HospitalInspections.org

Based on medical record (MR) review and staff interview, it was determined the governing body failed to ensure the Hospitalist referred MR # 3, an inpatient to a cardiologist for new and worsening Congestive Heart Failure (CHF). This did affect MR # 3 and had the potential to affect all patients treated at the facility.

Findings include:

MR # 3 was admitted to the facility on Thursday 1/19/17 following an emergency room (ER) visit with diagnoses, Acute Coronary Syndrome, Hypomagnesemia, Left Lower Lobe Pneumonia and Volume Overload. MR # 3's past history included Hypertension and Seizures.

The Primary Care Physician's history and physical documentation dated 1/20/17 included complaints in the ER, increasing shortness of breath and palpations, volume overload with left lower lobe infiltrate, later the morning of 1/20/17 converted to SVT (supraventricular tachycardia) in the 160's. MR # 3 was treated with Lopressor intravenous and converted back to sinus rhythm. Documentation also revealed MR # 3 had never been diagnosed with an arrhythmia in the past, denied any chest pain in the past and never had a cardiac workup in the past.

Medical record review revealed the following physician documentation:

Electrocardiogram on 1/19/17, Sinus tachycardia at 125 (beats/minute) with ventricular bigeminy, Old Anterior Infarction and Supraventricular tachycardia at 150; CKMB (creatinine kinase myocardial B)7.8, HC (high critical) at 8:21 PM. Portable chest xray findings suggestive of asymmetric CHF.

Echocardiogram on 1/20/17-moderate right atrial, mild right ventricular enlargement, left ventricular ejection fraction of 25 %, severe right ventricular systolic dysfunction, moderate to severe tricuspid regurgitation, mild to moderate mitral regurgitation. BNP (B Type N-Peptide), high, 3500 pg/mL (picogram/milliliter), brachial pulse 161 at 7:00 AM, 147 at 8:00 AM, scrotal edema present. At 2:53 AM, CPK (creatinine phosphokinase) 290 (high), CKMB 8.9 (high critical), at 3:08 AM, at 8:27 AM the CPK was 425, (H). Results of a liver sonogram-probable cirrhotic liver with ascites and right pleural effusion.

On 1/21/17, BP (blood pressure) 82/54, Brachial pulse 54, improvement in edema, with mild expiratory wheeze. Portable chest completed at 8:18 AM,-Consolidation in both lower lungs, bilateral pleural effusions appears worse since 1/19/17.

On 1/22/17, Portable chest xray completed at 7:33 AM-findings could be diffuse pulmonary edema or possibly pneumonia, with bilateral pleural effusions; mild expiratory wheeze; Intake/Output 960/575, creatinine 1.34 mg/dL (milligram/deciliter), plans included "cardiology work up as an outpatient".

Handwritten physician documentation dated 1/22/17 at 11:05 PM revealed MR # 3 expired at 11:00 PM.

In an interview on 3/2/17 at 10:58 AM, Employee Identifier (EI) # 1, Director of Nursing was asked by the surveyor if there was documentation a cardiologist consulted on the case. EI # 1 reported no, a cardiology consult was not completed. The cardiologist comes to the facility on Tuesdays. There was no documentation cardiology services were requested and or that a transfer of care was planned.

Based on the review of medical records (MR), policy and procedures and interview it was determined the facility failed to observe patients in restraints and document on the Restraint Flowsheet at a minimum of every 2 hours. This affected MR # 4, 1 of 2 restrained acute medical/surgical patients.

Findings include:

Restraint and Seclusion Policy:
Reviewed 06/13

Policy:
1. " Behavior management restraint/seclusion use is limited to emergencies in which there is immediate risk of harm to self and/or others.
2. Acute medical surgical restraint is limited to situations in which the restraint directly supports the medical healing of the patient. The patient's behavior is non-violent and non-aggressive...

Physical Restraint- the direct application of physical force to a patient, without the patient's permission to restrict freedom of movement. Physical force may be human, mechanical or a combination thereof to the patient's body that he/she cannot easily remove...

Physician's Orders:
1. Orders for restraint or seclusion must be either written or verbally given by a license independent practitioner...
4. Orders for restraint/seclusion must contain the following elements:
Date and time
Reason for restraint/seclusion
Physician signature, date and time
5. The time limits for restraint and seclusion orders are as follows:
For acute medical/surgical restraint up to 24 hours...

