HospitalInspections.org

Based on the review of the facility's Plan of Correction approved by the State Agency on 3/27/15, the facility's education documentation, audit tools, Rules and Regulations of the Medical Staff, and policy and interview, it was determined the facility failed to:


1. Follow their own Plan of Correction for monitoring emergency equipment. Refer to A 093.

2. Follow their own Plan of Correction for ensuring medical records (MR) contained the correct consents and were signed by patient / caregivers. Refer to A 131.

3. Follow their own Plan of Correction for education to be provided to clinician's and medical staff. Refer to A 392.

4. Ensure the patients received all medications, treatments as ordered by the physician. Refer to A 392.

5. Follow their own Plan of Correction for ensuring nursing and medical staff were educated on accurate documentation and swing bed process. Refer to A 467.

6. Follow their own Plan of Correction for ensuring a home medication policy was in place and clinical staff were educated. Refer to A 500.

7. Follow their own Plan of Correction for ensuring the nursing and medical staff were provided education regarding dietitian consults. A 621.

8. Follow their own Plan of Correction for ensuring all registered nurse (RN) staff were inserviced on freedom of choice form. Refer to A 823.

This had the potential to affect all patients served by this facility.

Findings include:

Refer to A 286, A 131, A 392, A 467, A 500, A 621, and A 823 for findings.

34107

Based on the review of the facility's Plan of Correction approved by the State Agency on 5/29/15, the facility's documentation, and interview, it was determined the facility failed to follow their own Plan of Correction for ensuring the Defibrillator Test Log was completed daily by the nursing staff. This had the potential to affect all patients served by this facility.


Findings include:

Review of the Plan of Correction approved by the State Agency on 5/29/15 at 482.12(f)(2) revealed "As of 4/28/15, Nursing management will monitor the log sheet daily for 2 weeks, weekly for 6 weeks, then added to ongoing monthly quality assurance monitoring by the QA designee starting in July 2015."

1. Review of the Defibrillator Log Monitoring form provided with the Plan of Correction revealed there was no documentation on 5/2/15, 5/3/15, 5/4/15, 5/9/15, 5/10/15, 5/13/15, 5/14/15 or 5/15/15 that nursing management ensured the Defibrillator Test Log was completed daily.

In an interview conducted on 6/16/15 at 9:30 AM with Employee Identifier # 1, Quality Manager, it was confirmed the Defibrillator Test Log was not monitored daily for 2 weeks as stated in the Plan of Correction.

Based on review of medical records (MR), Plan of Correction approved by State Agency on 5/29/15 and interviews with administrative staff it was determined the facility failed to obtain an informed consent for patients admitted to the facility for 2 of 2 inpatient MR reviewed. This affected MR # 1, and MR # 2, and had the potential to affect all patients served by this facility.

Findings include:

Review of the Plan of Correction approved by the State Agency on 5/29/15 at 482.13(b)(2) revealed to include, "...The policy and procedure (P & P) for signing patients' rights and consent for treatment were reviewed and revised on May 18, 2015...

Registration management and medical records will monitor the patient rights and consent for treatment forms daily for a month ending 6/29/15 and then weekly thereafter.

"Swing Bed Admission Registration Process...

After the patients are discharged out of the system from inpatient status and the registrar receive orders from the physician or nurse to change the patient to swing bed (SB) ...

The following forms are necessary for the new chart:

Conditions of admissions form,
Important message from Medicare about Your Rights Form,
The Patient Information Form
Rights as a Hospital Patient Form
Notice of Privacy Form
Advance Directives Form
Consent to Treatment Form

Patient Rights / Consent to Treatment Forms...

When patients are unable to sign forms registrars are to make a note on the forms stating that the patient is unable to sign due to _____ at the time of registration along with the date, time, and registrars signature...."

1. MR # 1 was admitted to a swing bed on 6/8/15 with diagnoses of Recurrent Falls, Weakness, History of Deep Vein Thrombus (DVT) and Hypertension.

Review of the MR revealed the following unsigned forms Conditions for Admission and An Important Message from Medicare about Your Rights.

