HospitalInspections.org

Based on interview and medical record review, the facility failed to ensure that Patient 19, 22 and 23 received their patient rights in a language they could understand, and failed to ensure Patient 20 received his/her patient rights to know what telephone number to use to make a complaint, and to ensure Patient 17 both understood and received his/her " Important Message From Medicare About Your Rights " within two days of admission. The sample size was 23 patients and the census was 398 patients.

Findings include:
The medical record review for Patient 19 was completed on 03/14/12. The record review revealed the 68-year-old patient was admitted to the facility via the emergency room on 03/04/12 and that a history and physical dated 03/04/12 stated that the patient complained of abdominal pain for eight hours. On 03/12/12 at 12:20 PM in an interview, the patient denied receiving his/her patient rights. On 03/12/12 at 12:20 PM, Staff A looked in the patient's room and was unable to find a copy of the patient's rights.
The medical record review for Patient 22 was completed on 03/14/12. The record review revealed the 55-year-old patient was admitted to the facility on 02/24/12 with a diagnosis of perineal pain and rectal carcinoma. The record review revealed a surgical intensive care unit history and physical that stated the patient was " Spanish speaking only." On 03/12/12 at 12:45 PM, Patient 22 was interviewed. Through an interpreter, the patient stated that they had not received their patient rights in Spanish, but would like to have them. On 03/12/12 at 12:45 PM, Staff A was unable to locate the patient's rights in Spanish.
The medical record review for Patient 23 was completed on 03/14/12. The record review revealed the 23-year-old patient was admitted to the facility on 03/07/12 with a chief complaint of right tibia (leg) fracture and a history and physical that stated the patient was a "Hispanic speaking only male." On 03/12/12 at 4:10 PM, Patient 23 was interviewed. Patient 23 stated that they had received their rights in English, but not Spanish, and would like to have them in Spanish, which is their native language.
The medical record review for Patient 20 was completed on 03/14/12. The record review revealed that the patient was admitted to the hospital on 03/07/12 with a chief complaint of intractable vomiting. A history and physical dated 03/07/12 stated that the patient had a malignant gastrointestinal tumor with metastasis. On 03/13/12 at 9:20 AM, Patient 20, in an interview stated that they had only just received their patient rights that morning. The patient stated that they did have complaints that they wanted to make. The surveyor showed the patient the complaint phone numbers, including that of the state hotline, in the patient rights.
The medical record review for Patient 17 was completed on 03/14/12. The record review revealed the 84-year-old patient was admitted to the facility on 03/07/12 and a history and physical that stated the patient had a chief complaint of weakness and fatigue, having laid in the bed for about one week just prior to coming to the hospital. On 03/12/12 at 11:38 AM, the surveyor and Staff A visited the patient. Observed on the patient's bedside table was the " Important Message From Medicare About Your Rights." The form was noted to be signed by the patient. On 03/12/12 at 11:38 AM, in an interview, the patient said that they had just signed the form that morning, did not understand it and was going to have their neighbor explain it to them later that day when they visited. On 03/12/12 at 12:00 PM, Staff B stated the patient wasn't always coherent.

Based on interview and medical record review the facility failed to ensure Patient 12 and 14 had their advance directives included in their medical record in a timely fashion. The sample size was 23 patients, the census was 398 patients.

