HospitalInspections.org

Based on observation and staff interview, the facility failed to provide a clean environment for storage of patient care equipment and supplies as evidenced by the accumulation of dust in the clean storage room. Findings:

Initial tour of the hospital conducted on 9/9/13 at 11:50 a.m. escorted by S6LPN revealed a room labeled clean utility located across from the nurses ' station. There were 5 (4 tiered) shelves with patients ' hygiene supplies, medical supplies. The contents of the room included patient hygiene supplies, and medical supplies, personal bath items, admit kits, IV fluids, peritoneal insertion kit, central line insertion, disposable diapers, disposable pads, and bed pans. Large amounts of dust balls were noted on the floor and layers of dust were observed on the shelves and an open sitz bath.

Inspection of the crash cart located behind the nurses ' station on 9/9/13 at 12:10 p.m. revealed the top of the cart and defibrillator were both coated with a layer of dust.

An interview on 9/9/13 at 12:05 p.m. with S5ADON revealed there were no cleaning logs or records of cleaning the storage room. He stated that housekeeping should be responsible for cleaning the room and there was no way to tell the last time it was cleaned. S5ADON confirmed that the floors were dirty, the shelves, crash cart, defibrillator, and sitz bath were all dusty. He stated the supply room was a clean area and the supplies and items were for patient use. When asked who was the Infection Control nurse, S5ADON replied he was.

Based on interview and record review, the hospital failed to administer pharmaceuticals in accordance with accepted professional principles as evidenced by:
1) failing to ensure all first dose medications (except in emergency situations) were reviewed by a pharmacist before the first dose was dispensed for 1 (#1) of 1 (#1) patients reviewed for medications dispensed when a pharmacist was not in the facility.
2) failing to ensure only the pharmacist admixed all drugs in the pharmacy using a laminar flow hood or another appropriate environment except in emergency situations.
3) failing to ensure that outdated drugs were not available for patient use.
4) failing to ensure that medications were reinstated for 1 (#3) of 1 (#3) patients reviewed for medication-hold periods expired.

Findings:

1) Failing to ensure all first dose medications (except in emergency situations) were reviewed by a pharmacist before the first dose was dispensed.

Review of the policy and procedure titled Order Processing: Pharmacy, Policy No. 14-11, stated in part:
A pharmacist shall review the prescriber ' s original order, or direct copy thereof, before the initial dose is dispensed. (with the exception of emergency orders when time does not permit).
If the order is written when the pharmacy is " closed " or the pharmacist is otherwise unavailable, it should be reviewed by a pharmacist as soon thereafter as possible, preferably within 24 hours.

Review of the medical record for Patient #1 revealed an order dated 9/8/13 at 1:30 p.m. for Primaxin 500mg (milligrams) IVPB (intravenous piggy back) q (every) 8 hours and Levoquin 500mg IVPB q 24 hours.

In an interview on 9/10/13 at 8:45 a.m., S3Pharmacist stated the orders for Patient #1 dated 9/8/13 at 1:30 p.m. for the Levoquin and Primaxin were written when a pharmacist was not at the hospital and the medications were given without having the first dose reviewed by the pharmacist.

In an interview on 9/9/13 at 2:00 p.m. with S3Pharmacist, she stated she worked Monday through Friday 8:00 a.m. until 4:00 p.m. and then was on call at night. S3Pharmacist also said she or another pharmacist worked a few hours on the weekend and holidays to get what needed to be done finished, then someone was on call if needed. S3Pharmacist stated she did not do a first dose review of new medications at night or on the weekends when she was not at the hospital. S3Pharmacist said if it was not entered into the computer system by a pharmacist, the nurses could override the medication dispensing machine and take the medications out of stock or enter the med as a onetime dose. S3Pharmacist said she thought the federal regulations stated a first dose review was recommended, but not required.


2) Failing to ensure only the pharmacist admixed all drugs in the pharmacy using a laminar flow hood or another appropriate environment except in emergency situations.

Review of the hospital policy titled Sterile Products: General, Policy No. 17-01, revealed in part:
The pharmacy shall prepare, label, distribute, and store sterile products in accordance with recognized authoritative references and pharmacy policies and procedures. Personnel who prepare and administer sterile products shall be properly oriented, educated, and trained.

In an interview on 9/10/13 at 3:00 p.m. with S2DON, she stated the nurses do intravenous admixtures at night. S2DON said during the day, the pharmacist did the admixtures under the laminar hood in the pharmacy.

In an interview on 9/10/13 at 3:15 p.m. with S3Pharmacist, she said the nurses mixed IV admixtures at night and on the weekends when she was not at the facility. S3Pharmacist also verified all IV admixtures mixed by the nurses were not emergency meds. S3Pharmacist said when she mixed the IV medications in the pharmacy, she used a laminar flow hood to decrease the possibility of contamination. S3Pharmacist said the reason the IV fluids did not have to be mixed under a hood at night is because the pharmacist was not there, so there was no other way to mix the medications. S3Pharmacist verified the nurses had not had any hospital orientation, education, or training to prepare or administer sterile products such as IV admixtures.

