HospitalInspections.org

1. Based on medical record review, review of hospital policies and interviews for one of three patients admitted to the hospital with bleeding and clotting difficulties (Patient #69), the hospital failed to ensure that the patient received a complete assessment by the physician and/or appropriate pain medication. The finding includes:

a. Patient #69 was admitted to the Emergency Department (ED) on 4/19/14 with severe abdominal pain. The triage note dated 4/19/14 at 8:02 AM indicated that the patient had level "8" left abdominal pain (scale of 1- 10), was a level 3 triage and had a history of a bleeding disorder (Von Willenbrand disease). The assessment by MD #17 dated 4/19/14 at 8:16 AM identified that the patient had left upper abdominal pain, had an allergy to aspirin and furtherincorrectly identified that the patient had no medical history. MD #17's orders dated 4/19/14 at 8:27 directed Torodol (pain medication- non- steroidal anti- inflammatory (NSAID) 30 milligrams (mg) intravenous (IV) push. The medication record noted that RN #15 administered the Torodol as ordered on 4/19/14 at 8:42 AM. MD #17's documentation further indicated that the patient's pain had worsened, had pain in the lower left abdomen that radiated to the left shoulder and ordered an abdominal scan (CT scan) on 4/19/14 at 9:47 AM. The abdominal CT scan dated 4/19/14 at 10:23 AM identified extensive diffuse hemoperitoneum and the patient was diagnosed with presumed hemorrhagic ovarian cyst. Following consultation with pharmacy, obstetrics and the patient's Hematologist (MD #20), the patient was deemed stable and was transferred to Hospital #2 for administration of required antihemophilic factor (Humate P) and surgery. Patient #69 was discharged from Hospital #2 on 4/20/14 following laparoscopic evacuation of hemoperitoneum and right ovarian cyst ablation. Interview with MD #4 (ED Director) on 5/8/14 at 11:00 AM indicated that MD #17 was required to question the patient about allergies and history and did not click the "drop- down" box for medical history in the electronic medical record (EMR). MD #4 further noted that if MD #17 had clicked the drop- down box, the patient's medical history of Von Willendrand's disease would have been populated in the medical history field. MD #4 identified that abdominal pain radiating to the shoulder in the lying position was indicative of an intrabdominal bleed and Torodol was contraindicated with Patient #69's "condition." Interview with MD #17 on 5/8/14 at 1:35 PM noted that although he/she questioned the patient about his/her medical history the patient did not identify that he/she had Von Willenbrand disease until after he/she questioned the patient about his/her delivering a baby at Hospital #2 (post Torodol administration). Interview with Patient #69 on 5/8/14 at 2:50 PM indicated that he/she informed MD #17 of his/her medical history and allergy to aspirin and related products when MD #17 first came in to examine him/her (8:16 AM and before Torodol administration). Review of MD #17's credential file on 5/13/14 noted that approved privileges included abdominal disorders.
The hospital rules and regulations of the medical staff identified that an appointee having privileges (MD #17) shall be responsible for the medical care and treatment of his/her patients in the hospital. The hospital rules and regulations further identified that the content of the medical record shall be pertinent and current and include, in part, personal history.

Based on review of the hospital's contracted service for the Heart Center and/or radiology, the hospital failed to ensure that the contracted service collaborated with the hospital to develop policies and procedures relative to the cardio-pulmonary bypass procedures and/or received yearly infection control training. The findings include:
a. During interviews on 5/6, 5/7 and 5/8/14, with the Director of the OR Services and the VP of Nursing, it was identified that the hospital did not have documentation on site directing the policy, procedure and standards for the contracted perfusion services which the contract stipulated would occur.
b. Additionally, the hospital failed to provide documentation that the equipment (bypass machine, heater/cooler, cell saver) utilized during cardiac procedures was maintained, according to manufacturer's directions, between patients and/or as the manufacturer stipulated (separate from preventative maintenance).
ie: The Terumo Perfusion System manufacturer's directions stipulate that the system requires cleaning and checking after every use of the flow sensors, the water trap, the centrifugal pump and roller pumps.
The Sarns Heater-Cooler Unit requires cleaning once a week with specific instructions for control of microbe growth with sanitation procedures required daily and/or weekly.
The Cell Saver requires bowl optic sensor cleaning daily with additional cleaning instructions.




14528

c. A tour of the radiology department was conducted on 5/6/14 with the Director of Diagnostic Services. Facility documentation identified that the facility radiologists were a contracted service and staff physicians included a total of nine radiologists. Review of hospital bylaws noted that medical staff was required to be credentialed every two years. Review of required yearly infection control (IC) training for hospital staff included computer- based education for bloodborne pathogens and isolation precautions. Interview with the Infection Preventionist (IP) on 5/6/14 at 2:35 PM indicated that hospital staff was required to complete yearly IC training via Health Stream which is computer- based training. He/she further noted that the hospital was looking into the yearly training for radiologists. Interview with the Assistant Director of Performance Improvement on 5/7/14 at 8:15 AM indicated that the Radiologists viewed a computerized disk that was required for credentialing every two years and was not complete with all of the required yearly IC training.

15482

Based on a review of clinical records, facility documentation, policy's, and interview, for two patients (Patient #13 and #16) that filed a grievance, the hospital failed to ensure the facility policy was followed. The findings include the following:
a. Patient #16 was admitted on 3/12/14 and subsequently expired on 3/27/14. Interview with the Director of Patient Relations on 5/7/14 indicated that she received a call on 4/1/14 from Person #7 requesting a meeting to discuss concerns identified while Patient #16 was hospitalized. The Director of Patient Relations stated the meeting was held on 4/4/14 and indicated that at the conclusion of the meeting, Person #7 seemed happy with the outcome and she referred the case to the Chief of the Hospitalist Program and the Chief Medical Officer (CMO). Interview with the Chief of the Hospitalist Program on 5/8/14 stated he was unaware of the complaint until 5/7/14 when he received an email from the CMO. The Director of Patient Relations failed to produce documentation related to this grievance.
b. Patient #13 had multiple hospital admissions for respiratory problems and/or infections on 2/26/13, 3/10/13 and 3/15/13. Patient #13's records for these dates identified that Person #4 was Patient #13's only next of kin and emergency contact listed. Review of e- mails sent from Person #4 to hospital staff indicated that Person #4 had various complaints regarding Patient #13's care and services dated 3/21/13 through 3/29/13. Interview with the Director of Patient Experience on 5/7/14 at 10:27 AM noted that he/she was in constant phone contact with Person #4, all issues were addressed timely and a written response to all issues was sent to Person #4 on 4/17/13. The hospital grievance policy identified that a written acknowledgement of all written grievances will be made to the person filing it within 24 hours of receipt and an estimated time for final response will also be given at this time. Periodic communication will continue if resolution takes longer than 10 working days. A follow-up letter will be sent when resolution is reached and the case is closed.

