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On the days of the recertification survey based on closed patient record reviews, interviews, and review of hospital by-laws, the hospital failed to ensure a history and physical and/or discharge summary was completed on 1 of 10 concurrent patient records reviewed for care and services. (Patient 4)

The findings include:

On 2/19/2014 at 2:00 p.m., review of Patient 4's closed chart revealed there was no history and physical or discharge summary in the chart. On 2/19/2014 at 2:05 p.m., the Health Information Management stated this was a guest services patient and guest services patients do not require a history and physical and/or discharge summary.

Hospital By-laws revealed, "...A complete history and physical examination must be recorded in the chart or dictated within 24 hours after admission of the patient...A licensed physician who is a member of the medical staff shall be responsible for the medical care and treatment of each patient in the hospital, for the prompt completeness and accuracy of the medical record, for necessary special instructions and for the transmission of reports of the condition of the patient...A discharge summary shall be written or dictated within 14 days on all medical records of patients hospitalized over 48 hours...If patient is hospitalized less than 48 hours a detailed progress note is required...In all instances, the content of the medical record shall be sufficient to justify the diagnosis and explain the treatment and end result...".

On the days of the recertification survey based on record review, interview, and review of hospital policy and procedure, the hospital failed to ensure the patient's nursing care plan was individualized, specific, updated, and completed for 1 of 10 concurrent charts reviewed (Patient 9) and 5 of 10 closed patient charts reviewed. (Closed Patient 5, 6, 7, 8, and 10)

The findings include:

On 02/20/2014 at 1:50 p.m., review of concurrent Patient 9's chart revealed there was no current updated nursing care plans. On 02/20/2014 at 2:20 p.m., Registered Nurse(RN) 2 verified the finding.









29886

On 2/20/2014 at 10:30 a.m., review of Patient 5's closed chart revealed the patient was admitted on 11/18/2014 with dizziness, blurred vision, and ataxia. Review of the patient's care plan revealed a non specific pre-printed care plan that did not identify the patient's risk for falls with goals and interventions to prevent falls. On 2/20/2014 at 3:00 p.m., the Chief Nursing Officer (CNO) verified the finding.

On 2/20/2014 at 11:00 a.m., review of Patient 6's closed chart revealed the patient was admitted on 11/17/2014 with alcohol withdrawal. Review of the patient's plan of care revealed a non specific care plan that was pre-printed and did not identify the patient's risk for falls related to impaired gait and ambulation and potential for alcohol withdrawal with goals and interventions to manage the problems. On 2/20/2014 at 3:05 p.m., the CNO verified the findings.

On 2/20/2014 at 1:15 p.m., review of Patient 7's closed chart revealed the patient was admitted on 12/04/2014 with abdominal pain and elevated white blood count, and an elevated Creatinine of 4.9. The patient had a non-specific care plan that was preprinted and with no interventions and goals specific to the patient's admission diagnoses and management of the problems. On 2/20/2014 at 3:10 p.m., the CNO verified the finding.

On 2/20/14 at 1:45 p.m., review of Patient 8's closed chart revealed the patient was admitted on 12/11/2014 with heart failure, elevated blood pressure, 6 liters of oxygen, severe respiratory distress on arrival to hospital, and required a monitored bed. The patient had a non-specific care plan that was preprinted and no goals and interventions specific to the patient's admission diagnoses. On 2/20/2014 at 3:11 p.m., the CNO verified the findings.

On 2/20/2014 at 2:25 p.m., review of Patient 10's closed chart revealed the patient was admitted on 1/11/2014 with abdominal pain following a discharge status post gall bladder removal. Review of the patient's plan of care revealed a pre-printed and non specific care plan unrelated to the patient's admission diagnoses. On 2/20/2014 at 3:15 p.m., the CNO verified the finding.

Hospital policy and procedure, titled, "...Subject: Care plans Amended: 11/2009...Procedure: 2." reads, "All RNs (Registered Nurses) and LPNs (Licensed Practical Nurse) are responsible and accountable for their patients care plans initiation and updates. A RN will review the plans of care at least every 24 hours...".

On the days of the recertification survey based on observations, interview, and review of the hospital policy and procedures, 2 of 2 Registered Nurses(RN 1 and RN 20) failed to correctly administer medications to 2 of 6 patients observed during medication pass. (Patient 4 and 9).

The findings are:

On 02/20/14 at 11:15 a.m., random observations of RN 20 administering medications to Patient (Pt) 4 revealed RN 20 administered the patient's medication without identifying the patient until after the medication administration was completed. On 02/20/14 at 11:18 a.m., RN 20 stated, "I know I did that the wrong way. I remembered to do it after I gave the medication, but I did check it this morning when I first gave medication."






