HospitalInspections.org

Based on observation, interviews, and review of facility documents, the facility did not meet the Condition of Participation (CoP) for Patients Rights by failing to:

1) a. Ensure seven of 54 sampled patients (Patient 308, 309, 310, 311, 316, 407, and 409) received a Medical Decision Maker notice in a language the patient understood.
bemuse nine of 54 sampled patients (Patient 309, 310, 311, 316, 407, 409, 507, 508, and 509) received a Conditions of Admission notice and a Consent for Observation Services in a language the patient understood.
c. Ensure four of 54 sampled patients (Patient 310, 506, 508, and 511) received a Consent for Surgery, Special Diagnostic, or Therapeutic Procedures in a language the patient understood.
d. Ensure three of 54 sampled patients (Patient 312, 408, and 511) received a Consent to Blood Transfusion and Labor Pain Information Authorization in a language the patient understood.
e. Ensure one of 54 sampled patients (Patient 410) received registration for Observation Services and Anesthesia Consent in a language the patient understood.
f. Ensure one of 54 sampled patients (Patient 102) was offered and received Patient's Rights information at registration.
(Refer to A 117)

2) The facility failed to assess or reassess patient's pain, pre- or post medication administration for five out of 54 sampled patients (Patients 202, 303, 402, 403 and 405) in accordance with the facility policy and procedure.
(Refer to A 129)

3) a. Ensure an anesthesia services obtained the consent for one of 54 sampled patients (Patient 203) for a surgical procedure.
b. Ensure staff verified informed consent for one of 54 sampled patients (Patient 203) was provided before the administration of a blood transfusion.
c. Ensure four of 54 sampled patients (Patient 205, 206, 208, and 209) "Conditions of Amission" consents were fully completed before patients received medical treatment in the ED.
d. Ensure one of 54 sampled patients (Patient 103) authorization for consent to surgery consent was completed in the Obstetrics unit (OB) in the patient's preferred language.
e. Ensure eight of 54 sampled patients (Patient 500, 501, 502, 503, 507, 508, 509, and 511) had completed Consent to Anesthesia Services in various units.
(Refer to A 131)

4) a..Ensure three of 54 sampled patients (Patient 103, 202 and 203) were provided with follow up in regards to their advanced directive while in the ICU.
b. Ensure hospital provided Advanced Directives education to the community.
c. Ensure hospital provided Advanced Directive education to the staff.
(Refer to A 132)

5) a. When the infant/child security alarm system was not maintained for the entire unit housing infants and children.
b. When Patient 201 incurred skin (2nd to 3rd degree) burns to the abdomen after staff provided her with a non-commercial heating pack while receiving care in the hospital.
c. Fall precautions were not fully implemented for Patient 203 while receiving care in the ICU.
d. Patients 207 and 208 were not provided fall prevention interventions education while receiving care in the emergency department.
e. Patient 202's blood pressure was not monitored as required when Levophed (vasoconstrictor) medication drip was infusing in the ED and ICU.
(Refer to A 144)

The cumulative effect of these systemic problems resulted in the facility's failure to ensure the patient's right to a safe environment was provided.

Based on interview and record review, the hospital failed to:

1. a. Ensure seven of 54 sampled patients (Patient 308, 309, 310, 311, 316, 407, and 409) received a Medical Decision Maker notice in a language the patient understood.

b. Ensure nine of 54 sampled patients (Patient 309, 310, 311, and 316, 407, 409, 507, 508, and 509) received a Conditions of Admission notice and a Consent for Observation Services in a language the patients understood.

c. Ensure four of 54 sampled patients (Patient 310, 506, 508, and 511) received a Consent for Surgery, Special Diagnostic, or Therapeutic Procedures in a language the patients understood.

d. Ensure three of 54 sampled patients (Patient 312, 408 and 511) received a Consent to Blood Transfusion and Labor Pain Information Authorization in a language the patients understood.

2. Ensure one of 54 sampled patients (Patient 410) received registration for Observation Service and Anesthesia Consent in a language the patients understood.

3. Ensure one of 54 sampled patients (Patient 102) was offered and received Patient's Rights information at registration.

These failures had the potential to result in patients not understanding the consent that they gave.

Findings:

1. The facility policy and procedure titled, "Informed Consent" revised 1/2019, indicated in part... "Patient and surrogate decision-makers must be able to understand what they are being asked to authorize, whether it is agreement to the general terms and conditions of the hospitalization or to give informed consent for a surgical or other procedures. If there is a communication barrier, the hospital must arrange for communication in a language or mode that can be understood by the patient or surrogate decision-maker. Documentation of Interpreter: The person providing the interpretation shall enter a progress not indicating the date and time the interpretation services were provided and the general nature of the conversation. This note shall be signed. If the patient or surrogate decision-maker was asked to sign a consent form, the interpreter shall complete the interpreter certification on the form itself."

During record review and concurrent interviews with Admin 7, on 7/2/19, from 4:05 p.m., until 5:18 p.m., Admin 7 confirmed Patients 308, 309, 310, 311, 312, and 316 did not receive information in a language understood by them as indicated in their Electronic Health Record.


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1. During a record review and concurrent interview with Admin 10 on 7/2/19 from 4:15 PM to 5:15 PM, Admin 10 acknowledged that Patients 407,408 and 409 did not received the appropriate forms in their primary language as indicated in the electronic health records.