The following restraints are used at Elmore Community Hospital and are listed from least restrictive to most restrictive:
Mitts
Vest
Soft limb- 1 or 2 extremities
Soft limb- 3 or 4 extremities.

Reassessment:
4. The continued need for the use of restraint or seclusion will be reassessed and documented at the following frequency:
For medical/surgical restraint every 2 hours...

Monitoring:
3. The following needs are provided for at least every 2 hours:
Nutritional and hydration needs
Removal of restraints and range of motion
Elimination needs...

Nursing personnel are required to complete the patient assessments and reassessments and provide for the patient's care needs as stated in the body of this policy and procedure. This information is recorded on the restraint flow sheet and is part of the patient's medical record."

MR # 4 was admitted to the facility 2/23/17 with diagnoses of Volume Depletion with Renal Insufficiency and Altered Mental Status.

The physician ordered use of soft restraints for patient safety time 24 hours on 2/23/17 while the patient was in the emergency room. A restraint flow sheet was present in the medical record dated 2/23/17 with the patient in right arm, right leg, left arm and left leg restraints. The nurse documented observation and reassessment at 7:00 PM and 9:00 PM while in the emergency room. The patient was admitted to the medical-surgical floor at 10:30 PM. The nurse documented, " Patient admitted with restraints. Type of restraints wrist, ankle, Siderails x (time) 4, soft."

The nurse documented at 2:00 AM on 2/24/17, " Removed ankle restraints."

The nurse documented at 8:00 AM on 2/24/17, " Assess patient for release/discontinue of restraint: Successful."

The nursing personnel failed to document patient assessments and reassessments and provide for the patient's care needs as stated in the policy and procedure for use of restraints. The nursing personnel failed to record on the restraint flow sheet. The only flow sheet in the medical record provided to the surveyor was from the emergency room stay 2/23/17 prior to admission to the floor.

In an interview 3/2/17 at 10:28 AM with Employee Indentifer (EI) # 1, Director of Nursing, it was confirmed no log was present for the use of restraints from 10:30 PM on 2/23/17 until 8:00 AM on 2/24/17 when the restraints were removed.

Based on review of medical records (MR), facility policies and procedures and interview it was determined the nursing staff failed to:

1. Perform wound care as ordered and ensure complete wound care orders were obtained.

2. Measure wounds and document wound assessments per policy

3. Ensure hospice patients on Respite care received needed wound care services and personal hygiene services.

4. Document accurately a Morphine drip infusion to include concentration and rate for a hospice General Inpatient (GIP) admission for pain management.

5. Perform and document nurse assessments every shift and patient monitoring every 2 hours.

6. Perform and document nutritional risk assessments, implement dietary recommendations and obtain daily weights as ordered.

7. Follow the Telemetry policy and procedure.

8. Complete documentation of events surrounding a patient death and follow the protocol for organ/tissue procurement.

9. Complete and document all required nursing competencies including skills and cardiopulmonary resuscitation (CPR).

This affected 4 of 4 patients with wounds that included MR # 8, 1, 10 and 9, 1 of 2 death records reviewed, MR # 3, 1 of 1 patient on Respite care, MR # 1 and 1 of 1 patient on GIP, MR # 2.

This had the potential to affect all patients treated at the facility.

Respite/ GIP Care
Date of Revision: 08/14

Purpose: Respite Care
Guidelines: " Will be provided for the patient whose caregiver is overwhelmed and requests for a short period of time to be placed in a skilled nursing facility. Conditions are as follows:
2) Full assessments will be done by hospice nurses. Hospice nurses will see the patient every day doing full assessments based on the frequency of visits according to the patients POC (Plan of Care)
4) Hospice nurses will provide dressing changes once, daily. If the dressing changes are required more than once a day, the facility nurse will do those.
5) Hospice aides will provide the baths and linen changes for the patient Monday through Friday. Facility aides will provide baths and linen changes over the weekend..."

Policies and Procedures: Prevention and Management of Wounds
Date of Revision: 03/14

Policy:
" 2. Assess skin condition at least one time per shift and document. If the patient has a pressure ulcer and the admitting doctor has not given any orders pertaining to wound care the following protocol should be followed:
a. Measure wound
b. Cleanse wound
c. Place a dry dressing on wound and secure it with tape
d. Obtain an order within 24 hours of admission regarding wound care.

