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Based on document review, policy review and staff interview, it was determined that the facility failed to provide to provide written response to patient grievances as required by federal regulation and facility policy.


Findings include:


The faciltiy's grievance log was reviewed. One of the grievances was selected for review of the grievance process. During the review, no evidence that a written report of the resolution of the grievance was provided to the complainant could be found. The patient advocate was interviewed on 10/20/10 at approximately 2:00 p.m. She stated that she usually responds to the patient verbally, but usually does not provide a written response as required by the facility's policy. The facility's policy "Complaint/Grievance Process- Pateint Representative" # 850073.001, last reviewed on 2/09 requires that a written response witll be sent to the patient via mail within 7 days of receipt of the grievance.

Based on record review, interview and policy and procedure review, it was determined that the facility did not provide RN supervision and evaluate the nursing care for 4 (#3,#13,#27 and #31) of 37 patients of the survey sample. This practice could potentially result in an adverse outcome for the patient.
Findings Include:
1. Patient #13 was admitted to the facility on 10/8/10 with a diagnosis of Congestive Heart Failure and Atrial Fibrillation. On 10/14/10 the patient was scheduled for a coronary bypass graft surgery (CABG). The patient signed the consent form for blood on 10/9/10. According to the Transfusion Administration Record dated 10/14/10 the patient received one unit of blood which started at 9:40 a.m.. and ended a 11:55 p.m.. The vital signs were taken when started and 15 minutes, 1 hour and 2 hours after transfusion started. According to policy and procedure for Administration of Blood revised 4/10 documented at the bedside verify the identification of the patient by checking the patient ' s wristband, blood bank identification band and the transfusion administration record. Additionally, check the patient name, date of birth, medical record number. The policy and procedure documents that two persons are required to cross check all identifying information on the blood product, the blood administration form and the patient identification band to verify there are no discrepancies. One of the persons must be a physician or Registered Nurse, the second person must be a physician or Registered Nurse or Licensed Practical Nurse and sign the Transfusion Administration Record to certify that all checks were performed and no discrepancies were found. All this is done prior to administration. However, the Transfusion Administration Record form in the section titled Bedside Verification was signed by the transfusing nurse and witness which were both Registered Nurses, but there was no date or time documented to ensure that the verification was done prior to the administration of the blood transfusion to the patient.

3. Review of the medical record for patient #3 revealed the patient was admitted on 10/10/10 with abdominal pain. Review of the physician ' s orders on 10/13/10 revealed an order to start a PCA (Patient Controlled Analgesic) with Morphine 1 mg/ml at a dose of 1.5 mg every six minutes as activated by the patient. Review of the PCA flow sheet revealed the PCA was initiated on 10/13/10 at 5:30 p.m. Review of the facility policy, " Patient Controlled Analgesia " , last revised 10/08, revealed a baseline assessment would be established prior to initiation of therapy and the patient will be reassessed every 15 minutes x2, every 30 minutes x2, then every two hours and as needed during infusion. Review of the PCA flow sheet revealed the baseline assessment was completed on 10/13/10 at 5:30 p.m. The patient was reassessed at 6:18 p.m. and then at 7:40 p.m. The patient was not assessed according to the facility ' s policy. Interview with the Director of Clinical Informatics and Compliance on 10/19/10 at 1:00 p.m. confirmed the patient was not assessed according to the facility ' s policy.

3. Patient #27 was admitted to the facility on 9/18/10 with the diagnosis of recurrent right pleural effusion. Review of the medical record revealed that the patient reported pain as 10 on a scale of 0 - 10 with 0 being no pain at 12:25 p.m. on 9/19/10. Review of the Medication Administration record revealed that pain medication was not administered until 2:41 p.m. The patient's pain level was not documented at the time the medication was administered. There was no documentation as to why there was a delay in administering the medication to the patient.

4. Patient #31 was admitted to the facility on 10/18/10 with a diagnosis of Urinary Retention, Urinary Tract Infection, and Pneumonia. The patient ' s vital signs were taken on 10/18/10 at 2:00 p.m.., 3:00 p.m.., 4:00 p.m.., 5:00 p.m..and 6:00 p.m.. However, the only vital signs documented were the pulse, blood pressure, and oxygen saturations. There was no documented evidence that the patients respirations were assessed at these times.