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On 02/20/2014 at 1:50 p.m., review of concurrent Patient 9's Medication Administration Record(MAR) required to be authenticated by the registered nurse or the licensed practical nurse after the administration of the patient's medication revealed that the MAR dated 12/13/2013 had missing nurse signatures for all the medications administered. The MAR dated 12/27/2013 had no nurse signature for "Multi-vitamin". The MARS dated 01/08/2014, 01/14/2014, and 01/25/2014 had no nurse signatures for "Lasix 10 mg (milligrams), Metformin 750 mg, ASA 81 mg, Lanoxin 0.125 mg, Allopurinol 300 mg, and Multi-Vitamin". On 02/20/2014 at 2:20 p.m., Registered Nurse(RN) 2 verified the findings.

Observations of RN 1 administering medications on 02/20/2014 at 9:30 a.m. revealed RN 1 did not perform hand hygiene before administration of medications for Patient 9 whose medications included Lasix 20 mg one-half tablet daily and Allopurinol 300 mg one-half tablet daily. RN 1 cleaned the pill splitting device and then removed the medications from the bottles placing them on the pill splitting device. RN 1 used fingers to adjust both pills in the splitting device without gloves. On 02/20/2014 at 9:50 a.m., the findings were verified with RN 1.

Hospital Policy, titled, "Drug Administration Rules", reads, " ....9. All patient identification and allergy bands will be checked prior to the administration of medications by the administering nurse (against the MAR)....26....A patient safety check is done by comparing the two identifiers (name of patient and the date of birth) found on the name band to the MAR or the label on the product.... " .

On the days of the recertification survey based on patient chart review and interview, the hospital failed to ensure its own staff obtained a physician order prior to completing a treatment performed for 1 of 10 concurrent patient charts reviewed. (Patient 4)

The findings are:

On 02/19/14 at 11:50 a.m., review of Patient 4's chart revealed there was no evidence or documentation of a physician's order for a treatment performed for 15 minutes with "dressing change to two wounds L(left) stump" on 02/18/2014 at 17:02 p.m. by the physical therapist. Staff Member 5 and Staff Member 15 verified the finding on 2/19/14 at 12:00 p.m.. On 2/20/14 at 12:00 p.m., Staff Member 25 revealed that a physician's order for the physical evaluation is completed and after the evaluation is performed, based on the findings and recommendations, the physical therapist communicates the recommendations to the physician and a physician order is obtained for the treatment.

On the days of the recertification survey based on observations, interview, and review of the hospital policy and procedures, the hospital failed to ensure its own staff discarded outdated and mislabeled drugs and biologicals from patient care areas. (Emergency Department, Laboratory, Operating Room 1, and Anesthesia Work Room)

The findings are:


On 02/19/14 at 10:20 a.m., random observations of the Pediatric crash cart in the Emergency Department located in Exam room 4 revealed five (5) expired Broselow Pediatric Emergency System packets. On 2/19/14 at 10:20 a.m., the finding was verified by Staff Member 4.

On 02/19/14 at 10:10 a.m., random observations of the Laboratory department revealed six (6) expired packs of spinal fluid controls dated 12/31/13, two (2) assayed urinalysis controls dated 12/31/13, one (1) vial of Liqui check urine toxicology control level S 2 10 milliliter (ml) dated 01/31/14, and two (2) Redgent Red Blood Cells 10 ml vials dated 01/31/14.

On 02/19/14 at 11:15 a.m., random observations of Operating Room 1 revealed two (2) opened 3 ml syringes, one (1) opened 20 ml syringe, one (1) opened 5 ml syringe and one (1) opened 10 ml syringe all on top of the anesthesia cart. Further observations revealed one (1) opened Phenylephrine 10 mg(milligram)/ml vial, one (1) opened Normal Saline 20 ml vial, one (1) opened Succinylcholine 10 ml multidose vial, and two (2) opened Zemuron 10 mg/ml vials all without date, time, and initials inside the anesthesia cart. The findings were verified by Staff Member 7 on 2/19/14 at 11:15 a.m..

On 02/19/14 at 11:25 a.m., random observations of the Anesthesia Work Room's anesthesia cart revealed one (1) prefilled syringe identified as Ephedrine 5 milligrams per ml (mg/ml) single dose vial dated 02/11/14, one (1) opened Sodium Chloride 0.9%(per cent) 20 ml single dose vial dated 12/11, one (1) opened Metoprolol 5 mg/5 ml single dose vial dated 11/5, six (6) opened 20 ml syringes, and six (6) opened 3 ml syringes. The findings were verified by Staff Member 7 on 2/19/14 at 11:25 a.m..