3. The location, stage, type of wound, width, length, depth, exudate, odor, presence of necrotic or granulation tissue, presence or absence of undermining or sinus tract formation and condition of surrounding skin should be documented on a daily basis as well as the condition of wound edge or every time the Nurse changes the dressing...

5. If doctor ordered dressing changes on admission orders should include specific cleaning solution...

6. Provide wound care as ordered or PRN (as needed)

10. Consider a nutritional consult

11. Document education to caregiver or patient related to wound care for after discharge and have patient or caregiver give return demonstration."

Prevention of Wound Infections
Date of Revision: 11/12

" Purpose: To insure appropriate technique in doing dressing changes.

Policy:
II. Decubitus and Stasis Ulcers...B. Documentation of the wound's description and progress toward healing will be done."

Nutritional Screening
Date of Revision: 09/14

Purpose

A) To ensure the provision of appropriate medical nutrition therapy to all patients...
B) To identify patients at high nutritional risk and establish the need for further assessment by a registered dietician.
C) Provide timely nutritional intervention for patient identified at nutritional risk by a clinician dietician.
D) To document data pertinent to the nutrition care of the patients and develop a nutrition care plan for the individual patient...

Procedure

A) All patients screened for possible nutritional risk within twenty four (24 hrs) of admission by nursing staff.
C) The patients that are at high nutritional risk will have a dietary consult.

Staff Competency Validation Program
Date of Revision: 06/13

Policy
"A competency plan will be developed on an on-going basis by Administration for licensed personnel that incorporates high-risk, problem prone patient care procedures. It is the responsibility of the employee to see that competency is completed..."

Telemetry
Reviewed 06/13

Subject: Telemetry Nursing Guidelines for Care of the Patient

I. Purpose
To provide stable patients with cardiac monitoring...

II. Enclusions...
A. Patients...whose cardiac condition requires constant EKG (electrocardiogram) monitoring...

III. Procedures
A. The patient's assigned RN (Registered Nurse) or LPN (Licensed Practical) are responsible...Any significant EKG change or arrhythmia strip will be inserted in the patient's chart no later that the end of the shift.

B. Documentation in the nurse's note must include:
1. documentation of rhythm every 8 hours.
2. any changes in patient's rhythm.
3. assessment of patient at time of rhythm change.
4. actions taken as a result of rhythm changes (BP, HR, LOC) [blood pressure, heart rate, level of consciousness]...

Organ/Tissue Procurement Protocol
Date of Revision/Review 02/15

Procedure...Determination of Suitability for Organ or Tissue Donation:

A. The Charge Nurse or designee will notify the AOC (Alabama Organ Center)...when death occurs...preferably...within the first hour following death...
C. The AOC...will evaluate each potential donor to determine suitability for organ/tissue procurement...
D. Routine Referral Form will be completed ...by the Charge Nurse or designee..."

1. MR # 8 was admitted to the facility 7/3/16 with a diagnosis of Allergic Reaction to Medication, Sepsis and Pressure Ulcer.

The physician orders for wound care dated 7/3/16 included, " Apply CurX to inside and perimeter of wound daily cover with ABD (abdominal) pad."

The wound assessment documented 7/3/16 at 1:55 PM included:
Wound dimensions (cm[centimeters]) length approximately 6 cm, width approximately 3 cm depth approximately 1.5 cm. Tunneling location around perimeter. Scant amount of drainage. Dressing: CurX to inside of wound and around perimeter, cover with ABD and paper tape.

The next documented assessment was 7/5/16 at 8:51 PM:
Wound assessment, stage 4 on sacrum, small amount of purulent drainage, dressing changed due to soiling; ABD pad with paper tape, simple dressing change.

The use of CurX was not documented as ordered.

The next documented assessment was 7/6/16 at 2:12 PM:
Wound assessment no changes from previous assessment, tunneling, small amount of drainage, slough present, did not measure, dressing changed per orders; ABD pad.

The next documented assessment was 7/7/16 at 9:37 AM:
Wound assessment no changes from previous assessment, tunneling, small amount of drainage, slough present, did not measure as was measured on admit, dressing ABD pad.

The next documented assessment was 7/8/16 at 10:24 AM:
Wound dimensions length 5 cm width 4 cm depth 1 cm redressed coccyx as ordered with CurX gel as ordered.

