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On the days of the Recertification Survey through observation, record review, hospital log review, review of hospital policy and procedure review, and interview, the governing body, in accordance with hospital policy and accepted standards of practice, failed to ensure that specific patient care requirements related to the rights of its patients for restraint measures, and infection control monitoring for diseases related to blood born pathogens were met for providing care and services of patients hospitalized with various medical conditions.


The findings are:

Cross Reference to A 0168: The hospital failed to ensure that verbal physician orders for patient restraints were obtained and authenticated by a physician every 24 hours for 7 of 9 patients with physician orders for restraints. (Patient #26, #37, #45, #47, #56, #11, and 57)

Cross Reference to A 0747: The hospital failed to provide a sanitary environment that prevents the potential transmission of sources and transmission of infections and communicable diseases in the emergency department, dialysis unit, medical surgical unit, and general hospital areas.

On the days of the Recertification Survey based on record review, interview, and hospital policy and procedure, the hospital failed to promote and protect the patient's right and dignity when restraints are required in that staff applied restraints without authentication of physician orders every 24 hours for 7 of 9 patient records reviewed for restraints, failed to assure that health consent forms for 7 of 62 open patient records, and failed to ensure the privacy and dignity for 1 of 1 patients observed in a hallway bed, and failed to ensure that 2 of 2 hospital staff protected patient health information.


The findings are:


Cross Reference to A 0117: The hospital failed to ensure that a health consent for treatment form was signed by the patient prior to initiating treatment for 7 of 62 patient records reviewed for care and services. (Patient #13, #34, #35, #36, #39, #50, and #56)

Cross Reference to A 0143: The hospital failed to protect the patient's privacy while receiving care and treatments from hospital staff in that the patient's bed was located in the emergency department hallway, and the patient was visible to all persons in the vicinity during the treatments for 1 of 1 patient located in the emergency department's hallway. (Patient #16)

Cross Reference to A 0147: The hospital failed to ensure 1 of 1 physician and 1 of 7 Registered Nurses protection of patient health information by way of unprotected computer screens visible to anyone in the area. (Physician #9 and Registered Nurse #7)

Cross Reference to A 0168: The hospital failed to ensure that verbal physician orders for patient restraints were obtained and authenticated by a physician every 24 hours for 7 of 9 patients with physician orders for restraints. (Patient #26, #37, #45, #47, #56, #11, and #57)

On the days of the Recertification Survey based on interview, patient record review, and hospital policy and procedure review, the hospital failed to ensure that a health consent for treatment was signed by the patient prior to initiating treatment for 7 of 62 patient records reviewed for care and services. (Patient #13, #34, #35, #36, #39, #50, and #56)


The findings are:


On 6/20/2013 at 1210, review of Patient #34's chart showed the patient was admitted for an Inguinal Hernia Repair. The patient's chart had a form with a stamped consent for treatment that read, "...SC Dept. (Department) of MH (Mental Health) and No Consent...". Further review of the patient's chart revealed the patient had signed the operative consent for the hernia repair. The patient's chart had documentation of a conversation between hospital staff and the Department of Mental Health stating the patient was mentally competent to sign the surgical consent present in the patient's medical record. On 6/20/2013 at 1230, the Director of Out Patient Services, revealed,"this is how we have always done this and registration is to use the stamp for all patients admitted from this facility." On 6/20/2013 at 1245, the registrar on duty revealed that when the hospital determines the patient is from that facility(DMH), the patient's consent for treatment is not ever signed by the patient, and the health consent for treatment form is stamped "...SC Dept. (Department) of MH (Mental Health) and No Consent...". The registrar stated, "patient rights are not given to the patient." On 6/20/2013 at 1330, the Chief Nursing Officer revealed that this procedure was not in hospital policy because it had not been an issue before.

On 6/18/2013 at 1125, review of Patient #13's electronic medical record revealed the patient was admitted on 6/12/2013 with a diagnosis of Hypoxia. The patient's chart had no signed consent for health treatment. The consent in the patient's medical record was stamped "...SNF (SKILLED NURSING FACILITY) UNABLE TO SIGN NO FAMILY PRESENT...". Review of the patient's medical record showed no documentation regarding further attempts by hospital personnel to contact the family or healthcare power of attorney to sign the patient's consent for health treatment. On 6/18/2013 at 1200, Charge Nurse #16 verified the hospital had made no further attempts to contact with the patient's family to obtain a signature for consent for health treatment.

Hospital policy, titled, General Consent-Policy # 8080-370-, reads, ".... Palmetto Health respects the right of each patient to make his/her own decisions with regard to matter that affect his /her medical treatment...Patients or their legal designee will be asked to sign the General Consent for treatment upon each admission or outpatient service...If the patient is unable to sign their consent or does not have a legal representative, documentation should be made on the original consent-including all follow up efforts...The procedure for following up on unsigned consent should take place during each shift via the "No consent Form for Patient Report"...Another person must consent for the incompetent adult patient if the attending physician determines the patient's inability to consent is not temporary and the delay occasioned by postponing treatment until the patient regains the ability to consent will result in significant detriment to the patient's health...".




25877

Review of Patient #35's chart on 06/20/2013 at 1515 revealed the patient was admitted to the hospital on 06/05/2013, and there was no signature on the copy of the patient's Medicare Appeals Form in the patient's chart. The copy of the form in the patient's chart was blank and unsigned. In an interview with Assistant Nurse Manager #6 on 06/20/2013 at 1520, the finding was verified.