3) Failing to ensure that outdated drugs were not available for patient use.

A tour of the nurses' station on 9/9/13 at 12:45 p.m. accompanied by S5ADON revealed a crash cart located in the nurses' station that was unlocked by S5ADON. Observation of the crash cart in drawer number 4 revealed a 15 gram tube of opened lubrication jelly with an expiration date of 5/13. The label posted on the tube read "expires 5/13 return to central supply".

In an interview on 9/9/13 at 12:45 p.m. with S5ADON, he stated the lubrication jelly was used by the respiratory therapists to lubricate the endotracheal tubes during a code.
S5ADON stated that the tube in the cart was available for use by the staff in an emergency, and it should have been returned to Central Supply.

A tour of Respiratory Department on 9/9/13 at 1:00 p.m. with S2 DON revealed a box which contained (28) 3 milliliters vials of 0.9 % Sodium Chloride Inhalation Solution (used for nebulizer treatments) which had an expiration date of 2/13.

In an interview on 9/9/13 at 1:00 p.m. with S2DON, she verified that the normal saline was used for nebulizer treatments and they were outdated as of 2/13. S2DON verified that the 28 vials of normal saline were accessible for patient use and should have been removed and discarded.
In an interview on 9/9/13 at 1: 10 p.m. with S9CRT, she confirmed that the 28 vials of Sodium Chloride Inhalation Solution in the respiratory department were outdated and accessible for patient use.

4) Failing to ensure that medications were reinstated for after medication-hold periods had expired.

Patient #3 is a 81-year-old female admitted to the hospital on 09/05/13 with the diagnoses of pneumonia.

Review of the physician orders revealed a telephone order dated 09/06/13 at 7:15 p.m. to hold Metformin for 48 hours by S10Physician.

Review of the Medication Administration Record (MAR) revealed that the Metformin was not continued after the 48-hour hold period. Further review revealed the Metformin was not resumed on 09/08/13 at 9:00 p.m., and the 09/09/13, 5:00 a.m. and 09/09/13, 1:00 p.m. doses were also missed. The patient was discharged on 09/09/13 at 2:00 p.m.

In a face-to-face interview on 09/10/13 at 9:50 a.m., S6LPN confirmed that the above indicated 3 doses were not given. She also indicated that the computer system was not capable of placing medications on hold, and the pharmacist had to discontinue the medications out of the electronic MAR system. She further indicated she thought the physician was responsible for reordering the medications after the hold period expired.

In a face-to-face interview on 09/10/13 at 10:00 a.m., S3Pharmacist indicated that she had to discontinue medications put on hold because the computer system does not allow a medication to be held for a specified amount of time. She also indicated she thought the physician was responsible for reordering the medication after a hold period expired, and she did not know if the ordering physician was aware of this situation or his responsibility for reordering a medication after he placed a medication on hold for a specified amount of time.

In a face-to-face interview on 09/10/13 at 10:10 a.m., S2DON indicated she thought the physician would be responsible for reinstating medication orders after initiating a hold order for a medication for a specified amount of time. She also indicated that she was not aware if the physicians were informed about the issue.

In a face-to-face interview on 09/10/13 at 1:00 p.m., S10Physician indicated that he was not aware the electronic MAR system was not capable of placing a medication on hold for a specified amount of time, and the medication was actually discontinued by the pharmacist. He further indicated he was not aware that he had to rewrite a medication order after the specified hold time expired in order for the patient to continue to receive the medication.






31048




31206

Based on interview and record review, the hospital failed to ensure medication errors were reported to the physician for 2 (#1, #2) of 20 (#1- #20) patients reviewed.

Findings:
Review of the policy titled Errors: Drug Administration, Policy No. 15-08, revealed in part:
Drugs administered in error or omitted shall be reported and reviewed in accordance with this policy.
Administration of a drug in any manner other than that prescribed is an error.
Drug administration errors shall be reported immediately to the practitioner who ordered the drug.
The drug administered in error or omitted in error and the action taken shall be properly recorded in the patient ' s medical record.

Patient #1

Review of the medical record for Patient #1 revealed he was a current patient who had been admitted on 8/26/13 to acute care and admitted to swing-bed on 8/29/13.

Review of the physician ' s orders dated 8/29/13 at 1910 for Patient #1 revealed an order for Requip 0.25 via peg (percutaneous endoscopic gastrostomy) TID (three times daily) and Sinemet 25/100 via peg TID.

Review of the MAR (medication administration record) dated 8/30/13 for Patient #1 revealed the nurse had not documented he received his 0500 doses of Requip 0.25 mg (milligrams) and Sinemet 25/100 mg.

Review of the nurse ' s notes, progress notes, and physician ' s orders for Patient #1 revealed no entry where the physician was notified about the 2 missed medications on 8/30/13 after the pharmacist discovered the errors.