The skilled nurses failed to follow the wound care policy, failed to dress the wound daily and failed to document wound care was provided as ordered. The nurses failed to document daily the location, stage, type of wound, width, length, depth, exudate, odor, presence of necrotic or granulation tissue, presence or absence of undermining or sinus tract formation and condition of surrounding skin as well as the condition of wound edge every time the nurse changed the dressing.

The electronic nurses note refers to the wound ostomy flowchart and see unisex body documentation. In an interview 3/2/17 at 10:30 AM with Employee Identifier (EI) # 1, Director of Nursing, confirmed the nurses were not utilizing the flow sheets or the unisex body for documenting wound care.

EI # 1 confirmed the nurses failed to follow the policy for wound care.

2. MR # 1 was admitted to the facility 2/23/17 through 2/28/17 for Respite care.

A review of the medical record provided to the surveyor failed to include a current hospice plan of care. The hospital medical record failed to include the terminal diagnosis for this 94 year old patient.

The Initial Interview completed by the facility nurse 2/23/17 at 11:17 AM, included Medical History/Integument: Wound Coccyx.

The Physical Assessment amended 2/23/17 at 7:37 PM documented Incision/Dressing: See wound Flowchart. Wound Assessment: See wound assessment flow chart.

The medical record documentation provided to the surveyor failed to include any wound assessments, the physician orders failed to include any orders to assess or change a dressing to the wound on the coccyx.

MR # 1 remained on Respite care from 2/23/17 through 2/28/17 for 5 days, during this time the hospice nurse visited daily, the hospice nurse failed to document any wound care in the hospital record or on the hospice record notes provided to the surveyor 3/2/17. The hospice aide failed to document any personal care provided to the patient during the 5 day stay.

The hospital documentation 2/23/17 at 12 noon by the CNA (certified nursing assistant) included, "Patient stated she/he was cold and did not want to take her/his clothes off until later."

2/24/17 at 12:45 PM the CNA documentation included, "Offered bath patient stated she will probably get one this evening. Night shift offered to put a gown on, she refused."

The Hospice documentation dated 2/25/17 by the visiting hospice nurse included, "Nurse asked patient if she/he needed hygiene care assistance from nurse at current time, due to nurse notes patient wearing same clothes as day before, but doesn't appear soiled. Patient states no at current time."

In an interview 3/2/17 at 11:00 AM with EI # 2, Assistant Director of Nursing, confirmed no wound care was provided while MR # 1 received Respite care for 5 days, the facility had no orders for wound care and didn't know if the hospice aide provided care or not as there was no documentation in the medical record.



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3. MR # 10 was admitted to the facility on 9/13/16 with diagnosis of Atrial Fibrillation and Status Post Amputation of First and Second Toe.

Record review included a physician order dated 9/13/16 at 5:45 PM for dressing change daily damp to dry L (left) foot. There was no documentation of what the dressing was to be dampened with. Additional orders at 11:22 PM included a dietary consult.

Patient Progress Note documentation dated 9/13/16 at 6:25 PM included Wound Ostomy Flowchart that revealed "...scratches and abrasions...arms. legs bilaterally, sores...stomach and wound...covered with dressing on left foot. Couldn't assess left foot; new dressing intact, clean and dry..." The Pressure ulcer/wound Location document of Site A, the left foot revealed toes amputated 6 wks ago.

There was no documentation the left foot wound was assessed and measured on 9/13/16 and no documentation the daily dressing change was performed.

Review of the Patient Progress Note dated 9/14/16 12:38 PM revealed " To consult...(podiatrist)...Will redress left foot with wet to dry dressing". At 1:19 PM, documentation revealed"...approx 6-7 cms from third toe to knuckle on foot length...4-5 cms wide from pad under toes across surgical site...Dressing...Damp to dry gauze packing, foot...''. There was no order for gauze packing to the left foot.

Record review revealed dietary recommendations dated 9/14/16 for protein supplement two times daily or 1 daily supplement of choice. There was no documentation MR # 10 was offered protein supplements during the inpatient stay.

Review of the 9/15/16 Patient Progress Note documentation at 4:51 AM included dressing remains intact to left foot, slight amount of serous drainage noted to dressing and a 1:34 PM physicians' order to wet with tap water and place Puricol on wound cover with a gauze dressing twice a week.

