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Based on record review (of the facility Quality Assurance (QA) plan and procedure for serious safety events), staff interviews and facility grievances, the facility failed to have an effective Quality Assessment and Performance Improvement Program. The facility failed to evaluate though the Quality Assurance and Process Improvement committee (QAPI) the concerns brought to them regarding care of Patient 1 at time of admission 4/19/18. The facility failed to complete an investigation to provide ongoing and measurable improvements to track potential adverse patient events to promote safe care hospital wide. During survey, record review documentation from Patient 8 revealed the patient's family called the unit nurse with concerns regarding lack of timely implementation of physician orders on admission 6/18/18. These concerns was not logged as grievance or communicated in any way to the Quality/Risk department for further investigation. A review of five (5) of 11 sampled records (Patients 1, 3, 5, 8 and 11) revealed a failure by nursing to implement and initiate physician orders in timely manner placing patients at significant risk. Facility census was 89. This failure of timely implementation of physician orders has the potential to impact ALL ADMISSIONS to the facility. This failure led to a determination that the Condition of Participation for Quality Assurance and Process Improvement (QAPI) was not met.

+ See additional deficiencies at A-385, A-395, A-405 and A-286.

Findings are:

A. A review of a Grievance/complaint submitted to the facility on 4/26/18 (one week after admission of Patient 1) included in summary from phone conversation between family member and unit nurse manager:
"waited almost 3 (three) hours for a blood draw/IV (intravenous) insertion while continued to have active bleeding..., hemoglobin of 6.7 recorded from physician office ....., did not receive transfusion of blood prior to surgery...., communication, timeliness and patient care summarized the telephone concerns". The facility action plan stated "nurse coached related to delegation and anticipation of care needs with a nose bleed." The grievance form was dated as completed on 5/23/18. Following this safety event occurrence and resultant grievance, staff were not provided additional communication for timely care nor was any further information regarding any investigation completed.

An interview with the Vice President of Patient Care Services on 6/28/18 at 9:40 am confirmed, "no IRIS (Incident Reporting Information System) report was completed on this grievance, nor was it reviewed as a near miss event." Additional interview with newly appointed Director of Quality/Risk Management on 6/28/18 at 10:50 am confirmed, "this grievance was not taken to the QAPI committee for review for an opportunity for improvement, nor did we look to see if systemic issue of adverse patient event, as those who reviewed this grievance did not do a complete investigation."

B. Review of Patient 8's medical record notes (from 6/18/18 by Unit Manager at 1553 (3:53 pm) - day of hospital admission) included:
"Phone call from family member with concerns of orders not being implemented, chart was found by computers at back of nurses station..., order was reviewed and left with unit secretary to be entered... Unit Director called to speak with family..." This concern from Patient 8's family was not brought forward to Quality/Risk department to provide any type of investigation of events to promote safety review. No grievance log was completed nor were any system alerts to staff initiated to promote safe care. Interview with the Vice President of Quality on 6/28/18 at 9:45am confirmed that Patient 8's concern "was not made as a grievance or brought to Quality, as the Unit Director did not report the incident."

D. A review of the facility process improvement and quality policies and procedures included multiple forms for analysis of an event:
Incident Reporting Information System (IRIS) - identification of problematic trends or circumstances,
Safety and Performance Improvement plans - focus on direct patient care delivery processes,
Sentinel and Significant Events - immediate response to sentinel or serious safety event,
Patient Safety Evaluation System - conduct safety activities and evaluate patient safety,
Safety First - First Meeting Checklist - Safety Algorithm, Safety Alerts,
Apparent Cause Analysis - events leading to system problems and remedial action needs,
Root Cause Analysis - Investigation and timeline worksheets.
An interview with the Division Vice President of Quality on 6/28/18 at 11:10 am revealed, "our expectation is for the facility to utilize one of these tools (as listed above) that are provided in our QAPI process to track and measure facility care needs and develop action plans."

This deficiency at Condition Level is a repeat citation as the Condition of Participation for QAPI was cited at the survey ending previously 1/24/18.

Based on record review of the facility Quality Assurance (QA) plan and procedure for safety events, staff interviews and record review of facility grievances/care concerns, the facility failed to analyze and track grievances to ensure thorough a thorough investigation was completed and a plan was implemented to promote timely patient care and treatment for 2 patients (Patient 1 and 8). The facility census was 86 at the time of survey. This failure had the potential to affect any patient admitted to the hospital.

Findings are:

A. A review of Patient 1's Grievance/complaint (submitted to facility on 4/26/18) included in a summary of a phone conversation with family member and the facility unit nurse manager; "waited almost 3 (three) hours for a blood draw/IV (intravenous) insertion while continued to have active bleeding..., hemoglobin of 6.7 recorded from physician office ....., did not receive transfusion of blood prior to surgery...., communication, timeliness and patient care summarized the telephone concerns." The facility action plan stated "nurse coached related to delegation and anticipation of care needs with a nose bleed." The grievance form was dated as completed on 5/23/18. Following this safety event occurrence and grievance, staff were not provided additional information regarding the provision of timely care nor was any further information regarding the investigation completed.

An interview with the Vice President of Patient Care Services on 6/28/18 at 9:40 am confirmed, "no IRIS( Incident Reporting Information System) report was completed on this grievance, nor was it reviewed as a near miss event." Additional interview with the newly appointed Director of Quality on 6/28/18 at 10:50 am confirmed, "this grievance was not taken to level of Quality for review for opportunity for improvement, nor did we look to see if there was a systemic issue of adverse patient event as those who reviewed this grievance did not do a complete investigation."

B. A review of Patient 8's medical record notes from 6/18/18 at 1553 (3:53 pm) included "Phone call from family member with concerns of orders not being implemented, chart was found by computers in back of nurses station..." The information from Patient 8's family recorded in the medical record was not brought forward to Quality Assurance and Process Improvement (QAPI)department, therefore there was no investigation of events to promote a quality review. No grievance log was completed nor were any system alerts communicated to staff to promote timely implementation of practitioner orders.