2. During record review and concurrent interview with Admin 10 on 7/2/10 at 5:10 PM, Admin 10 confirmed that Patient 410 received the registration for Observation Services and Anesthesia Consent in English while her other forms are in Spanish. The electronic health record indicated the primary language of the patient is Spanish.



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3. During a observation and interview with Patient 102, on 7/1/19, 11 a.m., Patient 102 and family members at bedside indicated that they did not receive copies of "patient's rights" prior to admission to hospital. After a brief search of room, family member stated, "No I don't think so."

During a interview with registration supervisor (Admin 9) on 7/1/19, starting at 11:10 a.m., while reviewing Patient 102 record, Admin 9 indicated Patient 102 came into the hospital via the emergency room, Stated, "She came through the ER, was probably given the opportunity to have copies of her patient's rights, conditions of admissions and information on advanced directives if the patient wants it, but they usually don't want to wait around for copies to be made." Admin 9 acknowledged the hospital has no way of knowing if Patient 102 actually was offered or received Patient's Rights information.

The hospital policy and procedure titled, "Conditions of Admissions Procedures" dated 10/9/18, was reviewed and procedures did not include offering patients copies of their admission documents inclusive of Patient Rights, Conditions of Admissions, Advanced Directives, Notice of Privacy Practices...




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1. During record review and concurrent interview with the Infection Control Nurse (ICN), on 7/2/19 at 5:00 P.M., she agreed that some medical records (Patient 506, 507, 508, 509, and 511) did not have appropriate consent forms in their preferred language, as indicated in their Electronic Health Record. She further stated, "all are in English and none in Spanish...I can't find anything."

Based in interview and record review the facility failed to assess or reassess patient's pain, pre- or post medication administration for five out of 54 sampled patients (Patients 202, 303, 402, 403 and 405) in accordance with the facility policy and procedure.

This facility failure has the potential for inadequate pain control for patient's 202, 303, 402, 403, and 405.

Findings:

The facility policy and procedure titled "Pain Management" dated 5/2017 indicated in part: Reassessment after the administration of medication to lessen pain should take place with the time frame consistent with the anticipated maximum effect of the medication:
Intravenous - 10-20 minutes
Subcutaneous or Intramuscular - 20-40 minutes
Oral - 30-60 minutes

During a record review, and concurrent interview Admin 7 on 7/2/19 at 8:25 a.m., the electronic health record indicated Patient 402 was given Norco 325/10mg 1 tablet by mouth every 6 hours as necessary for moderate pain on 6/27/19 at 9 p.m, 6/28/19 at 9 p.m., 6/30/19 at 5 p.m., and 7/2/19 at 6 a.m. Post pain medication reassessment was not documented. A medical surgical nurse (LN 5) acknowledged post pain medication was not done.

During a record review, and concurrent interview Admin 7 on 7/2/19 at 10 a.m., the electronic health record indicated Patient 403 was given Hydromorphone 0.2 mg intravenous push every two hours as necessary for severe pain on 6/30/19 at 5 PM. Post pain medication reassessment was not documented. Quality RN acknowledged post pain medication reassessment was not done.

During a record review, and concurrent interview Admin 7 on 7/2/19 at 11:10 a.m. electronic health record indicated Patient 405 was given Acetaminophen 325 mg by mouth every 4 hours as necessary for all levels of pain on 6/29/19 at 2 a.m. No post pain medication reassessment was documented. On 7/1/19 at 9 p.m. Patient 405 was given Tramadol 50 mg by mouth, no post pain medication reassessment was documented. Quality RN acknowledged post pain medication reassessments was not done.


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During a record review, and concurrent interview with Admin 6, on 7/2/19 at 9:52 am, of the Medication Administration Record, Patient 303 was given Ketorolac Injectable 30 mg intravenous push for moderate to severe pain on 7/1/19 at 4:20 p.m., no post pain medication reassessment was documented. Admin 6 confirmed post pain medication reassessment was not done.

During a record review for Patient 303 and concurrent interview with Admin 8, on 7/3/16, at 9:34 am, Admin 8 verified post pain medication reassessment was not done for Patient 303 on 7/1/19.

During a record review for Patient 303 and concurrent interview with LN 5, on 7/3/19, at 9:53 am, LN 5 confirmed post pain medication reassessment was not done for Patient 303 on 7/1/19.


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The hospital policy and procedure titled "Pain Management", dated 5/17, in part (2) (c.) (1) of the policy indicated "The comprehensive assessment should include ... the patient's impression as to the intensity of the pain, site (s), quality, (e.g. dull, sharp, throbbing, stabbing), radiation, onset (e.g. when did the pain start, is it increasing or decreasing), and sleep (e.g. does the pain interfere with your sleep or rest?) ..."

The hospital's "Patients Rights" document, dated 12/2016, indicated "You have the right to: 9. Appropriate assessment and management of your pain..."

During a review of Patient 202's pain assessment flowsheet in the E-record and concurrent interview with administrator (Admin 1) on 7/1/19 at 12:25 p.m., only the pain location and pain scale number was located in the pain flowsheet. Admin 1 was asked, if the pain location and number was a full pain assessment. Admin 1 attempted to click on various areas of the pain assessment flowsheet in attempts to locate more pain assessment elements. However, nothing was located. Admin 1 acknowledged this was not a full pain assessment. The "Pain Management", policy dated 5/17, was reviewed with Admin 1. According to the pain policy, there are more pain assessment elements e.g. quality, radiation ... Admin 1 acknowledged their P & P does not match their practice and what is being documented in the E-record. Admin stated "I agree; we need to add that (elements) on the flowsheet".

