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Based on observation, interview, and record review, the facility failed to ensure that an infant warmer and other emergency supplies were ready for infant care. This failure had the potential for the facility not to be ready to provide infant care in case of an emergency.

Findings:

On 6/11/12 at 2:30 pm, a tour of the facility's storage room/shower area was conducted with the Emergency Department Supervisor (EDS). In the corner of the storage room behind multiple clean medical supplies was a covered infant warmer with supplies wrapped in sterile packages on the bottom shelf. There was a clip board with a document titled, "Check List" with the last entry dated 10/2006.

EDS stated that the infant warmer was checked monthly when the other emergency carts were checked. EDS acknowledged that there was no evidence that the Infant Warmer had been checked monthly for over five years. EMS stated that staff needed to document when the Infant Warmer was checked to ensure that it and other supplies were ready for use.

Based on observation, interview, and record review, the governing body failed to implement written policies for conscious sedation management (a depressed level of consciousness in which a patient is able to maintain a good airway and can be aroused by physical stimuli) for one of 20 sampled patients. A patient was given conscious sedation medications without immediate availability of the appropriate reversal (medication that stops an adverse drug reaction) medication, and was not monitored as required by the facility policy. (Patient 3) This failure had the potential to put the patient at risk resulting in injury or death.

Findings:

On 6/12/12, Patient 3's record was reviewed. Patient 3 was an inpatient and had wound care performed by the physician at the bedside on 5/7, 5/8 and 5/9/12. Patient 3's physician ordered Dilaudid (a narcotic pain medication) 2 milligrams (mg) and Versed (a moderate sedation medication) 2 mg intravenous (IV) each day before the wound care procedure.

The facility's policy titled, "High-Alert Medications", approved by the governing board on 1/26/12, was reviewed. The policy stated that "shall provide for the safe handling and administration of medications designated as High Alert Medications and will increase awareness of High Alert Medications, thereby improving patient safety." It defined high-alert medications as "drugs that bear a higher risk of causing significant patient harm when they are used in error." The medications listed in the policy as appropriate for inclusion included moderate sedation drugs, such as Versed.

The facility policy titled, "Sedation/Analgesia" (conscious sedation), dated 12/5/2005, page 2 read, "This policy applies to the care of patients receiving a specific level of sedation/analgesia in all hospital settings under the care of non-anesthesia providers...."

On Page 3, "Pre-sedation protocol" instructed the following:
"2 A. A pre-sedation assessment is required... and will be documented in the patient's medical record."

On Page 4, 3 A, "The patient must be informed about the risks and benefits and must consent to the proposed sedation plan. 3 B, Documentation of informed consent will be included in the medical record."

On Page 4 A. "Verification of NPO (nothing by mouth) status in adult patients shall occur before the start of sedation and analgesia and shall be NPO for at least 4 hours prior to the procedure unless the physician has weighed (considered) the benefits for a shorted NPO period and it is documented in the medical record."

On Page 5, "Equipment and Supplies" read, "Equipment must be available appropriate for the size of the adult before sedation and analgesia are given. Minimal equipment in the area of the sedated patient must included: 5. Reversal medications Narcan (for narcotic medications) and Romazicon (for Versed) readily available."

Also on Page 5, "Monitoring and documentation of the procedure," read,
A. Baseline vital signs shall be recorded in the sedation record (an untitled form) before administering sedation and analgesia.
B. During sedation vital signs shall be monitored and documented in the sedation record at 5-minute intervals: 1. Heart rate - continuous monitoring. (By ECG (heart monitor) for patients with cardiac or pulmonary disease or pulse oximeter in all other patients.) 2. Respiratory rate. 3. Oxygen saturation (SaO2) continuous monitoring. 4. Blood Pressure.
C. General Appearance and responses to stimuli (level of consciousness-LOC).

On Page 8, "Post-Procedure Management" included the following: 2 A. Monitoring - Vital signs including BP, heart rate, respiratory rate and oxygen saturation taken and documented at 15 minute intervals or more often if needed.

In Attachment A to the policy, titled, "Agents Commonly Used for Procedural Sedation" listed Versed "side effects as respiratory depression" and when given "IV the onset is 2-3 minutes and the duration is 30 minutes."

Another Attachment to the policy, untitled form that included the following: initial assessment pre procedure, check-list, procedure (medication time and dosages), vital sign every 5 minutes (time, pulse, respiration, BP, SaO2, and LOC. The physician and registered nurse's signature.

