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Based on record reviews, interviews, and review of the hospital's policy and procedure, the hospital failed to ensure a one hour face to face was documented in the patient's chart for 2 of 2 closed patient records reviewed for restraint episodes. (Patient 2 and 3)


The findings are:


On 11/17/16 at 9:54 a.m., review of the closed record for Patient 2 revealed the patient was admitted on 06/15/16. Review of the patient's chart revealed the patient was restrained on 06/22/16, 06/30/16, 07/04/16, and 07/05/16. Review of the documentation in Patient 2's chart revealed the 1 hour face to face form was completed for each restraint episode, but the documentation on the restraint forms dated 06/22/16 and 06/30/16 failed to identify who or when the one hour face to face assessment(s) was completed. On 11/17/16 at 10:15 a.m., the Quality Coordinator revealed, "There are no details as to whom or when the one hour face to face assessment was completed."

On 11/17/16 at 10:30 a.m., review of the closed record for Patient 3 revealed the patient was admitted on 09/28/16. Review of the patient's chart revealed the patient was restrained on 09/28/16. Review of the patient's chart revealed there was no documentation on the one hour face to face assessment was completed. On 11/17/16 at 10:50 a.m., the Quality Coordinator revealed, "There is no additional documentation."

Hospital policy, titled, "Patient Care, Restraint and Seclusion:", reads, ".....IX. Documentation, A. The physician, LIP (licensed independent practitioner), or registered nurse with specialized training must document: 1. The 1-hour face to face medical and behavioral evaluation on the "Violent/Self Destructive Progress Note and Order" note form when restraint or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, staff, or others....".

Based on record review, interviews, and review of the hospital's policy and procedure, the hospital failed to ensure that 1 of 2 closed patient records contained documentation of the patient's behavior prior to the restraint episode or of the least restrictive interventions used prior to the initiation of restraints. (Patient 3)


The findings are:


On 11/17/16 at 10:30 a.m., review of the closed chart for Patient 3 revealed the patient was admitted on 09/28/16. Review of the patient's chart revealed there was no documentation of the patient's behavior prior to the initiation of restraints and no documentation of the least restrictive interventions used prior to the initiation of restraints. On 11/17/16 at 10:50 a.m., Quality Coordinator 1 revealed, "There is no additional documentation in the patient's chart."

Hospital policy, titled, "Patient Care, Restraint and Seclusion, reads, "....B. 3. A description of the patient's medical /behavioral condition or symptoms warranting the use of restraint or seclusion (complete section on safety restraint-nursing documentation)....5. Alternative or other less restrictive interventions attempted (as applicable) and the patient's response to those less restrictive interventions....".

Based on record reviews and interview, the hospital failed to ensure the nursing followed the physician's orders with wound care to meet the need of its patients for 1 of 3 closed record reviewed for care and services. (Patient 1)


The findings are:


On 11/16/16 at 11:07 a.m., review of Patient 1's closed chart revealed the patient was admitted on 10/29/16 with Painful RLE (Right Lower Extremity), Sepsis. Review of the patient's chart revealed a physician order for nursing dated 10/30/16 to "soak right foot BID (2 times per day) in Normal Saline. Repack wound with 25 %(percent) Dakins solution dressing and apply 4 x 4"s and Kerlix dressings." Review of the nursing assessments and reassessments in the patient's chart revealed there was limited documentation of wound care performed by either the physician and/or nurse from 10/30/16 - 11/16/16. On 11/16/16 at 12:19 p.m., the Information System Instructor 1 verified the findings. On 11/17/16 at 2:59 p.m., the Director of Medical Surgery 1 and the Information System Instructor 1 confirmed there was no documentation of wound care on 11/1/16, 11/6/16, 11/7/16 and 11/8/16.

Based on record reviews and interview, the hospital failed to ensure the administration/documentation of medication was timely for 1 of 23 patient charts reviewed for care and services. (Patient 5)


The findings are:


On 11/14/16 at 2:28 p.m., review of Patient 5's chart revealed a physician order dated 11/14/16 for Hydralazine 25 mgs (milligram) 1 tablet by mouth 3 times per day. There was no documentation indicating that the 2:00 p.m. dose of medication was administered on 11/14/16. On 11/14/16 at 3:26 p.m., Director 1 verified the findings, and acknowledged the hospital's policy is to give the medication within 1 hour time frame. On 11/15/16 at 12:11 p.m., review of the documentation revealed the medication from the previous day was "not administered", but it did not indicate a reason why.

Based on record reviews and interview, the hospital failed to ensure history and physicals are completed and updated as needed for 1 of 23 current patient charts. (Patient 5)

The findings are:


On 11/14/16 at 2:15 p.m., review of Outpatient Surgery Patient 4's chart revealed the patient was admitted on 11/11/16 for Deep Vein Thrombosis. Review of the patient's chart revealed there was no comprehensive History and Physical on the patient's chart prior to the surgical procedure on 11/12/16. On 11/14/16 at 2:25 p.m., the findings were verified by Information System Instructor 1.

