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Based on review of medical records, hospital policies and procedures, and interviews, it was determined that the governing body failed to demonstrate that it is effective in carrying out the operation and management of the hospital. The facility did not provide the necessary oversight and leadership as evidenced by the lack of compliance with 42 CFR 482.23 - Nursing Services.

A. Based on document review and interview, it was determined that the facility failed to ensure that the care of each patient was being monitored by the treating physician.

Findings include:

1. On 6/1/11 review of Medical Record #3 indicated that the patient presented to the Emergency Department (ED) on 1/6/11 at 20:35 for a change in mental status. The patient's past medical history was positive for hypertension, diabetes mellitus and cerebral vascular accident (CVA). The patient's medications at home were: Atenolol, Lisinopril, Simvastatin, Warfarin, Clonazepam, Aspirin, and Lantus. No dosages were provided by the patient or family at admission to the ED.
2. The patient was admitted on 1/7/2011 at 7:30 PM to PCU (Progressive Care Unit) and transferred from the ED to the unit on 1/8/11 at 02:28 with a diagnosis of Acute CVA. Physician telephone orders were written on 1/7/11 at 6:13 PM for the above medications with the exception of Warfarin (deferred to another physician for order) Lantus and Aspirin. The patient was placed on a 2 gm low sodium diet and on "Dexamethasone 4 IV (intravenous)mg (milligrams) q (every) 6 H (hours)." The admitting blood glucose result, via lab work up, was 146 (normal range 70-110).
3. The patient continued to have episodes of altered mental status with periods of agitation. On 1/11/11 at 1713, 5 days after the admitting blood glucose, the patient's blood glucose was 1097. There was no blood glucose monitoring between the abnormal results on admission on 1/7/11 and 1/11/11.
4. There was no evidence that Lantus or any other diabetic medication was prescribed.
5. The physician failed to ensure that the patient's diabetes was managed.
6. The above was confirmed on 6/2/11 with Staff #2 at approximately 12:30 PM.

Based on document review and interview, the facility failed to ensure that each patient was provided care supervised by a Registered Nurse (RN) and that medications were administered according to physician orders.

Findings include:

1. The facility failed to ensure that the Registered Nurse supervised and evaluated the care of each patient (Cross Refer 0395).


2. The facility failed to ensure that the Registered Nurse administered medication in accordance with physician orders (Cross Refer 0404).

A. Based on 5 of 5 medical records (#23, #24, #22, #20, #3) reviewed of patients needing wound care, it was determined that the facility failed to ensure that Registered Nurses (RN) implemented the Skin Care Management Orders policy for 5 of 5 patients.
Findings include:
Reference#1: The Skin Care Management Orders: Pressure Ulcer Policy stated, "Procedure:
1. The Registered Nurse identifies the patient with a pressure ulcer.
2. The Registered nurse will obtain physician signature and/or accept telephone permission to initiate Skin Care Management Orders: Pressure Ulcers.
Documentation: The Registered Nurse will document on the Skin Management Profile in patient's chart."
Reference #2: The Skin Management Profile sheet stated, " . . . Classification of Wound. . .
Stage II-Partial thickness skin loss involving epidermis and/or dermis. May appear as an abrasion, blister, or shallow crater.
UTD -Unable to determine. Completely covered with eschar, slough, scab.
SDTI -Suspected Deep Tissue Injury -Purple or maroon localized area of discolored intact skin or blood-filled due to damage or underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. "