In an interview on 9/9/13 at 2:15 p.m. with S3Pharmacist, she stated if she found a medication error, she would fill out an occurrence report and notify the nurse taking care of the patient. S3Pharmacist stated she did not notify the physicians about medication errors. S3Pharmacist said she had two medication variances for Patient #1 from 0500 on 8/30/13 for Requip 0.25 mg (milligrams) TID (three times daily) and Sinemet 25/100mg TID. S3Pharmacist said she had not yet completed an occurrence report for either of the omitted medications.

In an interview on 9/9/13 at 2:30 p.m. with S4LPN, she said she was working the day shift on 8/30/13 and was the nurse for Patient #1 when the pharmacist discovered the 2 missed medication doses from 0500 that morning. S4LPN said she could not locate any documentation in Patient #1 ' s medical record of the physician being notified of the missed doses. S4LPN said the physician notification would have been documented in the nurse ' s notes or on the MAR.

In an interview on 9/9/13 at 3:00 p.m. with S2DON, she stated when a medication error occurred, a medication variance form was completed and the physician had to be notified. S2DON said the notification of the physician should have been documented on an occurrence report or in the nurse ' s notes. After review of Patient #1 ' s medical record, she verified the 8/30/13 at 0500 doses of Requip and Sinemet had not been documented as having been given. S2DON also verified there was no documentation on the occurrence report or in the patient ' s medical record that the physician had been notified.

Patient #2

Review of the medical record for Patient #2 revealed he had been admitted on 8/16/13 with diagnosis which included cellulitis, dehydration and anemia.

Review of the physician ' s orders dated 8/27/13 at 1750 for Patient #2 revealed an order for Norvasc 5mg PO daily.

Review of the MAR for Patient #2 revealed Norvasc 5 mg had not been documented as having been given on 8/27/13.

Review of the medical record for Patient #2 revealed no documentation that the physician had been notified of the omitted Norvasc on 8/27/13.

Review of an occurrence report for Patient #2 dated 8/28/13 revealed he had an order written at 8/27/13 at 1750 for Norvasc 5 mg PO (by mouth) daily and the mediation had not been given. The occurrence report was written by S3Pharmacist.

In an interview on 9/9/13 at 3:15 p.m. with S2DON, she verified Patient #2 had a missed dose of Norvasc 5mg on 8/27/13. S2DON also verified no documentation of physician notification of the error was on the occurrence report in the medical record. S2DON stated the physician should have been notified and it should have been documented in the nurse ' s notes or on the occurrence report.

Based on record review the hospital failed to ensure TB (Tuberculosis) skin test on 7 of 7 employees reviewed were done in accordance with CDC (Centers for Disease Control) as evidenced by 4 staff having TB skin tests that were read outside of the CDC time guidelines, 1 that had no documentation that is was ever read and 2 staff members having no TB skin test performed. Findings:

Review of a CDC TB Skin Testing Guidelines document revealed: "Tuberculin skin test: The TB skin test (also called the Mantoux tuberculin skin test) is performed by injecting a small amount of fluid (called tuberculin) into the skin in the lower part of the arm. A person given the tuberculin skin test must return within 48 to 72 hours to have a trained health
care worker look for a reaction on the arm..."

Review of the personnel records for S12RN, S16RN, S17LPN, and S20MHT revealed the 4 TB skin tests were read outside of the CDC Guidelines of 48 - 72 hours after administration.

Review of the personnel record for S15Psychiatrist revealed he had a TB skin test placed on 6/10/13. Further review revealed no evidence the TB skin test was read.

Review of the personnel records for S18LPN and S19MHT revealed no documented evidence a TB skin test was performed.

In an interview on 9/10/13 at 1:30 p.m. with S2DON she confirmed the above findings.