Further review revealed a Wound Ostomy Flowchart dated 9/15/16 at 2:38 PM that included a wound assessment and dressing change with damp to dry gauze packing. There were no wound measurements documented and no physicians' order for damp to dry gauze packing.

Review of the physician orders dated 9/16/16 at 10:19 AM included: Dampen collagen dressing and place on wound twice a week and place dressing over it per wound clinic. There was no order for the solution to dampen the collagen.

Review of documentation on 9/16/16 at 10:51 AM included Patient Progress Notes which revealed the left foot wound was redressed. There was no documentation the left foot wound was assessed or what wound care was performed by staff.

In an interview on 3/2/17 at 10:01 AM, EI # 1, Director of Nursing confirmed the findings above.

4. MR # 9 was admitted to the facility on 10/28/16 with diagnosis of Acute Pyelonephritis and Pressure Ulcer to the Buttock. Past history included Atrial Fibrillation.

Record review revealed physician orders dated 10/28/16 for daily weights. There was no nutritional assessment completed for the high risk patient.

Review of the 10/28/16 Initial interview documentation revealed [spouse] stated wound dressed today before the emergency room visit.

Review of the 10/29/16 Patient Progress Notes documentation at 3:44 AM revealed a 4x4 (gauze) across middle of buttocks, dry/intact.
At 11:57 AM, wound status assessment re-evaluated. At 12:11 PM, pressure ulcer condition was "opened blister", physician described wound, 2 cm (length), 1 cm (width), approx (approximately) 4 cm in depth. Noted on RT (right) buttock. [caregiver] redressed per doctors orders.

There was no documentation of the condition of the surrounding skin, wound edges and presence or absence of exudate odor. There was no documentation for the specific wound care performed by the caregiver on 10/29/16.

Review of the 10/30/16 7:26 AM Progress Note documentation revealed "did dressing rt buttock as directed by [spouse]. There was no documentation of the wound care performed, the measurements of the wound and the condition of the surrounding skin.

During an interview on 3/2/17 at 10;50 AM, EI # 1 confirmed there was no weight documented on 10/29/16, no nutritional assessment completed and staff failed to follow policy for assessment and care of wounds.

5. MR # 3 was admitted to the facility on 11/19/16 with diagnoses including Acute Coronary Syndrome, Hypomagnesemia and Left Lower Lobe Infiltrate. Physician orders dated 1/19/17 included vital signs every 4 hours with oximetry and telemetry.

Review of medical record documentation for 1/22/17 included vital signs and oximetry at 12:01 AM, 7:04 AM, 11:45 AM, 3:17 PM and 11:00 PM. Vital signs and oximetry were not monitored and documented every 4 hours as ordered.

Record review revealed a nursing assessment on 1/22/17 performed at 7:15 AM and amended at 8:32 AM. There were no additional nursing assessments documentation on 1/22/17.

Record review revealed RN documentation on 1/22/17, the head of bed was elevated, a bath was completed and call light in reach at 2:44 PM. The next nurse documentation at 9:20 PM, which was 5 hours and 24 minutes later, was by the LPN "...resting in bed lethargic, appropriate responses...Zithromycin...hung. Will monitor patient."

The next documentation was 82 minutes later at 10:32 PM, "...lips pale and dry, eyes closed nonresponsive to verbal and tactile stimuli, RN, notified of code. Assisted with CPR..." There was no nurse documentation regarding the CPR that was initiated, that the code was unsuccessful and that Alabama Organ Center was notified.

The medical record included 1/22/17 documentation of a telemetry strip at 12:35 AM and at 8:32 AM. The RN documented "heart rhythm see telemetry strip". There was no telemetry strip in the medical record. The next heart rhythm was at 11:45 PM, which was 13 minutes after staff documented CPR in progress. There was no documentation MR # 3's heart rhythm was monitored every 8 hours per policy.

During an interview on 3/2/17 at 10:58 AM, EI # 1 confirmed staff failed to follow physician orders for care, conduct and document patient assessments including telemetry monitoring and follow policy and procedure and document events surrounding MR # 3's death.




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6. MR # 2 was admitted to the facility on 12/22/16 at 10:48 AM for hospice GIP for pain management. MR # 2 had a terminal diagnosis of Ovarian Cancer with Metastasis to the Liver.