An interview with the Vice President of Quality/Risk Management on 6/28/18 at 9:45 am confirmed that Patient 8's concern "was not developed as a grievance or brought to Quality, as the Unit Director did not report the incident."

C. A review of the Facility's Quality reporting system policies and protocols included a Safety Culture Diagnostic Assessment - Common Cause Analysis for Healthcare. This tool included a Safety Event Classification Algorithm to determine if an inconsistency from generally accepted performance standards (GAPS)involved the patient and if so, did the inconsistency in standards cause moderate to severe harm or death. This was intended for the facility to determine if the incident was:
1) not a safety event,
2) near miss safety event,
3) precursor safety event, or a
4) serious safety event.
Without any investigation completed or use of the facility tools, the facility was not able to determine if there was a need to revise processes regarding timely physician order implementation, or to determine the causal factors, placing continued patients at risk when physician orders were not implemented timely.

D. The facility Quality Risk Patient Safety Policy stated "An incident report will be completed to assist our health care facility in its effort to improve the safety and quality of care provided; these reports record accidents, unusual events, or near-miss situations which might result in injury or damage to persons or property and could involve potential litigation... the primary Reviewer assigned to follow up on the IRIS report is to complete necessary follow-up within 7 (seven) calendar days."

Based on staff interview, record review, observations, review of facility policies and procedures, and review of facility grievances; the facility failed to ensure the nursing staff provided adequate supervision of care by failure to consistently implement the providers orders within 1 hour for "now" orders for 1 sampled patient ( Patient 8) and within 2 hours for "other admission" orders for 4 patients (Patient 1, 3, 5 and 11)out of 11 sampled patients that were either direct admissions from an outside hospital or physicians office or admitted to the nursing floor from the emergency department. Nursing staff failed to initiate the Admission Health Assessment for 1 of 11 sampled patients (Patient 1) related to their condition upon admission. The failure to initiate the providers orders resulted in 1 patient (Patient 8) not receiving laboratory testing ordered for "now" until 5 hours and 45 minutes after admission to the nursing floor; the intravenous line (IV) not started until 5 hours and 30 minutes after admission to the nursing floor; and the placement of a nasogastric tube (tube inserted through nose into stomach) to low intermittent suction (LIS) to relieve abdominal pressure, nausea and vomiting due to a small bowel obstruction (a blockage of part of the intestine) until 4 hours and 30 minutes after admission to the nursing floor; Patient 1 (admitted to the floor at 1322 from the physician office with a recent recurrent nosebleed and a hemoglobin (red blood cell count) of 6.7) did not have the admission orders initiated, including starting the IV or getting the blood drawn for a blood transfusion until 2 hours and 30 minutes after arrival. Patient 1 started having profuse bleeding from the nares and mouth prior to the orders being initiated. These failures had the potential for other patients in the facility who were admitted to the nursing floor with provider orders to have a delay in the care as directed by their provider. These failures resulted in the determination by the Centers for Medicare and Medicaid (CMS) that the Condition of Participation for Nursing Services was not met, and that Immediate Jeopardy (IJ) conditions existed since 4/19/18 posing a threat of potential injury, harm, impairment or death of patients in the facility who were identified as needing hospital care under the orders of a provider. The failure to implement immediate effective action plans has the potential to affect the care of all patients in the facility. Sample size was 11, patient census at the time of the survey was 89.


The administrative staff implemented measures to remove the immediate jeopardy noncompliance on 6/29/18 by implementing the following:
- Timely initiation of stat and now orders within 30 minutes and routine orders within 2 hours on direct admissions.
- Initial assessments will occur within 2 hours for all direct admissions.
- An admission nurse will be on every inpatient unit to support the primary RN with direct admissions 24/7. These departments are identified as: Critical Care Unit (CCU); Progressive Care Unit (PCU); Burn Unit; Adult Inpatient Unit East (AIUE-ortho [care of pts with bone/tendons/ligaments issues], Neuro Unit [care of pts with disorders of nerves and nervous system], Peds [care of children]); and Adult Inpatient Unit West (AIUW-medical, surgical [care of pts with a variety of illnesses that may or may not need surgery to recover]).
- The admission nurse is to prioritize orders and ensure 100% of all STAT and NOW orders are initiated within 30 minutes, routine orders are entered and acted upon within 2 hours, and the initial assessment is initiated within 2 hours. The House Supervisor will notify the admission nurse of the direct admission. The Admission Nurse then coordinates with the primary nurse to ensure that the orders, assessment, database are completed. If the admission nurse is occupied, the house supervisor will deploy additional resources to support the admission nurse. The resources will be reallocated from within the hospital or brought in from outside.
- A leadership auditor will be present in the hospital 24/7 for the next 7 days starting on 6/28/18 at 10:00 PM. The leader will monitor all admissions to ensure the admission orders, both stat/now and routine, are initiated, entered and completed within established timeframe's. The leader will also monitor for initial admission assessment is completed within 2 hours.
- Educate all nursing staff to the timeliness of stat/now orders and completion of initial nursing assessment. 6/28/18-process change alert created and communicated to define timeliness of orders and expectations regarding stat/now orders and initial nursing assessment. 100% of staff currently working will be educated on 6/28/18 and all others prior to start of their next shift. Education on the role of the admission nurse and the responsibility of the house supervisor will be accomplished through a process change alert-read and acknowledged by all clinical nursing staff.

