HospitalInspections.org

Based on staff and family interviews and medical record and policy and procedure review, the facility failed to ensure advanced directives concerns were promptly addressed for 1 of 8 sample patients (#5) who provided information regarding advanced directives at the time of admission. The findings were:

Interview with patient #5's family on 3/4/16 at 4 PM revealed the patient and family talked with the physician at the time of admission on 1/8/16 about the patient's wishes regarding the desire not to have a "do not intubate" order. The patient's family further stated they were upset when they later learned the physician had written the order in spite of their conversation with him. Review of the physician's 1/8/16 admission orders revealed an order for do not resuscitate and "short term intubation only." Interview on 4/7/16 at 2:20 PM with the regulatory compliance director revealed he did not have a clear understanding of "short term intubation only", nor did he know the care that was to be implemented to comply with this order. Review of the physician's order and nursing notes showed no efforts to clarify this order and address the family's specific concerns regarding this issue until 1/11/16 (3 days).

Review of the Patient Rights and Responsibilities policies and procedures, approved September 2014 showed the facility supports and facilitates patient and the patient's advocate, involvement in decisions about care, treatment and services provided.

Review of the Do Not Resuscitate/Do Not Intubate policy and procedure, that is currently in draft form and waiting for required departmental approval, revealed no definition or references to "short term intubation only."

Based on staff and family interview and policy and procedure review, the facility failed to respond the request for medical record information for 1 of 1 sample patient (#5) whose family made this request. The findings were:

Interview on 4/7/16 at 2:20 PM with the regulatory compliance director revealed the request for patient #5's medical record had been received and the copies were provided as requested. He stated some of the medical record information was in a different format when viewed in the database, but the basic information except the care plan was provided as requested. He stated the family reported to him on 2/12/16 that the medical record information was incomplete and he could not send additional information until 4/4/16. Interview with the family member on 4/15/16 at 3:45 PM revealed the medical record information provided by the facility was again incomplete.

Review of the policy and procedure titled "Patients' Rights and Responsibilities", approved September 2014, showed "Patients and their advocates have the right to access, request amendment to, and receive an accounting of disclosures regarding their health information as permission as permitted under applicable law. This also extends to the patient advocate."

Based on review of medical staff files and Medical Staff Rules and Regulations and staff interviews, the facility failed to ensure the medical staff rules and regulations were followed during the appointment and privileging process for 3 of 5 physicians (#1, #2, #3). The findings were:

Review of the Medical Staff Rules and Regulations, Section II., Procedure for Appointment/Reappointment, dated 11/20/13, revealed a requirement for the medical staff service manager to initiate the verification process. Further review revealed this verification process included verifying at least three references from persons who can provide adequate references pertaining to the practitioner's professional competence and ethical character. On 4/5/16 at 3:15 PM the credentialing and privileging files for a selected sample of physicians were reviewed with the credentialing specialist. This review revealed the following concerns:
a. Physicians #1, #2, and #3 were granted clinical privileges with their initial appointments without evidence of professional competency in the privileged categories.
b. The lack of evidence of professional competency was not noted by the medical staff services manager, departmental chairman, and credentials committee.
c. During an interview on 4/5/16 at 3:15 PM, the credentialing specialist stated the process required references from medical or healthcare professionals who have knowledge of the applicant's current clinical abilities. She further stated the three physicians had been granted clinical privileges without evidence of professional competence in the privileged categories because the required reference information was incomplete or missing.

Based on medical record review and staff and family interviews, it was determined the hospital failed to ensure nursing staff responded to changes in condition promptly, nursing assessments and medication administration documentation were accurate, blood pressure monitoring was provided as ordered, medications were administered and/or held according to the physician's orders, rationale for withholding physician ordered medications was documented, and patients were weighed as ordered. The facility further failed to ensure respiratory staff obtained a physician's order to administer treatment that required a physician's order (refer to A395). In addition, the facility failed to develop individualized care plans with measurable goals and effective intervention reassessments (refer to A396). The cumulative effects of the identified deficient practices resulted in a determination that the facility failed to meet the Nursing Services Condition of Participation.