On 6/13/12 at 3:15 pm, during a concurrent interview and record review, Certified Registered Nurse Anesthetist (CRNA) E stated he would expect the monitoring to be the same for conscious sedation no matter whether it was given in the Operating Room, Emergency Department, or Nursing unit. CRNA E stated that the monitoring of the patient and documentation should be as written in the Sedation/Analgesia policy. CRNA E stated that it would be a beneficial for the nursing unit to have its own separate policy for giving conscious sedation medications.

In an observation and interview on 6/13/12 at 9:15 am, Pharmacy Nurse (PN) demonstrated how Versed was obtained from the Pyxis medication drawer. By the drug name there was a "BBW". PN stated that "BBW" stood for "Black Box Warning" and that drugs with a "BBW" had special instructions for use. PN stated that RN A would not have known what "BBW" meant or where to look for special instructions.

The next Pyxis screen before the nurse was able to sign the medication out of the Pyxis was a special instruction page, which was blank. PN stated that special instructions to the nurse are put on that page when medications had special concerns or procedures to follow before giving the medication. PN stated that the Pyxis system currently did not include instructions for giving Versed, and should be there to help the nurse know about special requirements for the use of a conscious sedation medication.

In an interview on 6/12/12 at 2 pm, RN A, an agency nurse (a temporary nurse hired from an outside source), stated that he had not received specific education or was aware of the facility's policy for conscious sedation. RN A stated that on the first day, 5/7/12, he had asked staff what he should do, and after that he did the same procedure on 5/8, and 5/9/12. RN A stated that when he obtained the conscious sedation medications (Versed and Dilaudid) from the Pyxis (automated drug dispensing cabinet) medication drawer, that Versed had a "BBW" next to the drug name. RN A stated that he did not know what "BBW" meant at the facility and continued to obtain and give the medication.

Following the interview on 6/12/12, RN A verified the following findings in Patient 3's record.
a. There was no documented pre procedural instructions, consent, and vital signs.
b. There was no documented vital signs and LOC every five minutes during the procedure.
c. There were no assessments documented following conscious sedation that included BP, pulse rate/rhythm, respirations, oxygen saturation, skin color, and LOC.
d. The untitled form for the conscious sedation procedure was not utilized on 5/7, 5/8, and 5/9/12.

On 6/13/12 at 12:30 pm, a concurrent interview and observation of the unit emergency cart with Administrator (Admin) was conducted. Admin confirmed that the emergency cart did not include Romazicon, the reversal medication for Versed. Admin confirmed that conscious sedation was given to an inpatient without the immediate availability of the reversal drug for Versed according to their policy.

In a interview on 6/12/12 3:40 pm, the Admin acknowledged the above findings and stated that the facility's policy had not been followed when Patient 3 was given conscious sedation as an inpatient, and that documentation did not show that Patient 3 was safely and appropriately monitored.

Based on observation, interview, and record review, the facility failed to ensure the provision of services were in accordance with appropriate policies and procedures and current standards of practice as evidenced by:

* Failure to implement policies for conscious sedation management (Refer to C 241)

* Failure to administer dispense and administer medications according to facility policy (Refer to C 276)

* Failure to ensure all staff followed current infection control practices (Refer to C 278)

* Failure to ensure all nursing staff were adequately trained (Refer to C 294)

* Failure to ensure all physician orders were written and followed according to facility policy (Refer to C 297)

The cumulative effect of these systemic problems resulted in the facility's inability to ensure the provision of services were in compliance with the statutorily mandated Condition of Participation: Provision of Services.

Based on observation, interview, and record review, the facility failed:

* To ensure that its "High-Alert Medications" policy regarding the dispensation and administration of Midazolam (Versed, a moderate sedation medication) was followed, for one of 20 patients. (Patient 3)

* To ensure that a Patient Controlled Analgesia (PCA) infusion was administered according to its policy for one of 20 patients. (Patient 15)

* To ensure that a Fentanyl (a narcotic pain medication) patch was administered according to its policy for one of 20 patients. (Patient 15)

These failures put the patients at risk for medication errors and/or adverse drug reactions involving serious injury and/or death.

Findings:

1. A review of Patient 3's record disclosed she had wound care performed by the physician at the bedside on 5/7, 5/8 and 5/9/12. Patient 3's physician ordered Dilaudid (a narcotic pain medication) 2 milligrams (mg) and Versed 2 mg intravenous (IV) each day before the wound care. (Refer to C 271)

The facility's policy titled, "High-Alert Medications," approved by the Governing Board on 1/26/12, was reviewed. The policy read, "shall provide for the safe handling and administration of medications designated as High Alert Medications and will increase awareness of High Alert Medications, thereby improving patient safety." It defined high-alert medications as "drugs that bear a higher risk of causing significant patient harm when they are used in error."