Based on record review and interviews, the hospital failed to provide organized and adequately staffed rehabilitative services to ensure the health and safety of patients as evidenced by: failing to provide rehabilitative services as ordered; failing to ensure there was sufficient qualified staff to provide services; failing to ensure there were written policies and procedures approved by the Medical staff for rehabilitative services; failing to establish clear lines of authority and responsibility to ensure the health and safety of patients; failing to properly supervise and administer the rehabilitative services; and failing to define in writing the required qualifications and competencies for the rehabilitative staff for 3 (#1, #4, #11) of 20 patients reviewed in the sample. Findings:
Patient #1
Patient #1 is a 78-year-old male admitted to the hospital on 08/29/13 with the diagnoses of urinary tract infection and dysphagia.
Review of the Physical Therapy Initial Evaluation and Treatment Plan, dated 08/29/13 at 10:08 a.m., for Patient #1 revealed he was to receive PT treatments twice per day, five days a week (Monday - Friday). Review of the physical therapy skilled notes revealed Patient #1 received therapy once on 08/29/13; once on 08/30/13; no PT on 09/02/13; no PT on 09/09/13; and once on 09/10/13.
In a face-to-face interview on 09/11/13 at 10:15 a.m., S5ADON verified that the above listed PT treatments were the only PT treatments provided to Patient #1.
Patient #4
Patient #4 is a 71-year-old female admitted to the hospital on 09/03/13 at 7:05 p.m. with diagnoses of pneumonia and urinary tract infection, and a long-standing history of anxiety and hallucinations which were documented as being auditory and visual and only at night.
Review of the orders revealed that a Speech Therapy Evaluation had been ordered for Patient #4 on 09/03/13. Further review of the medical record revealed that no Speech Therapy Evaluation had been performed for Resident #4.
In a face-to-face interview on 09/09/13 at 2:15 p.m., S6LPN indicated that she could not locate any documentation in the medical record that a speech evaluation had been done for Patient #4.
In an interview on 09/09/13 at 3:20 p.m., S7ST indicated that she had not received an order for a speech therapy evaluation on Patient #4. She further indicated that she performs the evaluations typically on the same day as ordered, and all of her documentation is left on the medical record at the time of service.
In a face-to-face interview on 09/09/13 at 3:35 p.m., S2DON indicated, in the presence of S6LPN, she was not aware that the speech evaluation had not been done on Patient #4, and did not provide any further evidence that it had been completed.
In an interview on 09/09/13 at 2:15 p.m., S6LPN indicated that PT treatments are done Monday through Fridays, twice per day (BID). She also indicated the physical therapist that provides PT treatments in the mornings had been out sick, and that is why PT treatments had not been provided as ordered. She further indicated that there is another physical therapist that provides PT treatments to patients in the afternoon and early evening hours.
Review of the Physical Therapy Initial Evaluation and Treatment Plan, dated 09/04/13 at 9:48 a.m., for Patient #4 revealed she was to receive PT treatments twice per day, five days a week (Monday - Friday). Review of the physical therapy skilled notes revealed Patient #4 did not receive a PT treatment on 09/05/13 (received only one); did not receive any PT treatments on 09/06/13 (Friday); did not receive any on 09/09/13; and received one on 09/10/13.
In a face-to-face interview on 09/11/13 at 10:15 a.m., S5ADON verified that the above listed PT treatments were the only PT treatments provided to Patient #4.
Patient #11
Patient #11 is a 69-year-old female admitted to the hospital on 09/09/13 at 1:30 p.m. with the diagnoses of pneumonia and bacteremia.
Review of the Physical Therapy Initial Evaluation and Treatment Plan, dated 09/10/13 at 5:45 p.m., for Patient #11 revealed she was to receive PT treatments twice per day, five days a week (Monday - Friday). Review of the physical therapy skilled notes revealed Patient #11 had not received a morning PT treatment on 09/11/13.
In a face-to-face interview on 09/11/13 at 10:15 a.m., S5ADON verified that the above listed PT treatments were the only PT treatments provided to Patient #11.
In a face-to-face interview on 09/11/13 at 10:50 a.m., S2DON indicated the morning physical therapist was still out sick, and the only physical therapist available for providing services was the therapist who works in the late in the afternoons and early evenings. She further indicated that the two physical therapists were the only two per diem therapists on staff to provide PT treatments, and there was not plan, that she was aware of, to provide alternative therapists if the therapists were unavailable to provide the services ordered. S2DON indicated there were no written policies and procedures regarding rehabilitative service.
Review of the organizational chart revealed no rehabilitative services were identified as part of the organizational structure.
In a face-to-face interview on 09/11/13 at 1:50 p.m., S2DON indicated she did not know who was to evaluate/perform skills assessments and competencies for the physical therapists on staff, and she did not know who supervises the rehabilitative services. She also indicated that the therapy services were contracted services until about 6 months ago when that company. The hospital then hired two per-diem physical therapists.
In a face-to-face interview on 09/11/13 at 2:00 p.m., S1Administrator indicated, in the presence of S2DON, there was no Director of the rehabilitative services because there was no " Rehab Program, " and the rehabilitative service falls under the swing bed service. S1Administrator indicated the Chief of Staff was responsible for all services (which would include the rehabilitative services). S1Administrator also indicated the physical therapists on staff would perform skills assessments, competencies and evaluations on each other as this would not be a function provided by the Chief of Staff. S1Administrator further indicated the rehabilitative service was under Nursing Services, though the rehabilitative service was not identified on the organizational chart under Nursing Services or any other place.
Review of the Medical Staff minutes dated 12/13/12, provided by S13HR, revealed no director appointed over rehabilitative services.
In a face-to-face interview on 09/11/13 at 2:40 p.m., S13HR indicated that S1Administrator stated the Chief of Staff was Medical Director over the hospital, and was not specifically appointed over the rehabilitative services.
In a face-to-face interview on 09/11/13 at 2:40 p.m., S13HR indicated the personnel files for the two per-diem physical therapists were incomplete, and did not contain a job description, a skills/competencies assessment, a resume/application, or a completed hospital orientation checklist.

