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Based on medical record reviews, review of facility documentation, review of facility policies and interviews for one of three patients reviewed for an initiated grievance complaint (Patient #44), the facility failed to ensure the response was timely. The finding includes:

Patient #44 was admitted to the facility on 12/25/15 with a chief complaint of confusion and was diagnosed, in part, with sepsis due to urinary tract infection with suprapubic tube. Facility documentation by Person #2 and received by the facility on 1/7/16 identified complaints of care provided to Patient #44. The facility documentation further indicated that the facility sent an initial written response to Person #1 on 1/14/16 and the final response letter was not sent to Person #2 until 2/22/16 (46 days and 32 business days after receipt of the complaint). Interview with the Risk Management Coordinator on 8/25/16 at 12:43 PM noted that according to hospital policy, the hospital had 30 business days to respond to a complaint. He/she further indicated that the complaint was not forwarded to the Patient Relation's Department timely and, therefore the response was not timely. Although the facility policy identified that the facility had 30 business days to send a final written response to a grievance, the policy did not reflect conformance with the Hospital Federal Regulatory Guidance that required most grievances be investigated and responded to within 7 days.

Based on observation, review of clinical records, hospital policies and procedures and interviews for one of five patients in the Emergency Department (ED) Behavioral Health (BH) crisis area, Patient #30, the hospital failed to ensure that the patient was informed of continuous video surveillance. The finding includes:

Tour of the Emergency Department (ED) Behavioral Health (BH) crisis area on 08/22/16 a 10:10 AM and interviews with RN #15 identified that all five, single, patient rooms were under continuous video surveillance that was monitored in the nursing station. RN #15 identified that, upon admission, each patient was verbally informed that they should not change their clothes in the room due to the continuous video surveillance. The notification of surveillance was not documented in the clinical record.

Observation and review of Patient #30's clinical record on 08/22/16, intermittently, from 10:10 AM through 11:30 AM identified that the patient was pacing, and entering and exiting his/her assigned room resulting in an episode of 4 point restraints. The episode continued with a staff member providing a one to one observation within the room. Continuous video surveillance was observed from the nursing station. Review of the clinical record failed to identify that the patient was informed of the continuous surveillance. At the time of observation, four other patients were also visible on the surveillance monitor.

A hospital policy for videotaping identified, in part, that the public safety department was authorized to conduct video surveillance as it relates to monitoring of behavioral patients in the Emergency Department who may pose a danger to themselves or others and therefore, require monitoring to ensure their own safety and/or the safety of any staff interacting with them. The policy failed to address patient notification of video surveillance.

1. Based on a review of clinical records, interview and policy review the facility failed to ensure that two of four patients reviewed for complaints of pain (#27 and #29) had pain assessments completed in accordance with hospital policy. The findings include the following:

a. Patient #27 was admitted to the hospital on 8/14/16 with mental status changes and chronic intractable pain. Review of the clinical record indicated that on 8/20/16 at 5:14 PM the patient was medicated with Motrin 400 mg for pain, absent a pain assessment utilizing the pain scale in accordance with hospital policy. Further review of the record failed to indicate that the patient's pain was reassessed following the administration of Motrin to determine the efficacy of the medication.

b. Patient #29 was admitted on 8/15/16 with ETOH withdrawal. Review of the initial nursing assessment indicated that the patient had right great toe pain. The assessment failed to identify a description/characteristics of the pain. Review of the record for the period of 8/15/16 through 8/20/16 failed to reflect that any other pain assessments were conducted. Interview with the RN on 8/22/16 at 10:30 AM indicated that the patient had chronic toe pain related to an old injury.

Review of the pain policy indicated that a pain assessment should be completed once per shift using a pain scale 0-10 (10 being the worst possible pain). The evaluation of pain is appropriate to patient condition and treatment and may include efficacy of pain management strategies.

2. Based on a review of clinical records, interview, and policy review, the facility failed to ensure that for one sampled patient (Patient #29) withdrawing from alcohol that the assessments and interventions were performed according to policy. The findings include the following:

a. Patient #29 was admitted on 8/15/16 with ETOH withdrawal. Review of the clinical record indicated that on 8/18/16 Clinical Institute Withdrawal Assessments (CIWA) were completed at 6:10 AM (score 2) and at 12:26 PM (score 8). The clinical record indicated that at 9:02 AM the patient received 2 milligrams (mg) of Ativan absent a CIWA assessment to determine dosing in accordance with facility protocol.