Based on observation, interview and record review, the hospital failed to:
1. Ensure an anesthesia services consent was obtained for one of 54 sampled patients (Patient 203) for a surgical procedure.
2. Ensure staff verified informed consent for one of 54 sampled patients (Patient 203) was provided before the administration of a blood transfusion.
3. Ensure four of 54 sampled patients (Patient 205, 206, 208, and 209) "Conditions of Admission" consents were fully completed before patients received medical treatment in the emergency department (ED).
4. Ensure one of 54 sampled patients (Patient 103) authorization for consent to surgery consent was completed in the Obstetrics unit (OB) in the patient's preferred language.
5. Ensure eight of 54 sampled patients (Patient 500, 501, 502, 503, 507, 508, 509, 511) had completed Consent to Anesthesia Services in various units.

These failures had the risk of patients making decisions without being fully informed.

Findings:

1. During a review of the clinical record for Patient 203, and concurrent interview with administrator (Admin 2) on 7/1/19 at 3:30 p.m.,the record indicated patient had a tracheostomy procedure on 7/1/19. Anesthesia services were provided to the patient during the surgical procedure. However, no anesthesia services consent form was located in the record. Admin 2 stated "No, anesthesia does not have a separate consent form, it's included with the surgical consent." The surgical consent form was reviewed. The consent form did not indicate the consent form was also for the anesthesia services provided to the patient.

On 7/3/19 at 9:15 a.m., the policy titled "Informed Consent", dated 1/19/ was reviewed with the Chief nurse officer (CNO) and Chief of quality (CQO) to understand the hospital's informed consent and consent process for anesthesia services. The CNO and CQO acknowledged and agreed there was no "Consent to Anesthesia Services" form or any evidence located in the record indicating patient had consented to the anesthesia services. The patient's consent for anesthesia services was not obtained prior to receiving anesthesia during the patient's surgical procedure on 7/1/19.

The hospital's policy and procedure titled "Informed Consent", dated 1/19, in the Informed Consent part of the policy indicated "The hospital's role in the informed consent process is to verify that the physician obtained the patient's informed consent before the physician is permitted to performed the procedure ..." In the Procedures That Require An Informed Consent part, indicated "Any procedure requiring anesthesia or sedation" informed consent must be obtained. In the Documenting Informed Consent part of the policy indicated "The doctor will complete the information (elements of informed consent) in the "Consent to ...or Special Procedure form. The form is completed in the hospital; a hospital staff member shall serve as the witness."

2. During an observation of Patient 203 in room 2, in ICU, on 7/1/19 at 2:15 pm., patient was observed receiving a unit of blood.

During a review of the clinical record for Patient 203 and concurrent interview with licensed nurse LN 2 on 7/1/19 at 2:48 p.m., a physician's (MD) order for a unit of (PRBCs) blood was located in the record. LN 2 was asked how nursing verifies if blood transfusion informed consent had been provided to patient. According to LN 2, the nurse calls the MD or the MD calls the nursing staff to notified them, if MD has provided informed consent to patient. If so, the nurse would document this in a nursing note. LN 2 navigated the Patient 203's record and was not able to locate the nursing note indicating, they (nurses) had verified the MD had provided informed consent to the patient for the blood. LN 2 attempted to locate in the MDs notes, if the MD had documented providing informed consent to patient. However, no note was found. LN 2 stated "No, I cannot find any MDs note where they documented informed consent for the blood was given."

During an interview with the administrator (Admin 1) and concurrent review of Patient 203's clinical record on 7/1/19 at 3:17 p.m., Admin 1 confirmed there was no documentation that the physician had provided informed consent for the blood transfusion and stated. "I don't see where they (MDs) documented they provided informed consent for the blood".

The hospital's policy and procedure titled "Informed Consent", dated 1/19, in the Informed Consent part of the policy indicated "The patient's physician is responsible for providing the information the patient needs in order to make an informed decision and for obtaining the patient's informed consent or refusal for the recommended procedure." In the Documenting Informed Consent part of the policy indicated "The patient's physician must document in the patient's record that he or she has conveyed the information required for an informed decision ...by writing a progress note in the patient's record."

3. The hospital's policy and procedure titled "Informed Consent", dated 1/19, in the Consent for General Medical Care part indicated "Consent is required for the general medical care provided to patient admitted to the hospital for inpatient or outpatient services, including services provided in the emergency department (ED).

The hospital's policy and procedure titled "Conditions of Admission (COA) Procedure", dated 10/9/18, in the Procedure part of the policy indicated "9. Have the patient sign and date, at the bottom of the form to accept the terms of the agreement. 10. The registration Rep. will sign and date as a witness."

During a review of Patients 205, 208 and 209 records and concurrent interview with the EDs registration representative (RR2) on 7/2/19 at 10:23 a.m., The conditions of admission (COAs) for Patients 205, 208, and 209 were observed not completed. The COA consent forms were missing the RRs signature and date. According to RR 2, she has the patients sign the COA consent form, takes the COA consent form back to the registration area, collects several patients COA forms in pile, she signs the COA forms at a later time and provide patients with a copy of the completed COA consent form. This was the reason Patient 205, 208, and 209's COA consent forms were not signed or witnessed and dated by her at the time the patient signed the COA form.