Based on record reviews and interview, the hospital failed to ensure that 2 of 23 patient charts had documentation of an updated history and physical assessment prior to procedures. (Patient 7 and 22)


The findings are:


On 11/15/16 at 2:11 p.m., review of Patient 7's chart revealed the patient was admitted on 11/15/16 to labor and delivery for a vaginal delivery. Review of the patient's history and physical assessment revealed the patient had a vaginal delivery on 11/15/16, but there was no update to the patient's history and physical prior to the delivery. On 11/15/16 at 2:25 p.m., Director 6 revealed, "There should have been an updated stamp on the paperwork."

On 11/16/16 at 9:50 a.m., review of Patient 22's chart revealed the patient was admitted on 11/14/16 for a vaginal delivery. Review of the patient's history and physical assessment revealed the patient's history and physical assessment was dictated on 11/14/16, and the update to the patient's history and physical assessment was dated 11/15/16 at 5:08 p.m. which was 3 hours after the patient's delivery at 2:10 p.m.. On 11/16/16 at 10:00 a.m., Director 6 revealed verified the finding.

Based on record reviews and interviews, the hospital failed to ensure patient informed consents were properly executed for 1 of 23 patients. (Patient 13)


The findings are:


On 11/15/2016 at 11:30 a.m., review of Patient 13's chart revealed an informed consent for the insertion of a central line placement, but the first witness and second witness failed to date and time their signatures.

Based on record reviews and interviews, the hospital failed to ensure staff followed physician orders or obtain physician orders before initiating care for 9 of 23 patients. (Patient 3, 13, 4, 5, 6, 7, 8, 9, and 22)


The findings are:


On 11/14/2016 at 12:20 p.m., review of Patient 3's chart revealed the patient had a central venous catheter inserted on 11/12/2016 at 10:30 p.m.. Review of the patient's chart revealed nursing staff used the central venous catheter without a physician's order. On 11/14/2016 at 1:30 p.m., the findings were verified by the Director of Nursing.

On 11/15/2016 at 12:20 p.m., review of Patient 13's chart revealed the patient had a central venous catheter inserted and placement was verified by a chest X-ray completed on 11/7/2016 at 9:15 a.m. Documentation in the patient's chart revealed nursing staff used the central venous catheter without a physician's order. On 11/15/2016 at 1:24 p.m., the finding was verified by the Director of Nursing.

On 11/14/16 at 2:15 p.m., review of Patient 4's chart revealed the patient was admitted on 11/11/16 for deep venous thrombosis of lower extremity. Review of the chart revealed physician orders for: orthostatic blood pressure every a.m., weight daily, and vital signs every hour. Review of the patient's chart revealed staff obtained one set of orthostatic blood pressures on 11/12/16, no daily weights had been obtained since the patient's admission on 11/11/16 admission, and the patient's vital signs were not documented every hour. On 11/14/16 at 2:49 p.m., the findings were verified by Information Systems Instructor 1. On 11/14/16 at 2:15 p.m., review of Patient 4's chart revealed the patient was admitted on 11/11/16 for Deep Venous Thrombosis of lower extremity. Review of the patient's chart revealed there were no daily progress notes by the physician. On 11/14/16 at 2:50 p.m., the findings were verified by Information Systems Instructor 1.

On 11/15/16 at 3:07 p.m., review of Patient 6's chart revealed the patient was admitted on 11/14/16 for a delivery. Review of the patient's chart revealed physician orders dated 11/14/16 for the patient's vital signs as every hour times four, then every 4 hours. Documentation post delivery of the placenta revealed the patient's vital signs were not obtained every hour, and then every four hours as ordered by the physician. On 11/15/16 at 3:15 p.m., the findings were verified by Director 6. On 11/15/16 at 3:07 p.m., review of Patient 6's chart revealed the patient was admitted on 11/14/16 for a delivery and an intravenous catheter was inserted. There was no physician order for the insertion of an intravenous catheter. On 11/16/16 at 4:26 p.m., the findings were verified by Information Systems Instructor 1.

On 11/15/16 at 2:11 p.m., review of Patient 7's chart revealed the patient was admitted on 11/15/16 for delivery, and an intravenous catheter was inserted. There was no physician order for the insertion of an intravenous catheter. On 11/16/16 at 4:24 p.m., the findings were verified by Information System Instructor 1.

On 11/15/16 at 2:27 p.m., review of Patient 8's chart revealed the patient was admitted on 11/15/16 for a vaginal delivery, and an intravenous catheter was inserted. There was no physician order for the insertion of an intravenous catheter. On 11/16/16 at 4:22 p.m., the findings were verified by Information System Instructor 1.