Review of the policy, entitled "Management of Acute Alcohol Withdrawal in Critical Care Patients", identified that the pharmacological management is based on the patient's score per protocol. The Ativan based protocol identfied in part, that for a score of 5-14 administer Ativan 2 mg IVP and reassess in two hours, for a score of 15-19, administer Ativan 4 mg IVP and reassess in 60 minutes, and for a score greater than or equal to 20, administer Midazolam 10 mg IVP, notify the provider and reassess in 15 minutes.

b. Patient #29 had a CIWA assessment on 8/18/16 at 12:48 PM that identified the patient's score was 11. The record failed to indicate that the patient was reassessed two hours later in accordance with the protocol (assessment completed at 4:25 PM). Review of the 4:25 PM assessment identified that the patient's score was 10. The record failed to indicate that the patient was assessed two hours later (assessment completed at 9:08 PM) in accordance with the facility protocol.

c. Patient #29 had a CIWA assessment on 8/19/16 at 10:20 AM that identified the patient's score was 9 and the patient was medicated with Ativan 2 mg, the subsequent reassessment was not completed until 2:27 PM, four hours later.

d. Patient #29 had a CIWA assessment on 8/20/16 at 7:24 AM that identified a score of 6 and although the patient was medicated with Ativan 2 mg at 10:32 AM, the clinical record failed to indicate that the patient was assessed two hours later (assessment completed at 2:19 AM) in accordance with the facility protocol.

Interview with the RN on 8/22/16 at 10:00 AM stated that the hospital's CIWA policy was not followed.


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3. Based on a review of clinical records, interview, and policy review for one of two sampled patients (Patient #43) reviewed for the retention of foam with the use of wound vacuum therapy, the facility failed to remove the foam prior to discharge. The finding included:

Review of the clinical record identified Patient #43 was admitted to the hospital on 7/23/14, underwent a Cesarean Section at thirty eight weeks gestation and was discharged to home on 7/27/14. On 7/31/14 Patient #43 underwent a surgical incision for a suspected infection and drainage of an abscess with placement of wound vacuum therapy. The record indicted that two pieces of white foam and one piece of silver foam was placed into the wound intraoperatively. Record review and interview with RN #13 on 8/25/16 at 1:15 PM stated she was the first nurse to change the dressing on 8/2/14 after surgery and removed all three pieces of foam that were placed into the wound on 7/31/14. RN #13 placed three pieces of white foam and one piece of silver foam into the wound on 8/2/14 during wound care. On 8/4/14 during the dressing change, the Wound Care nurse removed two pieces of white foam and one piece of silver foam and replaced black foam into the wound. The patient was discharged to home on 8/4/14. On 8/6/14 Patient #43 returned to the ED for a dressing change as the patient could not tolerate the dressing change from the community provider secondary to severe incisional pain. The clinical record identified black foam was removed and a Hydrofera Blue topical dressing with opsite was applied. On 12/12/14 Patient #43 was referred to MD #13, who was a surgeon for complaints of discomfort and a bulge on the left lateral side of her abdomen. Abdominal imaging did not identify a foreign body. On 1/23/15 Patient #43 underwent an exploratory laparotomy. The removal of a foreign body was extracted from the site of the Cesarean Section. Microscopic examination of the foreign body revealed the material to be white foam from the wound treatment. Further interview with the wound care nurse indicated she did not check the clinical record to ascertain how many pieces of foam where placed into the wound on 8/2/14 and assumed that only three pieces of foam were in the wound and not four. The wound care nurse identified she failed to check the clinical record where the type and amount of foam was documented and should have. The hospital policy entitled Negative Pressure Wound Therapy directed in part to time, date, initial, and list the amount/type of foam used in the wound on the draping once the dressing was completed. The policy failed to direct that the nurse would document what was removed from the wound and if a discrepancy in the count was identified to notify the physician.

4. Based on a review of facility documentation and interview, the facility failed to provide evidence of competency training for staff completing water testing and/or evidence that water testing results was reviewed with the Medical Director of the Dialysis Unit. The findings include the following:

a. On 08/23/16 at 9:30 AM, RN #100 was observed to complete the daily chlorine/ chloramine testing. Review of facility documentation provided indicated RN #100 had been signing off on water quality testing logs since Aug 2, 2016. Review of facility education records with documentation from the Engineering Director failed to reflect that RN #100 had been trained in water quality testing.


b. On 08/23/16 at 9:40 AM the surveyor was not provided with documentation from the Engineering Director and/or the Nurse Manager to indicate evidence that on-going monitoring of the chemical quality of the water, and actions taken when levels were outside the AAMI standards, were reviewed by the dialysis unit Medical Director, i.e. there is no mechanism to ensure the AAMI water quality logs are reviewed and signed off by the Medical Director. Interview with the Nurse Manager on 8/23/16 indicated that she reviews all the water testing.

