HospitalInspections.org

Based on record review and interview, the hospital failed to inform the patient their grievance investigation will not be completed within 7 days and the hospital continues to work on resolving their grievance for 3 out of 3 (#R1, #R2, #R3) grievances reviewed. Findings:

Review of the hospital's policy titled, Patient Grievance Rights and Grievance Resolution, revealed in part, 3. If the grievance is so complicated that it requires an extensive investigation, Sterling Surgical Hospital shall inform the patient or the patient's representative that the hospital is still working to resolve the grievance and will follow-up with a written response within 30 days.

Review of the hospital's grievance log for R#1's grievance revealed the grievance was received on 2/17/2021. There was no evidence the patient was notified the grievance investigation would take longer than 7 days. A letter was documented as sent to the patient on 03/17/2021.

Review of the hospital's grievance log for R#2's grievance revealed the grievance was received on 07/10/2020. There was no evidence the patient was notified the grievance investigation would take longer than 7 days. A letter was documented as sent to the patient on 08/04/2020.

Review of the hospital's grievance log for R#3's grievance revealed the grievance was received on 12/12/2020. There was no evidence the patient was notified the grievance investigation would take longer than 7 days. A letter was documented as sent to the patient on 01/05/2021.

An interview was conducted with S5Patient Advocate on 05/25/2021 at 3:00 p.m. She reported R#1, R#2, and R#3 were not notified the grievance investigation would take longer than 7 days to complete.

Based on record review and interview, the hospital's Governing Body failed to ensure the QAPI program reflected the complexity of the hospital's services as evidenced by failing to include all hospital services in the QAPI program. This deficient practice was evident by failing to include Dietary and Food Services in the hospital's QAPI program.
Findings:

Review of the current QAPI program revealed no quality indicators for Dietary and Food Services.

An interview was conducted with S2IC on 05/26/2021 at 11:30 a.m. S2IC reported she was contracted to assist with the hospital's quality assurance program. S2IC confirmed dietary and food services were not involved in the hospital's QA program prior to October 2020 and she was currently working on a plan to formalize the food and dietary services in the quality assurance program.

Based on record reviews and interviews, the DON and hospital failed to ensure the RNs and Surgery Technicians assigned the care of the patients had skill competencies. This deficient practice was evidenced by 3 out 3 (S3RN, S8RN and S7Surg Tech) personnel records reviewed for competencies failed to have documented evidence of their evaluation of competency. Findings:

Review of the Hospital's policy titled, Competency Assessment and Maintenance, revealed in part, Purpose: To provide guideline for assessing the competency of all hospital personnel prior to hire, during the orientation period and on an ongoing basis. All Sterling Surgical Hospital employees will participate in a Competency Assessment/Maintenance Program. The competency program will include the following components: ...3. Ongoing Competency Assessment: a. Hospital required competencies b. Department/Unit Specific Competencies c. Age-specific Competencies... 1) The department manager will identify department competencies which require verification. Department specific competency assessment will include criteria designed to demonstrate the employee's ability to care for patient relative to the patient's age/developmental needs. 2) The department manager will designate qualified observers within his/her department. The qualified observers will assist the department manager in the assessment process.

Review of the personnel records for S3RN, S8RN and S7Surg Tech revealed no documentation of skill competencies.

An interview was conducted with S6DON on 05/26/2021 at 11:00 a.m. She reported the hospital was in the process of hiring a nurse educator and the educator is going to set up skill competencies for each unit. S6DON reported she was aware of the lack of documentation of the staff's competencies.

Based on record review and interview the facility failed to ensure drugs and biologicals were administered in accordance with accepted standards of practice, the orders of the practitioner responsible for the patient's care and hospital policy. This deficient practice was evidenced by:

1) Failure to administer antibiotics in a timely manner as ordered by the physician for 3 (#5, #9, #19) of 15 sampled patients reviewed for medication administration.
2) Failure to administer preoperative antibiotics as ordered for 9 ( #1, #2, #3, #5, #6, #9, #10, #12, #18) of 15 sampled patients reviewed for medication administration.
3) Failure to reassess pain after administering a PRN pain medication for 3 (#2, 10, #11) of 15 sampled patients reviewed for medication administration.

Findings:

1. Failure to administer antibiotics in a timely manner as ordered by the physician

Review of the hospital policy titled, "Timing of Medication," revealed in part, "Time critical scheduled medications are medications for which an early or late administration of greater than 30 minutes from the scheduled administration time might cause harm or have significant, negative impact on the intended therapeutic or pharmacologic effect. Examples are as follows ... antibiotics ....'