The hospital grievance policy identified that a written acknowledgement of all written grievances will be made to the person filing it within 24 hours of receipt and an estimated time for final response will also be given at this time. The information will be entered in the computer system by the person who received it to allow for tracking and trending of patient feedback. Periodic communication will continue if resolution takes longer than 10 working days. A follow-up letter will be sent when resolution is reached and the case is closed.

1. Based on medical record reviews, review of hospital policies and interviews the hospital failed to ensure the appropriate disclosure of patient health information for two of three patients (Patient #13, #68), who were transferred/discharged to another facility. The finding includes:


a. Patient #13 was admitted to the hospital via ambulance on 3/10/13 at 10:03 AM with a diagnosis of acute exacerbation of chronic obstructive pulmonary disease. The ED record dated 3/10/13 at 2:56 PM identified that the ED Physician, MD #10, called and spoke with a physician in MD #12's office and the decision was made to admit the patient to a teaching service under MD #12's care. Facility documentation dated 3/21/13 by the Director of Health Information Management identified that MD #12 was contacted even though registration was informed that MD #13 was Patient #13's primary care physician (PCP) and that MD #12 was sent patient results. Facility documentation dated 3/22/13 from MD #10 indicated that Person #4 was upset because MD #12 visited Patient #13 in the hospital on 3/11/13 although MD #13 had replaced MD #12 as the patient's PCP prior to the 3/10/13 admission. Interview with the Performance Improvement Physician Director on 5/8/14 at 11:30 AM noted that a quick registration was done prior to registration and MD #12's office was initially notified/consulted instead of MD #13 because MD #12 was the patient's prior physician of record.

b. Patient #68 was admitted to the P5 unit on 3/18/13 and diagnoses included dehydration and gastroesophageal reflux disease. The initial W-10 sent with Patient #68 to Facility #4 identified that the patient was discharged to Facility #4 on 3/21/13. The initial W-10 incorrectly indicated that Person #4 (Patient #13's emergency contact) was Patient #68's emergency contact/responsible person. Facility documentation dated 3/21/13 at 2:45 PM from Person #4 identified that he/she received a phone call from Facility #4 regarding Patient #68 in error and that this was a violation of Health Information Privacy Act. Interview with the Director of Health Information Services on 5/8/14 at 11:40 AM noted that the Patient's record was sent to the appropriate facility. The Director of Health Information Services did not comment on Person #4's knowledge regarding Patient #68's discharge date and required admission to Facility #4 in reference to a patient's right to privacy.
The hospital patient rights policy identified a right to have all communications and records pertaining to care treated as private information and to have hospital staff honor their personal privacy. The hospital notice of privacy practices identified that the hospital staff respect the privacy of health information and are committed to maintaining patient confidentiality.




19826

2. Based on a review of clinical records, hospital documentation, policies and interviews for three of four patients (Patients #62, #63 and #64) that required surgery, the hospital failed to protect the patient's health information from unauthorized disclosure. The findings include:

a. Patient #62 was admitted on 12/27/13 for reconstruction of the right great toe joint surgery with implant and protein rich plasma injections for both plantar areas to be completed by MD #15. Review of the intraoperative record identified that RN #11 was the circulator in the case and Person #6 was present during the surgery and listed as the "physician/patient coordinator". Although the clinical record identified that MD #15 was in the Operating Room (OR) from 9:32 A.M. to 12:12 P.M., handwritten discharge orders were written at 9:50 A.M., during the surgical case.

Interview with MD #15, on 5/8/14 at 9:12 A.M., identified that due to time constraints, he dictates the immediate operative note, the post-operative and/or discharge physician orders to Person #6 (non-hospital employee) who transcribes (handwritten) this information in the patients clinical record. MD#15 then reviews what Person #6 wrote and subsequently signs the dictated documentation. MD #15 added that Person #6 rounds with him at the hospital with an intraoperative responsibility to ensure he has all the necessary equipment for each case.

Interview with Person #6, on 5/8/14 at 9:20 A.M., identified that his role during surgery is to ensure MD#15 has the necessary equipment available and he writes the immediate operative note, post-operative and/or discharge orders dictated by MD #15. Person #6 stated that MD #15 signs those documents.

b. Patient #63 was admitted on 2/7/14 for dermagraft application to the right foot procedure and bilateral foot protein rich plasma injection to be completed by MD #15. Review of the intraoperative record identified that RN #13 was the circulator in the case and Person #6 was present during the surgery and listed as an "office assistant". Review of the handwritten discharge orders identified that the orders were written at 11:15 A.M. prior to the start of surgery. Review of the clinical record identified that MD #15 was in the OR from 11:52 A.M. to 12:57 P.M.

Interview with MD #15, on 5/8/14 at 9:12 A.M., identified that due to time constraints, Person #6 documented the discharge instructions in the patient's clinical record and he signed off on the orders. MD #15 added that Person #6 rounds with him at the hospital with an intraoperative responsibility to ensure he has all the necessary equipment for each case.

Interview with Person #6, on 5/8/14 at 9:20 A.M., identified he writes the immediate operative note, post-operative and/or discharge orders dictated by MD #15 and the physician signs those documents.

c. Patient #64 was admitted on 4/10/14 for arthroplasty with implant of digits #2 and 3 of the right foot to be completed by MD #15. Review of the intraoperative record identified that RN #11 was the circulator in the case and Person #6 was present during the surgery and listed as "other". Review of the handwritten discharge orders identified that the orders were written at 8:30 A.M. prior to the start of surgery. Review of the clinical record identified that MD #15 was in the OR from 8:37 A.M. to 9:43 A.M. Review of the clinical record failed to identify that an immediate operative note was written.

Interview with MD #15, on 5/8/14 at 9:12 A.M., identified that due to time constraints, Person #6 documented the discharge instructions in the patient's clinical record and he signed off on the orders. MD #15 added that Person #6 rounds with him at the hospital with an intraoperative responsibility to ensure he has all the necessary equipment for each case.

Interview with Person #6, on 5/8/14 at 9:20 A.M., identified that he writes the immediate operative note, post-operative and/or discharge orders dictated by MD #15 and the physician signs those documents.

Review of the clinical records of Patients #62, 63 and 64 and interview with the Nurse Director of the Operating Room (OR), on 5/7/14 at 10:30 A.M., identified that s/he was not aware of the role that Person #6 carried out in MD #15's surgical cases. The Director stated that Person #6 would not have access to any patient's clinical records due to confidentiality and could not make any entries into the patient clinical records. In addition, the Nurse Director of the OR, identified that the handwritten post-operative/discharge orders for patients #62, 63 and 64 were written in advance and/or during the surgical procedures.