Hospital Policy, titled, "Outdated Drug Control", reads, " ...Once a month the pharmacy and all areas where drugs are stored in the hospital will be inspected for outdated drugs.... ".

On the days of the recertification survey based on observations and interview, the hospital staff failed to ensure the physical environment to include equipment was maintained in an clean and sanitary condition in the ultrasound room, the emergency room, and nursing unit.


The findings include:

On 02/19/2014 at 10:55 a.m., observations of the ice machine located on the nursing floor revealed a heavy layer of dust buildup behind and beside the ice machine, a patient wheelchair had a layer of dust, weigh scales had a layer of dust build up, and dusty ceiling vents were located in the ultrasound room and emergency exam room 1. On 02/19/2014 at 11:40 a.m., the findings were verified with the hospital's engineer.

On the days of the recertification survey based on observations and interview, the hospital failed to remove expired items from the hospital's code cart.

The findings include:

On 2/20/2014 at 10:30 a.m., observations of the hospitals crash cart located on the second floor revealed the pediatric defibrillator pads had expired 12/2013. On 2/20/2014 at 1035 a.m., Registered Nurse 2 verified the finding.

On the days of the recertification survey based on observations and interviews, the hospital failed to ensure its staff followed accepted infection control procedures for 2 of 2 Registered Nurses(RN) observed performing patient treatments. (RN 1 and RN 2)

The findings include:

On 02/20/2014 at 9:05 a.m., observations of Registered Nurse(RN) 1 administering medication to Patient 8 revealed RN 1 performed hand hygiene for less than 3 seconds after completing the medication administration and leaving the patient's room. Observations of RN 1 administering medications to Patient 9 revealed RN 1 administered the patient's medications but failed to perform hand hygiene after the medication was administered. On 02/20/2014 at 9:50 a.m., the findings were verified with RN 1.

On 02/20/2014 at 10:40 a.m., observation of RN 2 initiating an intravenous line (IV) on Patient 7 revealed RN 2 performed hand hygiene for less than 3 seconds after attempting to start the IV in the patient's right arm. After the second attempt to initiate the IV line, RN 2 performed hand hygiene for less than 3 seconds. RN 2 used an alcohol wipe to clean the site on the patient's arm, and then touched the site area several times without re - cleaning the site with alcohol before inserting the catheter needle into the patient's vein during both attempts to initiate the intravenous line. On 02/20/2014 at 11:15 a.m., the findings were verified with RN 2.





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On 02/19/14 at 10:00 a.m., random observations of the Emergency Department revealed opened suction tubing connected to suction canisters in Exam Room 4. On 02/19/14 at 10:30 a.m., Staff Member 3 revealed, "the tubing do not come in a separate package, it comes already connected to the suction canister".

On 02/19/14 at 11:30 a.m. random observation of the triage procedure revealed that Registered Nurse 1 failed to perform hand hygiene upon exiting and re-entering the triage room. On 02/19/14 at 11:33 a.m. until 12:15 p.m. random observation of the triage procedures revealed that Registered Nurse 1 failed to clean reusable patient equipment including patient chair, pulse ox probe, and oral thermometer between Patient 1 and Patient 2.

Hospital Policy, titled, "Patient Care Areas", reads, " ....II. All equipment which has been in contact with a patient or in their room is considered " dirty " ....A. All reusable equipment will be thoroughly cleaned of gross material with hospital-approved disinfectant before use on another patient.... ".

On the days of the recertification survey based on interview and review of personnel records, the hospital failed to ensure that appropriate patient care staff received training on the Organ Procurement Organization (OPO) services for 8 of 8 personnel charts reviewed. (Staff Member 3, 5, 6, 9, 12, 14, 21, and 22).

The findings are:

On 02/19/14 at 2:45 p.m., Staff Member 7 revealed, "Nurses receive training upon hire on the forms to complete and to call the designated OPO for every death". On 02/21/14 at 11:00 a.m., the hospital had no documentation of in-service or attendance sheets that showed Staff Member 3, 5, 6, 9, 12, 14, 21, and 22 had received the OPO training.

On the days of recertification survey based on interview and review of facility Organ Procurement Organization (OPO) documentation, the hospital failed to show evidence that it works cooperatively with the designated OPO for reviewing of death records.

The findings are:

On 02/19/14 at 3:15 p.m., review of OPO documentation revealed the hospital had no documentation that the hospital participated in the periodic review of the hospital's death records in collaboration with the designated OPO. On 02/19/14 at 4:15 p.m., Staff Member 7 revealed, "no review of death records are performed in cooperation with the designated OPO".