Patient #9
Review of the medical record for Patient #9, navigated by S3RN, revealed pre-op orders dated 5/20/2021 at 7:00 a.m. for "Ancef 2 gm IV piggyback 1 HOUR prior to incision," and post-op orders dated 05/20/2021 at 7:00 a.m. for" Ancef 2 GM IVP every 8 hours time 3 doses.".

Review of the MAR revealed that Ancef 2 GM was administered pre-operatively on 05/20/2021 at 9:15 a.m. and post-operatively 05/20/2021 at 6:30 p.m. Ancef 2 GM was administered on 05/21/2021 at 3:44 a.m., and at 10:45 a.m. On 05/25/2021 at 2:30 p.m., S3RN verified the administration of the antibiotics was not as ordered and not per hospital policy.

Patient #19
Review of the medical record for Patient #19, navigated by S3RN, revealed post-operative orders dated 02/23/2021 at 7:45 p.m. for "Ancef 2 gms every 8 hrs for 3 doses."

Review of the MAR for Patient # 19 revealed Ancef 2 GM given 02/23/2021 at 8:47 p.m. Ancef 2 GM was given 02/24/2021 at 3:06 a.m. On 05/26/2021 at 10:46 a.m., S3RN verified that the administration was not as ordered and not per hospital policy.

Patient #20
Review of the medical record for Patient #20, navigated by S3RN, revealed pre-operative orders dated 02/12/2021 at 6:10 a.m. for "Vancomycin 1 gm IV piggyback slowly in OR if patient is allergic is penicillin," and post-operative orders dated 02/12/2021 at 10:54 a.m. for "Vancomycin 1 GM IVPB every 12 hrs time 3 doses."

Review of the anesthesia record for Patient #20 revealed Vancomycin 1 GM given on 02/12/2021 at 6:45 a.m. preoperatively.

Review of the MAR for Patient #20 revealed Vancomycin 1 GM given 02/12/2021 at 5:47 p.m. and Vancomycin 1 GM given 02/13/2021 at 6:23 a.m. On 05/26/2021 at 10:54 a.m., S3RN verified that the administration was not as ordered and not per hospital policy.

Interview of S3RN on 05/26/2021 at 10:50 a.m., S3RN verified that the antibiotics were not being given as ordered or within the time frame specified by the policy. She suggested that it may be that the schedule is set when the orders are first placed in the computer system and are not being adjusted as subsequent doses are given.

2. Failure to administer pre-operative antibiotics as ordered by the physician.

Review of the hospital policy titled, "Timing of Medication," revealed in part, "Certain medications are not eligible for scheduled dosing times, either in general or in specific clinical situations. Typically, these are medications that require exact or precise timing of administration. Examples of such medications include, but may not be limited to the following ... "on-call" doses such as "pre-op. These drugs should be administered in a timely manner to ensure desired therapeutic outcome."

Patient #1
Review of the Pre-Procedure Orders, dated 05/21/2021, for Patient #1 revealed an antibiotic order for Ancef 2 grams IVPB in holding 60 minutes prior to incision (Ancef 1 gram for patients less than 80 kg).

Review of the Anesthesia Record dated 05/21/2021 revealed Ancef 2 grams was administered at 7:47 a.m. on 05/21/2021.

Review of the Intraoperative Nursing Report dated 05/21/2021 revealed the surgery start time was 8:17 a.m. (30 minutes prior to incision) The medical record review was navigated by S3RN.

Patient #2
Review of the Pre-Procedure Orders, dated 05/12/2021, for Patient #2 revealed an antibiotic order for Ancef 2 grams IVPB in holding 60 minutes prior to incision (Ancef 1 gram for patients less than 80 kg).

Review of the Anesthesia Record dated 05/12/2021 revealed Ancef 2 grams was administered at 7:30 a.m. on 05/12/2021.

Review of the Intraoperative Nursing Report dated 05/12/2021 revealed the surgery start time was 8:01 a.m. (31 minutes prior to incision) The medical record review was navigated by S3RN.

Patient #3
Review of the Pre-Procedure Orders, dated 05/06/202, for Patient #3 revealed an antibiotic order for Ancef 2 grams IVPB in holding within 60 minutes prior to incision (Ancef 1 gram for patients less than 80 kg).

Review of the Anesthesia Record dated 05/24/2021 revealed Ancef 2 grams was administered at 11:00 a.m on 05/24/2021.

Review of the Intraoperative Nursing Report, dated 05/24/2021, revealed the surgery start time was 10:10 a.m. The medical record review was navigated by S4RN.