Interview with RN #12, on 5/7/14 at 12:49 P.M., identified that prior to MD #15's surgical cases, Person #6 rounds and interviews patients with MD #15 in the pre-operative area, attends the surgical case where his/her role is to support MD #15 and provides information to OR team regarding necessary equipment for the surgical case. RN#12 stated that Person #6 does not provide any direct patient care and leaves the OR at the conclusion of the case.

Interview with RN #11, on 5/7/14 at 1:03 P.M., identified that prior to MD #15's surgical cases, Person #6 rounds and interviews patients in the pre-operative area asking the patients about allergies, recent medical history, what procedure having today, laterality of procedure, then attends the surgical case where his/her role is to provide information to the OR team regarding necessary equipment for the surgical case. RN#11 stated that Person #6 does not provide any direct patient care and leaves the OR at the conclusion of the case.

Interview with the Chief of Surgery, MD #16, on 5/7/14 at 11:45 A.M., identified that Person #6 works in MD #15's private office, attends MD #15's surgical cases in the role of technical assistant and should not have access to any patient's hospital clinical record, hard copy and/or electronic.

Interview with the HIPPA Privacy Officer, on 5/8/14 at 10:309A.M., identified that allowing Person #6 access to a patient clinical record is unusual and the hospital does not have a policy and procedure to address scribes.

Review of the hospital policy and procedure, titled Patient Rights and Responsibilities, identified that each patient has the right to have all records pertaining to their care treated as private information.

Review of the hospital policy and procedure, titled Confidentiality of Information, identified that all confidential information remains confidential and Protected Health Information (PHI) is defined as individually identifiable health information that is transmitted or maintained in any form or medium, including paper, electronic or oral. Further the policy identified that the Hospital ensures that confidential information is not disclosed except to authorized individuals in the normal course of performing their assigned duties.

Review of the hospital policy and procedure, titled notice of Privacy Practices, identified that the Hospital is required to maintain the privacy of each patients Protected Health Information (PHI) and this will be followed by the Medical Staff of the Hospital.

Review of the hospital policy and procedure, titled Individual Privacy Rights, identified that the Hospital respects the rights of patients with regards to PHI and will take reasonable precautions to maintain the confidentiality of that information.

Review of the Medical Staff By-Laws, dated 1/14, identified that each attending physician shall provide for professional care for his/her patients (s) in the Hospital, the attending physician is responsible for preparation of a complete, legible and legal medical record for each patient.

Based on a review of clinical records and policy review, for one of three patients reviewed for restraints (Patient #16), the facility failed to ensure that least restrictive restraints were utilized. The finding includes the following:

a. Patient #16 presented to the ED on 3/12/14 at 8:59 AM, was triaged at 10:20 AM with complaints of no appetite, urinary frequency and confusion with a history of dementia. The patient was diagnosed with acute myocardial infarction, congestive heart failure and right upper lobe pneumonia. Review of the clinical record indicated that on 3/13/14 the patient was placed in a jacket/vest restraint on 3/13/14 at 3:14 PM to protect medical lines (intravenous line). The monitoring flow sheet indicated that the behaviors that warranted the use of restraints included, cognitive impairment interferes with medical care and interference with medical tubes. Documentation failed to reflect that the chosen restraint was the least restrictive intervention to prevent the patient from pulling out the IV site. Review of the restraint monitoring flow sheet indicated that on 3/13/14 at 9:24 PM the patient was in a vest restraint and bilateral wrist restraints. The clinical record failed to reflect interventions used prior to the implementation of double restraints. The patient remained in a vest restraint and bilateral wrist restraints for the period of 3/13/14 at 9:24 PM through 3/17/14 at 9:07 AM.

Review of the policy and procedure, titled Restraint and Seclusion, identified in part, that restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member or others. A comprehensive assessment of the patient must determine that the risks associated with the use of the restraint are outweighed by the risk of not using it, whether a less restrictive device or intervention could offer the same benefit at less risk. Alternatives to restraint must be considered prior to the application of restraint. Documentation in the patient's medical record for each episode of restraint use includes in part, circumstances/behavior leading up to each use, alternatives tried or considered, and rationale for type.

Based on a review of clinical records, interview, and policy review, the facility failed to ensure that an order for restraints was obtained for one of three patients' (Patient #16) in accordance with facility policy. The finding includes the following:

a. Patient #16 presented to the ED on 3/12/14 at 8:59 AM with complaints of no appetite, urinary frequency and confusion with a history of dementia. The patient was diagnosed with acute myocardial infarction, congestive heart failure and right upper lobe pneumonia. Review of the clinical record indicated that on 3/13/14 at 3:14 PM, the patient was placed in a jacket/vest restraint and remained in restraints until 3/17/14 at 12:09 PM. Review of the restraint safety monitoring form indicated that on 3/15/14 through 3/16/14 the patient was in a vest restraint and bilateral wrist restraints, absent a physician's order. Record review and interview with the Director of Quality failed to identify that an order for restraints was obtained for the calendar day 3/15/14. The facility policy indicated that an order must be renewed each calendar day after a face-to-face examination by the physician, or delegated PA, APRN or resident.

Based on a review of clinical records, interview and policy review, for one of three patients reviewed for restraints (Patient #16), the facility failed to ensure that restraints were discontinued at the earliest possible time. The finding includes the following:

a. Patient #16 presented to the ED on 3/12/14 at 8:59 AM, was triaged at 10:20 AM with complaints of no appetite, urinary frequency and confusion with a history of dementia. The patient was diagnosed with acute myocardial infarction, congestive heart failure and right upper lobe pneumonia. Review of the clinical record indicated that on 3/13/14 the patient was placed in a jacket/vest restraint on 3/13/14 at 3:14 PM to protect medical lines (intravenous line). The monitoring flow sheet indicated behaviors that warranted the use of restraints included, cognitive impairment interferes with medical care and interference with medical tubes. Review of the restraint monitoring flow sheet indicated that on 3/13/14 at 9:24 PM the patient was in a vest restraint and bilateral wrist restraints. The clinical record failed to reflect interventions used prior to the implementation of double restraints. The patient remained in a vest restraint and bilateral wrist restraints for the period of 3/13/14 at 9:24 PM through 3/17/14 at 9:07 AM, although there were instances when documentation reflected that the patient was calm and/or sleeping.
Review of the facility policy indicated that the use of restrains should be frequently evaluated and ended at the earliest possible time and the readiness for discontinuation and/or consideration of the less restrictive methods.