1. Medical Record #23, reviewed on 6/2/11, indicated that the patient was admitted to the hospital on 3/16/11 and discharged on 3/18/11. Upon admission, the Skin Management Profile sheet contained documentation of multiple skin breakdown areas at the patient's sacrum, hips, heels, ankles, and legs. These pressure related wounds were classified as either Stage II or unable to stage. The Skin Management Profile sheet indicated that these wounds were being treated with a wet to dry dressing. There was no order from the physician to initiate Skin Care Management Orders.
2. Medical Record #24, reviewed on 6/2/11, indicated that the patient was admitted to the hospital on 3/23/11 and discharged on 3/25/11. Upon admission, the Skin Management Profile sheet contained documentation of multiple skin breakdown areas at the patient's sacrum, right hip, and heels. These pressure related wounds were classified as either Stage II, Stage III or DTI (sic). The Skin Management Profile sheet indicated that these wounds were cleansed on 3/23/11 with normal saline and that a dressing was applied. On 3/24/11 and 3/25/11 these wounds were cleansed with normal saline with "CDI" (unable to decipher initials). There was no order from the physician to initiate Skin Care Management Orders.
3. Medical Record #22, reviewed on 6/2/11, indicated that the patient was admitted to the hospital on 3/26/11 and discharged on 3/29/11. Upon admission, the Skin Management Profile sheet contained documentation of multiple skin breakdown areas at the patient's sacrum and buttocks. These pressure related wounds were classified as Stage II. The Skin Management Profile sheet indicated that these wounds were treated with Aloe Vesta cream. There was no order from the physician to initiate Skin Care Management Orders.
4. Medical Record #20, reviewed on 6/2/11, indicated that the patient was admitted to the hospital on 2/24/11 and discharged on 3/6/11. Upon admission the Skin Management Profile sheet indicated "Skin intact. Just some redness." There was no documentation as to where the redness was noted. Documentation dated 3/3/11 stated, "Skin intact. Redness noted on lower back/buttocks--duoderm applied." There was no order from the physician to initiate Skin Care Management Orders.
5. Medical Record #3, reviewed on 6/2/11, indicated that the patient was admitted to the hospital on 1/6/11 and discharged on 1/25/11. Upon admission the Skin Management Profile sheet indicated no skin breakdown until 1/15/11. The Skin Management Profile sheet indicated sacral and a right hip skin breakdown on 1/15/11 , Stage II; on 1/16/11, left and right heel suspected DTI, and a right lateral midback, Stage II. These areas, with the exception of the left and right heel, were treated with Duoderm until the patient's discharge on 1/25/11. There was no physician order for Duoderm or to implement the Skin Care Management Orders.
6. The above was confirmed on 6/2/11 at approximately 4:00 PM with Staff #3. The above referenced policy was not implemented.
B. Based on document review, it was determined that the facility failed to ensure that the registered nurse supervised and evaluated the nursing care for each patient in accordance with physician orders.
Findings include:
1. On 6/1/11 Medical Record #11 contained a physician order dated 5/28/11 at 7:30 AM for "Incentive spirometer 10x q (every) 1 circle (hour) while awake." The daily flow sheet dated 5/28/11 lacked evidence that the above order was implemented. There was no evidence that the patient was supervised in the use of the Incentive Spirometer.
2. The above was confirmed with Staff #3 on 6/1/11 at approximately 12 noon.

Reference: The patient Watch For Behavioral Indications stated,
DEFINITIONS: 2. Line of Sight: is defined as a staff member observing a maximum of 4 patients, all of whom are within the same physical space and/or room as the "observer" and within the same visual field of the "observer" at all times.
POLICY: . . .Line of Sight--The patient has an altered mental status and/or compromised physical condition and whose behavior places the patient at risk for self or other injury.
The patient on a Line of Sight Observation shall be reassessed by the RN whenever clinically indicated, but minimally every 12 hours. If an assessment indicates a watch is no longer needed, the watch may be discontinued prior to this period with a physician's order. An order for Line of Sight shall be renewed daily by the physician. The watch level may be increased, decreased, or discontinued at any time prior to this period with a physician order."
1. On 6/2/11, Medical Record #3 indicated that the patient presented to the emergency department (ED) for complaints of altered mental status and agitated behavior. The ED nurses' notes stated, "1/7/11 at 00:30 with an order for line of sight, no staff for now to do line of sight as per charge nurse ..., transferred pt (patient) infront (sic) of nurse station to closely watch pt. side rails up and stretcher low.
2. At 01:00 line of sight being done by . . .
The Patient Watch Observation Sheet indicated that the Line of Sight /Direct Observation was initiated on 1/7/10 (sic) at 1:00 AM and discontinued on 1/7/10 at 6:00 PM. There was no documentation of a verbal order for the initiation or termination of a line of sight.
On 1/7/11 at 23:15 the emergency room nurses note documented that the "patient got out of bed and slipped landed to his left side ... "
On 1/8/11 at 3:10 AM, 4 hours later, a telephone order, "Put pt on line of sight," was obtained. The above policy was not implemented.