Review of Patient #36's chart on 06/20/2013 at 1530 revealed the patient was admitted to the hospital on 06/07/2013, and there was no signature on the copy of the patient's Medicare Appeals Form in the patient's chart. The copy in the chart was blank and unsigned. In an interview with the Assistant Nurse Manager #6 on 06/20/2013 at 1535, the finding was verified.

Review of Patient #39's chart on 06/20/2013 at 0915 revealed the patient was admitted to the hospital on 06/19/2013, and there was no signature on the copy of the patient's Medicare Appeals Form in the patient's chart. The copy in the chart was blank and unsigned. In an interview with Nurse Manager #8 on 06/20/2013 at 0925, the findings were verified.

Review of Patient #50's chart on 06/20/2013 at 1900 revealed the patient was admitted to the hospital on 06/14/2013, and there was no signature on the copy of the patient's Medicare Appeals Form in the patient's chart. In an interview with RN #6 on 06/20/2013 at 1915, the finding was verified.

Review of Patient #56"s chart on 06/20/2013 at 1800 revealed the patient was admitted to the hospital on 06/13/2013, and there was no signature on the copy of the patient's Medicare Appeals Form in the patient's chart. In an interview with RN #5 on 06/20/2013 at 1820, RN #5 verified the finding.

On the days of the Recertification Survey based on observations and interview, the hospital failed to protect the patient's privacy while receiving care and treatments from hospital staff in that the patient's bed was located in the emergency department hallway, and the patient was visible to all persons in the vicinity during the treatments for 1 of 1 patient located in the emergency department's hallway. (Patient #16)


The findings are:


On 6/18/13 at 1200, random observations in the hospital's emergency department revealed Patient #16 whose bed was located in the emergency department's hallway received assessment of vital signs, intermittent needle therapy (INT) placement, blood specimen collection, administration of medication, and physical assessments in view of all persons in the vicinity. Observation of the physician's bedside patient assessment revealed the conversation between the physician and the patient pertaining to the patient's medical history and concerns could be overheard from the red zone nurse station located beside room 251 to the red zone nurse station located beside room 256 which is approximately 60 feet away. The findings were verified with Assistant Nurse Manager #2 on 6/18/13 at 1230.

On the days of the Recertification Survey based on observations, interview, and review of hospital policies and procedures, the hospital failed to ensure 1 of 1 physician and 1 of 7 Registered Nurses protected patient health information by way of patient health information on unprotected computer screens visible to anyone in the area. (Physician #9 and Registered Nurse #7)


The findings are:


On 6/18/13 from 1142 to 1149, observations in the emergency department revealed Physician #9 walked away from the computer and left the unprotected computer screen maximized with patient information visible to any persons in the area. On 6/18/13 from 1315 to 1319, observations in the emergency department revealed Physician #9 walked away from the computer and left the unprotected computer screen maximized with patient information visible to any persons in the area. The findings were verified with the Emergency Department Director, Diabetic Educator #1, and Assistant Nurse Manager #2, #3, and #4.

Review of hospital policy, titled, Corporate Compliance Safeguarding Protected Health Information PGR, reads, "....3.1.5 Computer monitors are positioned away from public areas to avoid observation by patients and visitors....".









30011

On 6/17/13 from 1535-1537, observations showed Registered Nurse #7 left the portable computer with the patient's health information on the computer screen visible to any persons in the vicinity parked outside the patient's room in the hallway. On 6/17/13 at 1540, Registered Nurse #7 stated, "I just didn't take the computer in the room with me, but I wasn't supposed to leave patient information up ".

On the days of the Recertification Survey based on interview, record review, and hospital policy review, the hospital failed to ensure that verbal physician orders for patient restraints were obtained and authenticated by a physician every 24 hours for 7 of 9 patients with physician orders for restraints. (Patient #26, #37, #45, #47, #56, #11, and 57)


The findings are:


Hospital policy, titled, "Non-Violent Restraint PGR, effective 6/07/2013, reads, "2. PHYSICIAN ORDERS FOR RESTRAINT 2.1. A written or electronic order shall be obtained immediately, but no later than 2 hours of initiation of the restraint from an authorized physician, NP (nurse practitioner), PA (Physician Assistant) or Second Year or Higher Resident. 2.2. The restraint order sheet/electronic order for "Non-Violent/Non-Self Destructive Behavior" is completed as follows: Time Limit-Order is valid for a maximum of 24 hours, Reason for restraint including patient behaviors and related causes, Type & (and) number of restraint(s) 2.3 A restraint order will not be written as a standing order or on an "as needed" or PRN basis. 2.4 A new restraint order is required every 24 hours....'..

On 6/19/2013 at 1400, review of Patient #26's chart showed the patient was admitted on 6/06/2013 with a diagnosis of Altered Mental Status and Unresponsive. Review of the patient's physician orders showed the patient had medical orders for restraints initiated on 6/08/2013 at 0223. The physician order was for soft wrist restraints for both wrists to be applied to prevent "...pulling of medical devices..". Review of the patient's chart showed a verbal physician order for restraints dated 06/13/2013 at 1639 that was placed electronically by Registered Nurse (RN) #40. Review of the patient's chart showed a verbal physician order for restraints on 6/14/2013 at 1100 placed electronically by RN #41. On 6/15/2013 at 1220, a verbal order for restraints was placed electronically by RN # 40. All of the above verbal orders for restraints were electronically sent to Medical Doctor #3. Review of the patient's chart showed no evidence that the physician authenticated the verbal orders within the 24 hour time frame per hospital policy. On 6/19/2013 at 1430, Charge Nurse #15 and the Nurse Manager verified that the verbal restraint orders had not been authenticated by the physician.