1. Based on a review of clinical records, interviews, review of hospital documentation and review of policies and procedures for three of four patients (Patients #62, #63 and #64) that required surgery, the hospital failed to ensure that Medical Staff By-Laws were enforced when a non-hospital employee was granted permission to perform duties outside of his/her scope of practice thus violating patient confidentiality. The findings include:

a. Patient #62 was admitted on 12/27/13 for reconstruction of the right great toe joint surgery with implant and protein rich plasma injections for both plantar areas to be completed by MD #15. Review of the intraoperative record identified that RN #11 was the circulator in the case and Person #6 was present during the surgery and listed as the "physician/patient coordinator". Although the clinical record identified that MD #15 was in the Operating Room (OR) from 9:32 A.M. to 12:12 P.M., handwritten discharge orders were written at 9:50 A.M., during the surgical case.

Interview with MD #15, on 5/8/14 at 9:12 A.M., identified that due to time constraints, he dictates the immediate operative note and the post-operative/discharge physician orders to Person #6 (non-hospital employee) who transcribes this information in the patients clinical record. MD#15 then reviews what Person #6 wrote and subsequently signs the dictated documentation. MD #15 added that Person #6 rounds with him/her at the hospital with an intraoperative responsibility to ensure he has all the necessary equipment for each case.

Interview with Person #6, on 5/8/14 at 9:20 A.M., identified that his/her role during surgery is to ensure MD#15 has the necessary equipment available and he writes the immediate operative note, post-operative and/or discharge orders dictated by MD #15. Person #6 stated that MD #15 signs those documents.


b. Patient #63 was admitted on 2/7/14 for dermagraft application to the right foot procedure and bilateral foot protein rich plasma injection to be completed by MD #15. Review of the intraoperative record identified that RN #13 was the circulator in the case and Person #6 was present during the surgery and listed as an "office assistant". Review of the handwritten discharge orders identified that the orders were written at 11:15 A.M. prior to the start of surgery. Review of the clinical record identified that MD #15 was in the OR from 11:52 A.M. to 12:57 P.M.

Interview with MD #15, on 5/8/14 at 9:12 A.M., identified that due to time constraints, Person #6 documented the discharge instructions in the patient's clinical record and he signed off on the orders. MD #15 added that Person #6 rounds with him/her at the hospital with an intraoperative responsibility to ensure he has all the necessary equipment for each case.

Interview with Person #6, on 5/8/14 at 9:20 A.M., identified that his role during surgery is to ensure MD#15 has the necessary equipment available and he writes the immediate operative note and/or post-operative/discharge orders dictated by MD #15. Person #6 stated that MD #15 signs those documents.

c. Patient #64 was admitted on 4/10/14 for arthroplasty with implant of digits #2 and 3 of the right foot to be completed by MD #15. Review of the intraoperative record identified that RN #11 was the circulator in the case and Person #6 was present during the surgery and listed as "other". Review of the handwritten discharge orders identified that the orders were written at 8:30 A.M. prior to the start of surgery. Review of the clinical record identified that MD #15 was in the OR from 8:37 A.M. to 9:43 A.M. Review of the clinical record failed to identify that an immediate operative note was written in accordance with Medical staff By-Laws.

Interview with MD #15, on 5/8/14 at 9:12 A.M., identified that due to time constraints, Person #6 documented the discharge instructions in the patient's clinical record and he signed off on the orders. MD #15 added that Person #6 rounds with him at the hospital with an intraoperative responsibility to ensure he has all the necessary equipment for each case.

Interview with Person #6, on 5/8/14 at 9:20 A.M., identified that his role during surgery is to ensure MD#15 has the necessary equipment available and he writes the immediate operative note and/or post-operative/discharge orders dictated by MD #15. Person #6 stated that MD #15 signs those documents.

Review of the clinical records of Patients #62, 63 and 64 and interview with the Nurse Director of the Operating Room (OR) on 5/7/14 at 10:30 A.M., identified that s/he was not aware of the role that Person #6 carried out in MD #15's surgical cases. The Director stated that Person #6 would not have access to any patient's clinical records due to confidentiality and could not make any entries into the patient clinical records. In addition, the Nurse Director of the OR, identified that the handwritten post-operative/discharge orders for patients #62, 63 and 64 were written in advance and/or during the surgical procedures.

Interview with RN #12, on 5/7/14 at 12:49 P.M., identified that prior to MD #15's surgical cases, Person #6 rounds and interviews patients with MD #15 in the pre-operative area, attends the surgical case where his/her role is to support MD #15 and provides information to OR team regarding necessary equipment for the surgical case. RN#12 stated that Person #6 does not provide any direct patient care and leaves the OR at the conclusion of the case.

Interview with RN #11, on 5/7/14 at 1:03 P.M., identified that prior to MD #15's surgical cases, Person #6 rounds and interviews patients in the pre-operative area asking the patients about allergies, recent medical history, what procedure having today, laterality of procedure, then attends the surgical case where his/her role is to provide information to the OR team regarding necessary equipment for the surgical case. RN#11 stated that Person #6 does not provide any direct patient care and leaves the OR at the conclusion of the case.

Interview with the Chief of Surgery, MD #16, on 5/7/14 at 11:45 A.M., identified that Person #6 works in MD #15's private office, attends MD #15's surgical cases in the role of technical assistant and should not have access to any patient's hospital clinical record, hard copy and/or electronic.

Interview with the HIPPA Privacy Officer, on 5/8/14 at 10:309A.M., identified that allowing Person #6 access to a patient clinical record is unusual and the hospital does not have a policy and procedure to address scribes.

Review of the hospital policy and procedure, titled notice of Privacy Practices, identified that the Hospital is required to maintain the privacy of each patients Protected Health Information (PHI) and this will be followed by the Medical Staff of the Hospital.

Review of the hospital policy and procedure, titled Provider Orders/Ordering Practice, identified that orders may be entered into the clinical record, electronic or paper, by authorized clinicians only.

Review of the Medical Staff By-Laws, dated 1/14, identified that each attending physician shall provide for professional care for his/her patients (s) in the Hospital, the attending physician is responsible for preparation of a complete, legible and legal medical record for each patient including an operative note which must be written following surgery and all orders written prior to surgery are canceled and must be re-written.