During an interview with Admin 1 on 7/2/19 at 10:35 a.m., the administrator was asked if what the ED RR 2 was doing was the correct manner of completing the COA consent forms. Admin 1 acknowledged and agreed the RR practice of completing the COA forms was not the correct manner. Admin 1 agreed the correct way to complete the COA consent forms was to ask the patient to sign the COA form, witness or sign the COA form at the time and provide a copy of the completed COA form to patient before patient received treatment in the ED.

During a review of Patient 206 record and concurrent interview with administrator (Admin 3) on 7/2/19 at 12:15 p.m., the record indicated no COA consent form had been completed for this patient. Admin 3 acknowledged and confirmed the COA consent form for this patient had not been completed at all.


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3. The hospital policy and procedure titled, "Informed Consent" dated 1/19, page 9 of 10, indicated in part... "Use of interpreter: If a consent is to be obtained from an individual who is not fluent in English, obtain services of a qualified interpreter. Use of a interpreter services is documented in the medical record. If the "consent to surgery or Special Procedure form has not been translated into the language the patient understands, the interpreter may translate the form orally and then document on form this has been completed. If the interpreter is not present, the nurse shall enter a note in the patients record indicating who provided the interpretation and the date and time. If a professional interpreter services, document service name and operator number in the space, translators name on the consent to surgery or special procedure form..."

During a observation on 1/2/19, starting at 10:30 a.m., in labor and delivery unit, room 4, Patient 103, was observed to be in bed, on her back, head of bed up in sitting position, holding a newborn baby. Identified family at bedside. Patient 103 indicated she did not speak English nor did family members.

During a interview with nurse manager (Admin 4) and concurrent medical record review of Patient 103's informed consents on 7/2/19, starting at 10:35 a.m., Admin 4 acknowledged that upon admission to hospital Patient 103 received conditions of admission in language of choice, Spanish. Admin 4 also acknowledged that Patient 104 signed a consent for "Primary Cesarean Section for breech presentation" consent written in English, Consent for "Application for Fetal Monitor," consent written in English. signed by patient "Key points to address safety use of PCA ( Patient controlled analgesia)" written in English and signed by Patient 103. Adm 4 reviewing doctor of record on consents, stated, " I know his partners speak Spanish but he does not." Further record review revealed that no use of interpreter services were documented in the chart, there was no nurses notes entered indicating a interpreter was used and no "space" on consent form for translators name as per policy and procedure. Adm 4 stated, "I have been working on this as a project (indicating consent process) in the OB area, not finished yet."







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4. During an interview with the Director of Perioperative Services (DPS), on 7/2/19 at 8:50 A.M., she stated that the current practice for Anesthesia Services is to fill out the Pre-Operative Anesthetic Evaluation form, where the Anesthesiologist relies on a statement printed on the form that says, "Consent: Patient/Parent understand and accept risk/alternatives/benefits of anesthetic plan. Informed consent given," and then provides a signature next to it. There is no patient/patient representative signature that confirms adherence to the anesthesia plan.

Review of the facility document titled, "Consent to Anesthesia Services," reveals the type of anesthesia used (offered and chosen), discusses the expected results/technique/risks, a place for the patient/patient representative signature with date and time, a place for the Anesthesiologist's signature, also with a date and time.

Clinical record reviews and concurrent interviews with the DPS and the Infection Control Nurse (ICN), on 7/2/19 at 9:10 A.M., indicated that Patient 500, 501, 502, and 503 did not have the Consent to Anesthesia Services form, but only had the Pre-Operative Anesthetic Evaluation form. The DPS and the ICN both agree that the two forms should be there for all patients undergoing procedures requiring anesthesia.

The facility policy and procedure titled "Informed Consent" revised 1/2019 indicated in part..."The patient's physician is responsible for providing the information the patient needs in order to make an informed decision and for obtaining the patient's informed consent or refusal for the recommended procedure...Specifically informed consent must be obtained for: any procedure requiring anesthesia or sedation."

Clinical record reviews and concurrent interview with the ICN, on 7/2/19 at 4:45 P.M., indicated that Patient 507, 508, 509, and 511 also did not have the Consent to Anesthesia Services form, and only had the Pre-Operative Anesthetic Evaluation form on the expanded patient sample. The ICN agrees that the Consent to Anesthesia Services form was missing on some records and states, "they should be consistently using this form..."

During an interview with the Chief of Quality (COQ) and the Chief Nursing Officer (CNO), on 7/3/19 at 9:15 A.M., they both stated that they will revise the form to reflect proper patient consenting. The CNO further states, "inconsistencies have been seen before and presented to the Anesthesia Committee...we gave examples on good consents based on professional standards, and will work on it."

Based on interview and record review, the hospital failed to:
1. Ensure two of 54 sampled patients (Patient 202 and 203) were provided with follow up in regards to their advanced directive (AD) while in the intensive care unit (ICU).
2. Ensure hospital provided Advanced Directives education to the community.
3. Ensure hospital provided Advanced Directive education to the staff.
4. Ensure one of 54 sampled patients (Patient 103) received follow up inquiry after receiving requested hospital information about advanced directives
These failures place patients at risk of not executing an advanced directive.