Based on interview and record review, the hospital failed to ensure the physician ordering drugs and biologicals timed and dated his authentication of telephone orders for 5 (#1, #3, #4, #10 #8) of 20 patients records reviewed.

Findings:

Review of the hospital policy provided by S2DON titled Documentation Policy revealed in part:
Physician signatures must be legible, dated and timed.

Patient #1
Review of the medical record for Patient #1 revealed the following telephone order written on 9/8/13 at 1415: 1) Tylenol 650 mg (milligrams) peg (percutaneous endoscopic gastrostomy) Q (every) 6 hours at 1500, 2100, 0300, 0900 x 24 hours 2) Motrin 600mg peg Q 6 hours at 1800, 0000, 0600, 1200 x 24 hours. Further review revealed S10Pphysician signed the order, but did not time or date his authentication.

Review of the medical record for Patient #1 revealed the following telephone order written on 9/6/13 at 2230: Tylenol 650 suspension per peg Q6 hours x 24 hours. Alternate with Motrin 600mg suspension per peg Q6 x 24 hours. Alternate with Tylenol 650 mg. S10Physician signed the order, but did not time or date his authentication.

Review of the medical record for Patient #1 revealed the following telephone order written on 9/4/13 at 1830: Mag Citrate bottle per peg x 1. S10Physician signed the order, but did not time or date his authentication.

Patient #3
Patient #3 is a 81-year-old female admitted to the hospital on 09/05/13 with the diagnoses of pneumonia.
Review of Paient #3's physician orders revealed a telephone order dated 09/06/13 at 7:30 a.m. for Albuterol 0.083% via nebulizer QID (four times per day) and PRN (as needed) for SOB (shortness of breath), Atrovent 0.02% via nebulizer QID and PRN for SOB; Metformin 500 mg (milligrams) po (by mouth) TID (three times per day) at 9:00 a.m.,1:00 p.m. and 9:00 p.m.; and Mucinex 600 mg po BID revealed S10Physician did not date or time his authentication.
Review of the physician orders revealed a telephone order dated 09/06/13 at 10:10 a.m. to discontinue Dulcolax and start Colace 100 mg po daily PRN constipation revealed S10Physician did not date or time his authentication.
Review of the physician orders revealed a telephone order dated 09/06/13 at 11:25 a.m. for Tylenol 500 mg po every 8 hours PRN for headache or pain revealed S10Physician did not date or time his authentication.
Review of the physician orders revealed a telephone order for Digoxin 0.25 mg IVP (intravenous push x's 1 now; normal saline at 75 ml (milliliters) per hour; telemetry, and to notify MD if heart rate is less than 60 or above 120; labs now for cardiac enzymes; and D-dimer revealed S10Physician did not date or time his authentication.
Review of the physician orders revealed a telephone order to discontinue Albuterol and Atrovent and start Xopenex 1.25 mg nebulizer treatments QID and PRN for difficulty breathing; repeat digoxin 0.125 mg IVP x's 1 now revealed S10Physician did not date or time his authentication.
Review of the physician orders revealed a telephone order for Restoril 15 mg, one, by mouth every hour of sleep revealed S10Physician did not date or time his authentication.
Review of the physician orders revealed a telephone order dated 09/06/13 at 7:15 p.m. to hold Metformin for 48 hours revealed S10Physician did not date or time his authentication.

Patient #4
Patient #4 is a 71-year-old female admitted to the hospital on 09/03/13 at 7:05 pm. Admitting diagnoses included urinary tract infection and pneumonia.
Review of Patient #4's physician orders 09/03/13 revealed the admission orders were obtained via a telephone order by S10Physician. Further review of the physician orders revealed S10Physician signed the orders, but did not date or time his authentication.
Review of Patient #4's physician telephone orders, dated 09/06/13, to administer Ativan 1 mg (milligrams) by mouth at every hour of sleep as needed for anxiety, and to decrease Solumendrol to 40 mg IVPB (intravenous piggyback) every 12 hours revealed S10Physician signed the orders, but did not date or time the his authentication.
Review of Patient #4's physician telephone orders, dated 09/06/13, to administer Zoloft 50 mg by mouth every morning and to give first dose now revealed S10Physician signed the orders, but did not date or time his authentication.
Review of Patient #4's physician orders, dated 09/08/13, to decrease Solumedrol to 20 mg IVPB revealed no time documented by S10Physician's authentication.

Patient #10
Review of the medical record for Patient #10 revealed a standing order dated 9/10/13 at 2145 for Regular Insulin per sliding scale. The entry was signed by S10Physician, but no date or time of authentication was listed.

Review of the medical record for Patient #10 revealed a telephone order on 9/10/13 at 2145 for Lactulose 20mg/30cc BID PO (twice per day by mouth) and Albuterol 0.083% and Atrovent 0.02% per neb QID (four times per day) and PRN SOB (as needed for shortness of breath). The order had been signed by S10Physician, but no time or date of authentication was listed.