On 6/19/2013 at 1430, a review of the hospital's Non-Violent/Non Self Destructive Restraint Plan of Care and Flow Sheet, reads, "...Reassessment of need to continue Restraints: May be done by RN. An order must be obtained at least once in a calendar day and must state the reason for the restraint. The patient is to receive a face to face reassessment by the physician after the original order expires, and a new order must be received if the restraints are to be continued after the initial restraint order had expired...The restraint plan of care flow sheet is to be used for one episode of restraints...".





27175

On 6/21/13 at 1130, record review revealed Patient #57 was intubated from 6/17/13 until 6/20/13, and placed on restraints from 6/17/13 until 6/20/13. Review of the patient's chart revealed there was no documentation of restraint physician orders written and authenticated every 24 hours. On 6/21/13 at 1145, Charge Nurse #14 reported that daily 24 hour physician restraint orders are not obtained because the patient is on the hospital's Airway Protection Restraint Protocol. Charge Nurse #14 reported that once the restraint protocol is initiated for airway protection, the physician order obtained for restraint initiation is continued until the patient is extubated.



25877

Review of Patient #37's chart on 06/20/2013 at 1630 revealed the patient was admitted on 06/06/2013 and was placed on bilateral soft wrist restraints related to mechanical ventilation and the patient's attempts to pull the ventilator out with the order to initiate the restraints dated 06/07/2013. Review of the patient's chart showed the patient was on bilateral wrist restraints from 06/07/2013 to 06/21/2013, but the chart had no further orders from the physician after 06/07/2013 for the wrist restraints. On 06/21/2013 at 1150, the Assistant Nurse Manager reported hospital policy had changed for patients in Critical Care and daily 24 hour physician orders for airway protection and for continued use of restraints during a 24 hour period was no longer used.

Review of Patient #56's chart on 06/21/2013 at 1700 revealed the patient was admitted to the hospital on 05/03/2013. Review of the patient's chart revealed the patient had physician orders for bilateral soft wrist restraints related to restlessness and agitation ordered on 6/08/2013 at 0850. Further review of the patient's chart revealed daily 24 hour physician orders were not authenticated. Review of the physician order for restraints dated start date/ time 06/08/13 at 0850 and stop date/ time at 06/09/13 at 0850 were not authenticated by the physician. There was another verbal physician order on the patient's chart with the same date of 06/08/13 with a start date/time 06/08/13 at 0846 and stop date/time of 06/09/13 at 0846 authenticated by the Physician Assistant 10 days later on 06/18/13 at 2204. Review of the patient's chart revealed orders for continued use of bilateral wrist restraints were not authenticated by the physician on 06/11/13 for start date/time 06/11/13 at 0000 to stop date/time 06/11/13 at 1949 until 06/14/2013 at 1812, and physician verbal orders for bilateral restraints were not authenticated by the physician for 05/15/13 start date/time 06/15/13 at 0000 to stop date/time 06/16/13 at 0000 until 06/17/2013 at 1238. A verbal physician order dated 06/12/13 for start date/time 06/12/13 at 0000 with no stop date/time was not authenticated by the physician. Registered Nurse #5 verified the findings on 06/21/2013 at 1115.

Review of hospital policy and procedure, reads, "...Critical Care Departmental Policy September 26, 2006 Initial Policy Revised January 2008...When the physician opts to utilize restraints for airway protection (see attached) specific to Critical Care, there is no longer a need for a daily order to continue the restraints every 24 hours...".


30011

On 6/18/13 at 1215, review of Patient #11's chart revealed the patient was admitted on 2/4/13. Review of the patient's electronic verbal physician orders dated 6/9/13 at 0000 recorded by the nurse revealed no authentication by the physician for soft restraints (both wrists).
Review of the electronic verbal orders for soft restraints (both wrists) and vest or papoose entered by the nurse on 6/10/13 at 0145 had no authentication by the physician.
Review of the electronic verbal orders for soft restraints (both wrists) and vest or papoose recorded on 6/11/13 by the nurse had no authentication by the physician.
Review of the electronic verbal orders for soft restraints (both wrists) and vest or papoose dated 6/12/13 at 0309 entered by the nurse had no authentication by the physician signature.
Review of the electronic verbal orders for soft restraints (both wrists) and vest or papoose dated 6/13/13 at 0422 entered by the nurse showed the physician's electronic signature was dated 6/17/13 at 2225.
Review of the electronic verbal orders for soft restraints both wrists dated 6/14/13 at 0058 entered by the nurse had no authentication by the physician.
Review of electronic verbal orders for soft wrist restraints dated 6/15/13 at 0019 entered by the nurse had no authentication by the physician signature.
Review of the electronic verbal orders for soft wrist restraints entered by the nurse on 6/17/13 at 0000 had no authentication by the physician.

Further review of the "Non-Violent /Non Self Destructive Restraint Plan of Care & Flow Sheet" revealed on 6/9/13 that the physician order was written for "soft restraints (both wrists)" but the patient had documentation in the chart that the patient was restrained with soft wrist restraints and a vest or papoose from 0000 6/9/13 to 0000 6/10/13. The findings were verified by Registered Nurse #4 on 6/18/13 at 1305.