Review of the record revealed MR # 2's pain escalated requiring a continuous Morphine infusion for pain management. Review of the ChartLink Physician Entered Orders revealed an order dated 12/22/16 at 10:30 PM for Morphine 10 mg (milligram) Inj (injection) Rate 10 ml/hr (milliliters per hour), may increase to 20 cc/hr (cubic centimeters per hour) 20 mg / hr if necessary.

Morphine 10 mg mixed in 100 ml of NS (normal saline) at 10 ml per hour equals an infusion of 0.1 mg per hour and 20 cc/hr equals an infusion of 0.2 mg per hour, not 20 mg/hour.

Further review revealed the above order was changed 12/22/16 at 11:43 PM as follows: Morphine 10 mg inj 10 ml/hr -add: Morphine 100 mg inj add: NS (normal saline) 100 ml, may increase to 20 cc/hr (20 mg/hr) if necessary.

Review of the nursing note documentation dated 12/22/16 at 10:39 PM revealed "received new order for Morphine drip 10 mg / 100 ml to infuse 10 ml over an hour...

There was no documentation the changed order dated 12/22/16 at 11:43 PM (100 mg in 100 ml of NS) was initiated. The patient's pain rate was documented as 8 out of 10 on 12/23/16 at 12:01 AM.

At 1:00 AM on 12/23/16 the nurse documented "remains hurting in back. Morphine gtt (drip) up to 20 cc/hr". The strength or concentration of the Morphine drip was not documented.

An interview was conducted on 3/2/17 at 9:45 AM with EI # 1 who confirmed the documentation of both the Morphine drip orders and the nursing documentation of administration was not clear.

*** Review of 3 of 5 nurse personnel files on 3/2/17 failed to demonstrate evidence of completed skill competency validations for 1 RN and 2 LPN files reviewed. There was no current CPR certification in 2 of 2 LPN files reviewed.

An interview conducted on 3/2/17 at 1:30 PM with EI # 2, Assistant Director of Nursing, confirmed the above findings.

Based on review of medical record (MR), policy and procedure and interviews it was determined the facility staff failed to check vitals signs every hour during blood administration per policy. This affected MR # 6, 7 and 8, 3 of 3 patients reviewed with blood transfusions. This had the potential to affect all patients who received blood transfusions at this facility.

Findings include:

Policy: Blood Administration
Reviewed 8/2014

Purpose: " To set guidelines and to define the responsibilities for the proper administration of blood components.
Policy: Blood is only administered by a nurse with demonstrated competency in blood administration...
Monitoring During Infusion:
The nurse observes the patient closely. Vital signs are taken immediately prior to obtaining the blood, within fifteen (15) minutes after initiating the transfusion and every hour until 1 hour AFTER the transfusion has been discontinued. The patient is also monitored during the transfusion for signs and symptoms of reactions..."

1. MR # 6 was admitted to the facility 1/14/17 with diagnoses of Anemia and Upper GI (Gastrointestinal) Bleed.

The physician orders included 1/14/17, " Type and Crossmatch 2 units of Packed Red Blood Cells, transfuse each unit over 4 hours."

The first unit of blood was started at 3:15 AM and ended at 6:20 AM. Vital signs were recorded at 3:15 AM, 15 minutes later at 3:30 AM and at 6:20 AM when the blood was completed. The patient's vital signs were not obtained between 4:30 AM and 5:30 AM.

The second unit of blood was started at 9:50 AM and ended at 12:35 PM. Vital signs were recorded at 9:50 AM, 15 minutes later at 10:25 AM and at 12:35 AM when the blood was completed. The patient's vital signs were not obtained between 11:25 AM and 12:35 PM.

The facility staff failed to monitor vital signs every hour until 1 hour after the transfusion was completed per policy.

In an interview 3/2/17 at 10:49 AM with Employee Identifier (EI) # 1, the Director of Nursing, confirmed the above information.

2. MR # 7 was admitted to the facility 1/19/17 with a diagnosis of Anemia.

The physician orders included 1/19/17, " Type and Crossmatch 2 units of Packed Red Blood Cells".

The first unit of blood was started at 10:55 PM and ended at 1:30 AM. Vital signs were recorded at 10:55 PM, 15 minutes later at 11:10 PM and at 1:30 AM when the blood was completed. The patient's vital signs were not obtained between 11:10 PM and 1:30 AM.