2. Based on a review of clinical records, interviews, review of hospital documentation and review of policies and procedures for one patient (Patient # 26) that brought medications from home then self-administered those medications while in the ED, the hospital failed to ensure that Medical Staff By-Laws were followed. The findings include:

a. Patient #26 arrived at the Emergency Department (ED) on 5/4/14 at 11:31 P.M., with suicidal ideation and racing thoughts with a past medical history that included schizophrenia, personality disorder and substance abuse. Review of the clinical record and interview with Assistant Nurse Director #2, on 5/5/14 at 11:01 A.M., identified an incomplete physician's order, dated 5/4/14 at 11:40 P.M., that approved Patient #26 to self administer his/her own Risperdal and Cogentin at the hour of sleep, absent the dosage, route and/or frequency. A nurses' note, dated 5/4/14 at 11:54 P.M., reflected Patient #26 took his/her own Risperdal and Cogentin, absent documentation that reflected dosage and/or route.

Review of hospital documentation, titled Patient's Valuables Form, identified that Patient #26 had two pill boxes in his/her possession, labeled am and pm that contained medications. These valuables were sent to the pharmacy by RN #10 on 5/5/14.

Review of Patient #26's Valuable's Form, home medications stored in the Hospital pharmacy and interview with Pharmacist #1, on 5/5/14 at 11:48 P.M., identified that the patient brought in unlabeled pill boxes that contained white and yellow pills. The ED staff did not follow the process of medications when brought in from home-including sending the medication to the pharmacy for identification and allowing the pharmacy to attach a barcode to the medication.

Interview with the Nurse Director of the ED, on 5/7/14 at 9:05 A.M., identified that the ED nursing staff should have sent Patient #26's personal medications to the pharmacy for identification and application of a barcode, the physician order for medications was not complete and the nursing documentation for self-administered home medication was not complete.

Review of the Hospital Policy and Procedure, titled Provider Orders, identified that medication orders must include the medication dose, route and frequency.

Review of the Hospital Policy and Procedure, titled Patient's Own Medication, identified that a physician order is required and must include the medication dose and directions for use, patient's own medications must be in a properly labeled container, the hospital pharmacy will apply a barcode to the medication, and the nurse will scan the medication, administer the medication and record the administration on the medication administration report.
Review of the Medical Staff by-Laws and Rules and Regulations, dated 1/14, identified that medication orders must include the medication strength, route and frequency.

1. Based on a review of clinical records and policy review for one of four patients (Patient #16) reviewed for nutrition, the facility failed to ensure that a dietary consult, initiated by nursing, was completed in a timely manner and/or that the patient's poor oral intake was addressed. The finding includes the following:

a. Patient #16 presented to the ED on 3/12/14 at 8:59 AM and was triaged at 10:20 AM with complaints of no appetite, urinary frequency and confusion with a history of dementia. The patient was admitted with acute myocardial infarction, congestive heart failure and right upper lobe pneumonia. The nursing admission history dated 3/13/14 indicated that on admission the patient's weight was 61 kilograms (134 pounds) and required thickened liquids. Review of the orders dated 3/13/14 identified a dietary consult was initiated based on triggers in the nursing admission data base (RN referral). The record indicated that the patient was seen by the dietician on 3/17/14, four days after the consult was initiated. The note indicated that the patient had inadequate oral intake, needed to be fed, required 1500 Kcals per day, fluid needs per the physician, and recommended ensure pudding three times a day. Nursing staff failed to follow-up with the Dietician when a consult was not initiated within the 24 hours per policy.

Review of the patient's food intake during the period of 3/13/14 through 3/22/14 indicated the patient consumed 0% of 16 meals and 5% - 30 % of 8 meals. On 3/20/14, the patient's weight was 57.8 kilograms (127 pounds). Review of the record failed to identify that the patient was consistently assisted with meals and/or reapproached with alternatives when meal consumption was poor. Documentation further failed to reflect that the physician was notified of the seven (7) pound weight loss.

Review of the policy indicated that in the event of a change, a nurse's note will be written and flagged as an annotation and will be communicated to other disciplines.

2. Based on a review of clinical records, interview and policy review, the facility failed to ensure that one of eight patients (Patient #16) was monitored in accordance with the triage policy while in the ED. The finding includes the following:

a. Patient #16 presented to the ED on 3/12/14 at 9:30 AM with complaints of no appetite, urinary frequency and confusion with a history of dementia. Vital signs were obtained at 10:08 AM according to the record. The patient was triaged as a level 2 at 10:20 AM and remained in the waiting room until 2:08 PM when a treatment room became available. The record lacked documentation that the patient's vital signs were assessed at 12:08 PM in accordance with policy that directed monitoring every two (2) hours for a triage level of two (2). The next set of vital signs was documented at 2:14 PM. Review of the ED record and interview with the Nurse Director of the ED on 5/8/14 at 9:30 AM identified that the patient remained in the ED room until 3/13/14 at 8:59 AM when the patient was admitted. The Nurse Director failed to provide evidence that the patient's vital signs were monitored every two hours per policy.

Review of the policy indicated that for patients triaged as level 2 of level 3 vital sign documentation should be every two hours.








19826

3. Based on a review of clinical records, interviews and policy review for one of four patients (Patient #12) that alleged inappropriate staff interaction, the hospital failed to ensure that the physician was informed of the allegation and/or for one patient (Patient # 26) that brought medications from home, the hospital failed to ensure that the nursing staff followed facility policy prior to allowing the patient to self administer. The findings include:

a. Patient #12 arrived at the Emergency Department (ED) on 11/27/13 at 10:20 P.M. via ambulance on a Police Emergency Examination Request (PEER) with the chief complaint of suicidal ideation via ingestion of over the counter medications with a past medical history that included mood disorder and polysubstance dependence. Patient #12 was diagnosed with overdose and admitted to the hospital via a Physician's Emergency Certificate (PEC) due to being a danger to self. Review of progress notes authored by RN #1 dated 12/8/13 at 9:05 and 9:06 P.M., identified that on 12/8/13 at 3:15 P.M. Patient #12 alleged that on 12/8/13 at approximately 9:55 A.M. Psychiatric Technician #1 took images of him/her while he/she was in the bathroom and Psychiatric Technician #1 deleted the images as directed by Patient #12. Review of the clinical record and interview with Assistant Nurse Director #2, on 5/8/14 at 11:06 A.M., identified that after Patient #12 alleged inappropriate staff interaction the patient was assessed by a Registered Nurse and the family and Hospital administration was informed of the allegation. The hospital failed to ensure that the attending physician was notified of the allegation. Interview with RN #1, on 5/8/14 at 1:15 P.M., identified that after the report he/she updated the charge nurse, the Unit Director and the patient's family member, however could not recall if s/he notified the attending physician.