Findings:

1. During an interview with Patient 202 on 7/1/19 at 9:35 a.m., patient was asked if he had an advanced directive (AD). Patient indicated he had no advanced directive. He was provided with the AD form, told to complete the form and bring it back to the hospital. Furthermore, patient expressed not knowing what to do with the AD form or how to complete it and did not know who to reach out in the hospital to assists him with the AD form.

During an interview with Patient 203's family member (FM) on 7/1/19 at 2:35 p.m. FM was asked if Patient 203 had an advanced directive. FM explained mother did not have an AD. She was given an AD form upon admission to complete. However, they "had no idea what to do with the form."

During an interview with licensed nurse (LN 1) caring for Patient 202 in the ICU on 7/1/19 at 9:52 a.m., LN 1 indicated nursing does not ask patients regarding advanced directives because admissions takes care of this.

During an interview with the ED registration representative (RR 1) on 7/2/19 at 10:20 a.m. RR 1 explained patient presents to the ED registration desk, the conditions of admission COAs are provided. Patient is asked if they have an advanced directive, if patient says "No", patient gets an AD form to complete and to bring it to medical records. If patient says "Yes" they have an AD. Patients are not asked to bring a copy of their AD because medical records will follow up. RR 1 was asked again who follows up with patients to ensure they bring a copy of their AD or when patients are given a blank AD form to complete and bring to the hospital. RR 1 stated "Medical records follows up with patients in regards to their advanced directive."

During an interview with medical record director (MRD) on 7/2/19 at 10:23 a.m., MRD explained medical records staff does not follow up patients to the floor to obtain a copy of their advanced directive. Medical Records only gets the patient's AD copy upon discharge, assuming the patient brought in a copy of their AD and provided it to the nursing staff, while in the hospital. However, medical records personnel does not go up to the floors to request a copy of the AD or completed AD form.

During an interview with social worker (SW) on 7/2/19 at 11:47 p.m., SW was asked if she had follow up with patients 202 and 203 regarding the AD form given to them to complete or to see if they had any questions about this AD form. SW stated "I only follow up with patients, if the nursing staff notifies me that I need to see the patient." SW confirmed not following up with patients 202 and 203 in regards to the AD forms.

During an interview with the chief nurse officer (CNO) on 7/2/19 at 4:45 p.m., the current practice and the Advanced Directive policy and procedure, dated 1/19, were reviewed with the CNO. The CNO acknowledged and agreed the current practice is not a fluid process, there is a gap, there is no one responsible in the hospital to follow up with patients to ensure a copy of the AD "will be made part of the medical record" as indicated by the policy and procedure.

The hospital policy and procedure titled "Advanced Directive-Patient Self Determination Act", dated 1/19, in the policy part indicated "The Advanced Directive will be made part of the medical record."

2. During an interview with the chief of quality (COQ) on 7/3/19 at 11:50 a.m., the COQ was asked if the hospital had an outreach advanced directive education program for the community. The COQ stated "No, we don't have any community outreach program for Advanced directives ..."

During another interview with the COQ on 7/3/19 at 12:35 p.m., the COQ indicated the hospital used to have an online post on advanced directives. However, COQ confirmed again, that currently there is no advanced directive education outreach program for the community because the hospital does not have an admissions director.

3. During an interview with the COQ on 7/3/19 at 11:50 a.m., the COQ was asked if the hospital staff had been provided with advanced directive education. The COQ stated "I'm not sure. I need to check."

During another interview with the COQ on 7/3/19 at 12:35 p.m., the COQ was asked again regarding the advanced directive education for the staff. The COQ stated "I will continue to follow up on the staff advanced directive education."

During another interview with the COQ on 7/3/19 at 1:10 p.m., the COQ indicated Health Stream course, which was taken by staff upon hire and annually, contain advanced directive content. COQ was asked to provide a staff roster indicating every staff has taken the course (with date and time), as she indicated. Also to provide a staff roster with the names of the staff who are required to take the course in order to compare the Health stream education roster and the staff roster to make sure all the required staff have taken the AD education. The COQ stated "I'll check if we have it." The hospital was not able to provide requested documents or any evidence that staff had received AD education.


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Patient 103 was admitted to the hospital on 7/1/19, the demographic face sheet indicated Patient 103 received advanced directives information on 5/29/19. Further review of record did not indicate any follow up of Patient 103 health care directives.

During a interview and concurrent record review with Admin 4 on 7/2/19, starting at 10:30 a.m., while reviewing Patient 103's clinical record Admin 4 acknowledged that record did not contain any follow up on Patient 103's directives.

Based on observation, interview, and record review, the hospital failed to ensure patients received care in a safe setting when:

1. When the infant/child security alarm system was not maintained for the entire unit housing infants and children.
2. When Patient 201 incurred skin (2nd to 3rd degree) burns to the abdomen after staff provided her with a non-commercial heating pack while receiving care in the hospital.
3. Fall precautions were not fully implemented for Patient 203 while receiving care in the ICU.
4. Patients 207 and 208, were not provided fall prevention interventions education while receiving care in the emergency department.
5. Patient 202's blood pressure was not monitored as required when Levophed (vasoconstrictor) medication drip was infusing in the ED and ICU.