31672

On 6/ 21/13 at 1343, review of Patient #47's chart revealed the patient was admitted through the emergency department on 6/12/13 at 2143 to the Surgical Trauma Intensive Care Unit (STICU) with a diagnosis of Moped versus Car. Review of the patient's emergency room documentation revealed the patient had wrist restraints initiated on 6/12/13, but there was no physician order written until 6/18/13.

On 6/ 21/13 at 1700, review of Patient #45's chart revealed the patient was admitted from the Operating Room (OR) on 6/20/13 at 0730 to the Cardiovascular Intensive Care Unit (CVICU) with a diagnosis of Coronary artery bypass graft (CABG) . Review of the patient's documentation in the chart showed the patient had wrist restraints initiated on 6/20/13. There was no physician order for the wrist restraints in the patient's chart.

On the days of the Recertification Survey based on interview and review of patient records, the hospital failed to ensure staff provided patient care per physician's orders for 4 of 62 patient records reviewed for care and services. (Patient #47, #49, #43, and #20)


The findings are:


On 6/ 21/13 at 1343, review of Patient #47's chart revealed the patient was admitted through the Emergency Department on 6/12/13 at 2143 to the Surgical Trauma Intensive Care Unit (STICU) with a diagnosis of Moped versus Car. Review of the patient's physician orders showed there was no written order for a urinary catheter placed from 6/12/13 until 6/14/13.

On 6/ 21/13 at 1400, review of Patient #49's chart revealed the patient was admitted from the Emergency Department (ED) on 6/7/13 at 0001 to the Medical Intensive Care Unit (MICU) with a diagnosis of Respiratory Distress. Review of the patient's physician orders showed there was no written order for a urinary catheter placed until 6/20/13 at 0920.

On 6/ 21/13 at 1700, review of Patient #43's chart revealed the patient was admitted from the Emergency Department (ED) on 6/19/13 at 2124 to the Coronary Care Unit (CCU) with a diagnosis of Respiratory Failure and Unresponsiveness. Review of the patient's physician orders showed there was no physician order for a urinary catheter or the oral gastric tube. The findings were verified with Clinical Educator #3 on 6/21/13 at 1700.

On 6/18/13 at 1535, review of Patient #15's open chart showed the patient was admitted into the emergency department on 6/18/13 with a diagnosis of chest pain. Review of the patient's chart showed the patient had a physician order for oxygen at 2 liters per minute via nasal cannula. Review of the patient's chart showed showed the patient was on room air and had never received oxygen per orders. On 6/18/13 at 1545, Assistant Nurse Manager (ANM) #2 reported that patients that come into the emergency department with chest pain are ordered oxygen as per protocol, and the staff apparently failed to place the oxygen on the patient.














25877

On 06/20/2013 at 0930, observations of LPN (Licensed Practical Nurse) #1 performing a daily wound care dressing change to the patient's left upper inner thigh revealed LPN #1 used Hypafix tape to secure the wound instead of paper tape, and failed to use the 3M No Sting Spray as ordered to the left side of the patient's scrotum. Review of Patient #20's physician orders for wound care on 06/20/2013 at 1050 revealed the physician's orders, read, "...Wound Care...Special Instructions: wound (L) (left) upper inner thigh Daily & PRN (as needed) drainage: Clean c (with) wound cleanser, pat dry. Lightly pack with Aquacel silver dressing, cover with gauze, allow underwear to hold in place or only small amount of paper tape Use 3M no Sting spray to left side scrotum...". The Nurse Manager of the 6 th floor medical surgical unit on 06/20/2013 at 1050 verified the finding.

On the days of the Recertification Survey based on interview, record review, and hospital policy and procedure review, the hospital failed to ensure that the nursing staff evaluate the nursing care for each patient by way of assessment and reassessment following an intervention for 4 of 62 open patient records reviewed for care and services. (Patient #25, #27, #54, and #5).


The findings include:


On 6/19/13 at 1500, record review revealed Patient #25 had a physician written on 6/10/13 for Caffeine Citrate 4.6 mg (milligrams), IV (intravenous) q (every) 24 hours. On 6/11/13 at 1500, when the Caffeine infusion was administered, there was no documentation of the patient's apical pulse.

On 6/20/13 at 1130, record review revealed Patient #27 had a physician order written on 6/20/13 at 0230 for Morphine 5 mg, IV, q 4 hours, PRN (as needed) for severe pain. On 6/20/13 at 0501, the morphine was administered, but there was no documentation of a pain scale assessment prior to and following the medication administration.

On 6/20/13 at 1930, record review revealed Patient #54 had a physician order written on 6/18/13 at 0636, for Percocet 5/325, 2 (tablets) tab, q 4 hours, PRN severe pain. Review of the patient's chart showed percocet was administered on 6/18/13 at 1941, 6/18/12 at 2349, 6/19/13 at 0502, 6/19/13 at 1015, and 6/19/13 at 2210, but there was no documentation of a pain scale assessment prior to and following the medication administration.