Review of the hospital policy and procedure, titled Safety Event Reporting, identified that when a patient safety event occurs the attending physician must be notified of the event and that notification is documented.



b. Patient #26 arrived at the ED on 5/4/14 at 11:31 P.M., with suicidal ideation and racing thoughts with a past medical history that included schizophrenia, personality disorder and substance abuse. Review of the clinical record and interview with Assistant Nurse Director #2, on 5/5/14 at 11:01 A.M., identified a physician order, dated 5/4/14 at 11:40 P.M., that directed Patient #26 may take his/her own Risperdal and Cogentin at the hour of sleep, absent the dosage, route and/or frequency. The clinical record failed to identify that nursing staff notified the physician of the incomplete order and according to a nurse's note, dated 5/4/14 at 11:54 P.M., allowed Patient #26 to consume his/her own Risperdal and Cogentin at the hour of sleep.

Review of hospital documentation, titled Patient's Valuables Form, identified that Patient #26 had two pill boxes, labeled am and pm that contained medications and these valuables were sent to the pharmacy by RN #10 on 5/5/14.

Review of Patient #26's Valuable's Form, home medications stored in the Hospital pharmacy and interview with Pharmacist #1, on 5/5/14 at 11:48 P.M., identified that the patient brought in unlabeled pill boxes that contained white and yellow pills and that ED staff failed to follow the process of medications that are brought from home-including sending the medication to the pharmacy for identification and allowing the pharmacy to attach a barcode to the medication.

Interview with the Nurse Director of the ED, on 5/7/14 at 9:05 A.M., identified that the physician's order was incomplete and nursing staff should have sent Patient #26's home medications to the pharmacy for identification and application of a barcode.

Review of the Hospital Policy and Procedure, titled Provider Orders, identified that medication orders must include the medication dose, route and frequency.

Review of the Hospital Policy and Procedure, titled Patient's Own Medication, identified that a physician order is required and must include the medication dose and directions for use, patient's own medications must be in a properly labeled container, the hospital pharmacy will apply a barcode to the medication, and the nurse will scan the medication, administer the medication and record the administration on the medication administration report.

Based on a review of clinical records and policy review, the facility failed to ensure that a comprehensive care plan was completed for one of three patients' reviewed for nutritional concerns (Patient #16). The finding includes the following:

a. Patient #16 presented to the ED on 3/12/14 at 8:59 AM and was triaged at 10:20 AM with complaints of no appetite, urinary frequency and confusion with a history of dementia. The patient was admitted with acute myocardial infarction, congestive heart failure and right upper lobe pneumonia. The nursing admission history dated 3/13/14 indicated that on admission the patient's weight was 61 kilograms (134 pounds) and required thickened liquids. Review of the orders dated 3/13/14 identified a dietary consult was initiated based on triggers in the nursing admission data base (RN referral). The record indicated that the patient was seen by the dietician on 3/17/14, four days after the consult was initiated. The note indicated that the patient had inadequate oral intake, needed to be fed, required 1500 Kcals per day, fluid needs per the physician, and recommended ensure pudding three times a day.

Review of the patient's food intake during the period of 3/13/14 through 3/22/14 indicated the patient had 0 % intake at 16 meals and 5% - 30 % of 8 meals. On 3/20/14, the patient's weight was 57.8 kilograms (127 pounds). Review of the care plan dated 3/13/14 failed to reflect that the patient's nutritional concerns were addressed.

Review of the facilty policy indicated that the interdisciplinary plan of care should be individualized for each patient.

1. Based on medical record reviews, review of hospital policies and interviews the hospital failed to ensure patient records were complete and/or accurate for 3 of 6 patients (Patient #69, #13, and #68). The findings include:

a. Patient #69 was admitted to the Emergency Department (ED) on 4/19/14 with severe abdominal pain. The triage note dated 4/19/14 at 8:02 AM indicated that the patient had a history of a bleeding disorder (Von Willenbrand disease). The assessment by MD #17 dated 4/19/14 at 8:16 AM identified that the patient had left upper abdominal pain, had an allergy to aspirin and further incorrectly identified that the patient had no medical history. Interview with MD #4 (ED Director) on 5/8/14 at 11:00 AM indicated that MD #17 did not click the "drop- down" box for medical history in the electronic medical record (EMR). MD #4 further noted that if MD #17 had clicked the drop- down box, the patient's medical history of Von Willendrand's disease would have been populated in the medical history field. The hospital rules and regulations of the medical staff identified that the appointee (MD #17) shall responsible for the prompt completion and accuracy of the medical record.

b. Patient #13 was admitted to the P5 unit on 3/15/13 with a diagnosis of hypoxia. The preadmission screening form identified that Patient #13 was responsible for self and was not conserved. The face sheet dated 3/15/13 indicated that Person #4 was the patient's next of kin/contact. Case management notes dated 3/26/13 at 7:30 PM identified that Patient #13 was discharged to Facility #3 via ambulance. The interagency referral information (W-10) lacked emergency contact/responsible person information (information for Person #4) and the area to document this information was left blank. Interview with the Director of Health Information Management (HIM) and/or Registrar #1 on 5/8/14 at 11:40 AM and 11:55 AM consecutively noted that Person #4's information should have been documented on the W-10, this had not been done and the face sheet was always sent with patients sent to other facilities via ambulance.

c. Patient #68 was admitted to the P5 unit on 3/18/13 and diagnoses included dehydration and gastroesophageal reflux disease. The initial W-10 sent with Patient #68 to Facility #4 identified that the patient was discharged to Facility #4 on 3/21/13. The initial W-10 further indicated that Person #4 was Patient #68's emergency contact/responsible person. Interview with the Director of Case Management on 5/7/14 at 10:10 AM identified that Case Manager #1 mistakenly entered the wrong contact information in Patient #68's electronic medical record on the W-10 because he/she was working on Patient #13's and Patient #68's discharge at the same time.
The hospital policy for case management identified a responsibility to complete the interventions necessary for discharge and assemble necessary referral, discharge summaries and pertinent information for placement prior to discharge.




19826

2. Based on a review of clinical records and Medical Staff By-Laws, the hospital failed to ensure the record contained an immediate post-operative note for one of four patients (Patient #64) that required surgery. The finding includes:

a. Patient #64 was admitted on 4/10/14 for arthroplasty with implant of digits #2 and 3 of the right foot to be completed by MD #15. Review of the clinical record failed to identify an immediate operative note.

Review of the Medical Staff By-Laws, dated 1/14, identified that the attending physician is responsible for preparation of a complete, legible and legal medical record for each patient including an operative note which must be written following surgery.