Based on medical record review and staff and family interviews, the facility failed to ensure prompt responses to changes in condition, accurate documentation for nursing assessments and medication administration, medications were administered and/or held according to the physician's orders, rationale for withholding physician ordered medications was documented, and patients were weighed as ordered. The facility further failed to ensure respiratory staff obtained a physician's order to administer treatment that required a physician's order and staff provided blood pressure monitoring according to the physician's orders. These failures affected 2 of 8 sample patients (#3, #5). The findings were:

1. Review of the 1/8/16 physician's admission history and physical showed patient #5 was admitted to the hospital due to progressive difficulties breathing. This review showed diagnoses included acute chronic obstructive pulmonary disease exacerbation, severe end-stage chronic obstructive pulmonary disease, emphysema, severe pulmonary hypertension, acute bronchitis, and acute hypoxemic respiratory failure. On 4/4/16, the surveyor requested a copy of the entire medical record. A review of the copied information provided by the facility and interviews with the staff and family revealed the following concerns regarding the care provided for the patient when s/he experienced a change in condition:
a. The facility failed to ensure prompt response to changes in condition. According to the 1/12/16 nursing documentation, the patient received three separate doses of Ativan .5 mg, during a four and a half hour time period, for anxiety. The last dose was administered at 2:32 AM. The post anxiety assessment showed the patient was sleeping at 3:10 AM. At 4:09 AM the nurse completed a head to toe assessment and noted the patient's thready bilateral pedal pulses, the mottled/blue (mottling is expressly caused by vascular changes, it will occur if there are any changes to the blood vessels) coloring on the bottom of both feet, and rapid breathing. The changes had not been noted on the previous head to toe assessment completed at 12:15 AM. Review of the hourly rounds and additional documentation of events from 4:09 AM until 9:10 AM revealed a reassessment of the mottling condition was not done until 5 hours later at 9:10 and 9:48 AM. Review of the head to toe assessment completed at 9:48 AM revealed the patient had difficulty swallowing; the nurse was unable to evaluate the patient's orientation due to lethargy; and the patient's circulation was within normal limits. Review of the 1/12/16 nursing notes showed no documentation about reporting the mottling to the physician. Interview with ICU RN #1 on 4/4/16 at 3:30 PM revealed the standard of practice was to complete a head to toe assessment every four hours and usually the frequency increases when patients had a significant change in condition.
b. The facility failed to ensure nurses assessed changes in condition in a timely manner. Interview with the patient's family on 3/4/16 at 4 PM revealed the family received a call from physician #1 on 1/12/16 telling them the patient's condition had worsened. The family further stated they arrived that day at approximately 8:20 AM and noted the patient's lack of responsiveness. Interview with physician #1 on 4/7/16 at 4:30 PM revealed he did not remember calling the family on 1/12/16, but he remembered talking with the patient at 8 AM that morning. He further stated the patient was alert and responsive at that time. According to the documentation and assessments dated 1/12/16, the patient's lack of responsiveness had not been noted by the nursing staff until 9:10 AM. Interview with physician #2 on 4/7/16 at 5:30 PM revealed the patient's lethargy was as likely due to overall decline in condition as the Ativan. He further stated the medication for reversing the effects of the Ativan was not prescribed because it would have affected the patient's heart.
c. The facility failed to ensure accurate assessments. The Glasgow Coma Scale (GCS) contains three measurements: Eye, Verbal, and Motor function. Each measurement is assigned a score and the GCS is the total of the three scores combined. The minimum GCS score is 3 (completely unconscious) and the maximum is 15 (fully alert). Review of the the nursing assessments completed on 1/12/16 at 9:48 AM, noon, and 3 PM revealed the nurses were unable to evaluate the patient's orientation due to the decreased level of consciousness. Further review revealed the nurses used the GCS assessment tool and determined the GCS at 9:48 AM and noon was "15", and "13" at 3 PM. Interview on 4/8/16 at 9:25 AM with the VP of nursing services revealed the GCS assessments were not an accurate assessment of the patient's condition.
d. The facility failed to ensure accurate assessments. Review of the the nursing assessments completed on 1/12/16 at 9:48 AM, noon, and 3 PM revealed the nurses were unable to evaluate the patient's orientation due to the decreased level of consciousness. However, review of the 1/12/16 "all nursing" documentation showed the patient was able to perform all activities independently at 7:55 AM and 2:10 PM, including independent bathing, dressing, feeding and grooming. Interview with the regulatory compliance director on 4/7/16 at 2:30 PM revealed the documentation was not accurate, because the patient was dependent on staff to provide this care at that time.
e. The facility failed to ensure accurate medication administration documentation. Review of the 1/12/16 nursing notes showed the nurse administered an oral blood pressure medication, Metoprolol, at 9:53 AM. During an interview with the regulatory compliance director on 4/7/16 at 2:30 PM he acknowledged the documentation was not accurate because the patient could not swallow medications at that time.
f. The facility failed to ensure medications were administered and/or held according to the physician's orders. Review of the physician's orders, dated 1/10/16, showed an order for intravenous Metoprolol 5 mg every four hours as needed for pulse rate greater than 130. According to the nursing documentation, this medication was administered on 1/12/16 at 4:35 PM. Review of the documented pulse rates at the time the medication was administered was 96 to 107. Further review revealed no rationale for why the medication was administered at that time.
g. The facility failed to document a rationale for withholding physician ordered medication. Review of the 1/12/16 "All Medications" documentation and physician orders, showed a subcutaneous injection of Enoxaparin (used to treat or prevent blood clots and their complications) that was scheduled to be administered at 9 AM was not administered at the scheduled time, nor was there evidence it was administered at a later time that day. Further review revealed lack of a documented explanation or physician's order for the omitted medication.
h. The facility failed to ensure the patient was weighed as ordered. Review of the physician's 1/8/16 admission orders showed staff were directed to weigh the patient daily. Interview with the regulatory compliance directoron 4/7/16 at 2:30 PM revealed staff did not weigh the patient at any time during the inpatient stay, and he had no explanation for why this had not been done as ordered.
i. The facility failed to ensure respiratory staff obtained a physician's order to administer treatment that required a physician order. Review of the 1/12/16 nursing and respiratory notes showed the patient's BIPAP was replaced with Vapotherm (a non-invasive high-flow respiratory support system that uses a mixture of oxygen and air to deliver a set concentration via nasal cannula.) On 4/7/16 at 2:30 PM, the regulatory compliance director and director of pulmonary services verified this treatment required a physician's order, but none had been obtained.
j. During an interview on 4/8/16 at 9:30 AM, the director of regulatory compliance stated problems with late entry charting and the medical record computer software program were identified prior to the surveyor's arrival on 4/4/16, but additional concerns about inaccurate nursing assessments/documentation identified during the 4/4/16 to 4/8/16 complaint survey had not been identified or addressed.