On the days of the recertification survey based on interview, chart review and review of the hospital policy and procedures, the hospital failed to ensure physician orders were authenticated prior to staff performing treatments on 2 of 10 concurrent patient charts reviewed. (Patient 3 and 4).

The findings are:

On 02/19/14 at 2:15 p.m., review of Patient 3's chart revealed a hospital physician order form dated 11/25/13 for " Cardiac Rehabilitation Phase II " that had no physician signature, date, or time. Further review of Patient 3's chart revealed there was no documentation in the chart for the Cardiac Rehabilitation Phase II program. On 02/19/14 at 2:20 p.m., Staff Member 2 stated that the faxed request was never received from the physician with the physician's signature.

On 02/19/14 at 11:50 a.m., review of Patient 4's chart revealed there was no documentation of a physician's order for a therapy treatment performed for 15 minutes ("dressing change to two wounds L(left) stump") on 02/18/2014 at 17:02 p.m. by the physical therapist. Staff Member 5 and Staff Member 15 verified the finding on 2/19/14 at 12:00 p.m.. On 2/20/14 at 12:00 p.m., Staff Member 25 revealed that a physician's order for the physical evaluation is for an evaluation only. After the evaluation is performed, based on the findings and recommendations, the physical therapist communicates the recommendations to the physician and a physician order is obtained for the treatment.

Hospital Policy, titled, "Authentication of Outpatient Orders", reads, "All outpatient tests performed in the clinical area must be accompanied by a physician's order....".

Hospital Policy, titled, "Authentication of All Orders ", reads, " ....All outpatient tests performed in the clinical area must be accompanied by a physician's order. All order written or electronically entered by a physician must be signed, dated, and timed by the ordering physician within 48 hours.... ".

On the days of the recertification survey based on record review, interview, and review of hospital policy and procedure, the hospital failed to ensure the patient's nursing care plan was individualized, specific, updated, and completed for 1 of 10 concurrent charts reviewed (Patient 9) and 5 of 10 closed patient charts reviewed. (Closed Patient 5, 6, 7, 8, and 10)

The findings include:

On 02/20/2014 at 1:50 p.m., review of concurrent Patient 9's chart revealed there was no current updated nursing care plans. On 02/20/2014 at 2:20 p.m., Registered Nurse(RN) 2 verified the finding.









29886

On 2/20/2014 at 10:30 a.m., review of Patient 5's closed chart revealed the patient was admitted on 11/18/2014 with dizziness, blurred vision, and ataxia. Review of the patient's care plan revealed a non specific pre-printed care plan that did not identify the patient's risk for falls with goals and interventions to prevent falls. On 2/20/2014 at 3:00 p.m., the Chief Nursing Officer (CNO) verified the finding.

On 2/20/2014 at 11:00 a.m., review of Patient 6's closed chart revealed the patient was admitted on 11/17/2014 with alcohol withdrawal. Review of the patient's plan of care revealed a non specific care plan that was pre-printed and did not identify the patient's risk for falls related to impaired gait and ambulation and potential for alcohol withdrawal with goals and interventions to manage the problems. On 2/20/2014 at 3:05 p.m., the CNO verified the findings.

On 2/20/2014 at 1:15 p.m., review of Patient 7's closed chart revealed the patient was admitted on 12/04/2014 with abdominal pain and elevated white blood count, and an elevated Creatinine of 4.9. The patient had a non-specific care plan that was preprinted and with no interventions and goals specific to the patient's admission diagnoses and management of the problems. On 2/20/2014 at 3:10 p.m., the CNO verified the finding.

On 2/20/14 at 1:45 p.m., review of Patient 8's closed chart revealed the patient was admitted on 12/11/2014 with heart failure, elevated blood pressure, 6 liters of oxygen, severe respiratory distress on arrival to hospital, and required a monitored bed. The patient had a non-specific care plan that was preprinted and no goals and interventions specific to the patient's admission diagnoses. On 2/20/2014 at 3:11 p.m., the CNO verified the findings.

On 2/20/2014 at 2:25 p.m., review of Patient 10's closed chart revealed the patient was admitted on 1/11/2014 with abdominal pain following a discharge status post gall bladder removal. Review of the patient's plan of care revealed a pre-printed and non specific care plan unrelated to the patient's admission diagnoses. On 2/20/2014 at 3:15 p.m., the CNO verified the finding.

Hospital policy and procedure, titled, "...Subject: Care plans Amended: 11/2009...Procedure: 2." reads, "All RNs (Registered Nurses) and LPNs (Licensed Practical Nurse) are responsible and accountable for their patients care plans initiation and updates. A RN will review the plans of care at least every 24 hours...".