3. Based on a review of clinical records, interviews, and policy review, the hospital failed to ensure the record accurately reflected the patient's next of kin for one of three patients (Patient # 29) reviewed for admission. The finding includes:

a. Patient #29 arrived at the Emergency Department (ED) on 4/25/14 at 8:17 P.M., via ambulance from a long term care facility with complaints of nausea and vomiting and subsequently admitted to the hospital with a small bowel obstruction. Review of the clinical record and interview with Assistant Nurse Director #4, on 5/5/14 at 1:05 P.M., identified that Person #9 was the next of kin although Person #8 signed the Patient Agreement, the Medicare Discharge Rights and the Authorization to Obtain Health Information for Medication History documents. Interview with the Director or Registration, on 5/7/14 at 10:59 A.M., identified that during the registration process Person #8 should have been listed as the next of kin and not Person #9.

Review of the hospital policy and procedure, titled Identification and Notification of Patient's Next of Kin, identified that upon admission the patient will be queried regarding their next of kin (the person's closest living relative).

Review of the hospital policy and Procedure, titled Consent, identified that persons authorized to consent of behalf of the patient include the next of kin.

4. Based on a review of clinical records, interviews, and policy review, the hospital failed to ensure that two of two patients (Patients #29 and 30) reviewed for Advanced Directives had the legal documents contained in the record in accordance with facility policy. The findings include:

a. Patient #29 arrived at the Emergency Department (ED) on 4/25/14 at 8:17 P.M., via ambulance from a long term care facility with complaints of nausea and vomiting and subsequently admitted to the hospital with a small bowel obstruction. Review of the clinical record and interview with Assistant Nurse Director #4, on 5/5/14 at 1:05 P.M., identified that registration staff identified Patient #29 had not executed Advance Directives and information was provided to the patient. Review of the nursing admission history completed by RN #7, dated 4/25/14, identified that Patient #29 had executed Advance Directives with a copy placed in the record, a discrepancy from the information obtained by Registration staff. Interview with RN #7, on 5/8/14 at 8:40 A.M., stated s/he did not place a copy of Patient #29's Advance Directives in the record rendering the record incomplete.

b. Patient #30 arrived at the ED on 5/2/14 at 5:36 P.M. with an elevated potassium level and anxiety and was admitted to the hospital with hyperkalemia. Review of the clinical record and interview with Assistant Nurse Director #4, on 5/5/14 at 1:05 P.M., identified that Registration staff identified that Patient #30 had executed Advance Directives. Review of the nursing admission history completed by RN #8 identified that Patient #30 had executed Advance Directives, however, a copy was not obtained and/or placed in the clinical record.

Review of the hospital policy and procedure, titled Advance Directives, Notice to Patients, identified that during the registration and admission process, the patient is queried and staff document whether or not the patient has executed Advance Directives. If the patient has Advanced Directives, the documents should be placed in the patient's clinical record/chart.

Based on a review of clinical records, interview, and policy review for one of three patient's reviewed (Patient #49) for obstetrical services, the facility failed to ensure that the fetal monitoring tracings were present in the record. The finding includes:


Patient #49 arrived to the Family Birthing Center, Triage unit, for observation, on 5/5/14 at approximately 12 Noon from the physician's office to rule out urinary tract infection. The patient's estimated due date was 7/10/14 (gestational age of 30 weeks and 4 days). The record reflected that an external fetal monitor (monitors fetal heart rate) was placed on the patient at 12:10 PM. Review of RN #5's nurses' note dated 5/5/14 at 5:05 PM identified that the patient was admitted to the Labor & Delivery unit and started on a Magnesium Sulfate drip.


Although review of the observation outpatient record reflected that the fetal heart rate was monitored, the record failed to identify that fetal monitoring strips were present in the clinical record during the period of 4:55 PM through 6:25 PM. Record review and interview with RN #5 on 5/7/14 at 10AM confirmed that the fetal heart rate was monitored, however, s/he failed to update the Centricity system (Perinatel system) when the patient moved from a triage bed to an inpatient bed, therefore, fetal monitoring strips were not recorded. RN #5 further identified that Centricity has the ability to transfer status to inpatient but the RN needs to change the status in the computer and in this case, that was not done.

1. Based on observation during tour of the Operating, Gastroenterology and Central Sterile Suites, the hospital failed to ensure that furniture/equipment utilized in those areas were intact and/or moisture resistant. The findings include:
a. During tour of the GI/OR/Central Sterile Suites several chairs and a stool were observed to have non-moisture resistant fabric and/or ripped fabric and/or slits in vinyl covering and/or tape holding pieces of the chair together rendering an inability to effectively disinfect the surfaces.

b. Observation of an OR (#1) identified a phone jack hanging from a wall with exposed plaster. Another room had a wall table whose corners were held intact with tape, exposing a taped surface that could not be cleaned.

c. Observation of the cardiovascular room identified an arm board with overlapping fold-back cover stored on the floor, propped against other equipment.





19907

2. Based on review of hospital documentation, observations and interviews with facility personnel, the facility failed to ensure that daily code cart checks were maintained. The finding includes:


a. Review of the code cart checks in the Intensive Care Units on 5/5/14 identified that code carts were not completed twice a day. Review of hospital policy identified that code 3/defibrillator is to be checked twice daily at the start of the shift. Interview with the Assistant Director on 5/5/14 identified that the code cart checks were not completed per hospital policy.

1. Based on medical record reviews, review of facility documentation, review of facility policies, observations and interviews for one of six patients (Patient #13), who required isolation and/or for one of multiple staff members observed for adherence to infection control practices, the facility failed to ensure that all staff utilized personal protective equipment and/or followed IC practices as required. The findings include:

a. Patient #13 was admitted to the ED and P5 unit on 3/10/13 and with a diagnosis of Influenza B. The ED physician notes by MD #10, noted that he/she called and spoke with a physician in MD #12's office and the decision was made to admit the patient to a teaching service under MD #12's care. Facility documentation dated 3/22/13 from MD #10 indicated that Person #4 was upset because MD #12 visited Patient #13 on 3/11/13 and was also upset that MD #12 did not wear a mask, gown or gloves when in the patient's room. Interview with MD #10 on 5/7/14 at 1:25 PM identified that he/she was the staff epidemiologist on 3/11/13, the patient was on droplet precautions that required the use of masks and hand washing and the droplet precaution sign was posted outside of the patient's door. MD #10 further indicated that he/she spoke to MD #12 on 3/11/13, instructed MD #12 on the use of a mask and hand washing and that MD #12 verbalized that MD #12 "understood." The hospital policy for droplet precautions identified that a mask was required before entering the room and to clean hands upon entering and leaving.
b. Patient #13 was admitted to the hospital on 3/15/13 with diagnoses of hypoxia and pulmonary disease. The nasal swab dated 3/19/13 identified Methicillin resistant Staphylococcus aureus (MRSA) and the patient was placed on contact precautions. The discharge summary dated 3/26/13 indicated a secondary diagnosis of possible MRSA pneumonia that was treated with Vancomycin for six days. Facility documentation dated 3/24/13 from Person #4 identified that PCT#1 entered Patient #13's room on 3/24/13 without wearing a gown or gloves. Interview with PCT #1 on 5/7/14 at 2:35 PM noted that he/she had returned to the patient's room without gown/gloves to hand the nurse a water pitcher for the patient and did not have gown and gloves on. He/she further noted that the Patient was on contact precautions and now wears a gown and gloves prior to entering all contact isolation rooms no matter what the reason.
In addition, facility documentation from Person #4 dated 3/24/13 identified that Dietary Aide #1 entered Patient #13's room without a gown on 3/24/13 to deliver breakfast. Facility documentation dated 3/26/13 indicated that the Director of Food Services at that time spoke with Dietary Aide #1 and Dietary Aide #1 "admitted" to not wearing a gown and that Dietary Aide #1 should receive the "fullest extent of discipline to be issued." Interview with Dietary Aide #1 on 5/8/14 at 9:42 AM noted that he/she was real busy on 3/24/13 because the evening aide on 3/23/13 did not help patients to fill out their menus. He/she further noted tat he/she left Patient #13's room to get the supervisor and when he/she walked back into Patient #13's room, he/she walked into the room without a gown.