The medications listed in the policy, as appropriate for inclusion, included Versed, a medication that was used for moderate sedation (a depressed level of consciousness in which a patient is able to maintain a good airway and can be aroused by physical stimuli). Safety procedures during the preparation and dispensing of high-alert medications included, "For High Alert Medications, a reminder message appears on the dispense screen to alert the caregiver to the high alert status of the medication. Each pocket containing a High Alert Medications is also labeled to alert the caregiver. High Alert intravenous infusions are clearly labeled using a font readily distinguishable from the rest of the label, i.e. High Alert: Requires Double Check."

On 6/13/12 at 9:30 am, a concurrent observation of the Automatic Drug Dispensing Cabinet (Pyxis) and interview with Pharmacy Nurse PN, a nurse who managed the drug room, was conducted. The facility's "High Alert Medication" policy was also reviewed with PN. When PN entered the name of the medication, "Versed" into the Pyxis, a screen appeared with "BBW" next to Versed. PN stated that "BBW" meant, "black box warning." PN stated that there were no instructions in the Pyxis regarding what to do when "BBW" appeared and agency nurses (temporary nurses hired from an outside source) at the facility would not know what that meant. No additional instructions appeared on the Pyxis screen or on the medication bottle itself. PN stated that she had not seen the High Alert Medication policy until the day before on 6/12/12. As a result, the alerts that should have been programmed into the Pyxis, according to the policy, had not been done.

During an interview on 6/13/12 at 12:15 pm, the Administrator (Admin) stated she had posted the High Alert Medication policy at the nurses station as a means of informing the nurses of the information contained in it. Admin was unable to state which of the nursing staff had read the High Alert Medications policy.

2. A review of Patient 15's record disclosed that he was admitted on 2/29/12 with a broken leg. The physician's orders upon admission included PCA infusion of morphine (a narcotic pain reliever) to be monitored per standard PCA protocol.

The PCA flowsheet was provided by the Administrator in response to a request for the standard PCA protocol. It required the following documentation: baseline vital signs; pain scale, sedation level, and respiratory rate once per hour for eight hours then every four hours; total dose delivered every eight hours, and IV site check every eight hours.

On 6/12/12 at 5:20 pm during a concurrent record review and interview, the Administrator confirmed that the PCA flowsheet had not been started on 2/29/12 (at the time the medication was started) and the above necessary documentation had not been done.

3. A review of Patient 15's record disclosed that he was admitted on 2/29/12 with a broken leg. The physician's orders upon admission included a Fentanyl patch (narcotic pain reliever delivered topically).

The facility policy titled, "Fentanyl Patch Order Form," dated 11/8/11, was reviewed. It read as follows: "This form must be used to order a Fentanyl patch for any patient admitted to the facility." It then listed several boxes that could be checked by the physician to indicate that that the patient had been evaluated as opioid tolerant (patients who take narcotics on a daily basis). The following statement was written in bold type, "If none of the boxes above are checked, do not administer Fentanyl patch."

On 6/12/12 at 5:20 pm during a concurrent record review and interview, the Administrator confirmed that there was no "Fentanyl Patch Order Form" in the record and the form should have been completed before the Fentanyl was started.

Based on observation, interview, and record review, the facility failed to ensure that all staff followed infection control practices and the facility policy for cleaning the blood glucose monitor (BGM) after use. This failure has the potential to spread and infections to other patients.

Findings:

On 6/13/12 at 11:40 am during an observation, Licensed Nurse (LN) C performed a test to check Patient 5's blood sugar using the facility's BGM. LN C and return the BGM to the storage without cleaning it.

In an interview on 6/13/12 at 11:45 am, LN C stated that the BGM was not cleaned after each use, but it was cleaned each night by the night nurse.

A policy, dated 10/13/09, and titled, "Bedside Glucose Testing" instructed, "The glucose meter must be cleaned and disinfected after each patient test." A form titled, "Point of Care Testing, Maintenance Schedule and Protocol," instructed staff that with "each day of use, wipe meter with 10 % bleach pad or cloth after each patient test."

On 6/14/12 at 8 am, the Administrator stated that LN C had not followed the facility's policy when she failed to clean the BGM after patient use.

Based on observation, interview, and record review, the facility failed to ensure that nursing staff was adequately trained and knowledgeable about facility procedures when a registry (a temporary nurse hired from an outside source), Registered Nurse A (RN):
* Was unable to demonstrate the use of emergency equipment-a defibrillator (used to shock the heart to correct abnormal heart beat or restart the heart).
* Did not know the acronyms (a group of letters to represent words) used by the facility to identify a specific drug safety warning, "BBW" (black box warning).
* Administered intravenous (IV) conscious sedation (a depressed level of consciousness in which a patient is able to maintain a good airway and can be aroused by physical stimuli) medication without specific knowledge or education in the appropriate facility procedure to follow.