Patient #8

Review of the medical record for Patient #8 revealed on 8/19/13 at 2005 (8:05 p.m.) telephone admission orders which included continuation of home medications.
Patient #8's home medications were as listed:
ASA ( aspirin) 81 mg po (milligrams by mouth), Surfak 240 mg po (milligrams by mouth), Lovenox 40 mg. sub Q (milligrams subcutaneous), Lasix 80 mg po (milligrams by mouth), Singular 10 mg po (milligrams by mouth), Crestor 2.5 mg po ( milligrams by mouth), Theo-dur 300 mg po (milligrams by mouth), Albuterol 0.083 % neb prn ( nebulaizer as needed), Atrovent 0.02% neb.prn (nebulaizer as needed), Prednisone 20 mg po (milligrams by mouth), Lantus 20 units sub Q (subcutaneous).
The order was authenticated by S10Physician's signature but was not dated/timed..

Review of the medical record for Patient #8 revealed a telephone order obtained on 8/19/13 at 2300 (11:00 p.m) revealed a standing order for Regular Insulin Sliding Scale was authenticated with S10PHysician's signature but was not dated/timed.

Review of the medical record for Patient #8 revealed a telephone order on 8/20/13 at 1350 (1:50 p.m.) for Voriconazole 300 mg (milligrams) IVPB (Intravenous piggyback) q (every ) 12 hr. (hour) x 12 doses was authenticated with S10Physician's but was not dated/timed.

In an interview on 9/10/13 at 10:10 a.m. revealed that the above orders should have be authenticated by S10Physician with the time and date.






31048




31206

Based on record review and interview, the facility failed to ensure that care plans were individualized based on patients care needs and kept current. This deficient practice was evidenced by having patient care plans that were not individualized, included no measurable goals, no documented interventions, and no documented evaluation for needed revision as related to change in patients condition for 2 ( #4, #8) of 2 (#4, #8) patients' care plans reviewed out of a total patient sample of 20. Findings:

Policies presented by S5ADON on 9/12/13 at 3:30 p.m. included three care plan polices with no documented evidence that the policies had ever been revised or approved by the hospital's governing body. S5ADON stated the policies presented were current and with the implementation of electronic care plans in 11/12, the policies were not updated.

Review of the policy titled Nursing Process/Care Plan, read in part: Purpose: To provide each patient with an individual plan of nursing care. The plan of care will be reflective of individualized standards of care which apply to that individual. Evaluation : Revising the care plan is included in the evaluation phase which addresses the level of effectiveness......ensure problem resolution. Ongoing changes in the patient's medical condition will be addressed and documented on the care plan.

Patient #4

Review of the History & Physical for patient #4 revealed she was a 71 year old female admitted from acute care to swing bed 9/3/13 with Urinary Tract Infection, Pneumonia, Joint pain, Malnutrition, and Anxiety. Past Medical History included Diabetes, Morbid Obesity, Urine incontinence, Depression, and Hyperactive Bladder.

Review of the medications revealed patient #4 was on Coudamin, Xanax 3 times a day, Vicodin as needed for pain, Lasix and oxygen.

Review of the physician's progress notes revealed patient #4 experienced visual hallucinations, illusions, and delusions which resulted in psychiatric consult and addition of respideral, ativan, zoloft, and Abilify. Patient #4 was discharged to the hospital's Behavioral Unit on 9/11/13.

Review of the care plan for patient #4 revealed 2 electronic documented goals which was initialed on the date of admission 9/3/13. The problems listed were related to Pneumonia and Urinary Tract Infection with no documented updated changes or evaluations and revisions as patient's condition changed. There was no documentation in the care plan of the patient's behavioral changes, addition of medications and adjustments as related to changes in behavior.

Patient #8

Review of the progress notes for patient #8 revealed he was admitted with Fungal Pneumonia, Hyperglycemia secondary to steroids, Chronic Obstructive Pulmonary Disease, and Weakness.

Review of the physician's orders revealed he was ordered Intravenous antibiotics, oxygen, respiratory treatments and physical therapy. A Physician's order dated 8/20/13 at 0830 read, "Pt. (patient ) refused PT (Physical Therapy) this morning states doesn't want therapy while he is here."

Review of electronic plan of care revealed 3 problems listed : 1. Activity intolerance.
2. Caregiver role strain. 3. Gas exchange impaired related to COPD/ Emphysema.
All problems were listed with no interventions, target dates, evaluations or revisions.

An interview on 9/11/13 at 10:20 a.m. with S11RN revealed the hospital care plans were electronic and upon admission the flow chart prompted the nurses to insert problems chosen from a predetermined computerized list. S11RN also stated the program also allowed the person to manually place in a problem/goal. S11RN said interventions had to be input by each individual as it was done and the RNs addressed the problems every shift. S11RN said the RN selected the date/time and the computer automatically recognized the person who was logged in and the name/title appeared along with any assessment completed. After a review of the electronic care plan, S11RN confirmed that evaluations were selected each shift, addressed occasionally, revised occasionally with no documentation except for the nurses initial that the area had been visited.