The facility policy for contact precautions identified that gown, gloves were required and to clean hands upon entering and leaving room or area.




15482


2. Based on observation and policy review, one staff member failed to perform hand hygiene between tasks in accordance with policy. The finding includes:

a. On 5/6/14 at 10:00 AM during tour of Pomeroy 8 with the Unit Director, RN #16 was observed in room #8035 obtaining a finger-stick blood sugar sample. RN #16 was observed with gloves on to obtain the blood sample. RN #16 gathered and discarded items and proceeded to the nurse's station where s/he discarded items, obtained a sani wipe, cleaned the glucometer, removed gloves and placed the glucometer in the medication room. RN #16 failed to perform hand hygiene between tasks.
Review of the policy indicated gloves should be changed if the patient interaction also involves touching mobile equipment. The policy indicated that hand hygiene should follow glove removal.

Based on observation and hospital policy review, the hospital failed to ensure that all operating room personnel had their hair contained within a cap. The finding includes:

a. During tour of the Operating Suite on 5/5/14 with the Assistant Director of the OR, observation of OR #10 identified a scrubbed personnel wearing a bouffant cap that failed to cover his/her entire head of hair, leaving hair exposed at the circumference of the cap as the staff member leaned over the sterile field. According to hospital policy, all OR staff should cover all hair when in the restricted/semi-restricted area.

The inspection consisted of a review of records, procedures, equipment and facilities, including the following: (a) in-house physics reports and follow-up corrective actions; (b) personnel dosimetry records; records of receipt of radioactive materials; (d) quarterly inventories; (e) records of area surveys; (f) records of calibration of available radiation detection instrumentation; (g) calibration of the dose calibrator, including linearity, and constancy determinations; and (h) leak test records.

In the Nuclear Medicine Department, one item of non-compliance was identified.

1) CFR 482.53(d) in part requires that signed and dated reports of nuclear medicine interpretations, consultations, and procedures be maintained.

Contrary to the above, Waterbury Hospital had records from 5/18/14 for patient I-131 therapy for hyperthyroidism and thyroid carcinoma that were not filled out or signed as required by Waterbury Hospital procedures.

Based on medical record review, review of hospital policies and interviews for 1 of 3 patients who had altered respiratory function (Patient #57), the hospital failed to ensure that the patient received respiratory treatments as ordered. The finding includes:

a. Patient #55 was admitted to the hospital on 5/4/14 with a history of lung cancer. Physician orders dated 5/5/14 at 10:44 AM directed a Duoneb respiratory treatment every 6 hours while awake. The medication record indicted that the patient received a respiratory treatment on 5/5/14 at 10:35 AM by the respiratory therapist (RT) and the next respiratory treatment was administered by the RT on 5/6/14 at 12:17 AM. Interview with the Assistant Director of RT on 5/6/14 at 10:00 AM identified that only RTs administer respiratory treatments. Review of the patient ' s record and interview with the Assistant Director of RT on 5/6/14 at 10:20 AM noted that Patient #55 should have received respiratory treatments on 5/5/14 at 4:40 PM and 10:40 PM, the 10:40 PM treatment was administered late (5/6/14 at 12:17 AM) and this might have been due to the fact that the patient was transferred to a different unit on 5/5/14. Further interview with the Assistant Director of RT on 5/6/14 at 11:00 AM indicated that he/she monitors, in part, missed respiratory treatments on a monthly basis. The hospital job description for RT identified a responsibility to administer prescribed respiratory care.

1. Based on a review of clinical records, policy review and interview, for one of three patients (#14) reviewed for respiratory services, the hospital failed to ensure the physician's order was followed. The finding includes:

a. Review of Patient #14's clinical record identified that the patient was admitted to the hospital on 11/23/13 with diagnoses that included, in part, a past medical history of interstitial lung disease with bronchiolitis obliterans with oxygen dependence, pulmonary hypertension and atrial fibrillation. A physician's order dated 11/24/13 at 7:57 AM, directed the administration of Albuterol aerosol every four (4) hours around the clock in keeping with the patient's frequency of medication delivery at home. The patient's record reflected that additional respiratory medications were added on an as needed (PRN) basis. Review of the Medication Administration Record (MAR) during the period of 11/24 at 8:00 AM through 11/27 at 12:00 AM, failed to indicated that the aerosolized albuterol was administered every four (4) hours (a total eight (8) times, mostly during the night hours). On some of those eight occasions, a PRN medication had been given during the interim times.

During interview on 5/7/14 at approximately 10:15 AM, RT #2 stated that Patient #14 was often anxious about receiving the respiratory treatments and treatments were delivered often on a PRN basis based on patient request.

Review of the hospital policies and job descriptions reflect that the respiratory therapist administers prescribed respiratory care per physician orders.



19907

2. Based on clinical record reviews, review of hospital policies and procedures and interviews with facility personnel who required respiratory services (Patient #15), the facility failed to ensure that education was provided to patients who required non-invasive positive pressure ventilation (CPAP) The finding includes:

a. Patient #15 was admitted to the hospital on 3/23/13 with sepsis and bacteremia. Review of the clinical record identified that on 3/27/13 the patient was started on non-invasive positive pressure (CPAP) due to respiratory distress. Further review failed identify that the patient was educated on the usage of the new equipment. Review of hospital policy failed to identify a mechanism on which patients are educated on the utilization of non-invasive positive pressure. Interview with the Director of Respiratory Services on 5/7/14 identified that there was no documentation noted that the patient was educated on how to use the CPAP machine.