Findings include:
The medical record review for Patient 14 was completed on 03/14/12. The record review revealed that the patient was admitted to the hospital on 03/04/12 and a history and physical that stated the patient was admitted to the surgical intensive care unit after a repair for an abdominal aortic aneurysm. The history and physical stated that the patient was a resident of a nursing home and had been having abdominal pain overnight. The record review further revealed that on 03/04/12 at 3:50 PM, it was not known whether the patient had advance directives and what they were. The record further revealed a social worker note dated 03/14/12 at 11:48 AM, that stated "I had left a message for the (spouse) yesterday re: patient's Advance Directives." The note stated that they had met with the spouse and that the spouse would bring in advance directive documents. On the afternoon of 03/15/12, Staff A was unable to explain why the hospital had waited ten days to clarify the patient's advance directives.
The medical record review for Patient 12 was reviewed on 03/14/12. The reviewed revealed the patient was admitted to the facility on 03/03/12 via emergency department and a history and physical dated 03/03/12 at 7:07 PM that stated the patient had an intracranial hemorrhage, agonal breathing, and that there had had been a large shift of the brain inside the skull. The record review revealed a note dated 03/03/12 at 6:17 PM that stated the patient had a signed living will, but that it was not with the patient or on file. A social worker note dated 03/14/12 at 4:16 PM, stated that the spouse had brought in a hard copy of the advance directive. On the afternoon of 03/15/12, Staff A was unable to locate documentation where the hospital had reminded family to bring in the signed advance directives in the eleven days between 03/03/12 and 03/14/12.

Based on interview, medical record review and policy review the facility failed to ensure that the rhythm strips for Patient 13 and 14 were interpreted according to hospital policy. The sample size was 23 patients, the census was 398 patients.

Findings include:
The medical record review for Patient 14 was completed on 03/14/12. The record review revealed that the patient was admitted to the facility on 03/04/12 and had a history and physical that stated the patient was admitted to the surgical intensive care unit after a repair for an abdominal aortic aneurysm. The history and physical stated that the patients was a resident of a nursing home and had been experiencing abdominal pain overnight. Review of this surgical intensive care unit patient's cardiac rhythm strips revealed 7 instances where the "pr" interval, "QRS" duration and the "QT" interval were not documented. These instances occurred 03/09/12 at 7:39 PM, 03/10/12 at 12:10 AM, 03/08/12 at 8:00 AM, 03/08/12 at 4:00 PM, 03/07/12 at 12:30 PM, 03/07/12 at 6:00 PM, and 03/05/12 at 7:30 AM.
The medical record review for Patient 13 was completed on 03/14/12 and revealed that the 53-year-old patient was admitted to the hospital's surgical intensive care unit on 03/09/12. The record review revealed a history and physical that stated the patient's chief complaint was difficulty breathing and swallowing. The history and physical went on to state that the patient was noted to have severe airway edema with closed cords and had to be taken emergently to the operating room. Review of the patient's surgical intensive care unit cardiac rhythm strips, revealed 3 instances where the "PR" interval, "QRS" duration, and the "QT" interval were not documented. These instances occurred 03/09/12 at 7:48 AM, 03/10/12 at 12:13 AM and 03/10/12 at 7:48 AM.
Review of the hospital's routine care protocol for the surgical intensive care unit (R7.1) was completed on 03/14/12. The review revealed staff are to initiate continuous cardiac monitoring and "Record ECG rhythm strip every 8 hour shift, analyzing and documenting PR interval, QRS duration, QT interval and interpretation."
This was confirmed on the afternoon of 3/13/12 in an interview of Staff C who confirmed the lack of documentation per hospital policy.

Based on interview and medical record review, the hospital failed to ensure Patient 15 and Patient 16, both of whom were hospitalized for injuries sustained in suicidal attempts, had care plans created and implemented to address suicide ideation, and failed to address Patient 22's language barrier. The sample size was 23 patients, the census was 398.