Hospital policy, titled, "Provision of Nursing Care Pain Management", revised 2/13, states, "Critical Notes 1. All patients will be evaluated for the presence of pain on admission, at least once a shift, after pharmacological and nonpharmacologic intervention and at discharge. 2. Use age and cognitively appropriate pain scale which makes sense to the patient. 3. Use the same scale every time with the same patients. Only change scales when the patient's cognitive abilities change. 4. Nurses will make a clinical judgement based on subjective and objective information...Adult Pain Scales: Numeric Verbal 0 - 10 Scale; Wong Baker Faces 0 - 10 Scale; Pain Assessment in Advance Dementia (PAINAD) Scale - use in adults with advanced dementia who are unable to self report...Documentation: 1. Document pain score, pain reevaluation , and Patient/family Education on appropriate forms. 2. Note: If patient appears asleep and unable to score pain after intervention, choose unable to score and then under nonverbal pain cues, choose appears sleeping."


31672

On 6/17/13 at 1600, review of Patient #5 chart revealed the patient was admitted on 6/17/13 at 2156 from the emergency department with a diagnosis of abdominal pain. Review of the patient's chart showed the patient received Morphine for pain in the emergency department on 6/16/13 at 2232. There was no pre-pain scale assessment documented by Registered Nurse (RN) #26 prior to the administration of the medication. On 6/18/13 at 0507, review of the patient's chart showed the patient received Hydromorphone for a complaint of pain, but there was no documentation of a post administration pain score assessment by RN #25.
The findings were verified with Nurse Manager #2 and Diabetic Educator # 1 on 6/18/13 at 1615.

On the days of the Recertification Survey based on interview, review of patient records, and review of hospital policies and procedures, the hospital failed to ensure the nursing staff develops, reviews, and revises a nursing care plan every twenty-four (24) hours for each patient for 7 of 62 open patient records reviewed. (Patient #5, 43, 44, 46, 47, 48, and 49)


The findings are:


On 6/7/13 at 1600, review of Patient #5's chart revealed the patient was admitted through the emergency department on 6/16/13 at 2156 to the Renal-Nephrology Floor with a diagnosis of Abdominal Pain. Review of the patient's nursing care plan revealed the nursing care plan was not initiated within 24 hours for a primary diagnosis of End Stage Renal Disease (ESRD).

On 6/ 21/13 at 1343, review of Patient #47's chart revealed the patient was admitted through the emergency department on 6/12/13 at 2143 to the Surgical Trauma Intensive Care Unit (STICU) with a diagnosis of Moped versus Car. Review of the patient's nursing care plan revealed the nursing care plan was not initiated within 24 hours for a primary diagnosis of Neurological for a closed head injury.

On 6/ 21/13 at 1600, review of Patient #44's chart revealed the patient was admitted from the Cath Lab on 6/19/13 at 1105 to the Coronary Care Unit (CCU) with a diagnosis of a Right groin Hematoma. Review of the patient's nursing care plan revealed the nursing care plan was not initiated within 24 hours. The patient's care plan was initiated on 6/21/13 at 0418.

On 6/ 21/13 at 1700, review of Patient #43's chart revealed the patient was admitted from the emergency department (ED) on 6/19/13 at 2124 to the Coronary Care Unit (CCU) with a diagnosis of Respiratory Failure and Unresponsiveness. Review of the patient's nursing care plan was not initiated within 24 hours. The nursing care plan was had not been initiated as of 6/21/13 at 1700.

On 6/ 21/13 at 1742 , review of Patient #46's chart revealed the patient was admitted through the emergency department on 6/18/13 at 1329 to the Surgical Stepdown Unit (SSU) with a diagnosis of Weakness. Review of the patient's nursing care plan revealed the nursing care plan was not initiated within 24 hours. The care plan was initiated on 6/19/13 at 2110.

On 6/21/13 at 1145, review of Patient #48's nursing care plan revealed the nursing care plan had not been updated every 24 hours on the following dates: 5/27/13, 6/6/13, 6/7/13, 6/8/13, 6/10/13, 6/11/13, 6/12/13, 6/13/13, 6/14/13, and 6/18/13.

On 6/21/13 at 1343, review of Patient #47 's nursing care plan revealed the nursing care plan had not been updated every 24 hours on the following dates: 6/12/13, 6/13/13, 6/15/13, 6/16/13, 6/20/13, and 6/21/13.

On 6/21/13 at 1405, review of Patient #49's nursing care plan revealed the nursing care plan had not been updated every 24 hours on the following dates: 6/12/13, 6/15/13, and 6/17/13.

On 6/21/13 at 1600, review of Patient #44's nursing care plan revealed the nursing care plan had not been updated every 24 hours on the following dates: 6/20/13 and 6/21/13.

On 6/21/13 at 1700, review of Patient #43's nursing care plan had not been updated every 24 hours on the following dates: 6/20/13 and 6/21/13.

On 6/21/13 at 1742, review of Patient #46's nursing care plan revealed the nursing care plan had not been updated every 24 hours on the following dates: 6/20/13 and 6/21/13. The findings were verified with Clinical Educator #3.

Hospital policy, titled, No. G-2, R-1, Guidelines, Patient Care, reads, "....3.1 The Registered Nurse will initiate the plan of care within eight hours of admission....".

On the days of the Recertification Survey based on interview, review of patient charts, review of Medication Administration Records (MAR), and review of the hospital policies and procedures, the Hospital failed to ensure staff reports medication errors on a documented occurrence report for 1 of 62 open patient records reviewed. (Patient #47)


The findings are:


On 6/21/13 at 1400, Clinical Educator #3 reported that when a patient's medication is ordered but not given, the hospital views the occurrence as a medication error and an Occurrence Report is filed. Clinical Educator #3 stated that a nurse can reschedule certain medications for a patient to be given at a later time, within a reasonable time frame, and that will suffice to cover why a medication was not administered as ordered. A reason for the rescheduling of a medication would occur if the patient has to go off the floor for a test or procedure and wasn't available for the administration of the medication.