Refer to A-395 and A-405

Based on staff interview, record review, observations, review of facility policies and procedures, and review of facility grievances, the facility failed to ensure that nursing staff provided adequate supervision of care by failing to consistently implement physician orders within 1 hour for "now" orders for 1 sampled patient (Patient 8) and within 2 hours for "other admission" orders for 4 patients (Patients 1, 3, 5 and 11) of 11 sampled patients that were either direct admissions from an outside hospital or physicians office; or who were admitted directly to the nursing units from the emergency department. Nursing staff failed to initiate a Admission Health Assessment for 1 of 11 sampled patients (Patient 1) related to their condition upon admission. The failure to initiate the provider orders resulted in 1 patient (Patient 8) not receiving laboratory testing ordered for "now" until 5 hours and 45 minutes after admission to the nursing floor; the intravenous line (IV) not started until 5 hours and 30 minutes after admission to the nursing floor; and the placement of a nasogastric tube (NG-tube inserted through nose into stomach) to low intermittent suction (LIS-hooking up of NG to a machine to pull the fluid out of gut) to relieve abdominal pressure, nausea and vomiting due to a small bowel obstruction (a blockage of part of the intestine) until 4 hours and 30 minutes after admission to the nursing floor; Patient 1 (admitted to the floor at 1322 from the physician office with a recent recurrent nosebleed and a hemoglobin (amount of red blood cells in the blood) of 6.7 (Normal level 13.5-17.0)) did not have the admission orders initiated, including starting an IV or getting the blood drawn for a blood transfusion until 2 hours and 30 minutes after arrival. Patient 1 started having profuse bleeding from the nares (nose)and mouth prior to the orders being initiated. These failures had the potential for other patients in the facility who were admitted to the nursing floor to have a delay in their care as directed by their provider. These failures resulted in the determination by the Centers for Medicare and Medicaid (CMS) that the Condition of Participation for Nursing Services was not met, and that Immediate Jeopardy (IJ) conditions existed since 4/19/18 posing a threat of potential injury, harm, impairment or death of patients in the facility who were identified as needing hospital care under the orders of a provider. The failure to implement immediate effective action plans has the potential to affect the care of all patients in the facility. Sample size was 11, patient census at the time of the survey was 89.

A removal of the IJ condition occurred on 6/29/18 following the implementation of measures to remove the immediate jeopardy noncompliance. See A 385.

Findings are:

A. A review of Patient 1's medical record revealed the patient was a 13 year old admitted on 4/19/18 at 1322 (1:22 PM) from the physicians office with a recent recurrent nosebleed. The Discharge Summary by (Doctor I - Dr I) for Pt 1 dated 4/20/18 at 3:01 PM revealed: PRESENTING HISTORY: revealed that Pt 1 "approximately 10 to 11 days prior to this admission suffered a nasal fracture while playing baseball. Approximately 4 days after that, (Pt 1) was seen by our office and nasal fracture diagnosis was confirmed, and (pt) underwent, in the office, closed reduction nasal fracture repair. Beginning a couple of days after that, in the first part of this week, (pt) started having severe, recurrent nosebleeds, initially left-sided and then subsequently more so right-sided. (Pt) was seen a number of times in the office relative to attempts at nasal cauterization [burning the tissue to stop bleeding] and various nasal packing methods, but continued to have reportedly severe nosebleeds at home, to the point (pt) was seen in the office the afternoon of admission, and a hemoglobin was checked - returning 6.7, indicating a likely significant blood loss from the nasal bleeding and the need was felt for admission to the hospital for observation and blood transfusion, and those arrangement and orders were made by on of my partners - (Dr H)." SUMMARY OF HOSPITAL COURSE: "Following (gender) admission, (gender) began having severe right and left -sided nasal bleeding, both anterior and posterior. I (Dr I) was called about the patient and after finishing up being in the operating room, came up to see (pt), whereupon noted the significant bleeding nasally (gender) was having, and I (Dr I) felt the need clinically then to [send the patient to] the operating room for exam of the nose under anesthesia with nasal bleeding assessment and control. This was all arranged in an expeditious (hurridly or rapid)fashion."

A review of the physician orders for Pt 1 revealed a telephone order received by the house supervisor for Admission to Outpatient Observation at 1256 (12:56 PM) on 4/19/18. A complete set of admission orders were faxed to the hospital from the clinic by Dr H at 12:57 PM on 4/19/18. The orders revealed:
Non Medication Orders: 1) VS (vital signs) routine; 2) Activity ad lib (as desires); 3) Diet as tolerated; 4) Hb (hemoglobin) 1 hour post transfusion-call to (Dr I)
Medication Orders: 1) 24 hour hold; 2) IV LR (lactated ringers- a solution with electrolytes given to those who have low blood volume) TRA (to run at) 60 cc/hr (cubic centimeters/hour); 3) T & C (Type & Crossmatch drawing blood to find a compatible blood type for transfusion) one unit of packed cell (a concentrated preparation of red blood cells) and give IV over 4 hours; 4) Cefzil (antibiotic) 250 mg (milligram) po (oral) BID (twice a day); 5) Norco (pain pill) 5/325 1 po q 4 hours prn pain (1 pill every 4 hours as needed for pain); 6) Tylenol Gr X (grains ten) po q 4 hours prn pain.
-1545 (3:45 PM) Orders for NPO (nothing by mouth) and Ancef 2 grams IVPB (IV piggyback) x 1 now.

A review of the Medical Record for Pt 1 revealed:
-4/19/18 per the Face Sheet/Demographic Sheet; the patient was admitted at 1322 (1:22 PM) to 5th Floor.
-4/19/18 at 1500 (3:00 PM) per the Nurses Notes; "NOSE STARTED TO BLEED PROFUSELY FROM NARES AND MOUTH. PT IN BR (BATHROOM) WITH MOM, GAVE CHAIR TO SIT PT DOWN ON. WENT THROUGH MULTIPLE KLEENEX AND BRAWN WIPES. PT GAGGING ON BLOOD AND SPITTING IT OUT. (DR I) NOTIFIED AND COMING UP TO SEE PT. Amount: large, Color: FRANK BLOOD"
-4/19/18 at 1600 (4:00 PM) IV started in right forearm with 20 gauge (size of needle) on 2nd attempt.
-4/19/18 at 1603 (4:03 PM) Admission Health Assessment - Pediatric documented.
-4/19/18 at 1620 (4:20 PM) Type and Crossmatch packed cells to give ASAP (as soon as possible).
-4/19/18 at 1700 (5:00 PM) to surgery. Anesthesia started at 1705 (5:05 PM) and ended at 1815 (6:15 PM). 1 unit blood given in surgery.
-4/19/18 at 1940 (7:40 PM) returned to room.
-4/19/18 at 2015 (8:15 PM) Hemoglobin drawn, results 7.0
-4/19/18 at 2115 (9:15 PM) Give additional unit of packed cells
-4/20/18 at 0621 (6:21 AM) Hemoglobin drawn, results 7.9
-4/20/18 at 1630 (4:30 PM) dismissed home with parents.