Based on a clinical record review and staff interviews, for one sampled patient (Patient #41) who was administered Oxytocin for the induction/augmentation of labor, the facility failed to ensure that a physician's order for titration of Oxytocin was documented in the record. The finding included:

Review of the clinical record identified Patient #41 was admitted to the hospital on 8/15/16 at thirty nine weeks gestation. Physician's orders dated 8/16/16 at 7:02 AM directed Oxytocin 30 units at 1 milliunit/minute and titrate every thirty minutes until labor was established. Oxytocin was initiated at one milliunit/minute at 8:00 AM and was incrementally increased to 9 milliunits/minute until 1:25 PM. Review of the physician's progress note dated 8/16/16 indicated at 1:25 PM the Oxytocin infusion was decreased to 4 milliunits/minute for recurring variables. Record review and interview with Nurse Manager #2 on 8/22/16 at 11:30 AM failed to indicate a physician's order that directed the titration of Oxytocin on 8/16/16 at 1:25 PM was documented as an order and should have.

Based on medical record review, review of hospital policies observations and interviews for one of four patients who had an out-patient surgical procedure (Patient #47), the physician failed to ensure that the history and physical was performed timely. The finding includes:

Patient #47 was admitted to the hospital on 8/23/16 for an endoscopic procedure. The undated History & Physical (H&P) printed on 7/2/16 identified that the patient had a complete H&P performed prior to admission. Observation on 8/23/16 at 10:45 AM noted that the patient was in the preoperative area. Interview with OR staff on 8/23/16 at 10:49 AM noted that the patient's physician had documented no changes to the H&P prior to seeing the patient and without performing a physical assessment. The facility rules and regulations of the medical staff identified that a H&P must be performed within 30 days prior to admission.

Based on on medical record recirew, reviewof hospital policies observations and interviews for two of six surgical patients who had a surgical procedure performed on 8/23/16 (Patients #46 and #47), the physician failed to completely assess the patient prior to the procedure. The finding includes:


Patient #46 was admitted to the hospital on 8/23/16 for a subcutaneous mastectomy. The history and physical (H&P) identified that the patient's H&P was performed prior to admission on 8/17/16. Observation on 8/23/16 beginning at 10:22 AM noted that the patient was in the properative area and both the anesthesiologist and surgeon entered the patient's room. Although the surgeon znd anestheiologist, in part, spoke with the patient, an assessment of the patient's heart and lungs was not observed. Interview with Patient #47 on 8/23/16 at 10:42 AM indicated that only the nurse listened to the patient's heart and lungs.

Patient #47 was admitted to the hospital on 8/23/16 for an endoscopic procedure. The undated H&P printed on 7/2/16 identified that the patient had a complete H&P performed prior to admission. Observation on 8/23/16 at 10:45 AM noted that the patient was in the preoperative area. Interview with Patient #47 on 8/23/16 at 10:45 AM indicated that the nurse assessed the patient's heart and lungs. Review of the patient's record and interview with staff on 8/23/16 at 10:49 AM noted that the patient's physician had documented no changes to the H&P prior to seeing the patient and without performing a physical assessment. The facility policy for modrate sedation identified that the physician's pre- procedure assessment must include a focused physical exam including auscultation of heart and lungs.

1. Based on observation, interviews, and policy review, the hospital failed to ensure Pharmacy Technician's followed procedure in preparation for sterile drug compounding activities. The findings include the following:


a. On 8/30/16 at 12:30 PM, Pharmacy Technician (PT) #5 was observed exiting the pharmacy compounding room. PT #1 was observed to remove her mask and head covering and was observed to have earrings in both ears. PT #5 failed to remove all jewelry prior to entering the ante room in preparation for compounding.


b. On 8/30/16 at 12:45 PM, PT #6 was observed to enter the ante room and proceeded to don appropriate footwear, head cover, and face mask. PT #6 failed to remove earrings and/or clean her glasses prior to entering the ante room. The technician performed hand hygiene by washing hands for twenty-five (25) seconds, prior to entering the compounding room. PT #6 failed to perform handwashing for at least 30 seconds in accordance with hospital policy.


c. On 08/23/16 at 2:45 PM, PT #1 was observed wearing cracked and chipped fingernail polish. Interview with PT #1 at 3:00 PM identified that s/he was aware that compounding should not be performed while wearing nail polish and, furthermore, had performed compounding activities earlier that day.