The following forms were not found in the patient's MR:
The Patient Information Form
Rights as a Hospital Patient Form
Notice of Privacy Form
Advance Directives Form
Consent to Treatment Form.

The surveyor questioned Employee Identifier (EI) # 2, Director of Nurses (DON) as to why the forms were not signed at the time of admission on 6/8/15. After, consulting with the registrars it was conveyed to the surveyor the patient was unable to sign the forms and the caregiver was not available.

Review of the 6/8/15 skilled nurse (SN) Admission revealed documentation of "wife at bedside".

On 6/16/15 at 1:30 PM the surveyor reviewed the MR again and found the 2 forms signed by the patient's wife. The other 5 forms were still not in the MR.

This was verified on 6/16/15 at 1:30 with EI # 2, Quality Manager.

Review of the MR audit tool to ensure Patient Rights and Consent for Treatment forms was signed as part of the Plan of Correction that contained admissions through 6/9/15 and did not list MR # 1 as a 6/8/15 admission.

In an interview conducted on 6/17/15 at 12:30 PM with EI # 1, the aforementioned findings were verified.

2. MR # 2 was admitted to the facility on 6/14/15 with the diagnoses of Chronic Obstructive Pulmonary Disease (COPD) Exacerbation 2 degree to Left Lower Lobe Pneumonia.

Review of the MR on 6/15/15 at 11:30 AM revealed no signed consent forms by the patient. The surveyor asked as to why they were not signed, "It was revealed the patient could not sign forms".

There was no documentation in the MR as to patient's inability to sign consent forms.

Further review of the MR did not contain the required Conditions of Admissions Form or Important Message from Medicare about Your Rights Form.

It was verified on 6/16/15 at 1:30 PM with EI # 1, Quality Manager, that the patient consents were still not in MR, not signed and no documentation as to why they were not signed.

34107

Based on review of medical records, policy and procedures, Plan of Correction, and interview, it was determined the nursing staff failed to ensure:

1. Patients received all ordered medications and treatments.
2. Physician's orders were obtained for care and maintenance of intravenous (IV) heparin (hep) lock.
3. In-services were conducted for medication documentation.

This affected Medical Record (MR) # 2 and MR # 1, 2 of 2 admitted patient MR's reviewed. And had the potential to negatively affect all patients served by the facility.

Findings include:

Facility Policy
Accuracy and Timeliness of Medical Record
Documentation
Written 1/1/14

Policy:
1. A complete, legible and accurate paper and / or electronic medical record will be maintained for every individual who is evaluated or treated as an inpatient, outpatient, or emergency patient at Greene County Hospital...

6. A patient's record is complete when the following criteria are met:
A medical history and physical examination...
Properly executed informed consent forms.
Practitioners' orders, nursing notes, reports of treatment, medication records...vital signs and other information necessary to monitor the patient's condition.

Review of the Plan of Correction approved by the State Agency on 5/29/15 at 482.23(b) revealed:

...Medication documentation policy reviewed on 4/28/15. In-services to be conducted by nurse educator and will conclude by 5/29/15.


There will be daily chart checks for 6 months using visual audits and checklist to evaluate the need for improvement and to identify areas for feedback and learning. These will be monitored by the Director of Nursing or designee and will continue to be monitored every quarter.

Completion Date: 5/29/15


1. MR # 2 was admitted to the facility on 6/14/15 with the diagnoses of Chronic Obstructive Pulmonary Disease (COPD) Exacerbation 2 degree to Left Lower Lobe Pneumonia.

Review of the 6/14/15 Physician History and Physical (H & P) documentation as, "Medications: As per nurse's list.
Physical Exam: Weak, looks sick...
Vitals: Maximum Temperature 101.3..."

Review of the 6/14/15 Physician's Orders revealed the written physical orders to include, "Same home med's, and Chest Percussion every 4 hours" did not include an order for nursing to maintain intravenous (IV) access via saline lock or medication to manage patient's temperature.