On the days of the recertification survey based on observations, interview, and review of the hospital policy and procedures, 2 of 2 Registered Nurses(RN 1 and RN 20) failed to correctly administer medications to 2 of 6 patients observed during medication pass. (Patient 4 and 9).

The findings are:

On 02/20/14 at 11:15 a.m., random observations of RN 20 administering medications to Patient (Pt) 4 revealed RN 20 administered the patient's medication without identifying the patient until after the medication administration was completed. On 02/20/14 at 11:18 a.m., RN 20 stated, "I know I did that the wrong way. I remembered to do it after I gave the medication, but I did check it this morning when I first gave medication."






25877

On 02/20/2014 at 1:50 p.m., review of concurrent Patient 9's Medication Administration Record(MAR) required to be authenticated by the registered nurse or the licensed practical nurse after the administration of the patient's medication revealed that the MAR dated 12/13/2013 had missing nurse signatures for all the medications administered. The MAR dated 12/27/2013 had no nurse signature for "Multi-vitamin". The MARS dated 01/08/2014, 01/14/2014, and 01/25/2014 had no nurse signatures for "Lasix 10 mg (milligrams), Metformin 750 mg, ASA 81 mg, Lanoxin 0.125 mg, Allopurinol 300 mg, and Multi-Vitamin". On 02/20/2014 at 2:20 p.m., Registered Nurse(RN) 2 verified the findings.

Observations of RN 1 administering medications on 02/20/2014 at 9:30 a.m. revealed RN 1 did not perform hand hygiene before administration of medications for Patient 9 whose medications included Lasix 20 mg one-half tablet daily and Allopurinol 300 mg one-half tablet daily. RN 1 cleaned the pill splitting device and then removed the medications from the bottles placing them on the pill splitting device. RN 1 used fingers to adjust both pills in the splitting device without gloves. On 02/20/2014 at 9:50 a.m., the findings were verified with RN 1.

Hospital Policy, titled, "Drug Administration Rules", reads, " ....9. All patient identification and allergy bands will be checked prior to the administration of medications by the administering nurse (against the MAR)....26....A patient safety check is done by comparing the two identifiers (name of patient and the date of birth) found on the name band to the MAR or the label on the product.... " .

On the days of the recertification survey based on observations and interviews, the hospital failed to ensure its staff followed accepted infection control procedures for 2 of 2 Registered Nurses(RN) observed performing patient treatments. (RN 1 and RN 2)

The findings include:

On 02/20/2014 at 9:05 a.m., observations of Registered Nurse(RN) 1 administering medication to Patient 8 revealed RN 1 performed hand hygiene for less than 3 seconds after completing the medication administration and leaving the patient's room. Observations of RN 1 administering medications to Patient 9 revealed RN 1 administered the patient's medications but failed to perform hand hygiene after the medication was administered. On 02/20/2014 at 9:50 a.m., the findings were verified with RN 1.

On 02/20/2014 at 10:40 a.m., observation of RN 2 initiating an intravenous line (IV) on Patient 7 revealed RN 2 performed hand hygiene for less than 3 seconds after attempting to start the IV in the patient's right arm. After the second attempt to initiate the IV line, RN 2 performed hand hygiene for less than 3 seconds. RN 2 used an alcohol wipe to clean the site on the patient's arm, and then touched the site area several times without re - cleaning the site with alcohol before inserting the catheter needle into the patient's vein during both attempts to initiate the intravenous line. On 02/20/2014 at 11:15 a.m., the findings were verified with RN 2.





31395

On 02/19/14 at 10:00 a.m., random observations of the Emergency Department revealed opened suction tubing connected to suction canisters in Exam Room 4. On 02/19/14 at 10:30 a.m., Staff Member 3 revealed, "the tubing do not come in a separate package, it comes already connected to the suction canister".

On 02/19/14 at 11:30 a.m. random observation of the triage procedure revealed that Registered Nurse 1 failed to perform hand hygiene upon exiting and re-entering the triage room. On 02/19/14 at 11:33 a.m. until 12:15 p.m. random observation of the triage procedures revealed that Registered Nurse 1 failed to clean reusable patient equipment including patient chair, pulse ox probe, and oral thermometer between Patient 1 and Patient 2.

Hospital Policy, titled, "Patient Care Areas", reads, " ....II. All equipment which has been in contact with a patient or in their room is considered " dirty " ....A. All reusable equipment will be thoroughly cleaned of gross material with hospital-approved disinfectant before use on another patient.... ".