On 6/21/13 at 1343, review of Patient #47's chart revealed the patient was admitted on 6/12/13 at 2143 through the Emergency Department with a diagnosis of Moped versus car. Review of the patient's chart showed a scheduled medication, Clindamycin 600 milligrams (mg) / (per) 50 milliliters (ml), an antibiotic, prescribed to be given every 8 hours intravenous (IV). Review of the patient's medication administration record(MAR) revealed the medication was administered on 6/20/13 at 0921 with the next dose of medication due at 1800. Further review revealed no documentation that the 1800 ordered dose of the Clindamycin was not documented as administered. There was no documented reason in the patient's chart as to why the medication was not administered. Further review of the patient's MAR revealed the next dose of the Clindamycin was documented as given on 6/21/13 at 0229.

On 6/21/13 at 1930, the Director of Critical Care Services verified the finding and confirmed no Occurrence Report was filed by the nurse.

Review of hospital policy No. 7071-49, Pharmacy: Medication Error Reporting, reads, "....1. When medication errors occur resulting in a direct effect on patient care, an occurrence report must be filled out....".

Review of Policy No. B.11, Occurrence Reporting and Follow Up, reads, "....1.1 The individual first made aware of the occurrence or near miss event shall take responsibility for completing the Occurrence Report Form in conjunction with the Department Director or his/her Designee....".

On days of the Recertification Survey based on observation, interview, and review of the hospital policies and procedures, the Hospital failed to ensure controlled medications were locked in a secure area in the emergency department.


The findings are:


On 6/18/13 at 1158, random observations in the Emergency Department in trauma bay one (1) revealed a pediatric emergency medication box, with only a plastic seal to secure it, contained 2 carpujects of expired Diazepam 10 milligrams (mg) / 2 milliliters (ml). After removing the controlled medication from the drug box on 6/18/13 at 1202, Assistant Nurse Manager (ANM) #3 stated that the medication should not be in this box anyway.

Review of hospital policy No. 7071-31, titled, Pharmacy: Controlled Substance, reads, "....controlled substances are stored and dispensed according to state and federal laws and regulations....".

On the days of the Recertification Survey based on observation and interview, the Hospital failed to ensure drugs were not expired in the Pediatric emergency medication box in the emergency department.


The findings are:


On 6/18/13 at 1158, random observations in the emergency department's Trauma Bay 1 revealed a Pediatric medication box on the crash cart which had 2 carpujects of Diazepam 10 milligrams (mg)/ 2 milliliters ( ml) that expired on 6/1/13, 1 Abboject of Epinephrine 1:10,000 that expired 6/1/13, and 1 vial of Lidocaine 2% - 100 mg that expired 6/1/13. The findings were confirmed with the Emergency Department Director and Assistant Nurse Manager (ANM) #3.

On the days of the Recertification Survey based on observations, interview, and review of the hospital policies and procedures, the Hospital failed to ensure staff monitored supplies and equipment to meet an acceptable level of safety and quality in the emergency department


The findings are:


On 6/18/13 between 1055 and 1115, random observations in the emergency department revealed four (4) emergency crash carts that had no documentation of the daily required shift checks on the following dates:
Green Zone 1 - Non-Acute Care:
6/02/13- No 7 PM shift
6/05/13- No 7 PM shift
6/06/13- No 7 AM shift or 7 PM shift
6/07/13- No 7 PM shift
6/11/3- No 7 AM shift or 7 PM shift
6/12/13- No 7 PM shift
6/14/13- No 7 AM shift or 7 PM shift
6/15/13- No 7 PM shift

Green Zone 2- Non- Acute Care:
6/03/13- No 7 PM shift
6/04/13- No 7 PM shift
6/07/13- No 7 PM shift
6/12/13- No 7 PM shift
6/13/13- No 7 AM shift
6/14/13- No 7 PM shift
6/15/13- No 7 AM shift

Purple Zone Pod 3- Pediatrics:
5/27/13- No 7 AM shift
5/28/13- No 7 PM shift
5/29/13- No 7 AM shift or 7 PM shift
5/30/13- No 7 AM shift or 7 PM shift
5/31/13-No 7 AM shift
6/03/13- No 7 PM shift
6/04/13- No 7 AM shift
6/05/13- No 7 AM shift
6/11/3- No 7 AM shift

Purple Zone Pod 4- Pediatrics:
5/31/13- No 7 AM shift
6/05/13- No 7 AM shift

On 6/18/13 at 1135, random observations in the emergency department revealed a patient nourishment refrigerator that did not have a documentation of the daily temperature per the hospital's own policy. The findings were verified with the emergency department Director and the Assistant Nurse Manager (ANM) #2, #3, and #4.

On 6/18/13 at 1100, random observations in the Pediatric Emergency Department revealed there were no electrical outlet covers installed in 13 of 13 patient rooms. The findings were verified with the Emergency Department Director on 6/18/13 at 1101.

On 6/18/13 at 1131, random observations in the Emergency Department in the Yellow Zone revealed 4 Hill ROM beds, 3 stretchers, 2 Roll out beds, and 2 bedside tables. This area is adjacent to where the psychiatric patients are observed in a non-lockdown area. On 6/18/13 at 1133, the Director of the emergency department confirmed the objects should be moved from cluttering the hallway, as this is a patient, staff and visitor safety issue.