C. Based on document review and interview, it was determined that the facility failed to ensure that the registered nurse evaluated the nursing care of each patient.
Findings include:
On 6/2/11 Medical Record #3 indicated that the patient presented to the emergency department (ED) on 1/6/11 at 20:35 for change in mental status and agitated behavior. The patient's past medical history was positive for hypertension, diabetes mellitus and cerebral vascular disease (CVA). The patient was taking Atenolol, Lisinopril, Simvastatin, Warfarin, Clonazepam, Aspirin, Lantus and Aricept, dosages unknown. The physician's telephone order dated 1/7/11 at 1:13 PM stated, "Family to obtain dosage of all home meds tonight." Physician telephone orders were written on 1/7/11 at 6:13 PM for the above medication with the exception of Warfarin (deferred to another physician for order) Lantus and Aspirin. It could not be determined if the medication dosages were obtained from the family.
The medication reconciliation form dated 1/8/11 at 4:00 PM indicated that the medication information was obtained from the ED orders and listed medication for Atenolol, Lisinopril, Simvastatin, Warfarin, Clonazepam. On the form the Aspirin and Lantus had dosages unknown, and although Aricept had a complete order it was not circled as being continued.
From the patient admission on 1/6/11 until 1/11/11 there was no evidence that the nursing staff obtained the dosage of the Lantus medication that the patient was taking at home. Despite the patient's medical history of diabetes and continued altered mental status with episodes of agitation to lethargy, there was no evidence that the patient was assessed for sign and symptoms of hyperglycemia. The patient's blood sugar on 1/11/11 at 1713 was 1097 (normal 70-110).
The above was confirmed with Staff #1 on 6/2/11 at 12:30 PM.

D. Based on document review, it was determined that the facility failed to ensure that the medication reconciliation policy was implemented for 3 of 4 patients, #s 1, 5, 6.
Findings include:
Reference: The Medication Reconciliation policy stated,
"PROCEDURE: III Procedure: Discharge
1. Discharge reconciliation is the process of reviewing the MAR, progress notes and prescriptions as compared to the patient's home medication list upon discharge. Special attention should be devoted to prevention of therapeutic duplication of ordered medications when comparing both lists.
2. Documentation and communication of discharge medication orders occurs via the discharge summary. The discharge nurse must reconcile the discharge medications with the home medications and the medication the patient was on during the hospital stay.
3. The patient, and their family as necessary, is given a complete list of reconciled medications via the discharge summary at discharge. The patient/family must sign the form after education is provided to the patient on the discharge medications."
1. On 6/2/11 Medical Record #1 contained a Multidisciplinary Patient Discharge Summary form dated 3/3/11. The Medication Reconciliation form gave a list of home medication to be continued upon discharge to include Lipitor 20 mg (milligrams) by mouth daily. The Multidisciplinary Patient Discharge Summary form listed the medications administered by the nurse the day of discharge, and noted to "resume all meds tomorrow." Lipitor 20 mg po (milligrams by mouth) was also listed, however, it was crossed off. The medication administration record for 3/3/11 indicated that Lipitor was being administered daily at bedtime. The Multidisciplinary Patient Discharge Summary form failed to indicate to the patient to take Lipitor 20 mg. po at bedtime the day of discharge and daily thereafter.
2. On 6/2/11 Medical Record #2 contained a Behavioral Health Brief Discharge Summary form and Discharge Summary form dated 3/9/11. The Medication Section of the form documented Haldol and Cogentin to be continued at home. The patient had been on Depakote and this medication was gradually being decreased. The last physician order dated on 3/8/11 stated, "Depakote 250 mg. po daily." The patient received Depakote 250 mg. the day of discharge, 3/9/11. There was no evidence in the nurses' note of a discussion with the physician prior to the patient being discharged regarding the patient continuing Depakote at home.
3. On 6/1/11 Medical Record #5 contained a Multidisciplinary Patient Discharge Summary form dated 2/6/11. The Medication Reconciliation form lacked reconciliation of home medication to be continued upon discharge, 2/6/11.
4. On 6/2/11 Medical Record #6 contained a Multidisciplinary Patient Discharge Summary form dated 2/4/11. The Medication Reconciliation form lacked reconciliation of home medication to be continued upon discharge, 2/4/11. The Multidisciplinary Patient Discharge Summary lacked evidence of Lipitor and a bronchodilator to be continued at home; both were taken by the patient during the hospital stay. There was no evidence in the nurses' notes of a discussion with the physician to determine if these two medications were to be continued at home.