Based on record review, staff interview, and review of policy and procedures, it was determined the facility failed to ensure that the nursing staff developed and kept current a nursing care plan for one (#2) of 37 patients sampled. This practice does not ensure that individual patient goals are met.
Findings include:
Review of the medical record for patient #2 revealed the patient was admitted on 10/12/10 with a diagnosis of chest pain. Review of the patient ' s plan of care revealed the plan was initiated on 10/12/10 and education/knowledge deficit was identified as a problem. Interventions and goals were set for the patient. No other problems were identified. The plan of care was reviewed by an RN from 10/13/10 to 10/16/10 on each shift. On 10/14/10 skin integrity was identified as a problem and initiated on the plan of care. Education continued to be identified from 10/13/10 to 10/16/10. Review of the record revealed the patient had a CABG (Coronary Artery Bypass Surgery) on 10/15/10. Review of the plan of care on 10/15/10 and 10/16/10, the day of surgery and post operative day #1, revealed no problems identified related to the patient ' s recent surgery. Review of the plan of care on 10/17/10, post operative day #2 revealed problems related to pain, safety, cardiovascular and musculoskeletal systems were identified and initiated on the plan of care. Review of the facility ' s policy, " Assessment/Re-assessment of the Patient " , last revised 10/10, states the multidisciplinary Plan of Care is to be completed upon admission and re-evaluated with any changes in patient ' s goals, with a minimum of documenting the progress towards the goals every shift. Interview with the charge nurse and Clinical Analyst on 10/18/10 at 12:00 p.m. confirmed the plan of care was not updated with the patient ' s change in condition on 10/15/10.

Based on record review and staff interview, it was determined that the medication administration order was not administered in accordance with the physician ' s orders for one (#3) 37 patients sampled. This practice does not promote for the safe administration of medications.
Findings include:
Review of the medical record for patient #3 revealed the patient was admitted on 10/10/10 with abdominal pain. Review of the physician orders revealed on 10/11/10 at 6:00 a.m. an order for Zosyn 3.375 g (grams) IV (intravenous) every six hours. Review of the MAR (Medication Administration Record) for 10/11/10 and 10/12/10 revealed on 10/12/10 the scheduled dose at 6:00 p.m. was not given. There was no documentation why the medication was not given. Review of the physician orders revealed on 10/11/10 at 6:00 a.m. an order for Flagyl 500 mg IV every eight hours. Review of the MAR for 10/11/10 and 10/12/10 revealed that on 10/12/10 the Flagyl was given at 11:07 a.m. and again at 1:50 p.m. The medication was administered approximately three hours between doses. The medication was not administered according to physician ' s orders. Interview with the RN caring for the patient and with the Clinical Analyst on 10/18/10 at 11:30 a.m. confirmed the medication was not given as ordered by the physician.

Based on record review, document review and staff interview, it was determined that the facility failed to ensure 2 (#20,#22) of 37 sampled patients had documentation a history and physical examination within 24 hours of administration. This practice does not ensure all care providers involved in the patient's care have access to vital patient information.


Findings include:


1..Patient #20 was admitted to the facility's Emergency Department (ED) on 10/16/10 and was transferred to the facility's senior behavioral care unit on 10/17/10. A review of the medical record conducted on 10/19/10 at approximately 10:00 a.m. revealed a psychiatric evaluation had been completed on 10/18/10 by the psychiatrist, however, no History and Physical examination could be found. The Charge nurse was interviewed at the time of the record review and state that several phone calls had been placed to the consulted medical physician, who had not yet responded.

2. Patient #22 was admitted to the facility's ED on 10/16/10 and transferred to the facility's senior behavioral care unit on the same day at 9:05 p.m. The patient's medical record was reviewed on 10/19/10 at approximately 11:00 a.m. No History and Physical examination could be found. The Charge nurse was interviewed at the time of the record review. She confirmed that the physician responsible to perform the examination had been consulted, but had not responded. She also stated that the patient was being discharged that morning without the History and Physical having been performed.

3. Review of the medical staff Rules and Regulations dated 2/09 requires that a comprehensive history and physical examination is to be completed within 24 hours of the patient's admission to the facility.

Based on observation, policy review and interview the facility failed to ensure that outdated mislabeled or otherwise unusable drugs and biologicals are not available for patient use.
During tour accompanied by the Director of Pharmacy on 10/18/2010 at 3:10 p.m., the refrigerator in the ER#2 medication room was found containing expired medications such as: 100 milliliters of Cephalexin 250 mg/ml and 30 milliliters of Azithromycin 200 mg 5/ml. Both medications were powders that had been reconstituted by the nurses who had dated the bottles with the open date and kept in the refrigerator past the allowed expiration date after reconstitution by manufacturer ' s specifications of 14 days for the Cephalexin and 10 days for the Azithromycin.
On 10/18/2010 at 3:15 p.m. during interview with the Nurse Director of the Emergency department she stated that the expiration dates after they were mixed should have been written on the bottles confirming that both bottle of antibiotics were past their expiration dates.
On 10/19/2010 at 4:30 p.m. during review of the facility ' s policy and procedure of Medication Administration (policy no. 850042.005) it was found under the " Safe Handling of Medications " that: Discontinued or outdated medications, or medications in containers with damaged illegible or missing labels must be returned to the Pharmacy for disposal.
On 10/21/10 at approximately 10:30 a.m. during tour of the facility's out patient wound care center a tube of santyl ointment with an expiration date of 7/10 was noted in a medication storage area in room #5.

Based on record review, facility policy and procedure review, and interviews the facility did not ensure that nutritional needs for food allergies, food intolerances, and diet continuity were met in accordance with dietary practices and facility policies and procedures for two of 37 sampled patient records(#15) and (16).