Interview on 9/11/13 at 12:25 p.m. with S5ADON revealed that the care plan program was implemented in 11/12 and there were still updates in progress. After S5ADON reviewed the electronic care plans for the above mentioned patients, he indicated the flow chart information carried over to the progress notes (nurses notes, CNA documentation...) According to S5ADON, the interventions had to be documented by the individual staff member. The options at the top of the problem list when opened were to be selected and information added. S5ADON confirmed that there was no documented interventions, target dates, revision and resolutions indicated for the above patients. S5ADON stated that more staff training was needed in documentation of care plans.

Based on record review and interview the hospital failed to ensure the H&P (history and physical exam) were dictated or recorded within 24 hours of admission per the Medical Staff By-Laws as evidenced by 3 (#6, #12, #14) of 6 (#5, #6, #7, #12, #13, #14) psychiatric medical records having the H&P dictated or recorded more than 24 hours after admission. Findings:

Review of the Dequincy Memorial Hospital Bylaws of the Medical Staff Medical Records/Chart Content section revealed: "...2. A complete admission history and physical examination shall be dictated or recorded within 24 (twenty-four) hours of admission..."

Review of a hospital policy titled "Medical Consultations/Physical Examinations", Reference #2019, no date effective, no date last reviewed or revised, presented as current hospital policy by S12RN, revealed in part: "...Policy: A medical consultation with staff privileges will be provided to the psychiatric patient within 24 hours after admission..."

Review of the medical record of patient #6 revealed an admission date/time of 9/5/13 at 1915. Further review of the medical record revealed the H&P was dictated on 9/6/13 at 2120, greater than 24 hours after admission.

Review of the medical record of patient #12 revealed an admission date/time of 8/21/13 at 1200. Further review of the medical record revealed the H&P was dictated on 8/22/13 at 1746, greater than 24 hours after admission.

Review of the medical record of patient #14 revealed an admission date/time of 8/5/13 at 1100. Further review of the medical record revealed the H&P was dictated on 8/7/13 at 1754, greater than 24 hours after admission.

In an interview on 9/10/13 at 1:33 p.m. with S2DON the above findings were confirmed.

Based on record review and interview, the hospital failed to ensure that the History and Physical for 1 (#4) of 2 records reviewed and the Progress Notes for 2 (#3 and #4) of 2 (#3 and #4) records reviewed were timed and dated with the authentication of the record.
Review of Patient #4's History & Physical and Progress Notes dated 08/30/13, 08/31/13, 09/01/13, and 09/02/13 revealed S10Physician did not date or time his authentication.
Review of Patient # 3's Progress Notes dated 09/06/13, 09/07/13 09/08/13, revealed S10Physician did not date or time his authentication.
In a face-to-face interview on 09/11/13 at 10:00 a.m., S5ADON verfied that the above mentioned documents did not have a date or time with the physician authentication.

Based on observation and interview, the hospital failed to ensure the protection of medical records against loss or destruction by failing to store medical records in a manner that would protect them from damage.
Observation of the medical record storage area for the acute and skilled care patients, and the record storage area for the psychiatric unit revealed all medical records were stored on open wooden shelves with no type of coverage protecting the records. Further observation revealed the medical records stored in both areas were located in very close proximity to the water sprinklers.
In a face-to-face interview on 09/11/13 at 2:30 p.m., S8MR Director indicated she was aware of the issue of the medical records not being stored in a manner to protect them from damage. She further indicated the hospital was in the process of ordering new metal storage cabinets with doors to provide protection for the medical records.
In a face-to-face interview on 09/12/13 at 9:25 a.m., S1Administrator indicated he was aware the medical records were not stored in a manner to protect them from damage. He further indicated that he had received bids for new medical record storage equipment for the hospital, and the hospital was planning to change the current method for storing medical records.

Based on interview and record review, the hospital failed to ensure an effective quality assurance program was in place to evaluate the quality and appropriateness of treatment as evidenced by no documented corrective actions and evaluations for medication errors.

Findings:

Review of the quality assurance minutes revealed the following medication occurrence reports:
6/2013- 25 medication related occurrences identified: 10 missed doses, 1 wrong medication, 1 duplicate dose, 1 incorrect medication from the pharmacy, 5 wrong time doses, 6 no order clarifications, 1 communication error, 1 medication record error.
The corrective plan of action was listed as: Medication incidents were addressed by DON.

5/2013- 35 medication related occurrences identified: 9 missed doses, 1 wrong dose, 1 duplicate dose, 3 wrong time, 6 no order clarification, 1 policy and procedure not followed.
The corrective plan of action was listed as: Medication incidents were addressed by DON.