An interview with Registered Nurse (RN K) on 6/27/18 at 9:40 AM revealed about Pt 1, that the patient came in about 1:30 PM and was assigned to another nurse, but I went to get things started. "I knew that the pt was admitted for a nosebleed, and had been hit by a baseball the week before. Went to the doctors office with a nosebleed and sent here for blood, 2 units, and to spend the night. I did vital signs (but did not enter them till went to surgery), they were fine." "(Parent) told me that hemoglobin was 6, but appeared fine, no head to toe assessment done, not light headed." "About 3:30-4:00 PM Pt had a nosebleed, pretty bad. Had a small bleed on admission but this one was bad. Know documentation is poor. Pt in bathroom. I was concerned and regretting IV not started. I went and called (Dr I), bleeding a lot, said give Ancef and we are going to take (gender) to surgery. In about 10 minutes (Dr I) was up on floor. I know (Parent) complained I wanted to get IV started in bathroom, (Pt 1) bleeding and spitting blood into toilet, but got (gender) to bed for IV start. The bleeding had slowed." "I was not concerned about pt till bleeding started, bright red blood running out." "(RN L -was assigned RN) but had gotten 2 post ops (patients just out of surgery) down the hall and was busy with them when the patient (Pt 1) came, the charge RN asked me to help get pt settled."

An interview with Dr I on 6/28/18 at 12:40 PM revealed that (Pt 1) was admitted by Dr I's partner (Dr H) from the office. Understood that (Dr H) had sent orders, had a hemoglobin at office and was a 6.7 which trigger the need for a blood transfusion in response to previous bleeding. The plan had been to get the blood and spend the night. "The patient probably had an ethmoidal artery (an artery that is high in the nasal cavity) injury secondary to the nasal fracture trauma, the bleeding breaks loose, then the vessel spasms and stops bleeding, the spasm relaxes and new bleeding, that fits the picture of the history of bleeding. I am not sure the delay in transfusion adversely affected (Pt 1) since had blood immediately in surgery." "The patient was an uncommon occurrence. The patient was not bleeding on admission and put on observation. Type and crossmatch and get the blood in, (gender) needed hospital to be watched, but not an emergency case on admission and was stable , but concern hemodynamically (relating to the blood circulation to the organs) not stable without the transfusion. (Pt 1) needed nursing monitoring." When inquired to Dr I if (gender) gave an order for now/stat what would be the expectation of it getting completed? "It to be done in an hour."

Review of a patient grievance received on 4/26/18 from Pt 1's parents revealed the concern included:
-After the patient was admitted, waited almost 3 hours for a blood draw/IV insertion while (child) continued to have active bleeding. Once the nurse (RN K) finally attempted to insert the IV, it was while (gender) was over the toilet and perched (gender) arm on the trash can to do the IV insertion. (Parent) had to suggest they move (gender) from the toilet/trash can situation to the room with a bin for blood while inserting IV, hemoglobin was 6.7 prior to admit." "The (child) bled the whole time until surgery (from 1 PM- 5 PM), and the IV was only in arm for a short time prior to surgery. (Parent was concerned at the hemoglobin levels had likely dropped significantly after hours of waiting and very little time for fluids/did not receive transfusion prior to surgery."
ACTION: revealed that the staff involved were interviewed and coaching was provided as applicable.
There was no mention of this moving on to the Quality Committee for review of looking at other patients as a possible recurrent issue.

Interview with the RN N (Quality Director) on 6/27/18 at 2:00 PM, RN N revealed that there was no further follow up or documentation regarding the 4/26/18 grievance from Pt 1's parents. (Note: RN N has held the position of Quality Director at this facility for only 2 weeks so was not here when this grievance was received.)

B. A review of Patient 8's medical record revealed the patient was admitted on 6/18/18 at 1130 (11:30 AM) from a rural hospital with nausea, vomiting, abdominal pain and a small bowel obstruction. Review of the History and Physical Examination by Dr J dictated on 6/18/18 at 12:41 PM revealed, Pt 8 had a left hip repair on 6/10/18 and dismissed from a hospital on 6/13/18. On 6/15/18, the patient started having nausea, vomiting and abdominal pain. On 6/17/18 Pt 8 went to the Emergency Room (ER) in a rural hospital and had a workup which showed an ileus (lack of movement of the bowel) versus obstruction and a Urinary tract infection (UTI). Pt 8 was treated in the ER and advised to be admitted but declined and returned home. Pt 8 continued to have nausea, abdominal pain, and vomiting and no stool or gas. Pt 8 was seen by (gender) primary care doctor and it was set up for a direct admit to this hospital for further evaluation. The ASSESSMENT AND PLAN: 1) Small-bowel obstruction (SBO); 2) (UTI) ; 3) Postop day #8 left hip repair; 4) Acute kidney injury; 5) Hypothryoidism; 6) History of colon cancer, status post resection with ostomy. The patient will be admitted to the medical floor. We will keep the patient NPO, place an NG, provide supportive care, bowel rest. Consult surgery.