2. Review of the 3/30/16 admission note for patient #3 showed s/he had diagnosis that included acute respiratory failure and hypertension. Review of the medication orders for the patient revealed the physician ordered Clonodine .1 mg every 4 hours as needed for blood pressures of above 150 systolic and above 90 diastolic. The following concerns were identified during review of the April 2016 medication administration record:
a. On 4/1/16 the patient's blood pressure was not checked from 9:30 AM to 4:44 PM (7 hours). Later at 6:42 PM the patient's blood pressure was 164/110 and Clonodine was administered as ordered. However, his/her blood pressure was not checked again until 5 hours later at 11:48 PM and it was 139/101.
b. On 4/2/16 at 6:33 PM, the patient's blood pressure was 152/97 and Clonodine was administered as ordered. However, his/her blood pressure was not checked again until 5 hours later at 11:41 PM and it was 139/94.
c. On 4/3/16 at 3:56 AM the patient's blood pressure was 152/109. The patient did not receive Clonidine for the elevated blood pressure until 5:16 AM.
d. During an interview on 4/8/16 at 10:15 AM, the VP of nursing services and director of regulatory services revealed the gaps between the blood pressure checks should have been less than 5 hours and the gap between the time of the blood pressure reading and medication administration should have been less than one hour and twenty minutes.