Review of hospital policy, titled, Refrigerators Maintenance and Monitoring Procedures/Guidelines/Rules, reads, ".... 4..Documentation of daily temperature readings of all patient refrigerators is required....".

Review of hospital policy, titled, Emergency Code Cart and Defibrillator Checks PGR, reads, "....PH Richland 1. The code cart is to be checked every AM (morning) and PM (evening) (daily on operational days that operate 12 hrs or less) and after each use for the following parameters....".

On the days of the Recertification Survey based on observations, record reviews, and hospital policies and procedures, and other data, the hospital failed to provide a sanitary environment that prevents the potential transmission of sources and transmission of infections and communicable diseases in the emergency department, dialysis unit, medical surgical unit, and general hospital areas.

The findings are:

Cross Reference to A 0749: The Infection Control body failed to ensure staff followed its own infection control procedures to ensure a sanitary hospital environment to decrease the potential for cross contamination for 2 of 2 Certified Clinical Hemodialysis Technicians (CH #1 and #2), 2 of 2 Registered Nurses (RN) observed (RN #2 and RN #35) and multiple hospital staff in surgical attire with a covering in the dialysis unit, emergency department, medical surgical unit and general areas of the hospital.

Cross Reference to A 0750: The hospital's infection control body had no mechanism to capture Hepatitis B positive (HBV) patients who are treated and cared for in the dialysis setting.

On the days of the Recertification Survey based on observations and interview, the Infection Control body failed to ensure staff followed its own infection control procedures to ensure a sanitary hospital environment to decrease the potential for cross contamination for 2 of 2 Certified Clinical Hemodialysis Technicians (CH #1 and #2), 2 of 2 Registered Nurses (RN) observed (RN #2 and RN #35) and multiple hospital staff in surgical attire with a covering.


The findings are:


On 6/17/13 at 1430, observations in the hospital's contracted dialysis unit revealed Clinical Certified Hemodialysis Technician #1 and Patient Care Technician #1 providing care to hemodialysis patients on the treatment floor without wearing any PIPE (personal protective equipment). On 6/17/13 at 1435, PCT #1 reported that all staff are to wear PIPE which includes a gown, gloves, and a mask for potential blood exposure.

On 6/17/13 from 1443 until 1448, observations on the dialysis treatment floor revealed CCHT #2 entered the dialysis unit from the hospital and traveled from dialysis station #3, #5 and #6 without donning any type of PIPE. On 6/17/13 at 1505, random observations of the dialysis treatment floor revealed Registered Nurse ( RN) #1 entered the dialysis treatment floor and provided patient care at dialysis station #6 without wearing any PIPE. On 6/17/13 at 1507, random observations on the dialysis treatment floor revealed clipboards were placed on the top of 6 of 6 dialysis machines. On 6/17/13 at 1517, RN #1 was observed writing on the clipboards that were lying on top of the dialysis machines located at station #4, #5, and #6. RN #1 traveled between each dialysis station and back to the nurse station without wearing any PIPE and without performing hand hygiene. On 6/17/13 from 1505 to 1517, the observations were verified with Nurse Manager #1. On 6/17/13 at 1515, RN #1 reported that when providing patient care, staff wear a gown and gloves while cannulating, and can wear a accessed if so desired.

On 6/19/13 at 1855, random observations in the acute dialysis unit revealed RN #20 turned the dialysis machine alarm off at station #6 without gloves.
The findings were witnessed and observed by Nurse Manager on 6/19/13 at 1855.


29886

On 6/17/2013-6/21/2013, random observations in the dining room, in the and in the halls throughout the hospital, observations showed staff garbed in surgical masks, hats, and surgical attire without any lab coats covering the uniforms. Hospital policy, titled, Surgical Attire Surgery Policy No. 715.011, states, "...Policy statement: To maintain environmental control and promote a high level of cleanliness and hygiene within the Surgical Department. Masks are to be worn in the O.R. (Operating Room) suites whenever sterile supplies are open. They are to be changed between cased and should not be worn when leaving the department. Masks should have a facial compliance to prevent venting. They are not to be saved by hanging around the neck or tucked into a pocket..." "...A lab coat or cover gown should be worn over the scrub uniform when leaving the surgical are. When leaving the surgical area, lab coats must be closed..."


30011

On 6/18/13 at 1615, random observations of the dialysis unit revealed a patient with Isolation Precautions in the Isolation Room being provided care by Registered Nurse #35 who exited the Isolation Room and proceeded to the sink to wash hands, and then, discarded the Personal Protective Equipment (PPE). On 6/18/13 at 1635, Nurse Manager #1 revealed PPE is discarded inside the Isolation Room, and then, staff exit the room to wash their hands.

Hospital policy, reads, "Fresenius Medical Care, Dialyzing Patients with Positive Hepatitis B Antigen, Personal Protective equipment (PPE) must be removed and discarded or left in the isolation room/area if not soiled....".