Review of the the 6/15/15 skilled nurse (SN) Patient Progress Note at 3:15 AM, 5:13 AM, 7:33 AM revealed the documentation, "IV patent with dressing dry and intact..." At 8:16 AM the SN documented, "Attempted to flush Saline Lock (SL) with 10 cubic centimeters (cc) of Normal Saline (NS). IV would not flush... Will contact physician (MD) for orders to restart IV."

Review of 6/15/15 8:24 AM Nurses note revealed, "MD notified...verbal order received to restart patient's IV....Flushed with 10 cc NS..."

Review of the MR did not reveal a physician's verbal order was written by the SN.

Review of the MR did not reveal documentation of what home medications were to be continued.

Review of the 6/15/15 SN note at 7:33 AM revealed the documentation, "Respiratory Nursing Interventions: Encourage to turn, cough, and deep breath (TCDB)".

There was no documentation the SN performed patient chest percussion every 4 hours as ordered by the physician.

In an interview conducted on 6/17/15 at 12:44 PM with Employee Identifier (EI) # 2, Director of Nurses (DON), it was confirmed the physician failed to provide complete orders for the patient and SN failed to document the verbal order for IV or provide treatments as ordered per the physician.

2. MR # 1 was admitted to a swing bed on 6/8/15 with diagnoses listed as "Recurrent Falls, Weakness, History of Deep Vein Thrombus (DVT) and Hypertension.

Review of the 6/8/15 Physician H & P revealed documentation as, "Medication: Aspirin, Lipitor 40 daily, Coumadin 1 milligram (mg) daily."

Review of the 6/8/15 1:30 PM Physician's Telephone Order revealed the only medications ordered for the patient as "Home medications: 1 mg Coumadin QHS (hours of sleep). 25 mg Hydrochlorothiazide (HCTZ)".


Review of the 6/9/15 1:30 PM and the 6/10/15 8:46 AM SN note revealed documentation, "Pain Intervention: As needed (PRN) medication, as needed by patient". There were no PRN pain medication ordered by the physician.

Review of the 6/15/15 Medication Record 11:07 AM revealed Atorvastin Calcium (Lipitor) 20 mg tablet (tab), 40 mg HS was started at 1:07 AM and Warfarin Sodium (Coumadin) 1 mg tab, 2 mg HS was started on 6/13/15 at 12:49 PM.

Review of the MR revealed there were no physician orders or physician's verbal orders found for the Lipitor or Coumadin.

Further review of the MR revealed there was no physician order's for the 6/8/15 Complete Blood Count (CBC), Basic Metabolic Profile (BMP) or the 6/10/15 International Normalized Ratio (INR) performed on the patient.

An interview was conducted on 6/17/15 with EI # 2, and it was confirmed the medications and labs were ordered by nursing staff and there was no evidence of a physician's order was obtained.

There was no documentation of the Medication documentation policy was reviewed or in-services were conducted. The Medication documentation policy was requested and not provided during the survey. It was confirmed via email 6/18/15 by, EI # 1, Quality Assurance Nurse there was no medication documentation policy.

Based on review of medical records (MR), Plan of Correction approved by State Agency on 5/29/15 and interviews with administrative staff it was determined the facility failed to follow their Plan of Correction to educate physicians and nursing staff on complete and accurate documentation, including physician orders. This had the potential to affect all patients served by this facility.


Findings include:

Review of the Plan of Correction approved by the State Agency on 5/29/15 at 482.24(c)(2)(vi) revealed, "... 3. The policy and procedure (P & P) on swing bed admissions was revised on 4/27/15 and reviewed with the Physicians as well as nursing staff. In-service to train clinical staff on complete and accurate documentation as well as MD orders began on 4/27/15 and will be ongoing as needed...

Review of the Swing Bed Admission Process was revised on 5/18/15 and approved by the Medical Board on 6/16/15.

There was no documentation that in-services were conducted to educate the Physician's or clinical staff on swing bed admissions, complete and accurate documentation or physician orders as stated in the accepted Plan of Correction.

An interview was conducted on 6/17/15 at 1:15 PM with Employee Identifier, 2, Director of Nurses, it was confirmed there was no documentation of in-services.