E. Based on a review of the medical records of three patients placed in physical restraints for behavior management and a review of facility policy and procedure it was determined that the patient's response to the intervention of physical restraint was not assessed for one of three patients.

Findings include:

Reference: The 'Behavior Management Debriefing After Restraint/Seclusion is Discontinued' section of facility policy titled RESTRAINT/SECLUSION stated:
"1. Debrief with the patient following a restraint or seclusion episode.
Note: The patient and staff participate in a debriefing about the restraint or seclusion episode. Debriefing is an important aspect in reducing the recurrent use of restraint or seclusion by identifying what led to the incident and what could have been handled differently. Debriefings also allow the opportunity to ascertain that the patient ' s physical well being, psychological comfort, and right to privacy were addressed.
2. Include the patient, and if appropriate, the family with staff members who were involved in the episode and who are available to participate in the debriefing.
3. Perform debriefing a soon as possible after the episode but not to exceed 24 hours.
4. Provide counseling to the patient for any emotional trauma that may have occurred during the restraint or seclusion. Modify the treatment plan as indicated.
5. Document the debriefing on a separate Behavioral Health Debriefing Form and placed [sic] in the medical record."

1. Review of the medical record of Patient #12 indicated that he/she was in physical restraints on 5/21/11 and 5/22/11. There was no evidence in the medical record of any of the components of the above referenced policy section having been implemented. There were no Behavioral Health Debriefing Forms in the medical record.


F. Based on a review of facility policy and procedure and the medical record of one patient, it was determined that a registered nurse did not adequately supervise and evaluate the nursing care for the patient.

Findings include:

Reference #1: The 'Guidelines for completion of "The Patient watch Observation Sheet" Part D' section of policy titled PATIENT WATCH FOR BEHAVIORAL INDICATORS indicated: "For patients placed on One-to-One Observation . . . : a. The sheet is initiated for any type of a patient watch that is ordered and maintained by the staff member assigned to the watch. (Part D)
b. The staff member assigned to the patient watch will document the behavior of the patient on the check sheet every 15 minutes as indicated using the activity code at the bottom of the form. . . ."

1. PHYSICIAN ORDER FORM FOR PATIENT WATCH LEVEL form in the medical record of Patient #12 indicated that the patient be placed on 'One to One Observation' at 2:30am on 5/21/11. The only PATIENT WATCH OBSERVATION SHEET in the medical record was documented as having been initiated by nursing staff at 7:15am on 5/21/11 - 4 hours and 45 minutes after the order was written. Additionally, the form indicated that the patient was monitored on 'Line of Sight/Direct Observation', not "One to One Observation' as ordered.