On 11/15/16 at 1:40 p.m., review of Patient 9's chart revealed the patient was admitted on 11/14/16 for Biliary Colic, and an intravenous catheter was inserted, but there was no physician order for the insertion of an intravenous catheter. On 11/16/16 at 4:28 p.m., the findings were verified by Information System Instructor 1.

On 11/16/16/ at 9:50 a.m., review of Patient 22's chart revealed the patient was admitted on 11/14/16 for a vaginal delivery and an intravenous catheter was inserted, but there was no physician order for the insertion of the intravenous catheter. On 11/16/16 at 4:20 p.m., the finding was verified by Information System Instructor 1.










36397

On 11/14/16 at 2:28 p.m., review of Patient 5's chart revealed the patient was admitted on 11/13/16 with acute Pyelonephritis. Review of the patient's chart revealed there was no documentation of a daily progress note by the physician. Further review of the nursing orders dated 11/13/16 for "I & O (input and output): Strict every 8 hours" revealed missing documentation/multiple gaps in documenting the patient's intake and output. There was no documentation every 8 hours by nursing as ordered. On 11/4/16 at 3:26 p.m., the Director 1 verified the findings.

Based on observations and interview, the hospital failed to have evidence of therapeutic menus to meet the individual nutritional needs of patients who required therapeutic diets.


The findings are:


On 11/14/16 at 10:37 a.m., random observations in the kitchen area revealed no menus were posted or was there any therapeutic menus posted. Review of the patient menus revealed patients make choices daily and the menus repeat daily. The only therapeutic diet noted on the patient menu was 2 gm (gram) Sodium. On 11/14/16 at 11:25 a.m., Dietary Manager 1 revealed, "The staff is aware of therapeutic diets. For example, cardiac patients with no salt, regular diet, and 1800 diets are the same. 2 gm sodium diets can choose only 1 starch and diabetics are sugar free." Dietary Manager 1 also acknowledged having the therapeutic menus on disc, if needed. Requested to review the disc. On 11/16/16 at 9:00 a.m., Information Systems Instructor 1 maneuvered through the disc via the computer but was unable to show the surveyor the therapeutic menus. On 11/16/16 at 9:15 a.m., Registered Dietician 1 reviewed the disc information and reported there were therapeutic menus on the disc for teaching purposes, but was not in comparison to the patient menu selections. Random samples of various diets and/or meal plan was given for review to include some guidelines, but by the end of the day, no therapeutic diet menus were presented for review. On 11/16/16 at 9:45 a.m., Registered Dietician 1 verified how the staff would identify the therapeutic diets by confirming what was said for no salt for cardiac patients, sugar free for diabetics, etc. Registered Dietician 1 stated, "The staff was in-serviced on this, but no evidence of attendance. Only print out of the different types of menus that was discussed".

Based on review of the food temperature control logs, review of the hospital's general principles policy and procedures, and interview, the hospital failed to ensure the safety of patients by ensuring the temperatures of the foods served to patients are within acceptable ranges.


The findings are:


On 11/14/16 at 1:16 p.m., review of the food temperature monitoring log for the month of November 2016 revealed data was missing such as
the food item was noted but the temperature block was blank on 1/1/16 through 11/4/16, 11/7/16, and 11/9/16 through 11/14/16, log sheets are dated but no documentation of data on 11/5/16 and 11/6/16, and the times vary for temperature checks on:
11/1/16: temperature checks recorded at 09:00 a.m., 11:00 a.m. and 3:00 p.m.;
11/3/16: temperature checks recorded at 09:00 a.m., 11:00 a.m., 3:00 p.m., and 5:00 p.m.;
11/7/16: temperature checks recorded at 09:00 a.m. and 11:00 a.m.,
11/8/16: temperature checks recorded at 11:00 a.m. and 1:00 p.m., and
11/10/16: temperature checks recorded at 07:00 a.m., 03:00 p.m. and 05:00 p.m. On 11/14/16 at 1:20 p.m., Dietary Manager 1 verified the findings.

The hospital's policy and procedure, titled, "General Principles", reads, ".....Food should be kept in "safe zone" as much as possible (0 degrees - 41 degrees Fahrenheit / 40 degrees - 180 degrees Fahrenheit). They should be taken from a cold safe state, cooked at a high enough temperature to destroy any bacteria, and cooled rapidly to a cold safe state. Cook foods should reach a temperature throughout of at least 165 degrees Fahrenheit."