Findings include:

1. Record review for patient #15 revealed a list of allergies/intolerances to foods that included: pineapple, citrus, chocolate, milk products and peanuts. Interview on 10/18/10 from 11:00 a.m. to 4:45 p.m. with the RD assisting in the electronic record review related that the nurse who input electronically the diet orders for this patient did not highlight "Food Allergies/Preferences/Intolerances". Review of the Nutritional Risk Factors that nursing completes electronically at admit did not include food allergies/intolerances and the "Nutritional Risk Factors" documented "No risk identified" so the patient did not trigger a consult with dietary. The "Patient Meal Worksheet" states under "Allergy: No Chocolate, No Dairy, No Peanut", which omits the food group of dairy. The physician prescribed a regular diet at admit with low fat milk and yogurt with breakfast and dinner in the "Comment" section which is in conflict with the list of food allergies/intolerances. Patient #15 was admitted to the facility on 10/14/10 and as of 10/18/10 at the time of this record review had not been seen by an RD regarding the food allergies and intolerances.

Interview with the patient on 10/18/10 at 12:50 p.m. related that s/he is intolerant to regular milk but wants to consume dairy products for the vitamin D due to her rheumatoid arthritis. S/he related that s/he sometimes gets the soy milk listed on his/her meal ticket - about three times since s/he has been here and has also received the regular lowfat milk when there was no soy milk available. She has received yogurt at times but not always with breakfast and dinner as s/he prefers.

Review of the facility's Nutritional Services Policy No. 700158.003, reviewed and revised on 03/2010, for Patient Screening, Assessment and Reassessment includes, "Food intolerances and allergies" under Nutrition Assessment and Reassessment.

Review of the patient's meal tray slip for 24 hours finds soy milk listed for breakfast and lunch but yogurt was not listed. Interview with the RD during this time relates that the facility has lactaid milk and soy milk. Review of the patient's medications did not find medications listed for lactose intolerance to regular dairy products.

2. Record review for patient #16 revealed this patient had transferred to the hospital from a nursing home and was admitted to the hospital on 10/18/10. Review of paperwork in the patient's "hard record" found that this patient had been on a pureed enhanced foods diet at the nursing home. The doctor prescribed diet at admit to the hospital was a soft diet. The patient received two meals, breakfast and lunch, on the prescribed soft diet. There was no continuity for the patient's prior diet at the time of admission to the hospital and the prescribed diet at the hospital. The patient's diet was changed to a puree diet at 4:20 p.m. on 10/18/10 after a chart review for a low Body Mass Index.

Based on observation, and record review, it was determined the facility infection control officer did not develop and infection control system for identifying, reporting, investigation for controlling the potential for the spread of infections for 1 (#33) for 37 patients on the survey sample and failed to ensure the proper storage of endoscopic equipment.

Findings Include:

1. Patient #33 was admitted to the facility on 10/20/10 to the Obstetrics floor for Caesarean Section ( C- section). The patient was observed at 8:10 a.m.. in the pre-operative room on the obstetrics floor dressed in hospital gown, Intravenous fluids hanging of lactated ringer in right top forearm, hooked up to the fetal monitor, and with head of bed elevated with patient slightly positioned on the left side. The nurse was taking the patients nursing history and physical and medical history. At 8:25 a.m.. the patients personal cell phone fell on the floor from the left side of the bed. The nurse was observed walking around from the right side of the bed and picked up the cell phone and handed it to the patient. The nurse walked back around to the right side of the bed and proceeded to pull back the blanket from the patient abdomen and touched the top of patient ' s abdomen with bare hand without washing hands prior. The Director of the Obstetrics floor and Director of Compliance verified with surveyor regarding this infection control issue.
2. The tour of the Endoscopy scope processing room was conducted on 10/20/10 at 9:05 a.m.. with the Director of the Operating Room. The endoscopy scopes after washing from the Evo tech machines are placed in a cabinet hanging for drying. There were two poles with attachments at the top on right and left sides of the cabinet. The scopes hanging from the right side it was observed at 9:05 a.m.. a light source bronchoscope(# 1489) wrapped around the metal pole with the tip touching the floor mat. On the left side of the cabinet 2 pediatric colonoscopes used for flush port ( #9281) were observed hanging and the rubber ends were observed at 9:05 a.m.. touching the mat on the floor.

Based on record review and staff interview, it was determined that the facility failed to document the final discharge plan for ongoing care of 1 (#28) for 37 sampled patients following discharge.


Findings include:

The medical record of patient #28 was reviewed. On 9/16/10 the physician wrote and order for a Case Management consult for placement or referral for home health care. A case management note on 9/17/10 indicated that the patient wished to return home and chose a home health agency. Review of the medical record revealed not order from the physician as to what home health services were required. The physician's discharge summary contained no information regarding the referral to the home health agency. The Director of Case Management was interviewed on 10/19/10 at 2:15 p.m. She indicated that she could not determined what services were needed by the patient or that an order for the service had been obtained from the physician. She agreed the documentation was incomplete and unclear.