These failures created an unsafe hospital environment and had the potential to cause additional loss, injury or adverse consequences to patients.


Findings:

The facility policy and procedure titled, "Code Pink Procedure-Infant/Child Abduction Prevention and Response Plan" from 2019 safety manual, indicated in part,... "1. An infant proximity monitoring system is in place in the Labor and Delivery and Med/Surg Departments..." Under section titled, "Surveillance 1. Security manager is responsible for: initiating regular infant/child security rounds, checking maintenance of CCTV equipment, alarm systems and locks."

During a observation and concurrent interview with director of perinatal services ( Adm 4), on 7/1/19, starting at 9:55 a.m., rooms 242, 243, 244, 245, 246 and 247, were observed to be empty and outside of the established perinatal unit. Adm 4 indicated these rooms were utilized for both medical surgical and obstetric patients "overflow" when the established perinatal unit was filled to capacity. While testing the infant tag proximity monitoring system, the monitoring alarms leaving from these rooms revealed a significant delay of 52 seconds. A non keyed exit from these rooms did have access to corridors leading to exits to the outside. When describing the lack of alarms, Adm 4 stated, "The hospital went through a upgrade six days ago and new sensors were placed in the ceiling. We must have missed a spot, installation is not completed it will be done today."

During a interview with IT director (Adm 5), chief nursing director (CNO) and Adm 4 on 7/2/19, starting at 9 a.m., Adm 5 indicated there would be significant technical difficulties to get the overflow rooms security system in working order. Adm 5 stated, "Configuration was never put in place because the rooms involved were medical surgical beds." Both CNO and Adm 4 confirmed converted beds( from general acute to perinatal) had been utilized by the hospital and that State authority had not approved a change in licensed bed classification/services.

During a interview with corporate executive officer (CEO), on 7/2/19, starting at 9:45 a.m., CEO shared memo, dated 7/2/19, addressed to State agency indicating that rooms 242-247, would not be used for obstetric/post partum patients and newborns until the hospital receives licensing authority approval of request to change bed classification. CEO also acknowledged the need to repair and maintain infant security monitoring system prior to infants accessing over flow rooms.


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2. A review of the clinical record for Patient 201 was conducted on 7/2/19. According to the record, a patient was a 42-year-old female who was admitted to the hospital on 4/26/19 due to worsening abdominal pain associated with nausea and vomiting. Diagnosis included diabetic neuropathy (damage body nerves thus decreasing sensation or feeling on body area).

A review of the Nursing General Note, dated 4/27/19 at 5:31 a.m., indicated " ...CNA came and told me about a blister on the pt. stomach which was open, went in to assess, noted a hot pack made by a staff member laying on the bed near the area of the lower abdomen where the burns where... when assessing the skin noted 3 areas of blisters in the LLQ, one area which was open the pat had been scratching her stomach, the other 2 areas which are smaller are closed and intact, took picture .... When talking to the patient she stated she had requested 3 hot packs throughout the night between 9:00 p.m. -3:00 a.m., she think it came from the second one because the third one was too hot she had set it on the side of the bed ..."

A review of the Consultation Report (surgeon who assessed the burns) note, dated 4/27/19 at 9:05 p.m., indicated "Apparently on the evening of 4/26, the patient requested that one of the hospital staff provide her with heating pad because of the abdominal pain from apparently this was a heating pack that was heated in the microwave and sometime thereafter rechecked the patient, found that this heating pad had apparently created a burn on the abdominal wall as evidenced by blister formation."

During an interview with the chief nurse officer (CNO) on 7/2/19 at 3:44 p.m., the CNO explained the hospital does not have any commercial heating packs. When Patient 201 requested a heating pack, the staff made a heating pack (towels wrapped with chux) which was heated in the microwave and was given to the patient. The CNO was asked that if the hospital does not have heating packs and the patient request for heating packs, what was the nursing staff supposed to do. The CNO agreed the hospital, perhaps, needs to have something equivalent to a heating pack in order for staff to provide to patients when they request a heating pack. The CNO was asked if Patient 201 was keep safe and was cared in a safe setting while in the hospital. CNO agreed Patient 201 was not kept safe while in the hospital and the setting was not safe either because the patient incurred abdomen skin burns while being cared in the hospital.

3. During a record review of Patient 203, and concurrent interview with licensed nurse (LN 2) on 7/1/19 at 3:43 p.m., the safety E-record flowsheet indicated patient's fall risk score was 35. LN 2 explained patients get assessed for fall risk. If patient's score is >25, yellow non-skid socks and a yellow wrist band is applied to the patient, indicating patient is at risk for falls.

During on observation of Patient 203 while laying on her bed in the ICU and concurrent interview with licensed nurse (LN 4) on 7/1/19 at 3:45 p.m., Patient 203 was observed without a yellow fall wrist band. LN 4 confirmed there was no yellow wrist band on patient and stated "I'm going to put one yellow wrist band on now."

The hospital policy and procedure titled "Fall Prevention Program", date 7/16, indicated "Patients who score 25 or greater on the Morse Scale are consider "At Risk" for falls." In the Fall Prevention Interventions part of the policy indicated "2) At risk patient will have ... yellow arm band to serve as an identifier for the entire health care team."