Based on observations, interviews, and review of hospital policy and procedures, the hospital failed to ensure 1 Physician and 1 Certified Registered Nurse Anesthetist 1 and Biomedical Technician 1 removed their surgical attire(caps, shoe covers, and surgical masks) prior to going to the medical surgical unit, failed to remove expired supplies from the patient care areas, and staff failed to disinfect hospital equipment(Work station on Wheels) between patients, (Registered Nurse 2, 3 and Respiratory Therapist), and multiple observations in the dietary kitchen.


The findings are:


On 11/14/16 at 10:35 a.m., random observations in the medical surgical unit revealed Physician 1 wearing scrub shoe covers, a surgical mask around the neck, and a scrub cap. On 11/14/16 at 3:20 p.m., the findings were verified by Information System Instructor 1.

On 11/14/16 at 11:18 a.m., random observations in the medical surgical unit revealed Certified Registered Nurse Anesthetist 1 wearing scrub shoe covers, a surgical mask around the neck, and a scrub cap. On 11/14/16 at 3:20 p.m., the findings were verified by Information System Instructor 1.

On 11/15/16 from 11:49 a.m. - 11:54 a.m., random observations in the Operating Room(OR) revealed these expired items:
OR Clean Supply Room: (3) manipulator pro devices expired 10/2016, and
Anesthesia Workroom: (10) fiberoptic bronchoscope swivel adapter expired 06/16. On 11/15/16 at 11:54 a.m., the findings were verified by Director 2.

On 11/16/16 at 9:03 a.m., observations of Patient 11 revealed Registered Nurse (RN)2 rolled the workstation on wheels (WOW) into the patient's room to administer the patient's medication, but failed to disinfect the WOW after administering the patient's medications and before rolling the Wow into the next patient's room .

On 11/16/16 at 9:32 a.m., observations of Patient 19 revealed RN 3 rolled the WOW into the patient's room to administer the patient's medications, but RN 3 failed to disinfect the WOW before rolling the WOW into another patient's room.




36397

On 11/14/16 at 10:22 a.m., random observations in the dietary area in the dry storage area revealed 1 medium sized plastic covered pale unlabeled, but with what appeared to be beans of some sort. Observations in the kitchen area revealed 2 large jugs 3.79 liters of Worcestershire sauce, mislabeled, dated received 12/28/16 and 1 large jug 3.79 liters of Worcestershire sauce expired,and the label read, "used by 11/13/16." On 11/14/16 at 10:29 a.m., Dietary Manager 1 verified the findings.

On 11/14/16 at 12:01 p.m., random observations in the 3 compartmental sink area revealed 50 QAC QR Test Strips Code 295 expired January 2015. On 11/14/16 at 12:02 p.m., Dietary Manager 1 verified the findings.

On 11/15/16 at 111:09 a.m., random observations in the main hallway near the stress lab revealed Biohazard Staff 1, who was escorting a visitor, was wearing surgical shoe covers. On 11/15/16 at 11:10 a.m., Quality Coordinator 1 verified the findings.

On 11/15/16 at 11:42 a.m., observations of Patient 21 revealed Respiratory Therapist (RT) 1 entered the patient's room and rolled the WOW (workstation on wheels) to the patient's bedside, performed hand hygiene, identified the patient, and administered medication as ordered, proceeded with multiple assessments heart, lungs, etc. , cleansed the stethoscope, and documented via WOW. After the patient's nebulizer treatment was completed, RT 1 reassessed the patient using the stethoscope and then, placed the stethoscope around his/her neck, performed hand hygiene before leaving the patient's room, but RT 1 failed to disinfect the WOW after patient care and failed to disinfect the stethoscope after providing direct care. On 11/15/16 at 11:57 a.m., the RT 1 verified the findings.

Based on review of the hospital's operating room log, the hospital failed to ensure the operating room log was complete.


The findings are:


On 11/16/16 at 11:40 a.m., review of the hospital's operating room log revealed the following items were missing from the log:
Name of nursing personnel (scrub and circulating),
Type of anesthesia used and name of person administering it, and
Pre and post operative diagnosis. On 11/16/16 at 11:55 a.m., Director 2 revealed, "Yhis is the type of book we've been keeping since I've been here."

Based on record reviews and interview, the hospital failed to ensure that 1 of 3 swing bed patients received a consultation based on the patient's assessment findings. (Swing Bed Patient 3)


The findings are:


On 11/14/16 at 11:18 a.m., review of Swing Bed Patient 3's chart revealed the patient was admitted to a swing bed on 03/11/16. Review of the patient's chart revealed a speech therapy referral on 05/13/16 and 06/13/16 with no additional information related to the referrals. On 11/14/16 at 11:29 a.m., Director 1 revealed, "The referral is based on the nursing assessment and the physician has to decide if he wants to do the referral or not. The physician has to delete it from the system if he doesn't want to do anything." There was no documentation that verified the physician did not want the speech therapy consult, and there was no documentation to verify that the speech therapy consult was completed.