Reference #2: The 'Behavior Management Use' section of facility policy titled RESTRAINT/SECLUSION stated: "The RN will:
a) Assess the patient at the initiation of restraint or seclusion and then every 15 minutes. This assessment includes, as appropriate to the type of restraint or seclusion, the following:
* Signs of any injury associated with application
* Nutrition and hydration
* Circulation and range of motion in the extremities
* Vital signs and interpreting relevance to safety of patient
* Hygiene and elimination
* Physical and psychological status and comfort
* Readiness for discontinuation of restraint or seclusion"

1. Medical Record of Patient #12 indicated an order for '4 Point Locked Restraint' for 4 hours at 3:30am on 5/21/11. Further review of the medical record indicated that assessments were only done once per hour without evidence of vital signs having been assessed at any time during the restraint episode.


G. Based on review of the medical record of one patient who was treated in the emergency department and not admitted or transferred from the facility and review of facility policy and procedure, it was determined that nursing staff did not maintain responsibility for the disposition of the patient.
Findings include:
Reference: The PROCEDURE section of facility policy and procedure titled 'Discharge Procedure' indicated: "Verify appropriate discharge order on physician's order sheet. . . ."
1. Review of the NURSING DISPOSITION section in the medical record of Patient #20 indicated: ". . . Disposition: Discharged. . . .
Verbal and Written discharge instructions given / reviewed with: Patient. . . ."
2. There was no order for discharge in the medical record. Additionally, the patient was a 12 year old child accompanied by his/her mother. The discharge instructions should have been given and reviewed with the patient's mother instead of the patient.

Based on document review, it was determined that the facility failed to ensure that physician orders were implemented.
Findings include
1. On 6/2/11, Medical Record #3 contained the following physician orders:
a. 1/12/11 at "6 PM -Order Clarification: Lantus 100 units SQ (subcutaneous) x 1 dose now." Review of the Patient Medication Record for stat (now/immediate) administration for 1/12/11 lacked evidence of Lantus 100 units being administered at 6 PM. Lantus 100 units was not administered until 10 PM, according to documentation.
b. 1/16/11 at 830 PM "Give Lantus 20 units S.Q. x 1 dose now . . ." Review of the Patient Medication Record for stat medication administration revealed that Lantus 25 units was administered at 8:30 PM and not 20 units as ordered.
c. 1/12/11 (no time written) "Blood Culture x 2" and at 1645 "blood cx (culture) x 2 sets today." The lab results for blood culture stated, "1/12/11 1155 and 1140 Cancelled: Blood Culture, Reason: No Sample Received Stat." There was no other blood culture results until 1/22/11.
2. The above physician orders were not implemented. There was no evidence that the physician was notified.

Based on a review of a drug reference book, the medical records of two mental health patients and interview with administrative staff, it was determined that not all of the elements that must be present in orders for all drugs to ensure safe administration were present.

Findings include:

Reference: The INDICATIONS & DOSAGES section for the drug Ativan in the Nursing 2010 Drug Handbook indicated: "Anxiety Adults .... Maximum 10mg daily. ....."

1. Review of the preprinted ADMISSION ORDERS section of a BEHAVIORAL HEALTH SERVICES form dated 5/25/11 at 6AM (6:00am) in the medical record of Patient #13 indicated that the physician ordered 'Ativan 1mg PO (by mouth) every 4 hours PRN for psychosis with agitation' and 'Ativan 2mg IM every 6 hours PRN for anxiety with severe agitation.' The orders did not indicate the maximum allowable amount to be administered in 24 hours. In a 24 hour period, if all of the Ativan ordered were to be administered, the patient would receive 14mg.

2. Interview with Administrator #6 indicated that there are no policies regarding the allowable maximum amount of Ativan that a patient may receive for agitation in 24 hours, nor were there parameters for administration of each prescribed dose.