A review of the Inpatient Medicine Service Routine Admission Orders received on 6/18/18 at approximately 12:45 PM (per interview with Dr J on 6/28/18 at 9:10 AM) included:
-Nasogastric Tube to Low Intermittent Suction if nausea/vomiting
-NPO (nothing by mouth)
-NOW Lab of- CBC (complete blood count) with differential; Basic Metabolic Profile; TSH (abbreviation for thyroid stimulating hormone blood test); Magnesium; Phosphorus; Serum Lactic Acid
-KUB (abbreviation for kidney ureters, bladder; is a frontal xray of the abdomen)-R/O Obstruction/ileus (obstruction of the bowel)
-Consult Surgery on call today for SBO (small bowel obstruction)
-Start IV of NS (normal saline)@ 100 cc (cubic centimeters)/hr; Rocephin 1 gm (gram) IV q (every) daily for UTI (urinary tract infection); Protonix 40 mg (milligrams) IV daily
THE ORDERS WERE NOT ENTERED INTO THE ELECTRONIC MEDICAL RECORD UNTIL 1621 (4:21 PM)

A review of the Medical Record for Pt 8 revealed:
-6/18/18 per the Face Sheet/Demographic Sheet the patient was admitted at 11:30 AM to 5th Floor
-6/18/18 at 12:18 PM the charge nurse (RN O) completed the Adult Health Assessment on Pt 8
-6/18/18 at 12:41 PM the History and Physical were completed and orders written

THE MEDICAL RECORD LACKED DOCUMENTATION UNTIL 353PM:
-6/18/18 1553 (3:53 PM) nurses note from RN O revealing, "(Adult Child) called with concerns of orders not being implemented, chart was found by computers in back of nurses station. Order was reviewed and left at Unit Secretary Desk to be entered. 1605 (4:05 PM)- NG placed per order. (Adult Child) notified at 1616 (4:16 PM) that NG was placed. (RN M-5th floor director) called to speak with family and address their concerns."
-6/18/18 at 4:05 PM NG placed -CHART LACKED DOCUMENTATION OF NG INSERTION RELATED TO TUBE SIZE, PT'S TOLERANCE TO PROCEDURE
-6/18/18 at 1620 (4:20 PM) KUB done
-6/18/18 at 1630 (4:30 PM) IV Protonix 40 mg given at 1630 (4:30 PM) - CHART LACKED DOCUMENTATION OF IV INSERTION
-6/18/18 at 1715 (5:15 PM) NOW Lab of- CBC with differential (blood test to check the white blood cells and hemoglobin levels); Basic Metabolic Profile (blood test to check electrolytes); TSH (thyroid stimulating hormone checks how thyroid is working); Magnesium (checking level in the blood); Phosphorus (checks level in the blood); Serum Lactic Acid (checks the level of the lactic acid in blood)drawn
-6/18/18 at 1745 (5:45 PM) repeat KUB (x ray of kidneys, ureters and bladder) completed after NG adjusted- CHART LACKED DOCUMENTATION OF STARTING OF LOW INTERMITTENT SUCTION
-6/21/18 at 1255 (12:55 PM) dismissed to home.

An interview with RN O on 6/28/18 at 8:45 AM revealed, RN O recalled Pt 8, the patient was admitted to (room number) and "I went in and do everything, but I let the main nurse do the head to toe assessment. I let the main nurse (RN P) know the patient was there and needed to input the assessment. RN P told me 3-4 hours later that (gender) had not seen the orders. Just happened that the (adult child) called me about the same time with the concerns." When asked what the expectation was when a patient is admitted to the floor, RN O stated, "The nurse needs to be watchful for the chart and checking within the hour, if no orders call the doctor, should have IV, NG etc started."

An interview with Dr J (admitting doctor for pt 8) on 6/28/18 at 9:02 AM revealed, I am aware of (Pt 8) and the case. "I agree with the delay in order initiation is a concern. This was an unusual circumstance, not an issue before." When I say "Now/Stat" for orders I expect in an hour or two, it's a medical floor so patients are not that sick as if in Progressive or Intensive Care Units, I would expect that sooner." "We discussed this case as a team. I wasn't happy either, if a new patient we have to know what is happening." "The lab took much longer than I expected."

An interview with the Vice President of Nursing on 6/28/18 at 10:15 AM, inquired if a grievance, concern or incident report was made up related to the (Adult Child) phone call on 6/18/18 at 3:53 PM, "No, there was not a report generated following the phone call."

C. A review of Patient 3's medical record revealed the patient was admitted to 5th floor from the ER on 6/24/18 at 0345 (3:45 AM) with nausea, left lower quadrant abdominal pain, a small bowel obstruction and hernia (weakness in abdominal wall).
Pt 8 was admitted by Dr J (admitting doctor for pt 3) from the ER.

A review of the Medical Record for Pt 3 revealed:
-6/23/18 at 2355(11:55 PM) admit to ER
-6/24/18 at 0210 (2:10 AM) orders written for admission to floor
-6/24/18 at 0345 (3:45 AM) arrived at floor
-6/24/18 at 0624 (6:24 AM) NG tube to suction if needed if increased nausea/vomiting
-6/24/18 at 8:10 AM Consult surgery Indication: hernia/SBO
-6/24/18 at 11:00 AM Surgery consult, abdominal pain, nausea, vomiting this morning; to surgery for incarcerated left hernia
-6/24/18 at 12:30 PM orders received from surgeon for NG LIWS (Low intermittent wall suction); ice chips ok; KUB in am indication-bowel obstruction; activity as tolerated
-6/24/18 at 1330 (1:30 PM) returned to room following surgery
-6/24/18 at 1530 (3:30 PM) KUB x 1 now for NG placement - THE RECORD LACKED DOCUMENTATION ON THE INSERTION OF THE NG
-6/25/18 at 0730 (7:30 AM) surgeon progress note completed, NG canister empty, Remove NG - THE RECORD LACKED DOCUMENTATION OF THE REMOVAL OF THE NG
-6/26/18 at 1200 (12:00 Noon) dismissed to home

An interview with Dr J on 6/28/18 at 9:02 AM revealed, inquired from Dr J the provider's expectation for the nurse to place an NG following an order, Dr J stated, "if the patient is actively nauseated and vomiting, the expectation would be different for a non-symptomatic patient. If symptomatic, I would expect the NG to be placed within an hour.