Review of the Hand Hygiene and Garbing policy directed compounding personnel, in part, to remove all jewelry, and be free from nail polish. The policy indicated that staff should use a low linting towel to wipe corrective eyeglasses with an appropriate disinfectant and hand hygiene must be performed for at least 30 seconds.


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2. Based on observation, review of facility documentation, interviews, and policy review, the off-site compounding pharmacy associated with the hospital satellite surgical center, who compounds sterile pharmaceuticals, failed to ensure the segregated compounding room was in compliance with United States Pharmacopeia, Chapter 797, Pharmaceutical Compounding - Sterile Preparations. The findings include:


Tours of the satellite compounding pharmacy and interviews with the Pharmacy Operations Manager and Pharmacist #2 on 08/25/16 at 9:20 AM and 08/26/16 at 3:15 PM identified a pharmacy work area with an open laminar flow hood (certified ISO 5) positioned in the middle of the back half of the room facing away from the hand sink.

The following concerns were identified:

a. A suspended ceiling contained porous, cork-like tiles that were not sealed and/or cleanable and had the potential of releasing particles into the pharmacy environment.

b. The surveyor utilized a 70% isopropyl alcohol impregnated pad to wipe the wall of the compounding room leaving white residue on the pad consistent with non-epoxy paint. The Pharmacy Operations Manager was unaware of the type of paint used on the walls.

c. The Pharmacy floor was covered with vinyl-like sheeting with a plastic cove-base and was not sealed rendering an inability to effectively disinfect the surfaces.

d. No pressure gauges to monitor temperature and/or humidity levels in the compounding room were observed.

e. Review of air and surface cultures obtained in the hood conducted every six months by a contracted service identified no growth, however, air and/or surface cultures of the area directly outside of the open hood and/or line of demarcation were not obtained. The Pharmacy Operations Manager stated he was unaware that cultures in these areas was required.

Interview with the Pharmacy Operations Manager on 08/26/16 at 3:15 PM identified that based upon assessment by the hospital's Pharmacy Consultant and his understanding of the American Society of Health-Systems (ASHP) Guidelines on Compounding Sterile Preparations (CSP's) the compounding was safe due to the BUD of less than twelve hours.

Review of USP-797 guidelines identified, in part, that low risk level CSPs with a 12 hour or less BUD shall be in a segregated compounding area restricted to sterile compounding activities that minimize the risk of CSP contamination. The hospital failed to minimize the risk of CSP contamination.

Based on observation of the Radiology Department, staff interviews and a review of the facility documentation, the hospital failed to ensure an acceptable level of safety and quality. The findings included:

a. On 8/23/16 at 10:00 a tour of the Computed Tomography (CT) imaging room identified multiple intravenous needles were stored in a cabinet that was left unlocked and unattended.

b. Observation of the CT room identified an unlocked cabinet that was utilized for mechanical storage. A bottle of di-electrical oil was found within the cabinet. Interview with the Director of Radiology on 9/23/16 at 10:30 AM identified all sharp objects and/or other equipment that has a hazardous potential should be secured at all times. Subsequent to the surveyors inquiry all cabinets were locked.

On 9/1/2016 and 9/6/2016, as part of the periodic state Federal Hospital Survey, the Nuclear Medicine, and Radiology Departments of Lawrence Memorial Hartford and its satellite facilities were inspected for compliance with federal and state regulations and acceptable standards of practice.

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

In the Radiology Department, 4 items of non-compliance were identified within the scope of the inspection. In the Nuclear Medicine Department, no items of non-compliance was identified within the scope of the inspection.

a. R.C.S.A 19-24-7 and 19-25a-4 requires in part that an evaluation of the radiation hazards incident to the use of radiation sources under a specific set of conditions.

The adequacy of surveys shall be subject to review by the department's representatives.

Contrary to the above, Lawrence and Memorial Hospital was unable to produce a shielding design or shielding surveys for their x-ray operatories and radiation therapy rooms that are in compliance with current regulatory standards, e.g., NCRP reports 147 and 151.

b. R.C.S.A 19-24-8 (5)(C) requires in part that each area or room in which sources of ionizing radiation other than radioactive materials are used shall be conspicuously posted with the sign or signs bearing the radiation caution symbol and appropriate wording to designate the nature of the source.