Findings include:
The medical record review for Patient 15 was completed on 03/14/12 and revealed the 32-year-old patient was admitted to the facility on 03/06/12. The record review revealed a surgical intensive care unit history and physical dated 03/07/12 at 2:12 PM that stated the patient had thrown self from vehicle, ran into interstate traffic and was then struck by a vehicle traveling 50 mph. The history and physical further stated the patient told the first responders not to try to save them. The patient sustained multiple fractures to the vertebrae, legs and face. The record review revealed a social worker progress note dated 03/13/12 at 10:45 AM, that stated the patient's actions had been a suicide attempt and the patient had a mental health history of bipolar, schizoaffective disorder and borderline personality disorder. The record review did not reveal any care planning that addressed the patient's suicide gesture, nor evidence the patient's suicide ideation was assessed each day by staff.
The medical record review for Patient 16 was completed on 03/14/12. The record review revealed the 54-year-old patient was admitted on 03/05/12 and an adult psychiatric consult dated 03/06/12 at 9:36 AM, stated the patient was found unconscious under a bridge after an attempted suicide. The consult noted the patient had stated that they were surprised they had survived the fall, that the patient thought about suicide daily and the patient had told self to stop thinking about it and just do it. The record revealed a "suicide risk" care plan was in place to assess for evidence of suicide ideation. The record did not contain documented evidence the staff had asked the patient whether they had any thoughts of harming themselves with any purposeful frequency.
On the afternoon of 03/13/12, Staff D confirmed the lack of a suicide care plan for Patient 15, and a lack of a suicide care plan that was being followed for Patient 16.
The medical record review for Patient 22 was completed on 03/14/12 and revealed the 55-year-old patient was admitted to the facility on 02/24/12 with a diagnosis of perineal pain and rectal carcinoma. The record review revealed a surgical intensive care unit history and physical that stated the patient was " Spanish speaking only." On 03/12/12 at 12:55 PM the surveyor, Staff A and Staff E visited the patient. In an interview at that time, Staff E stated the patient gives signs to the nurses to communicate needs. The surveyor observed an empty box for a new telephone that has two handsets. (One handset is for the patient and one is for the clinician so a language service can translate via telephone.) However, the surveyor did not see the actual telephone in the room. On 03/12/12 at 12:55 PM in an interview, Staff E stated the actual phone was at the nursing station, not at the bedside and could not explain why.

Based on observation, medical record review and review of nursing standards committee meeting minutes, the hospital failed to construct a policy and a framework for nursing to differentiate between which medications were time-critical and which ones were not according to Federal guidelines issued 12/11. This has the potential to affect all 398 hospital patients.

Findings include:
The medical record review for Patient 18 was completed on 03/14/12, revealing that the patient was admitted on 03/06/12 for a gastrointestinal bleed. On 03/13/12 at 9:15 AM, the surveyor observed the patient receiving their medications. The surveyor observed the patient receive Lopressor, Carafat and Nexium. A dose of Lanoxin was given later at 9:22 AM. A review of the patient's medication administration record did not reveal where the medications were differentiated between those that are considered time-critical and those that are considered non-time-critical.
The medical record review for Patient 20 was completed on 03/14/12 and revealed that the patient was admitted to the hospital on 03/07/12 with a chief complaint of intractable vomiting. A history and physical dated 03/07/12 stated the patient had a malignant gastrointestinal tumor with metastasis. On 03/13/12 at 9:30 AM, the surveyor observed the patient receiving their medications. The surveyor observed the patient to receive two laxatives, Dexamethasone, Methadone and Zofran. A review of the patient's medication administration record did not reveal where the medications were differentiated between those that are considered time-critical and those that are considered non-time-critical.
Review of the meeting minutes for the Nursing Standards Committee was completed on 03/14/12. The review revealed that a meeting had taken place on 03/13/12. In the topic of new business, the Associate Director of Inpatient Pharmacy discussed which drugs are to be considered time-critical, and which are to be determined non-time critical. The minutes state the next meeting will be 04/10/12.
On the afternoon of 03/13/12 in an interview, Staff F and Staff G said a new policy has not yet been formulated to address the new regulations at 482.23(c). They stated the "30-minute rule" was still in place and they felt they were not out of compliance with the requirements. Staff F and G further stated when the Nursing Standards Committee completed the review of medications, the list would still need to go to the Pharmacy and Therapeutics Committee, the Medical Staff Committee, the Medical Executive Committee and then to the Board for final approval.