D. A review of Patient 5's medical record revealed the patient was admitted to 5th floor from the ER on 6/23/18 at 1334 (1:34 PM) with abdominal pain and a possible small bowel obstruction. Review of the History and Physical Examination by Dr K (admitting doctor for Pt 5) dictated on 6/23/18 at 1311 (1:11 PM) revealed, Pt 5 had developed abdominal distention with nausea and vomiting. In the ER a CT (CAT) scan showed a small bowel obstruction. The patient has diffuse abdominal pain and has a white count (indicates possible infection) of 20,000. PLAN: admission; give some Invanz out of concern for the abdominal pain and leukocytosis (elevated white blood count); IV fluids; NG to intermittent suction; At this point do not think it is a surgical abdomen and we will see how (gender) responds to the NG

A review of the Inpatient Medicine Service Routine Admission Orders received on 6/23/18 at approximately 1:34 PM (per interview with Dr K on 6/28/18 at 8:30 AM) included -Nasogastric Tube to Low Intermittent Suction - X ray for placement.
THE ORDERS WERE NOT ENTERED INTO THE ELECTRONIC MEDICAL RECORD UNTIL 1612 (4:12 PM)

A review of the Medical Record for Pt 5 revealed:
-6/23/18 at 1344 (1:44 PM) admit order to go to 5th floor
-6/23/18 at 1334 (1:34 PM) Physician Order for NG tube to Low Intermittent Suction - X ray for placement.
-6/23/18 at 1500 (3:00 PM) ER record reflects Pt 5 delivered to room on 5th floor
-6/23/18 at 1612 (4:12 PM) admission orders entered into electronic medical record
-6/23/18 at 1729 (5:29 PM) Pt 5 vomited
-6/23/18 at 1831 (6:31 PM) Zofran (medication to stop vomiting) given IV for nausea and vomiting
-6/23/18 at 1835 (6:35 PM) NG placement - THE RECORD LACKED DOCUMENTATION ON THE INSERTION OF THE NG
-6/23/18 at 1921 (7:21 PM) KUB for NG placement
-6/26/18 at 1747 (5:47 PM) to surgery for exploratory laporotomy/adhesions (surgery through small holes in abdomen to check for scar tissue or other problems in abdomen) and hernia repair
-6/26/18 at 2115 (9:15 PM) returned to room following surgery

An interview with Dr K (admitting doctor for pt 5) on 6/28/18 at 8:30 AM revealed, Dr K recalled admitting Pt 5 after seeing the patient in ER. Reviewed the record with Dr K regarding the patient arriving to the floor at 1334 (1:34 PM) with an order to place an NG and that Pt 5 had vomited at 5:29 PM and the NG placed at 6:35 PM. "Oh My, that a long time!" "Actually I think I told the ER nurse to put the NG in, but can't be sure, but after going to floor, if it didn't happen until after 6:00 PM, that is too long." When inquired what Dr K's expectation was regarding the NG placement, "I would prefer within an hour- for sure, but I really would of preferred it would of gotten done while still in ER." "I would consider a patient with this condition that the NG would be placed within an hour at the latest." "For this patient, from 1:44 PM -7:21 PM when the suction would have been started is 6 hours of feeling poorly. I did not feel (gender) was an acute (surgical) abdomen, but certainly needed the NG for comfort and then to consult with the surgeon in the morning." "I would say that on occasion there has been a problem with order initiation. It's the nurses responsibility to drive the orders."

E. A review of Patient 11's medical record revealed the patient was a direct admit to the Progressive Care Unit from a Cardiology (heart doctor) Clinic on 6/25/18 at 1528 (3:28 PM) with chest pain, congestive heart failure (fluid around heart) and shortness of breath. Admission orders were received at 1448 (2:48 PM) prior to the patient's arrival.
A review of the Medical Record for Pt 11 revealed:
-6/25/18 at 1528 (3:28 PM) Admitted to Progressive Care Unit directly from physician clinic
-6/25/18 at 1448 (2:48 PM) Physician Order for Saline Lock, Saline Flush now, BID (two times per day)and PRN (as necessary)per Vascular Access Flushing Guidelines.
-6/25/18 at 1713 (5:13 PM) ORDERS ENTERED INTO THE ELECTRONIC MEDICAL RECORD
-6/25/18 at 2000 (8:00 PM) IV Saline Lock (IV catheter that is capped) inserted into the Left forearm

An interview with the VP of Nursing on 6/27/18 at 5:00 PM revealed, "I spoke with the nurse regarding the delay to start the IV. The nurse told me since the patient had no IV med's wasn't in a hurry to get it started. The nurse has been coached."

F. On 6/27/18 at 9:55 AM a tour of the 5th floor was completed. The 5th floor medical/surgical area is divided into:
-AIUE (Adult Inpatient Unit-East) which includes pts with joint replacements, orthopedic and pediatrics. The AIUE has 3 nurses stations that have 1 Unit Clerk to assist with all 3 nurses stations.
-AIUW (Adult Inpatient Unit-West) which includes pts with medical, surgical and oncology needs. The AIUW has 3 nurses stations that have 1 Unit Clerk to assist with all 3 nurses stations.
-THE UNIT CLERK DUTIES INCLUDE ENTERING THE PHYSICIAN ORDERS INTO THE ELECTRONIC MEDICAL RECORD.