Based on medical record review and staff interview, the hospital failed to ensure care plans were developed and failed to ensure developed care plans were individualized, complete with measurable goals, and periodically evaluated for 4 of 8 sample patients (#1, #2, #3, #5). The findings were:

1. Review of the medical record showed patient #1 was an inpatient from 3/30/16 to 4/6/16. Further review revealed staff did not develop a care plan for this patient.

2. Review of the medical record showed patient #2 was an inpatient from 4/1/16 to 4/4/16. Further review revealed staff did not develop a care plan for this patient.

3. Review of the medical record showed #3 was an inpatient from 3/30/16 to 4/5/16. Review of the care plan showed identified problems included impaired gas exchange, at risk for falls and activity intolerance. Further review revealed goals and periodic evaluations were lacking; and interventions were unclear and not individualized.

4. Review of the medical record showed patient #5 was an inpatient from 1/8/16 to 1/14/16. Review of the care plan showed identified problems included impaired gas exchange, alteration in nutrition, anxiety, and ineffective breathing pattern. Further review revealed goals and periodic evaluations were lacking; and interventions were unclear.

5. During an interview on 4/8/16 at 10:15 AM, the CNO and quality director revealed staff did not consistently develop care plans for all patients. They further acknowledged the care plans patients #3 and #4 were not individualized, complete with measurable goals, and periodically evaluated.

6. Review of Smith, Duell, and Martin, "Clinical Nursing Skills," Seventh Edition, 2012, Chapter 3, "Managing Client Care" showed, "...care plans are an integral part of providing nursing care. Without them, quality and consistency of client care may not be obtained."

Based on medical record review and staff and family interviews, the facility failed to ensure prompt responses to changes in condition, accurate documentation for nursing assessments and medication administration, medications were administered and/or held according to the physician's orders, rationale for withholding physician ordered medications was documented, and patients were weighed as ordered. The facility further failed to ensure respiratory staff obtained a physician's order to administer treatment that required a physician's order and staff provided blood pressure monitoring according to the physician's orders. These failures affected 2 of 8 sample patients (#3, #5). The findings were:

1. Review of the 1/8/16 physician's admission history and physical showed patient #5 was admitted to the hospital due to progressive difficulties breathing. This review showed diagnoses included acute chronic obstructive pulmonary disease exacerbation, severe end-stage chronic obstructive pulmonary disease, emphysema, severe pulmonary hypertension, acute bronchitis, and acute hypoxemic respiratory failure. On 4/4/16, the surveyor requested a copy of the entire medical record. A review of the copied information provided by the facility and interviews with the staff and family revealed the following concerns regarding the care provided for the patient when s/he experienced a change in condition:
a. The facility failed to ensure prompt response to changes in condition. According to the 1/12/16 nursing documentation, the patient received three separate doses of Ativan .5 mg, during a four and a half hour time period, for anxiety. The last dose was administered at 2:32 AM. The post anxiety assessment showed the patient was sleeping at 3:10 AM. At 4:09 AM the nurse completed a head to toe assessment and noted the patient's thready bilateral pedal pulses, the mottled/blue (mottling is expressly caused by vascular changes, it will occur if there are any changes to the blood vessels) coloring on the bottom of both feet, and rapid breathing. The changes had not been noted on the previous head to toe assessment completed at 12:15 AM. Review of the hourly rounds and additional documentation of events from 4:09 AM until 9:10 AM revealed a reassessment of the mottling condition was not done until 5 hours later at 9:10 and 9:48 AM. Review of the head to toe assessment completed at 9:48 AM revealed the patient had difficulty swallowing; the nurse was unable to evaluate the patient's orientation due to lethargy; and the patient's circulation was within normal limits. Review of the 1/12/16 nursing notes showed no documentation about reporting the mottling to the physician. Interview with ICU RN #1 on 4/4/16 at 3:30 PM revealed the standard of practice was to complete a head to toe assessment every four hours and usually the frequency increases when patients had a significant change in condition.
b. The facility failed to ensure nurses assessed changes in condition in a timely manner. Interview with the patient's family on 3/4/16 at 4 PM revealed the family received a call from physician #1 on 1/12/16 telling them the patient's condition had worsened. The family further stated they arrived that day at approximately 8:20 AM and noted the patient's lack of responsiveness. Interview with physician #1 on 4/7/16 at 4:30 PM revealed he did not remember calling the family on 1/12/16, but he remembered talking with the patient at 8 AM that morning. He further stated the patient was alert and responsive at that time. According to the documentation and assessments dated 1/12/16, the patient's lack of responsiveness had not been noted by the nursing staff until 9:10 AM. Interview with physician #2 on 4/7/16 at 5:30 PM revealed the patient's lethargy was as likely due to overall decline in condition as the Ativan. He further stated the medication for reversing the effects of the Ativan was not prescribed because it would have affected the patient's heart.
c. The facility failed to ensure accurate assessments. The Glasgow Coma Scale (GCS) contains three measurements: Eye, Verbal, and Motor function. Each measurement is assigned a score and the GCS is the total of the three scores combined. The minimum GCS score is 3 (completely unconscious) and the maximum is 15 (fully alert). Review of the the nursing assessments completed on 1/12/16 at 9:48 AM, noon, and 3 PM revealed the nurses were unable to evaluate the patient's orientation due to the decreased level of consciousness. Further review revealed the nurses used the GCS assessment tool and determined the GCS at 9:48 AM and noon was "15", and "13" at 3 PM. Interview on 4/8/16 at 9:25 AM with the VP of nursing services revealed the GCS assessments were not an accurate assessment of the patient's condition.
d. The facility failed to ensure accurate assessments. Review of the the nursing assessments completed on 1/12/16 at 9:48 AM, noon, and 3 PM revealed the nurses were unable to evaluate the patient's orientation due to the decreased level of consciousness. However, review of the 1/12/16 "all nursing" documentation showed the patient was able to perform all activities independently at 7:55 AM and 2:10 PM, including independent bathing, dressing, feeding and grooming. Interview with the regulatory compliance director on 4/7/16 at 2:30 PM revealed the documentation was not accurate, because the patient was dependent on staff to provide this care at that time.
e. The facility failed to ensure accurate medication administration documentation. Review of the 1/12/16 nursing notes showed the nurse administered an oral blood pressure medication, Metoprolol, at 9:53 AM. During an interview with the regulatory compliance director on 4/7/16 at 2:30 PM he acknowledged the documentation was not accurate because the patient could not swallow medications at that time.
f. The facility failed to ensure medications were administered and/or held according to the physician's orders. Review of the physician's orders, dated 1/10/16, showed an order for intravenous Metoprolol 5 mg every four hours as needed for pulse rate greater than 130. According to the nursing documentation, this medication was administered on 1/12/16 at 4:35 PM. Review of the documented pulse rates at the time the medication was administered was 96 to 107. Further review revealed no rationale for why the medication was administered at that time.
g. The facility failed to document a rationale for withholding physician ordered medication. Review of the 1/12/16 "All Medications" documentation and physician orders, showed a subcutaneous injection of Enoxaparin (used to treat or prevent blood clots and their complications) that was scheduled to be administered at 9 AM was not administered at the scheduled time, nor was there evidence it was administered at a later time that day. Further review revealed lack of a documented explanation or physician's order for the omitted medication.
h. The facility failed to ensure the patient was weighed as ordered. Review of the physician's 1/8/16 admission orders showed staff were directed to weigh the patient daily. Interview with the regulatory compliance directoron 4/7/16 at 2:30 PM revealed staff did not weigh the patient at any time during the inpatient stay, and he had no explanation for why this had not been done as ordered.
i. The facility failed to ensure respiratory staff obtained a physician's order to administer treatment that required a physician order. Review of the 1/12/16 nursing and respiratory notes showed the patient's BIPAP was replaced with Vapotherm (a non-invasive high-flow respiratory support system that uses a mixture of oxygen and air to deliver a set concentration via nasal cannula.) On 4/7/16 at 2:30 PM, the regulatory compliance director and director of pulmonary services verified this treatment required a physician's order, but none had been obtained.
j. During an interview on 4/8/16 at 9:30 AM, the director of regulatory compliance stated problems with late entry cha