4. During an observation and concurrent interview with patient in Room 9 (Patient 207) on 7/2/19 at 9:48 a.m., Patient 207 was observed wearing a yellow wrist band. Yellow socks were observed on the over-bed table. Patient 207 was asked, if she knew what the yellow color wrist band and socks meant. Patient did not know what the yellow color wrist band and socks meant. Patient was asked is staff had educated her on this. Patient reply "No".

A review of Patient 207's clinical record was conducted. The ED physician's note on 7/2/19 at 9:16 a.m., indicated "Patient is alert and oriented to self, place, month, day, year and reason for being in the ED."

During an observation, and concurrent interview with patient in Room 11 (Patient 208) on 7/2/19 at 9:50 a.m., patient was observed wearing a yellow color wrist band and socks. Patient did not know why she was wearing the yellow color socks and wrist band. Patient stated "The socks are on because my feet are cold. The wrist band I don't know." Patient was asked is staff educated her on this. Patient reply "No one has told me anything".

A review of Patient 208's clinical record was conducted. The ED triage note on 7/2/19 at 8:30 a.m., indicated patient was a good historian, no confusion, or forgetfulness.

The hospital policy and procedure titled "Fall Prevention Program", date 7/16, indicated "The patient and family will be educated on fall prevention interventions ..."

5. During a record review of Patient 202, and concurrent interview with licensed nurse (LN 1) on 7/1/19 at 11:18 a.m., the record indicated patient was started on Levophed (vasoconstrictor, used to treat life-threatening low blood pressure (B/P) (hypotension) that can occur with certain medical conditions) medication drip on 6/30/19 at 11:55 p.m., while in the ED, then, transfer to the ICU due to low blood pressure. LN 1 explained patients needed to be monitored closely by taking the B/Ps every 15 minutes and every 5 minutes when infusing and tiltrating Levophed medication drip to make sure the B/P does not drop suddenly. The vitals B/P flowsheet was reviewed with LN 1 who acknowledged the B/P s were not taken every 15 minutes as required, while Levophed was infusing .

During a review of the "Intravenous Vasoactive Medications" policy and procedure with administrator (Admin 1) on 7/1/19 at 11:18 a.m., Admin 1 acknowledged and agreed this was a patient safety issue for patient not be monitored as required.

The hospital policy and procedure titled "Intravenous Vasoactive Medications: Monitoring of Critical Care Services", dated 6/18, in the Procedure part of the policy indicated "5) Vital signs interval to a minimum of every 15 minutes and document vital signs in EMR. 6) Vital signs can be monitored more frequently during titration of medication to avoid unsafe fluctuations in blood pressure."

Based on interview and record review, the hospital failed to prioritize its performance improvement activities that: Focus on high-risk, high-volume, or problem prone areas; consider the incidence, prevalence, and severity of problems in those areas and affect health outcome ,patient safety and quality of care. The failure to ensure that specific QAPI program activities were met created the potential for persistent poor healthcare practices and placed patients at risk for harm.

Findings:

On 7/2/19, starting at 12 p.m., during an interview with the Quality Improvement Risk Management Director (COQ), stated she was in charge of data collection. QAPI is included in QI/RM. She indicated the Quality improvement data for performance improvement projects is collected monthly and presented to the Guidance Committee on a monthly basis. Review of 3 months random minutes ( October 2018, January 2019 and March 2019) did not reveal QAPI performance improvement project data available that tracked and trended data over time with sustainable performance improvement to patient care and safety. There were no reports or projects focused on skin integrity, consent completion, fall prevention or accurate required materials made available to patients in patient preferred language. A concurrent review of the Safety Committee for random pulled months of February 2019 and March 2019 did not reveal identification of infant security alarm monitoring concerns.

Based on record review and interview, the facility failed to ensure a Licensed Nurse (LN5), evaluated and notified the physician as indicated in the hospital's policy when one of 54 sampled patients (Patient 306) heart rate increased to 160 beats per minute.

This facility failure had the potential to result in a delay of the patient's care.

Findings:

Facility policy and procedure titled,"Physician Notification Regarding Change in Patient Condition-Guidelines" revised 1/14 indicated in part..."Purpose. To provide guidelines for all RNs to notify the primary physician of a change in patient status. Procedure. Identify the patient's primary physician and contact. Wait no longer than five minutes between attempts at notification. Documentation of notification will be in the Nursing Notes with the physician response, the action plan and the patient outcome from the intervention(s)."

During a record review and concurrent interview with the administrator (Admin 8), on 7/3/19, at 9:34 am, Admin 8 confirmed MD should be contacted as soon as RN noticed increase in Patient 306's heart rate.

During a record review and concurrent interview with licensed nurse (LN5), on 7/3/19, at 9:53 am, LN5 acknowledged that MD notification by RN should be done as soon as possible and was not done for Patient 306's change of condition.

During a record review and concurrent interview with Admin 6, on 7/3/19, at 10:06 am, Admin 6 confirmed that RN should have contacted MD as soon as possible by RN for Patient 306 and notification of MD was not done per policy.

Based on interview and record review, the facility failed to develop and update individualized, person-centered care plans for nine of 54 sampled patients (Patient 400, 402, 501, 502, 506, 507, 509, 510, and 511).

This facility failure has the potential to pose a risk of not providing appropriate, consistent, and individualized care to the patients.