G. Review of Facility Policies and Procedures included:
-Policy 4595209 - Provider Orders- Receiving, Clarifying and Reviewing, Last reviewed on 2/2018 included: "Implementation of orders will be in a timely manner with priority given to STAT and NOW orders.;"The nurse who is assigned to the patient is accountable for completion of the orders."; "Transcribing Providers Orders-Written orders are to be transcribed in a timely manner with priority givent to STAT or NOW orders; A licensed nurse will verify the orders by date, time and signature.
-Policy 4513905 - Management of Gastrointestinal Tubes, Enteral Feedings, Rectal Tubes, Last reviewed 1/2018 included: a reference to the "Clinical Key for Nursing-Nasogastric Tube (NG): Insertion, Irrigation, and Removal. This Procedure guide identified expected documentation to include: -Length, size and type of NG tube inserted; Naris (nostril) in which tubed was inserted; length of of tube outside of naris (documented in patient's record or posted in a location easily accessible for ongoing reference); Patient's tolerance of procedure; Confirmation of tube placement; Method used to confirm tube placement; Character of gastric contents and their pH value; Whether NG tube is clamped or connected to drainage or to suction; Amount of suction applied; Amount of gastric aspirate removed; Amount and character of contents draining from NG tube every shift; Removal of intact NG tube; Final amount and character of drainage when NG tube is removed
-Policy 4702294 - Inpatient Admission Assessment and Reassessment, Last reviewed on 3/2018 included: "Admission Assessment Process: initiate the process as soon as possible based on the patient's needs, care and treatment and complete as soon as possible, but no later than 24 hours.

Based on record review, staff interview and review of facility policy and procedures the facility failed to ensure that 3 of 11 sampled patients (Pt's 1, 8 and 11) received timely implementation of the provider's medication admission orders. Pt 11 (admitted directly from a Cardiology Clinic to the Progressive Care Unit) did not have an Intravenous (IV) Line placed until 4 1/2 hours after admission with chest pain, congestive heart failure and shortness of breath; Pt 8 (admitted directly from an outside rural hospital to 5th floor) did not receive an IV line or IV medication until 5 hours after admission with a small bowel obstruction, nausea and vomiting; and Pt 1 (admitted directly from a ENT (Ears, Nose, Throat) Clinic to 5th floor) did not receive an IV line until 2 1/2 hours after admission with a recurrent nose bleed and hemoglobin of 6.5. The failure to implement physician orders has the potential to delay the comfort and care of the patients.

Findings are:

A. A review of Patient 11's medical record revealed the patient was a direct admit to the Progressive Care Unit from a Cardiology Clinic on 6/25/18 at 1528 (3:28 PM) with chest pain, congestive heart failure and shortness of breath. Admission orders were received at 1448 (2:48 PM) prior to the patient's arrival.

A review of the Medical Record for Pt 11 revealed:
-6/25/18 at 1448 (2:48 PM) Physician Order for Saline Lock, Saline Flush now, BID ( two times per day)and PRN (as necessary) per Vascular Access Flushing Guidelines
-6/25/18 at 1528 (3:28 PM) Admitted to Progressive Care Unit directly from physician clinic
-6/25/18 at 2000 (8:00 PM) IV Saline Lock inserted into the Left forearm

An interview with the VP of Nursing on 6/27/18 at 5:00 PM revealed, "I spoke with the nurse regarding the delay to start the IV. The nurse told me since the patient had no IV med's [the nurse] wasn't in a hurry to get it started. The nurse has been coached."

B. A review of Patient 8's medical record revealed the patient was admitted on 6/18/18 at 1130 (11:30 AM) from a rural hospital with nausea, vomiting, abdominal pain and a small bowel obstruction. Admission orders were received at 12:45 PM after the admitting Doctor (Dr) J, completed the History and Physical.

A review of the Medical Record for Pt 8 revealed:
-6/18/18 at 1130 (11:30 AM) Admitted to 5th floor directly from a rural hospital.
-6/18/18 at 1245 (12:45 PM) Physician Order for an IV of Normal Saline (NS) @ 100 cubic centimeters (cc)/hr; Protonix 40 milligrams (mg) IV daily and Rocephin 1 gram (gm) IV daily.
-6/18/18 at 1630 (4:30 PM) IV Protonix 40 mg given at 1630 (4:30 PM) (The medical record did not have documentation of the IV insertion.)
-6/18/18 1553 (3:53 PM) nurses note from RN O revealing, "(Adult Child) called with concerns of orders not being implemented, chart was found by computers in back of nurses station. Order was reviewed and left at Unit Secretary Desk to be entered. 1605 (4:05 PM)- NG placed per order. (Adult Child) notified at 1616 (4:16 PM) that NG was placed. (RN M-5th floor director) called to speak with family and address their concerns."

An interview with RN O on 6/28/18 at 8:45 AM revealed, RN O recalled Pt 8, the patient was admitted to (room number) and "I went in and do everything, but I let the main nurse do the head to toe assessment. I let the main nurse (RN P) know the patient was there and needed to input the assessment. RN P told me 3-4 hours later that (gender) had not seen the orders. When asked what the expectation was when a patient is admitted to the floor, RN O stated, "The nurse needs to be watchful for the chart and checking within the hour, if no orders call the doctor, should have IV, NG etc started."

C. A review of Patient 1's medical record revealed the patient was a 13 year old admitted on 4/19/18 at 1322 (1:22 PM) from the physicians office with a recent recurrent nosebleed.

A review of the Medical Record for Pt 1 revealed:
-4/19/18 the patient was admitted at 1322 (1:22 PM) to 5th Floor.
-4/19/18 at 1500 (3:00 PM) per the Nurses Notes; "NOSE STARTED TO BLEED PROFUSELY FROM NARES AND MOUTH. PT IN BR (BATHROOM) WITH MOM, GAVE CHAIR TO SIT PT DOWN ON. WENT THROUGH MULTIPLE KLEENEX AND BRAWN WIPES. PT GAGGING ON BLOOD AND SPITTING IT OUT. (DR I) NOTIFIED AND COMING UP TO SEE PT. Amount: large, Color: FRANK BLOOD"
-4/19/18 at 1600 (4:00 PM) IV started in right forearm with 20 gauge on 2nd attempt.