An interview was conducted with S4RN on 05/25/2021 at 10:00 a.m. She reported the surgery start time is the time the incision is started and S4RN confirmed the Ancef was not administered 60 minutes prior to the incision as per the physician order.

Patient #5
Review of the medical record for Patient #5, navigated by S3RN, revealed a pre-operative order for "Vancomycin 15mg/kg (max dose=2 grams) IVPB 1 HOUR prior to incision."

Review of the electronic record for Patient #5, S3RN found preoperative Vancomycin 1 gram was administered at 11:20 a.m.

Review of the anesthesia record reveals the start time was 12:04 p.m. On 05/25/2021 at 9:26 a.m. S4RN verified that start time and incision time were considered the same at this facility.

On 05/25/2021 at 9:27, S3RN then verified that the pre-operative antibiotics were not given as ordered and not per hospital policy.

Patient #6
Review of the Pre-Procedure Orders, dated 05/24/2021, for Patient #6 revealed an antibiotic order for Ancef 2 grams IVPB in holding 60 minutes prior to incision (Ancef 1 gram for patients less than 80 kg).

Review of the Anesthesia Record dated 05/24/2021 revealed Ancef 2 grams was administered at 7:30 a.m. on 05/24/2021.

Review of the Intraoperative Nursing Report dated 05/24/2021 revealed the surgery start time was 7:47 a.m. (17 minutes prior to incision) The medical record review was navigated by S3RN.


Patient #9
Review of the medical record of Patient #9, navigated by S3RN, revealed a pre-operative order dated 5/20/21 at 7:00 a.m. for Ancef 2 mg IV piggyback 1 HOUR prior to incision."

Review of the anesthesia record for Patient #9 revealed Ancef 3 gms administered on 05/20/2021 at 7:30 a.m. Start time was 7:51 a.m.

On 05/25/2021 at 2:46 p.m., S3RN verified that the antibiotic was not given as ordered and not per hospital policy.

Patient # 10
Review of the Pre-Procedure Orders, dated 04/07/2021, for Patient #10 revealed an antibiotic order for Ancef 2 grams IVPB in holding 60 minutes prior to incision (Ancef 1 gram for patients less than 80 kg).

Review of the Anesthesia Record dated 04/07/2021 revealed Ancef 2 grams was administered at 7:32 a.m. on 04/07/2021.

Review of the Intraoperative Nursing Report dated 04/07/2021 revealed the surgery start time was 8:02 a.m. (30 minutes prior to incision) The medical record review was navigated by S3RN.

Patient #12
Review of the Pre-Procedure Orders, dated 02/17/2021, for Patient #12 revealed an antibiotic order for Ancef 2 grams IVPB in holding 60 minutes prior to incision (Ancef 1 gram for patients less than 80 kg).

Review of the Anesthesia Record dated 02/17/2021 revealed Ancef 2 grams was administered at 7:30 a.m. on 04/07/2021.

Review of the Intraoperative Nursing Report dated 02/17/2021 revealed the surgery start time was 7:50 a.m. (20 minutes prior to incision) The medical record review was navigated by S3RN.


Patient # 18
Review of the medical record for Patient #18 revealed a pre-operative order for "Vancomycin 15mg/kg (max dose=2 grams) IVPB to be completed within 2 hours prior to incision (rate=1gm/hr)."

Review of the anesthesia record reveals" vancomycin 1.5 mgs @0748am" and a start time of 9:10 a.m.

On 2/26/2021 at 10:39 a.m. S3RN verified that the time listed was the start of the infusion and if it was given at the specified rate, the infusion would still be in process at the time of incision.

Interview of S3RN on 05/26/2021 at 10:50 a.m., S3RN verified that she was now aware that most of pre-operative antibiotics are not being administered as ordered and not per protocol and would need investigation into resolving the issues.


3. Failure to reassess pain after administering a PRN pain medication

Review of hospital policy titled, "Pain Management", Part B, Assessment revealed in part:
2. The presence of pain is assessed on admission to the hospital, post invasive procedure and when the patient complains of pain. The assessment is performed by: physician, RN, LPN, or other licensed healthcare staff and documented in the medical record.
3. The frequency of pain reassessment shall be directed by the intensity of the patient's pain and the effectiveness of pain relief strategies. However, when pain is present, a pain reassessment is generally performed at least every 4 hours and more often as needed by a licensed healthcare provider.

Patient #2
Review of Patient #2's medical record, navigated by S3RN, revealed a PRN order, dated 05/12/2021, for Morphine 3 mg IVP every 3 hours for pain scale 8-10.