34107

Based on review of facility policy and procedure, Plan of Correction accepted by the State agency on 5/29/15, and staff interview, it was determined the facility failed to develop and implement a policy for home medication verification.

This had the potential to affect all patients served by the facility.

Findings include:

Review of the Plan of Correction approved by the State Agency on 5/29/15 at 482.25(b) revealed, "...A new policy and procedure was implemented on 5/11/15 for the verification of home medications which states that only the pharmacist or MD using pharmacy designated tool can verify home medications if the pharmacist is not available. No home medications will be administered until verified by the pharmacist and only 3 days maximum. Nursing staff was in-serviced on 5/11/15 and will be completed by 5/29/15..."

The survyeor was presented with 2 facility policies for Home Medications:

Policy # 1.
Policy For Home Medication(s)
Revision: 4/28/15
This policy was provided to surveyor on 6/15/15.

"...A nurse may adminster a patient's own medication if: is non-formulary and its use will be short term-term..."

Policy # 2.
Patient's Own Medication (Usage)
Reference # 6301
Revision date: 5/30/15
This policy was provided to surveyor on 6/16/15 at 2:00 PM.

There was no documentation provided to surveyor the staff was inserviced as indicated in Plan of Correction on 5/11/15 and completed by 5/29/15.

Review of the policies provided to surveyor did not contain the 3 days maximum usage as stated in the Plan of Correction.

On 6/16/15 the surveyor left questions for pharmacy staff regarding the 3 days maximum listed on the Plan of Correction.

On 6/17/15 at 7:30 AM the surveyor was presented with another copy of Patient's Own Medication (Usage) policy # 6301 with the added verbage written in pencil, "The patient's own medications can be used for a maximum of 3 days while in the facility."

In an interview on 6/17/15 at 1:40 PM with Employee Identifier (EI) # 3, Chief Executive Officer (CEO), the surveyor asked the following questions:
A. Were both home medication policies were approved at the 6/16/15 at 7:30 AM meeting? The answer was yes.
B. Which home medication policy was to be used?
The answer was policy # 2 reference # 6301.
C. Were you aware of the changes made by the pharmisist after the approval of policy? The answer was no.
D. How would this policy changes be handled?
The answer was it would be brought before the medical director, and medical board.
E. How will staff be educated on all policy changes?
The pharmacist will educate Director of Nurses and Quality Assurance Nurse and they will educate the staff.

Based on the review of the facility's Plan of Correction approved by the State Agency on 5/29/15, in-sevice documentation, and interview, it was determined the facility failed to provide training to the nursing and medical staff regarding dietitian consults. This had the potential to affect all patient's served by the facility.

Findings include:

Review of the Plan of Correction approved by the State Agency on 5/29/15 at 482.28(a)(2) revealed:

"...Policies were reviewed on 4/27/15. Training will be given to nursing and medical staff on diet orders and dietitian consults, this will conclude by 5/29/15."

In an interview conducted on 6/17/15 at 8:00 AM with Employee Identifier (EI) # 4, Dietary Manager it was confirmed there was no documentation of policy reviews or training was provided to the nursing or medical staff regarding dietitian consults.

Based on the review of the facility's Plan of Correction approved by the State Agency on 5/29/15, in- service documentation and interview, it was determined the facility failed to provide training to the nursing and medical staff regarding freedom of choice forms. This had the potential to affect all patient's served by the facility.

Findings include:

Review of the Plan of Correction approved by the State Agency on 5/29/15 at 482.43(c)(6)(7)(8) revealed: "...All registered nurse (RN) staff will be in-services on freedom of choice form to begin compliance with providing these services in the absence of social services. This will be completed by 5/29/15."

Review of the documentation of education and in-services provided to the surveyor on 6/15/15 and 6/16/15 did not reveal evidence of the in-service regarding the freedom of choice form.

In an interview conducted on 6/17/15 at 12:25 PM with Employee Identifier # 2, Director of Nurses, it was confirmed there was no documentation the in-services were conducted