An interview with Registered Nurse (RN K) on 6/27/18 at 9:40 AM revealed about Pt 1, "that the patient came in about 1:30 PM and was assigned to another nurse, but went to get things started." RN K indicated that at the time of admission the patient appeared fine and had come from the doctor's office, pt had the nose bleed cauterized and had a small bleed on admission. "The (parent) had told me at the office the hemoglobin was 6." "I was not concerned about pt till bleeding started, bright red blood running out."
D. Policy 4595209 - Provider Orders- Receiving, Clarifying and Reviewing, Last reviewed on 2/2018 included:
-"The nurse who is assigned to the patient is accountable for completion of the orders."
-"Implementation of orders will be in a timely manner with priority given to STAT and NOW orders."
-Transcribing Providers Orders-Written orders are to be transcribed in a timely manner with priority given to STAT or NOW orders; A licensed nurse will verify the orders by date, time and signature.

Based on record review, staff interview and review of facility policy and procedures the facility failed to ensure that the electronic medical record for 3 of 11 sampled patient records (Patients 8, 5 and 3) reflected the time, type and location of the insertion of an IV (intravenous) for 1 patient (Patient 8); reflected the time, type, location and patients tolerance of the insertion and/or removal of an NG (nasogastric) tube and NG suction, description of the amount, color and return of NG fluids for patients (Patients 8, 5 and 3). This failure had the potential to affect the continuation of care while the patient was treated at the hospital.

Findings are:

A. A review of Patient 8's medical record revealed the patient was admitted on 6/18/18 at 1130 (11:30 AM) from a rural hospital with nausea, vomiting, abdominal pain and a small bowel obstruction. Admission orders were received at 12:45 PM after the admitting Doctor (Dr) J, completed the History and Physical.

A review of the Medical Record for Pt 8 revealed:
-6/18/18 at 1130 (11:30 AM) Admitted to 5th floor directly from a rural hospital.
-6/18/18 at 1245 (12:45 PM) Physician Order for an IV of NS (Normal Saline) @ 100 cubic centimeters (cc)/hr; Protonix 40 mg (milligrams) IV daily and Rocephin 1 gm(gram) IV daily.
-6/18/18 at 4:05 PM NG placed
-6/20/18 at 11:45 AM Surgeon progress notes identified "will DC (discontinue) NG"

THE RECORD LACKED DOCUMENTATION OF:
-IV insertion including time, placement, size and fluids initiated.
-NG insertions including time, which nares, size and how patient tolerated procedure, description and amount of fluid returned.
-When NG suction was initiated including what type of suction, consistent documentation of description and amount of fluid returned every shift.
-When NG was removed including time, tube appearance and how patient tolerated procedures.

B. A review of Patient 5's medical record revealed the patient was admitted to 5th floor from the ER on 6/23/18 at 1334 (1:34 PM) with abdominal pain and a possible small bowel obstruction.

A review of the Medical Record for Pt 5 revealed:
-6/23/18 at 1344 (1:44 PM) admit order to go to 5th floor
-6/23/18 at 1334 (1:34 PM) Physician Order for NG tube to Low Intermittent Suction - X ray for placement.
-6/23/18 at 1500 (3:00 PM) ER record reflects Pt 5 delivered to room on 5th floor

THE RECORD LACKED DOCUMENTATION OF:
-NG insertions including time, which nares, size and how patient tolerated procedure, description and amount of fluid returned.
-When NG suction was initiated including what type of suction, consistent documentation of description and amount of fluid returned every shift.

C. A review of Patient 3's medical record revealed the patient was admitted to 5th floor from the ER on 6/24/18 at 0345 (3:45 AM) with nausea, left lower quadrant abdominal pain, a small bowel obstruction and hernia.

A review of the Medical Record for Pt 3 revealed:
-6/23/18 at 2355(11:55 PM) admit to ER
-6/24/18 at 12:30 PM orders received from surgeon for NG LIWS (Low intermittent wall suction) following surgery at 11:00 AM; ice chips ok; KUB ( in am indication-bowel obstruction; activity as tolerated-6/24/18 at 1330 (1:30 PM) returned to room following surgery
-6/24/18 at 1330 (1:30 PM) returned to room following surgery
-6/24/18 at 1530 (3:30 PM) KUB (abbreviation for kidneys, ureters, bladder; is an xray of the abdomen)x 1 now for NG placement
-6/25/18 at 0730 (7:30 AM) surgeon progress note completed, NG canister empty, Remove NG

THE RECORD LACKED DOCUMENTATION OF:
-NG insertions including time, which nares, size and how patient tolerated procedure, description and amount of fluid returned.
-When NG suction was initiated including what type of suction, consistent documentation of description and amount of fluid returned every shift.
-When NG was removed including time, tube appearance and how patient tolerated procedures.

A review of the facility Policy and Procedure's included:
-Policy 4672952 - Documentation of Nursing Care, Last reviewed 4/2018 included: The patient's medical record is a legal document that serves as an important tool to relay complete and accurate patient information in an organized and easily retrievable manner.; Action includes the intervention (activity, medication, consultation etc) and equipment utilized.
-Policy 4513905 - Management of Gastrointestinal Tubes, Enteral Feedings, Rectal Tubes, Last reviewed 1/2018 included: a reference to the "Clinical Key for Nursing-Nasogastric Tube: Insertion, Irrigation, and Removal. This Procedure guide identified expected documentation to include: -Length, size and type of NG tube inserted; Naris (nostril) in which tube was inserted; length of of tube outside of naris (documented in patient's record or posted in a location easily accessible for ongoing reference); Patient's tolerance of procedure; Confirmation of tube placement; Method used to confirm tube placement; Character of gastric contents and their pH value; Whether NG tube is clamped or connected to drainage or to suction; Amount of suction applied; Amount of gastric aspirate removed; Amount and character of contents draining from NG tube every shift; Removal of intact NG tube; Final amount and character of drainage when NG tube is removed.

An interview with RN Q (RN assisting with the electronic medical records) on 6/27/18 at 3:45 PM verified, there was no further information in the patients electronic medical record relating to the insertion or discontinuation of the NG's or IV.