Findings:

An interview and concurrent clinical record review with the Director of Perioperative Services (DPS), and the Infection Control Nurse (ICN), on 7/2/19 at 10:20 A.M. A.M., indicated that Patients 501 and 502 had similar care plans on pain and not person-centered. The DPS and the ICN both agree that the care plans are not customized according to each patient's needs.

An interview and concurrent record review of the expanded patient sample with the ICN, on 7/2/19 at 4:30 P.M., indicated that Patient 506, 507, 509, 510, and 511 also had similar care plans on pain. The ICN states, "They need to focus what's wrong and not just check the boxes...all I see are copy forward type of care plans."

The facility policy and procedure titled "Patient assessment, Reassessment and Care Planning" revised 2/2019, indicated in part..."Patients shall be assessed with a plan of care developed based on assessed needs," and "Care Plan: The initial assessment should lead to the development of a nursing care plan focused on the problems and issues identified."

The facility policy and procedure titled "Evaluation of Care Plan; Peri-Operative Services" revised 12/16, indicated in part..."Evaluation of nursing interventions prevents patient injuries and/or complications and provides for the continuity of care for each individualized patient."

The facility policy and procedure titled "Surgical Chart; Completion of" revised 7/16, indicated in part..."Each patient shall have an individualized plan of care that includes the collection and assessment of patient health data, relevant to the operative procedure."








39912



During record review and a concurrent interview with Admin 7 on 7/2/19 at 8:25 AM indicated Patients 400 and 402 have pain care plans that were very similar. The care plans for the two patients was not individualized to the patient's needs, location of the pain and interventions. The Quality RN acknowledged the care plan was not individualized and indicated they have the ability to customize the care plan but it was not done.

Based on observation, interview and record review, the hospital failed to ensure staff scan patient's wrist band prior to administering a Levophed (vasoconstrictor, used to treat life-threatening low blood pressure B/P (hypotension) that can occur with certain medical conditions) medication drip for one of 54 sampled patients (Patient 202) to match the medication order with the correct patient.

This failure place patient at risk of being administer the incorrect medication, since, no medication order and patient match safeguards were used.

During an observation of Patient 202's intravenous IV medication drips infusing on 7/1/19 at 9:48 a.m., while laying in bed inside room 1 in the ICU. A full bag of Levophed medication drip was observed infusing at 3 mcg/kg/min into patient's chest portal catheter.

During a review of Patient 202's electronic medication administration record (e-MAR) and concurrent interview with licensed nurse LN 1 on 7/1/19 at 10:39 a.m., the e-MAR did not show when the Levophed medication drip was hang/administer. According to LN 1, this morning she requested a bag of Levophed medication of 4mg/250ml dextrose and was hanged/administered at around 8:00 a.m., However, the medication bag was not scanned before it was hanged/administered, that's the reason the medication does not appear in the e-MAR. LN 1 was asked, if that was normal to hang/administer a medication drip without scanning it. LN 1 reply "No, normally we scan the levophed drip before we hang it. We will scan the new bag soon."

During an interview with chief nurse officer (CNO) on 7/3/19 at 9:40 a.m., the CNO was asked, if it was a normal practice to hang/administer medication drips prior to scanning the medication. The CNO acknowledged and agreed the medication must be scan prior to being administer/ hang by the nursing staff.

The hospital policy and procedure titled "KBMA: Knowledge Base Medication Administration", dated 7/18, indicated "3 Identify the patient. a) Open the barcode computer application icon from the eMAR. d) Scan the barcode on the patient's wristband. If the barcode is not scannable, obtain a new wristband from registration. Medications must not be administered without scanning patient's wristband except for emergent situations. e) Scan barcode of each medication to be administered to confirm "Match Made" appears"

Based on observation and interview, the facility failed to date labels on the intravenous tubing for three out of 54 sampled patients.(Patients 202, 300 and 400).

This facility failure has the potential for patients to develop an infection, if the tubing is not replaced according to the policy and procedure.

Findings:

The facility policy and procedure titled "Intravenous Central and Peripheral Catheter; Care and Maintenance", dated 11/2016 indicated in part: tubing and central line caps will be properly labeled with date, time and initial ... all other tubing will be changed every 72 hours.

During an observation and concurrent interview Admin 7 on 7/1/19 at 9:35 a.m., Patient 400's intravenous tubing was observed having no label indicating time, date and initials of the nurse. The Quality RN acknowledged tubing was not labeled.


35399

During an observation of Patient 202's unlabeled Vancomycin IVPB medication and Normal Saline 250 ml intravenous (IV) tubing and concurrent interview with licensed nurse (LN 1) on 7/1/19 at 12:45 p.m., the tubing was observed with no label with date of when the tubing needed to be changed. LN 1 acknowledged the observation and agreed the IV tubing needed to have a label indicating the date tubing needed to be changed , 72 hours after hanging the medication.

The hospital policy and procedure titled "Intravenous Central and Peripheral Catheter: Care and Maintenance", dated 11/1/6, in the Procedure (4) (a) part of the policy indicated "All tubing will be properly labeled with date/time/initial. 3) All other IV tubing will be changed every 72 hours."


40678


During an observation and concurrent interview with Admin 7, on 7/1/19, at 10 a.m., Patient 300's intravenous tubing was observed with no label indicting date, time, and initials of LN. Admin 7 confirmed intravenous tubing was not labeled.