.2/21/11 2120 (9:20 p.m.) K+ = 3.2 give 20 meq KCL in 100 ml normal saline over 1 hour, repeat X 2 doses per previous order.
This verbal order was scanned to pharmacy at 2130 (9:30 p.m.) and remained unsigned signed by the physician during the 10:00 a.m. medical record review on 2/24/11.
Blood Potassium levels:2/21/11Order time 8:42 a.m. Draw time - 9:18 a.m. -Per an arterial blood sample- = 3.3 mmol/l (dilution of potassium per liter- Normal 3.6-5.2 mmol/l)Order time- 8:42 a.m. Draw time- 9:04 Received Time - 9:05 a.m. called TO THE ICU- 9:28 a.m. Venous sample = 3.1 mmol/l (Normal 3.5-5.1 mmol/l) Order time: 8:50 a.m. Draw time - 1307 (1:07 p.m.) Received time 13:08 Called to the ICU 13:4? (unable to read) = 2.6 mmol/lOrder time 9:57 a.m. Draw time 9:57 a.m. Received time 10:10 a.m. Called to ICU 10:2? (unable to read)Order Time 10:30 a.m. Per an Arterial blood sample= 2.6 mmol/lOrder time 10:24 a.m., Draw time 11:18 a.m. received 11:18 a.m. Called to ICU 12:11 p.m. Venous sample=3.3 mmol/lOrder Time 10:24 a.m. Received time 10:43 a.m. Arterial blood sample= 3.8 mmol/lPharmacy Medication Administration Record: Dated 2/21/11Verified 08:51 a.m. Potassium Chloride (via Central Line Only) 20 meqDose 20 meq IV (Intervenous) Every 1 hour
Dispensed [20 meq mEq per 100 ml over 1 hour Start date and time = 2/21/11 at 9:00 Stop date and time 02/21/2011 11:00 a.m. Administered: 10:55 Late reason :Per protocol According to the CNO, the ICU nurse director and pharmacist this does is for the 08:30 a.m. order.Potassium Chloride (Via central line only) 20 meqDose 40 MEQ IV as needed Dispensed: [ 20 mEq per 100 ml]*40 MEQ =200 ml *Each bag over 1 HR (hour) x 2 for K less than 4Last verified: 2/21/11 15:23 (3:23 p.m.) Administration Times:
16: 14 (4:14 p.m.)16:27 (4:27 p.m.)18:38 (6:38 p.m.) 2136 (9:36 p.m.)04:58 (4:58 a.m.) 2/22/11When asked the CNO was unable to determine which physician order was associated with the administration time. The CNO recommended the ICU nurse director be interviewed for clarification. The nurse director was interviewed at 10:00 a.m. After joint review of the medical record the nurse director stated, "I do not know why there is an administration at 4:14 p.m., and then at 4:27 p.m." When asked to identify the solutions used for potassium delivery the nurse director, reviewed the nursing notes, and was unable to determine the solution used for the IV delivery for all doses documented. When asked to match each order with the potassium dose administered the nurse director continued to review the medical record and stated, "I think he got all of his doses."
The multiple potassium orders documented as "previous order" lacks the clarity of the dose and diluent of the potassium administration.

Based on record review the facility failed to provide legible progress notes for 1 (Patient #22) of 36 patient records reviewed.


The finding include:

On 2/24/11, a review of the clinical record for Patient # 22 revealed a physicians progress note dated 12/22/10, time and contents of the progress note is not legible.

Physicians progress note dated 12/22/10 and timed at 9:15 p.m., also contained contents on the bottom portion that are not legible.

29800


Based on review of closed medical records, verbal orders were not authenticated within 48 hours by the ordering physician for 2 (Patients #22 and #27) of 36 patient records reviewed.

The findings include:

1. On 2/24/11, a review of physician's orders for Patient #22 dated 12/22/10 at 9:00 p.m., 12/23/10 at 12:20 a.m., and 12/23/10 at 12:45 a.m., revealed telephone (verbal) orders were not dated, timed, or authenticated by the physician as of this date.


2. During a medical record review conducted on 2/24/2011 at 10:00 a.m., the following verbal orders were not signed by the physician for Patient #27:A. 2/21/11-1825 (6:25 p.m.) For K+ (Potassium) of 3.6 (Lab value) give 2 runs of 20 meq KCL in 100 ml per previous order.This order, reviewed on 2/24/11 at 10:00 a.m., was not signed by the physician within 48 hours, and does not clarify the IV solution to add the K+ into.B. 2/21/11 2120 (9:20 p.m.) K+ = 3.2 give 20 meq KCL in 100 ml normal saline over 1 hour, repeat X 2 doses per previous order.This order was scanned to pharmacy at 2130 (9:30 p.m.)This order was not signed by the physician within 48 hours.

An interview with the Chief Nursing Officer at the time of review confirmed the orders required a physician signature within 48 hours. She stated, "These orders should be signed by the physician."