Findings:

1. On 6/11/12 at 11:35 am, RN A was asked to demonstrate testing of the inpatient unit crash cart defibrillator. RN A was unable to locate the switch to turn on the defibrillator or verbalize the appropriate steps to test if the defibrillator was working properly. Another nurse present demonstrated the use of the unit while RN A stood by.

2. On 6/13/12 at 5:10 pm, RN A stated that he had worked at the facility since 10/11. RN A stated he had observed during the medication pass to patients that many of the medications had "BBW" after the name of the drug. RN A stated he did not know the meaning of the acronym, "BBW" meant and had not asked other nurse what it meant.

In an concurrent observation and interview on 6/13/12 at 9:15 am, Pharmacy Nurse (PN) demonstrated how medications were obtained from the automated drug dispensing cabinet, Pyxis. PN stated that "BBW" stood for Black Box Warning and that medications with a "BBW" had special instructions for use in another binder. PN stated that RN A, an agency nurse, might not have known what "BBW" meant or where to look for special instructions.

3. On 6/12/12, Patient 3's record was reviewed. Patient 3 was an inpatient and had wound care performed by the physician at the bedside on 5/7, 5/8 and 5/9/12. Patient 3's physician ordered conscious sedation medications, Dilaudid (pain medication) 2 milligrams (mg), and Versed (sedative) 2 mg IV each day before the wound care procedure. The following were identified in the record and did not follow the facility's policy:
a. There was no documentation that pre procedural instructions were given or consent was obtained.
b. There was no documented assessment of blood pressure, pulse rate, respiration, temperature, skin sensation, level of consciousness immediately prior to administering conscious sedation, during, or following conscious sedation.

The policy, dated 12/5/2005, instructed nursing staff to obtain consent, pre-procedure vital signs, monitor the patient during and after the procedure, and to have emergency equipment and medication, Romazicon, available to reverse the side effects of Versed.

On 6/12/12 at 9:10 am, RN A stated that he was not aware that Versed was considered a conscious sedation medication when he had given the medication. He stated that he had not received specific training in the hospital procedure to use conscious sedation medication for inpatients. RN A confirmed documentation as required by the facility's policy was not completed.

Based on interview and record review, the facility failed to ensure that all verbal orders for medications were written in accordance with its policy for two of 20 sampled patients, and failed to ensure that all physicians' orders for intravenous (IV) fluids were followed as written for one of 20 sampled patients. This had the potential to result in medication errors and inaccurate treatment records. (Patients 11, 13, and 14).

Findings:

1. A review of Patient 11's Emergency Department record disclosed that she was seen on 3/2/12 for a complaint of chest pain. Some of the medication orders were written by the nurse as verbal orders from the physician. These medication orders did not contain "V.O." to signify that they were verbal orders, were not timed, and not signed by the nurse who wrote the orders.

During an interview on 6/11/12 at 5 pm, the Emergency Department (ED) Manager confirmed that the medication orders should have had "V.O." or verbal orders written next to them, as well as the time and signature of the person who took the verbal order from the physician.

2. A review of Patient 13's Emergency Department record disclosed that the patient was seen on 2/10/12 for a complaint of abdominal and chest pain. Some of the medication orders were written by the nurse as verbal orders from the physician. These medication orders did not contain "V.O." to signify that they were verbal orders, were not timed, and not signed by the nurse who wrote the orders.

During an interview on 6/12/12 at 8:50 am, the Administrator confirmed that the medication orders should have had "V.O." or verbal orders written next to them, as well as the time and signature of the person who took the verbal order from the physician.

A policy titled, "Medication Orders", last revised 6/11, was reviewed. It read as follows: "Verbal/telephone orders will be documented immediately on the Physician's Order sheet. Documentation of the order will include date, time, instructions, method obtained, and practitioner's name and signature of the person obtaining the order."

3. A review of Patient 14's Emergency Department record disclosed that she was seen on 5/2/12 for a complaint of abdominal pain. There was a physician's order to start an IV with fluids at a "to keep open" (TKO) rate (10 milliliters per hour). The nurse started a saline lock IV (IV that had been flushed but had no fluids infusing through it) instead of at the TKO rate.

During an interview on 6/12/12 at 9:35 am, the Administrator confirmed that the physician's order was for IV fluids at a TKO rate and the nurse instead started a saline lock IV.