In an interview on 9/12/13 at 10:00 a.m., S2DON verified data had been collected on the numbers and types of medication errors, but no data was included on the corrective actions taken to remedy the errors or the evaluations of the corrective actions. S2 DON provided one document from 5/6/13 which addressed the medication errors from 5/13 and 6/13. The letter revealed: On May 6th 2013, I moved this nurse to days to be closely monitored for medication errors. I shadowed her all day for medication pass. She was very confident with no medication errors for that day. Her schedule will remain day shift. Pharmacy is to notify me of any further errors. I have not had any more reported. No other documentation of corrective actions was presented.

Based on interview and record review, the hospital failed to ensure all patient care services were evaluated by the quality assurance program as evidenced by not including the hospital's physical therapy services.

Findings:

Review of the quality assurance binder presented by the hospital revealed no documentation of the physical therapy services at the hospital being reviewed for quality assurance.

In an interview 9/12/13 at 9:45 a.m. with S2DON, she stated she was just informed on 9/11/13 that the physical therapy department was under the supervision of the nursing department. S2DON said the physical therapists had been employees of the hospital for approximately 6 months. S2DON verified the physical therapists had not had appropriate orientation, no policies or procedures governing their practice, no director, and no competencies. S2DON verified the physical therapists were not included in the quality assurance program.

Based on record review and interview the hospital failed to ensure the Psychiatric DPU (distinct part unit) met the applicable State Licensure Laws by:

1) failing to meet the Hospital Licensing Standards LAC (Louisiana Administrative Code) Subchapter R. Psychiatric Services 48:I.9501.C1 or C2 or C3. (See findings at 0583 and 0585)

2) failing to meet the Hospital Licensing Standards LAC Subchapter K. Infection Control 48:I.9423.D. (see findings at 0278)

Based on record review and interview the hospital failed to ensure the psychiatric evaluation was performed within 60 hours as evidenced by 1 (#5) of 6 (#5, #6, #7, #12, #13, #14) psychiatric medical records reviewed having a psychiatric evaluation which was performed 5 days after the admission of the patient. Findings:

Review of a hospital policy titled "Assessments. AS-02: Psychiatric Evaluation", no date approved, no date last reviewed or revised, presented as current hospital policy by S12RN, revealed in part: "Policy: A comprehensive Psychiatric Evaluation is conducted and documented in the medical record by a Credentialed Psychiatrist or Psychiatric Nurse Practitioner within 60 hours following an inpatient admission..."

Review of the medical record for patient #5 revealed he was admitted to Dequincy Memorial Hospital Psychiatric DPU on 8/30/13 at 1730 per the admission orders. Patient #5 was received in transfer from another psychiatric facility where a psychiatric evaluation was documented. Further review of the same Psychiatric Evaluation revealed S15MD documented his Initial Psychiatric Evaluation on the same form and signed the document on 9/4/13 at 1610.

In an interview on 9/10/13 at 9:40 a.m. S12RN confirmed the documentation by the psychiatrist who was granted Medical Staff privileges at Dequincy Memorial Hospital did not document the Initial Psychiatric Evaluation until 9/4/13, 5 days after admission.

Based on record review and interview the hospital failed to ensure the Psychiatric DPU (distinct part unit) had a qualified Director of Psychiatric Nursing Services. This was evidenced by S12RN being designated as the Psychiatric DPU Program Manager with less than the required 3 years of psychiatric nursing experience per the hospital's Position Qualifications for Program Manager. Findings:

Review of a Dequincy Memorial Hospital Job Description for Program Manager of the BHU (behavioral health unit) revealed in part: "Position Qualifications: Graduation from an accredited Nursing program with at least five (5) years of nursing experience and at least (3) years of psychiatric nursing experience..."

Review of the personnel record for S12RN revealed he had 14 months of documented Acute Psychiatric Nursing care experience.

In an interview on 9/10/13 at 3:00 p.m. with S2DON and S12RN both confirmed the resume in the personnel record of S12RN contained no documented evidence of 3 years of psychiatric nursing experience.

Based on record review and interview the hospital failed to ensure the Psychiatric DPU (distinct part unit) had a qualified Director of Psychiatric Nursing Services. This was evidenced by S12RN being designated as the Psychiatric DPU Program Manager with less than the required 3 years of psychiatric nursing experience per the hospital's Position Qualifications for Program Manager. Findings:

Review of a Dequincy Memorial Hospital Job Description for Program Manager of the BHU (behavioral health unit) revealed in part: "Position Qualifications: Graduation from an accredited Nursing program with at least five (5) years of nursing experience and at least (3) years of psychiatric nursing experience..."

Review of the personnel record for S12RN revealed he had 14 months of documented Acute Psychiatric Nursing care experience.

In an interview on 9/10/13 at 3:00 p.m. with S2DON and S12RN both confirmed the resume in the personnel record of S12RN contained no documented evidence of 3 years of psychiatric nursing experience.