25877

On 06/20/2013 at 0930, observations of LPN (Licensed Practical Nurse) #1 performing a daily wound care dressing change to Patient #59 revealed that prior to starting the procedure, LPN #1 positioned the patient for the dressing change to the left inner upper thigh. LPN #1 used soap and water to cleanse his/her hands but cleansed his/her hands and fingers with soap for less than 10 seconds before rinsing and drying. LPN #1 put on a clean pair of gloves and took the old dressing off of the wound and placed the soiled dressing in the trash can without removing his/her soiled gloves. Then, LPN #1 applied the wound cleanser to the patient's wound to clean the inside of the wound. After cleaning the inside of the wound, LPN # 1 removed the soiled gloves and failed to perform hand hygiene. Then, LPN #1 put on a clean pair of gloves, used the scissors to cut a piece of the Aquacel Silver dressing, and placed it in the wound, and covered the wound with a dry gauze. Next, LPN #1 applied Hypafix tape to secure the dressing. LPN #1 removed one glove to write initials and date on the dressing. After answering the patient's questions related to the wound, LPN # 1 assisted the patient to pull up underwear to help keep the dressing in place. LPN # 1 removed the soiled glove but failed to perform hand hygiene. LPN #1 gathered up the patient's dirty sheets and placed the sheets in a bag and carried the soiled sheets to the soiled work room. In the soiled work room, LPN #1 used an alcohol sanitizer to clean the hands for less than 10 seconds but not thoroughly cleaning all surfaces of the hands and fingers until dry. LPN #1 went to the nurse station and used soap and water to cleaning the hands and fingers for less than 10 seconds before rinsing and drying.

Hospital policy and procedure, titled, Hand Hygiene, effective June 2011, reads, "... 1. HAND HYGIENE INDICATIONS 1.1 Before and after patient contact 1.2 After contact with a contaminated source (i.e., body fluids, non-intact skin, and/or environmental surfaces) 1.3 Before and after invasive procedures 1.4 After glove removal 1.5 After using the restroom 1.6 Before and after eating 1.7 When hands are visibly soiled 2. HAND WASHING PROCEDURE 2.1 Wet hands. 2.2 Apply soap. 2.3 Rub hands together vigorously for 15 seconds covering all surfaces of fingers and hands. 2.4 Rinse hands with water. 2.5 Dry hands thoroughly with paper towels. 2.6 Use dry paper towel to turn faucet off. 3. ALCOHOL HAND SANITIZER...3.3 Apply product to the palm of the hand (quarter-size puddle if a gel product or golf ball size if foam agent). 3.4 Rub on all surfaces of hands and fingers to include web spaces until completely dry.

Guidelines and standard nursing practice in the health care setting set forth in the Recommendation and Reports for the Centers for Disease Control, reads, "Morbidity and Mortality Weekly Report Recommendations and Reports October 25, 2002/Vol 51/No. RR-16 Guideline for Hand Hygiene in Health-Care Settings...2. Hand-Hygiene technique...B. When washing hands with soap and water, wet hands first with water, apply an amount of product recommended by the manufacture to hands and rub together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse hands with water and dry thoroughly with a disposable towel. Use towel to turn off the faucet (lB) (90-92,94,411)...". Guidelines and standard nursing practice in the health care setting set forth by the Centers for Disease Control, reads, "...Hand Hygiene Guidelines Fact Sheet...When using an alcohol-based hand rub, apply product to palm of one hand and rub hands together, covering all surfaces of hands and fingers, until hands are dry...".

On the days of the Recertification Survey based on interview, review of submitted data, and review of hospital policies and procedures, the hospital had no mechanism to capture Hepatitis B positive (HBV) patients who are treated and cared for in the dialysis setting.


The findings are:


On 6/18/2013 at 1400, observation showed a patient in the isolation room undergoing dialysis. Staff on the dialysis unit identified the patient as an undocumented person with Hepatitis B who presented to the Emergency Room and was sent from the emergency room to the dialysis unit for dialysis. On 6/19/2013, the Nurse Manager reported that this patient with the Hepatitis B or any patients who might present for dialysis with Hepatitis B is not captured any hospital infection control log.

On 6/19/13 at 1115, the Risk Manager Director confirmed the hospital had no system to capture Hepatitis B patients who present to the hospital for dialysis.

On 6/20/13 at 0910, the Infection Control Director reported that there is no means of monitoring Hepatitis patients who present to the hospital for dialysis.

Review of the Contract Agreement between the Hospital and Fresenius Medical Care CAN Kidney Centers, reads "....Duties of Provider....1.04 Provider shall provide policies, procedures, and techniques pertaining to the methods by which the SERVICES are rendered at the Hospital....".

Review of Policy, FMS-CS-IC-II-155-140A, Dialyzing Patients with Positive Hepatitis B Antigen (HBsAg+), reads "....If there are current HBV+ patients on census, the isolation area/room and equipment cannot be used for HBV negative patients on other shifts or days due to the risk of cross-contamination....".

On the days of the Recertification Survey based on interview, review of patient electronic medical records (EMR), and review of hospital policies and procedures, the hospital failed to ensure each patient had a documented and authenticated History and Physical (H&P) completed within twenty-four (24) hours of admission for 1 of 62 open patient records reviewed for care and services. (Patient #44)


The findings are:


On 6/21/13 at 1630, review of Patient #44's chart revealed the patient was admitted on 6/19/2013 at 1105 after a heart catheterization for a right groin hematoma. Review of the patient's chart revealed there was no H&P documentation to be found for the admission. The findings were verified with Clinical Educator #3.

Review of hospital policy, titled, Rules and Regulations, reads, ".... B. Medical Records 2.. A complete history and physical examination shall be dictated or written and designated as an initial assessment within twenty-four (24) hours after admission....".