Contrary to the above, Lawrence and Memorial Hospital did not have conspicuously posted radiation signs on the occupational side (x-ray technologist) of their x-ray operatories.

c. R.C.S.A 19-25a-1 (a) requires in part that the owner of devices emitting x-rays which are used for diagnostic or therapeutic purposes shall register their devices with the Department.

R.C.S.A 19-25a-1 (b) requires in part that no x-ray device shall be used unless registered with the Department.

Contrary to the above, Lawrence and Memorial Hospital did not register their x-ray devices at the hospital and Pequot Health Center.

The facility did not ensure that the condition of the physical plant and the overall hospital environment was developed and maintained in such a manner that the safety and well-being of patients were assured. The findings include the following:


a. On 08/22/16 at 11:30 AM the surveyor, while accompanied by the Engineering Director, observed that the patient use corridors in the 4-2 Wing lacked continuous, handrails on both sides of the corridor, as required by section # 2.1-7.2.2.10 of "Guidelines for the Design and Construction of Hospitals and Outpatient Facilities" and the "CT Public Health Code"; i.e. there are large portions of corridor wall area lacking hand rails including the fronts of nurses' stations, between doors, etc.


b. On 08/23/16 at 9:00 AM the surveyor was not provided with documentation from the Engineering Director to indicate that the ED Crisis (Behavioral Holding) Project, located within the Emergency Department had received approvals prior to its use, as required by CT General Statutes, Public Act No. 13-234; i.e. nursing unit in use at time of facility inspection- items listed on project approval letter had not been addressed; i.e. issue was cited at last survey and not addressed.


c. On 08/23/16 at 9:20 AM the surveyor, while accompanied by the Engineering Director, observed that the privacy curtains located within the Dialysis Nursing Unit were too short and not adequate for use in this area; i.e. curtains provide no privacy when patients are toileting chair-side.

Based on review of facility documentation, review of facility policies, observations and interviews the facility failed to ensure that a sanitary environment was maintained in the operating rooms (OR) and/or rehabilitation areas. The findings include:


a. A tour of the operative areas was conducted on 8/23/15 with the Director of Perioperative Services. Observations at 9:40 AM identified a surgical procedure in progress in OR #7. The observation also noted that the Physician's Assistant and Surgeon with ears exposed, thereby exposing sideburns on either side of the head. Interview with the Clinical Coordinator on 8/23/15 at 9:48 AM indicated that per the hospital policy all hair and ears must be covered when in the operative suite. The facility policy for surgical attire identified that head, hair, ears and facial hair is to be covered on all personnel entering the semi- restricted and restricted (OR) areas.


b. A tour of the operative areas was conducted on 8/23/15 with the Director of Perioperative services. Observations from 9:40 AM to 10:09 AM identified breaches in the vinyl coverings of a positioning device stored on a hall cart for use in the OR and an OR table in OR #8. Rusted and or peeling paint was observed on equipment to include soiled linen carts and OR tables. The sticky residue of tape was also observed on the vinyl covering in the minor treatment room. The breaches in vinyl, paint and or rusted, and or tape residue rendered the equipment unable to be properly sanitized. The observations also identified dust build- up on horizontal surfaces in the minor treatment room and in OR #8. Interview with the Clinical Coordinator on 8/23/16 at 9:50 AM noted that the OR's and treatment rooms were sanitized between cases using sanitizing wipes and were terminally cleaned at the end of the day. The facility policy for environmental cleaning of the surgical practice setting directed to wipe down all surfaces between cases (germicidal wipe) and all horizontal surfaces to include tables, stands, pedals, wheels and castors are to be cleaned at the end of the daily surgical schedule.

c. A tour of the out- patient rehabilitation (Rehab) area was conducted on 8/24/16 at 9:53 AM with the Manager of Rehab. Observations at 10:05 AM identified Patient #55 holding onto the parallel bars and ambulating while the physical therapist (PT) observed and cued the patient. The patient finished his/her session, the PT sanitized his/her hands and recorded the session. Although sanitizing wipes were observed on the wall of the Rehab area, the parallel bars were not sanitized following use by Patient #55. Observation at 10:15 AM noted another patient holding onto the same parallel bars that were not sanitized following use by Patient #55. Interview with the Director of Rehab on 9/24/16 at 10:15 AM indicated that he/she did not believe that the facility had a policy to direct the cleaning of therapy equipment between patient uses. The facility policy for standard precautions identified that reusable equipment must be cleaned and reprocessed before using in the care of another patient.