The second unit of blood was started at 2:00 AM and ended at 4:45 AM. Vital signs were recorded at 2:00 AM, 15 minutes later at 2:15 AM and at 4:45 AM when the blood was completed. The patient's vital signs were not obtained between 2:15 AM and 4:45 AM.

The facility staff failed to monitor vital signs every hour until 1 hour after the transfusion was completed per policy.

In an interview 3/2/17 at 10:45 AM with EI # 1, confirmed the above information.

3. MR # 8 was admitted to the facility 7/3/16 with a diagnosis of Allergic Reaction to Medication, Sepsis and Pressure Ulcer.

The patient received a blood transfusion 7/7/16 due to a low Hemoglobin of 8.3.

The blood was started at 10:40 AM and ended at 1:55 PM. Vital signs were recorded at 10:40 AM, 15 minutes later at 11:05 AM and at 1:55 PM when the blood was completed. The patient's vital signs were not obtained between 11:05 AM and 1:55 PM.

The facility staff failed to monitor vital signs every hour until 1 hour after the transfusion was completed per policy.

In an interview 3/2/17 at 10:30 AM with EI # 1, confirmed the above information.

Based on medical record (MR) review, facility policy and procedure and interview, the facility failed to ensure staff followed the policy for medical record documentation that included events surrounding a patient death. This affected MR # 3 and had the potential to affect all patients treated at the facility.

Findings include:

Documentation General Guidelines
Reviewed 08/12

Purpose:

To ensure...all documentation in the patient's record is legible, accurate and complete

Guidelines:

1. Nursing documentation is now charted electronically...accessed by a specific user...2. Documentation of nursing care shall be...a. Legible; b. Accurate; c. Complete...reporting...patient's status, including signs and symptoms, responses, treatments...nursing care rendered...unusual occurrences; d. Timely; e. Charted at the time or after the care...is provided..f. Documentation of patient care ...not in the sequence of time...shall be recorded as a "late entry", including a date and time the late entry was made as well as the date and time the care was provided...

MR # 3 was admitted to the facility on 11/19/16 with diagnoses including Acute Coronary Syndrome, Hypomagnesemia and Left Lower Lobe Infiltrate.

Record review revealed at 1/22/17 at 10:32 PM, "[MR # 3]...lips pale and dry, eyes closed nonresponsive to verbal and tactile stimuli, RN (registered nurse) notified of code. Assisted with CPR (cardiopulmonary resuscitation)..."

Found in the medical record was a document typed on a personal computer with a medical record label attached identifying MR # 3. The document contained entries from 9:00 PM till 10:50 PM describing events of the health status and death. The document failed to include the date written, the date of the events and was not signed by the writer and any other staff named in the document.

In an interview on 3/2/17 at 10:58 AM, Employee Identifier # 1, Director of Nursing confirmed the staff failed to follow the medical record documentation policy.

Based on observation, review of facility policy and interview, it was determined the facility staff failed to follow the policy for accounting for controlled substances. This had the potential to negatively affect all patients served by the facility.

Findings include:

Facility Policy:
Subject: Narcotic Keys
Department: Surgical Services
Revised date: 12/16

Policy:

"...2. A dual nurse narcotic count will be conducted at the beginning of the shift and at the end of the shift, prior to leaving the facility at the end of the day.

3. If there are any discrepancies in the count at any time, an incident report will be completed and the OR (operating room) Director notified..."

An observation was conducted in the Surgery Services Department on 2/28/17 at 4:00 PM with Employee Identifier (EI) # 3, Surgery Services Director. The surveyors and EI # 3 reviewed the narcotics present and narcotic count for the department. The Percocet count was incorrect.

The surveyor requested the daily narcotic shift count sheets for all controlled substances. Review of the surgery department narcotic count sheets revealed staff had failed to document narcotic counts at the beginning and the end of the each shift from 9/27/16 to 3/1/17. There was no documentation narcotic counts were completed each day the department operated.

In an interview on 2/28/17 at 4:10 PM, EI # 3 confirmed staff failed to sign out all narcotics and conduct narcotic counts per the facility policy.

Based on observations during the facility tour with hospital staff by the Fire Safety Compliance Officer and staff interviews, it was determined that the facility was not constructed, arranged, and maintained to ensure patient safety.

Findings were:

Refer to Life Safety Code violations.