Review of Patient #2's MAR, dated 05/12/2021 at 8:43 p.m., revealed the patient was given 3 mg Morphine for pain. Review of Patient #2's nurse notes revealed no documentation of reassessment after medication administration.

Patient #10
Review of Patient #10's medical record, navigated by S3RN, revealed a PRN order, dated 04/07/2021, for Oxycodone/APAP (Percocet) 5/325 PO 2 tabs every 4 hours for pain scale 5-7.

Review of Patient #10's MAR, dated 04/08/2021 at 8:03 a.m., revealed the patient was given 2 tabs Oxycodone/APAP (Percocet) 5/325. Review of the nurses notes for Patient #10 revealed no documentation of reassessment after medication administration.

Patient #11
Review of Patient #11's medical record, navigated by S3RN, revealed a PRN order, dated 02/08/2021, for Oxycodone/APAP (Percocet) 5/325 PO 2 tabs every 4 hours for pain scale 5-7.

Review of Patient #11's MAR, dated 02/10/2021 at 2:33 p.m., revealed the patient was given 2 tabs Oxycodone/APAP (Percocet) 5/325.

Review of Patient #11's nurse notes revealed no documentation of reassessment after medication administration.

In an interview on 05/26/2021 at 10:14 a.m. S3RN verified that nursing staff did not reassess pain after administration of PRN pain medication within hospital policy for the above mentioned patients.




















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Based on record review and interview, the hospital failed to complete and document an anesthesia post-operative evaluation. This deficient practice was evidenced by failure to complete the post-operative assessment in its entirety for 9 (#1, #2, # 5, #6, #9, #10, #11, #12, #18) of the 20 sampled patients.

Findings:
Review of hospital policy titled, "Preoperative/Postoperative Anesthesia Visits" revealed in part, "All patients scheduled for general, regional, MAC or local / standby anesthesia at the facility will be interviewed by the Anesthesiologist and / or CRNA prior to the surgical procedure. A post-anesthesia assessment will be conducted immediately upon arrival in PACU. Periodic post-anesthesia assessments will be performed during the PACU by the Anesthesiologist and / or CRNA following a final postoperative anesthesia assessment in which the patient has met all discharge requirements.

Patient #1
Review of the medical record for Patient #1 revealed the Anesthesia Post-Operative Evaluation was signed but was not filled out, dated, or timed. On 05/24/2021 at 1:51 p.m., S3RN verified the form was incomplete.

Patient #2
Review of the medical record for Patient #2 revealed the Anesthesia Post-Operative Evaluation did not include the patient's vital signs. On 05/24/2021 at 3:50 p.m., S3RN verified the vital signs were not completed on the form.

Patient # 5
Review of the medical record for Patient #5, navigated by S3RN, revealed the Anesthesia Post-Operative Evaluation, dated 05/24/2021, did not include the patient's vital signs. On 02/25/2021 at 9:27 a.m., S3RN verified the vital signs were not completed on the form.

Patient #6
Review of the medical record for Patient #6 revealed the Anesthesia Post-Operative Evaluation was signed but not include vital signs, date, or time. On 05/25/2021 at 9:51 a.m., S3RN verified the form was incomplete.

Patient # 9
Review of the medical record for Patient #9, navigated by S3RN, revealed the Anesthesia Post-Operative Evaluation dated 05/20/2021, was signed and dated but not filled out. On 02/25/2021 at 2:46 p.m. S3RN verified that the form was incomplete.

Patient # 10
Review of the medical record for Patient #10 revealed the Anesthesia Post-Operative Evaluation did not include the patient's vital signs. On 05/25/2021 at 3:20 p.m., S3RN verified the vital signs were not completed on the form.

Patient #11
Review of the medical record for Patient #11 revealed the Anesthesia Post-Operative Evaluation did not include the patient's vital signs. On 05/26/2021 at 9:30 a.m., S3RN verified the vital signs were not completed on the form.

Patient #12
Review of the medical record for Patient #12 revealed the Anesthesia Post-Operative Evaluation did not include the patient's vital signs. On 05/26/2021 at 10:00 a.m., S3RN verified the vital signs were not completed on the form.

Patient #18
Review of the medical record for Patient #18, navigated by S3RN, revealed the Anesthesia Post-Operative Evaluation, dated 02/22/2021, did not include the patient's vital signs. On 05/26/2021 at 10:36 a.m., S3RN verified the vital signs were not completed on the form.


In an interview on 05/26/2021 at 12:00 p.m., S3RN verified the Anesthesia Post-Operative Evaluation was not completed in its entirety for the above mentioned patients.