1. Based on a review of clinical records, review of hospital policy, review of hospital documentation and interviews with hospital personnel for 2 of 4 patients (#22 and #17) admitted under observation and/or same day surgery care (SDC) status, the hospital failed to ensure that a timely discharge planning evaluation was completed and/or that the plan was discussed with the patient. The findings include:

a. Patient #22 was admitted to the hospital's ED on 10/20/15 at 23:09 and triaged a level 2 (ESI 1-5, 2=emergent) after falling down 6 stairs. Review of the clinical record identified that the patient sustained head trauma with a head laceration requiring 31 staples, a sternum fracture, a cardiac contusion with a posterior hematoma and a pulmonary contusion. A Physician Order dated 10/21/15 at 5:10 AM directed that Patient #22 be admitted to observation status with syncope and collapse. The patient was not admitted as an inpatient or discharged within 24 hours, but remained on observation status for 4 days, being discharged on 5/24/15 at 3:19 PM. The attending physician, MD #15 was not available for interview at the time of investigation.

Review of the hospital policy entitled Level of Care Assignments directed in part that SDC meant a patient with a known diagnosis who enters the hospital for a specific procedure or treatment and was discharged in twenty-three hours. Observation status was described as a patient who required the use of a bed and periodic monitoring to evaluate his/her condition and determine the need for a possible inpatient admission. The policy also identified that a determination of patient's level of care assignment was to occur within 24 hours of admittance to observational status.

b. Review of Patient #22's clinical record and interviews with the Case Manager, RN #12 on 8/24/16 and 8/25/16 identified that the patient was admitted under observation status on 10/21/15 at 5:10 AM. Although the patient was alert and oriented, review of the patient's Observation Notice completed by RN #12 indicated that the patient's daughter (not the patient) was informed of the patient's observational status on 10/22/15. Review of the Notice and interview with RN #12 identified the Notice was not timed and RN #12 could not recall the conversation and did not know if the daughter understood the conversation. RN #12 identified that the conversation would not have been completed within 24 hours of the Admission Observation Order, 10/22/15 at 5:10 AM.

Review of the Public Act 14-180 identified in part, that each hospital shall provide oral and written notice to each patient that the hospital places in observation status of such placement not later than twenty-four hours after such placement. Such oral and written notices shall include a statement that the patient is not admitted to the hospital but is under observation status and a statement that observation status may affect the patient's Medicare, Medicaid or private insurance coverage for hospital services, home care or services in a skilled nursing facility. The written notice shall be signed and dated by the patient receiving the notice or the legal guardian, conservator or other authorized representative.


c. Review of the clinical record identified Patient #17 was admitted to the hospital on 5/6/16 with a status of outpatient same day surgery care (SDC). Patient #17 had a diagnosis that included pes planus, posterior tibial tendon nerve dysfunction, and acquired flatfoot deformities of the left foot. On 5/6/16 a triple arthrodesis using wright medical cannulated screws and Grafton augmentation bone putty was performed. Patient #17 was discharged to home on 5/13/16 with twenty four hour assistance from family members and in home visiting nurse and physical therapy services. Interview and review of the clinical record with the Director of Case Management on 8/25/16 at 4:00 PM indicated that Patient #17's hospital admission status on 5/6/16 was ordered as SDC which is identified as a patient who enters the hospital for a specific procedure and is discharged within twenty-three hours. Physician's orders were not changed to observation status until 5/9/16. Observation status was defined by the hospital as the use of a bed and periodic monitoring to evaluate a condition to determine the need for inpatient admission. When on observation status the physician was responsible to write an order with a date and time and admit or discharge the patient within 24 hours (but not to exceed 48 hours). Interview with MD #17 on 8/31/16 at 9:30 AM indicated an order for an admission status change from SDC to observation should have been written on 5/7/16 and was not. Interview and review of the clinical record with the Director of Case Management identified when Patient #17's status changed to an observation level of care the patient should have been provided verbal and written communication describing the allowable time frame for an observation status and should have been informed that a hospital admission may not have been approved after twenty-four hours and was not.

d. Review of the physician progress notes dated 5/7/16 identified Patient #17 required a skilled level of care. Interview with the Director of Case Management on 8/25/16 at 4:15 PM indicated a case manager did not see Patient #17 again until 5/9/16 and informed the patient that although assistance was needed with ambulation, pain management and activities of daily living he/she did not meet the criteria for inpatient hospitalization as these services could be provided in a skilled nursing facility or in the home. Further interview with the Director of Case Management indicated Patient #17 should have been seen by case management on 5/7/16 and informed of his/her options regarding discharge and was not.