Based on interview and record review, the facility failed to ensure that physicians wrote discharge summaries in a timely manner for two of 20 sampled patients and failed to accurately date and time each entry in one of 20 sampled patients. This had the potential to result in records not being completed in accordance with its policy. (Patients 2, 6, and 16)

Findings:

1. A review of Patient 16's record disclosed that he was admitted on 4/29/12 and expired on 5/5/12. The discharge summary was completed by the physician on 6/12/12, which was 38 days after Patient 16 had expired.

On 6/14/12 at 1:45 pm, the Health Information Management (HIM) Manager confirmed that according to the Medical Staff Rules, physicians must complete a patient's record 14 days after discharge. The HIM Manager confirmed that Patient 16 had expired on 5/5/12 but the discharge summary wasn't completed until 6/12/12.

The facility's Medical Staff Rules, last revised 5/27/10, were reviewed. It read as follows: "All clinical entries in the patient's medical record shall be accurately entered and authenticated to include the date and time. All inpatient charts are to include a discharge summary. The patient's medical record shall be completed at the time of discharge. . . When this it not possible . . . , the patient's chart will be available in the medical records department for 14 days."

The facility policy titled, "Chart Completion", last revised in 2007, read as follows: "Discharges must be completed within 14 days of discharge."



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2. A review of Patient 2's record disclosed the following issues:
a. Patient 2 was admitted to acute care on 4/27/12, and discharged on 5/1/12. The discharge summary from acute care on 5/1/12, was not signed by the physician, 42 days later.

b. Patient 2 was then admitted to a lower level of care on 5/1/12, and discharged from the facility on 5/3/12. The discharge summary from the lower level of care, dated 5/3/12, was dictated 19 days after discharge on 5/22/12 and unsigned.

On 6/12/12 at 3:55 pm, Health Information Assistant (HIA) stated that the above records were incomplete and that discharge summaries were to be completed within 14 days after discharge.

3. A review of Patient 6's record disclosed that Patient 6 underwent surgery on 8/25/11, and was later admitted as an inpatient on 8/26/12.

The following were identified in the record:
a. A document titled, "Frequent Vital Sign Record" included documentation of vital signs and was undated.
b. A Physician's Progress Note, dated 9/1/11 at 10 am, showed a "Delayed entry" without reference to the date that the entry was delayed.
c. A document titled, "Post Anesthesia Flow Sheet," dated 8/25/11, on page two, included a heart monitor strip that was incorrectly dated 9/25/11.

On 6/13/12 at 3 pm, HIA confirmed the above findings and that the record was incomplete and not accurately documented.

d. Verbal orders on a Physician's Order sheet was incorrectly dated 8/25/11 and untimed.
e. A document titled, "Notice to Patients in Observation Care" was undated and was signed by Patient 6.

On 6/14/12 at 1 pm, Registered Nurse (RN) B confirmed the above two findings. RN B stated that all verbal orders should include the time the nurse received the order and forms signed by the patient should be dated.

Based on interview and record review, the facility failed to review and revise all of its healthcare policies on an annual basis and failed to have the current Infection Control policy manual available for staff use. These failures had the potential to result in the use of out of date policies that were not consistent with the current standard of practice.

Findings:

The policy and procedure review forms and logs and the Governing Body minutes for the past 12 months were reviewed.

The Nursing Department, Surgery Department, Emergency Department (ED) and Imaging (Radiology) Department policy and procedure manuals were not reviewed in the past year.

1. During an interview on 6/14/12 at 12:20 pm, the Administrator confirmed that the Nursing Department manual was not current, and the sign off sheet that documented when it had last been approved by the Governing Body was missing.

2. During an interview on 6/14/12 at 12:45 pm, the Surgery Manager stated that the Surgery Department policy manual was waiting for final approval. The last Governing Board approval was dated 12/23/09.

3. During an interview on 6/14/12 at 12:55 pm, the ED Manager (EDM) stated that ED policies were waiting for final approval. The last Governing Board approval was dated 12/23/09.

4. During an interview on 6/14/12 at 1:10 pm, the Radiology Department Manager stated that the policies in his department were not current and needed to be reviewed and revised.

The policies and procedures log showed the policy committee had last approved the Radiology Department policy manual in 11/08. The date it was last approved by the Governing Board was left blank.

5. The Infection Control policies had been approved by the Governing Body within the past year; however, the current manual was not available for staff use.

During an interview on 6/11/12 at 5 pm, the Administrator confirmed that the Infection Control policy manual that was available for staff use was last approved by the Governing Body in 2009. The most current manual was "missing."