Based on staff interview and medical record review the facility failed to clarify physician orders and verify accuracy of the drug and drug dosage, route and frequency for 2 (Patients #14 and #27) of 36 patients sampled. The facility failed to adhere to the fundamental purpose of pharmaceutical services by not ensuring the safe and appropriate use of medications and medication-related devices.
The findings include:

1. Patient #14 was admitted to the hospital on 12/12/10. The patient's diagnoses included, but were not limited to, Seizures, Dehydration and Hypothyroidism. Review of the admission orders revealed that Synthroid 100 mcg. was to be given "ac" (before meals), however the frequency of administration was not documented. Review of the Medication Administration Record (MAR) for 12/13/10 and 12/14/10 also showed the order as "ac" and a note to clarify the frequency of the medication.

The MAR's for 12/13/10 and 12/14/10 show the Synthroid was not administered to the patient either day.

Interview with the pharmacist on 2/22/11 revealed that when the admission orders are not clear a note is written for clarification. The order gets clarified by the nurse notifying the doctor, or by the pharmacist who will notify the doctor. This patient was discharged on 12/14/10. The patient's discharge order included a prescription to decrease the Synthroid to 75 mcg. The patient did not receive the prescribed Synthroid on 12/13/10 and 12/14/10.

Synthroid is to be taken prior to meal in the a.m. as a daily medications (given once a day). *Mosby's Nursing Drug Reference 23rd Edition, 2010.
2. Patient #27 was admitted 2/21/11 for diagnoses including (but not limited to) Diabetic Ketoacidosis, Shortness of Breath, and Acute Respiratory failure. The review of the documentation in the medical record reveals the patient is unable to maintain a stable Potassium (electrolyte) level, due to his diabetic status. The review of the medical record reveals the Standard Electrolyte Replacement Protocols dated 2/21/11 was signed by the physician on 02/22/11. The Protocol had the following components crossed out with an "X".

An interview with the Intensive Care Unit (ICU) nurse director was conducted on 2/24/11 at 10:00 a.m. The nurse stated, "I do not know why this is crossed out like this." To verify the nurse director was asked what the "X" through these components meant. The nurse director commented those are crossed out and that means these are not to be used. The following Potassium physician orders were first reviewed with the Chief Nursing Officer (CNO) at 9:00 a.m. The CNO verified the orders were incomplete regarding the type of solutions and times for the administration of the Potassium, by stating "yes these should identify the type of solution and required clarification by pharmacy and nursing." The following physician orders are documented in the physician order section of the medical record:
2/21/11- 8:30 a.m.- KCL (Potassium Chloride) 20 meqs (Miliequivilants) / 100 cc (Milliliters) NSS (Normal Saline Solution X (times) 2 doses start now pt (patient) has CVP (Central Venous Pressure).
This indicates the patient has a central venous access line to measure central venous pressure. This order is not clear if the KCL is ordered to be delivered through this line. A physician order on 2/21/11 was received as a verbal order at 1345. The order does not identify the solution for dilution of the Potassium.
2/21/11 - 1625 (4:25 p.m.) For K+ of 2.5 give 2 runs of KCL 20 meq in 100 ml previous K+ replacement order. This was scanned to pharmacy at 1700 (5:00 p.m.)
A review of the medical record on 02/24/2011 at 10:00 a.m. reveals the order refers to the previous K+ replacement order. During the nurse director interview the nurse commented the 2/21/11 order at 8:30 a.m. noted normal saline solution, but the 1420 order documents may be in sterile water for injection. The nurse commented this could be confusing with the multiple potassium orders for this patient. The nurse continued by commenting this would be sent to the floor by the pharmacy and would be administered in the solution provided by pharmacy.
2/21/11-1825 (6:25 p.m.) For K+ of 3.6 give 2 runs of 20 meq KCL in 100 ml per previous order. This order does not identify the dilutant solution.
Pharmacy Medication Administration Record: Dated 2/21/11Verified 08:51 a.m. Potassium Chloride (via Central Line Only) 20 meqDose 20 meq IV (Intervenous) Every 1 hour
Dispensed [20 mEq per 100 ml over 1 hour Start date and time = 2/21/11 at 9:00 Stop date and time 2/21/11 11:00 a.m. Administered: 10:55 Late reason :Per protocol According to the nurse director the patient had a 4.9 mmol/l Potassium level. The nurse director commented the level and order should have been clarified prior to administration. According to the CNO, the ICU nurse director and pharmacist this dose is for the 08:30 a.m. order.Potassium Chloride (Via central line only) 20 meqDose 40 MEQ IV as needed Dispensed: [ 20 mEq per 100 ml]*40 MEQ =200 ml *Each bag over 1 HR (hour) x 2 for K less than 4Last verified: 2/21/11 15:23 (3:23 p.m.) Administration Times:
16: 14 (4:14 p.m.)16:27 (4:27 p.m.)18:38 (6:38 p.m.) 2136 (9:36 p.m.)04:58 (4:58 a.m.) 2/22/11When asked the CNO was unable to determine which physician order was associated with the administration time. The CNO recommended the ICU nurse director be interviewed for clarification. The nurse director was interviewed at 10:00 a.m. After joint review of the medical record the nurse director stated, "I do not know why there is a administration at 4:14 p.m. and then at 4:27 p.m." When asked to identify the solutions used for potassium delivery the nurse, reviewed the nursing notes, and was unable to determine the solution used for the IV delivery for all doses documented. When asked to match each order with the potassium dose administered the nurse director continued to review the medical record and stated "I think he got all of his doses."
The pharmacy medication administration record does not include the type of dilute solution the potassium was injected into for infusion.