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2. Based on review of clinical records, hospital policies and procedures, and staff interviews for one of three patients reviewed for discharge from the emergency department, Patient #23, the hospital failed to ensure that the patient had a safe disposition including access to necessary medications and medical equipment to ensure his/her ongoing health and wellbeing. The findings include:

Patient #23 was transferred from Skilled Nursing Facility (SNF) #1 to the ED on 05/20/15 at 11:56 AM on a Physician's Emergency Certificate (PEC) for a psychiatric evaluation. Accompanying documentation identified that SNF #1 would not accept the patient for readmission because they were unable to meet the patient's needs, the patient no longer required SNF level of care, and the health and/or safety of others would be in danger. Review of the clinical record identified diagnoses that included hypertension (HTN), type two diabetes mellitus (DM), muscle weakness, reactive depressive psychosis, chronic obstructive pulmonary disease, sleep apnea, degenerative joint disease, morbid obesity and urge incontinence. Medications and treatments included, in part, Advair Discus twice a day, famotidine twice a day, Lexapro daily, Wellbutrin XL once a day, Abilify daily, Novolog Flexpen Syringe, inject 26 units subcutaneously with dinner, Trazadone daily, Lantus 100 units/ml vial inject 72 unit subcutaneously daily at HS, Novolog Flexpen Syringe give, 24 units with lunch, MS Contin CR 30 mg tabs, one by mouth at bedtime, Oxycodone HCL 5 mg tab, give 10 mg every 4 hours for moderate pain as needed, albuterol as needed, Zofran as needed, Trazadone 50 mg tablet 2 times per day, Novolog Flexpen Syringe give 24 units subcutaneously with breakfast, BiPap at HS with settings eight over five with a respiratory rate of twelve, accuchecks twice daily, and oxygen at 2liters via nasal cannula to maintain oxygen saturation greater than 92%. The PEC identified that Patient #23 had been physically and verbally abusive and threatening towards staff and roommate and had barricaded him/herself in the bedroom. The patient's mental condition was described as alert and oriented with poor insight, preoccupied, and resisting and refusing care, presently as a danger to self and others as well as gravely disabled. At 12:16 PM the patient's blood glucose was elevated at 124 mg/dL (range 65-110) and Novolog 24 units was administered at 2:23 PM. Patient #23 was assessed by MD #23 and Licensed Alcohol and Drug Counselor (LADC)/Licensed Professional Counselor (LPC) and PhD #1 and determined not to be a danger to self or others and/or gravely disabled and appropriate for disposition home with his/her mother. Recommendations included medication management and in-home visiting nurse services. A psychosocial nursing assessment documented by crisis RN on 05/20/16 at 7:03 PM identified that the patient's mother stated that the patient could stay with him/her. A formal referral was made to the local Visiting Nurse Association (VNA) with instructions provided to the patient and/or his/her mother that the VNA would be contacting them the next morning to set up an intake. Medication and/or equipment needs were not discussed. A nursing note dated 8:38 PM identified that the patient ambulated with a walker, and was discharged home via ambulance and verbalized understanding of discharge instructions and follow-up care. An Interagency Referral Form from the ED dated 05/20/15 by MD #23 directed that the patient should follow-up with his/her primary health care provider if there were any problems and the telephone number was provided, however, an appointment was lacking. Discharge instructions included to return home with mother, medications administered in the ED, activity level of supervision for activities of daily living and mobility with a walker. A home health agency was authorized to provide nursing, physical therapy, social work, and a home health aide.

An ED report documented by MD #23 on 05/20/15 at 11:55 PM identified that the patient was discharged from the ED in stable condition and the patient's mother felt comfortable taking him/her home. Review of the clinical record lacked documentation of a disposition plan related to the immediate need for medication management, oxygen, bipap, and/or glucose monitoring.

Interview with MD #23 on 08/26/16 at 2:00 PM identified that Patient #23 exhibited no emergent medical and/or psychiatric problems and the mother was willing to take the patient home. There was no need for prescriptions and/or equipment because the patient was going to be evaluated by the VNA the following day and follow-up with their medical provider. MD #23 identified that the mother could call 911 and return to the ED if there were any problems and, furthermore that because the patient was a type 2 diabetic, he/she should be alright without insulin until the following day. Additionally, the patient's oxygen saturation had been within normal limits on room air while in the ED.
Review of a follow up ED record identified that the patient returned to the ED via ambulance on 05/21/15 at 10:25 AM with a chief complaint of dizziness, indicating that he/she did not have any insulin and/or any other of his/her 17 medications. Additionally, the patient's mother was physically disabled and unable to provide the care and services need by the patient. Blood glucose level was elevated at 235 mg/dL (range 70-105). The patient was being evaluated by a case manager and department of developmental services worker for placement as the mother cannot care for the patient at home. Disposition included transfer to SNF #2 on 05/21/15 at 7:55 PM.

A hospital policy for discharge procedures identified the purpose of promoting patient safety during transitions between care settings. The discharge process includes interviewing the patient and/family as appropriate to assess patient conditions impacting discharge, medical issues, cognition, living situation, social systems, functional level and anticipated changes prior to discharge to assess capacity for self-care with potential options or services to augment care deficits as well as current concerns and discharge needs. The hospital policy lacked specific directions for discharge from the ED.




29049

Based on a review of the clinical record and interview, the hospital failed to develop a discharge plan for one sampled patient (#40) reviewed in the Neonatal Intensive Care Unit. The finding included:

a. Review of the clinical record identified Patient #40 was delivered on 7/18/16 at forty one weeks gestation after exposure to Subutex in utero. Patient #40 was admitted to the neonatal intensive care unit on 7/20/16 with withdrawal symptoms and was treated with Morphine and Phenobarbital for neonatal abstinence. A referral was made to child and protective services on 7/19/16 due to the maternal use of Subutex. Interview and review of the clinical record with MSW #1 on 8/25/16 at 2:10 PM identified although social work notes dated 7/22/16 and 8/11/16 indicated staff were collaborating with Department of Children's and Family on this case, a discharge plan was not developed and should have been. Interview and review of the clinical record with Nurse Manager #5 on 8/26/16 at 3:15 PM lacked evidence that nursing had initiated discharge planning as a problem with interventions that were individualized for Patient #40.

Based on medical record review, review of facility policies and interviews for one of three patients reviewed for anesthesia services (Patient #45), the facility failed to ensure that recovery from anesthesia was totally assessed. The finding includes:


Patient #45 had abdominal surgery on 10/14/15 and received both general anesthesia and epidural analgesia/anesthesia per the anesthesia consent. The immediate postoperative note dated 10/14/15 identified that an epidural catheter was in place for pain management. Post anesthesia care unit (PACU) documentation dated 10/14/15 indicated that the Epidural pain medication administration was initiated at 4:20 PM and the patient was transferred to an inpatient unit at 6:40 PM and had no movement or sensation to the both lower extremities. Nursing narratives dated 10/14/15 at 10:08 PM identified that the provider was notified, in part that the patient remained unable to bend his/her own knees. Although nursing assessments dated 10/14/15 to 10/15/15 at 7:32 AM identified that the patient was unable to move his/her legs, the post anesthesia assessment by the anesthesia provider noted that the patient had adequately recovered from anesthesia. Interview with Anesthesiologist #1 indicated that although he/she did not perform the anesthesia recovery evaluation, the patient's decreased movement/sensation of the lower extremities should have been assessed and documented in the comment section for the anesthesia record or in a progress note. Subsequently, Anesthesiologist #1 was notified of the patients lower extremity paralysis at 4:49 PM on 10/15/15, assessed the patient, documented the assessment and ordered that radiologic testing be performed. The facility policy for Epidural pain management identified that anesthesia service responsibilities included daily rounds to include, in part, assessment for adverse effects.

Based on review of the clinical record, review of hospital documentation and interviews with hospital personnel for 1 (Patient #33) of 3 patients reviewed for ED admission, documentation and interviews failed to reflect that the patient was monitored and/or reassessed prior to discharge. The finding includes:


Patient #33 was admitted to the hospital ED on 6/18/15 at 3:15 AM complaining of left hip pain that was 10/10 on pain scale (0-10, 10 worst). Review of the clinical record and interview with MD #11 on 8/26/16 identified that the left hip was negative for fracture and that the patient received Toradol for pain. Although the ED record indicated that the patient was allergic to Toradol, MD #11 identified that the patient had no specific allergies to Toradol and had tolerated ibuprofen. Patient #33 received Ketorolac Tromethamine 15 mg IM at 4:31 AM on 6/18/15 and left the ED ten minutes later at 4:41 AM. Review of the record and interview with MD #11 identified that Patient #33 was not monitored for a medication reaction following administration prior to discharge.