HospitalInspections.org

Based on observation, interview, and policy review, the provider failed to:
*Monitor one of two blanket warmer's temperature.
*Have a preventative maintenance program in place for one of one blanket warmer in the whirlpool room.
Findings include:

1. Observation on 5/30/23 at 2:45 p.m. of the blanket warmer in the whirlpool room revealed:
*One blanket was in the warmer.
*The dial on the warmer had been turned to one hundred fifty degrees Fahrenheit (F).
-The dial also contained a green-colored area for the blanket temperature that stopped at one hundred twenty degrees (F).
*There had not been a thermometer placed in the blanket warmer to accurately measure the temperature in the warmer.
*Summary of instructions posted on the side of the warmer was not to have exceeded the one hundred twenty degrees (F).
*Temperature check of the warmer with the thermometer placed on top of the blanket was one hundred thirty-two degrees (F).
--Ten degrees (F) over recommended temperature.
-Temperature check of the warmer with the thermometer placed inside of the blanket had been one hundred fifty-six degrees (F).
--Thirty-six degrees over the recommended temperature.

Interview on 5/31/23 at 9:00 a.m. with ward clerks (WCs) E and H regarding monitoring the temperature and restocking the whirlpool room blanket warmer revealed:
*They thought that laundry restocked the blanket warmer and maintenance had kept track of the temperature.
*The nursing department had not been monitoring the temperatures in the blanket warmer.

Interview on 5/31/23 at 3:10 p.m. with director of plant operations (DPO) D regarding monitoring the temperature of the blanket warmer in the whirlpool revealed:
*He was not aware that maintenance should have been monitoring the blanket warmer temperatures.
*The blanket warmer was maintained yearly by biomedical services.
*He had been informed by director of nursing (DON) B of the need for a thermometer to have been placed in the warmer to monitor temperatures.

Interview on 5/31/23 at 3:40 p.m. with DON B regarding the monitoring of the temperature for the whirlpool room blanket warmer revealed:
*She had informed DPO D the need for a thermometer for the blanket warmer to monitor the temperatures daily.
*She agreed that the temperature for the whirlpool room blanket warmer was not being monitored.

Review of the provider's May 2023 Blanket Warmer policy revealed:
*"The warmer dial displays the appropriate temperature range."
*"The blanket warmer will be checked daily to observe for the temperature."
*"The ideal temperature of the warmer will be between one hundred and one hundred twenty degrees (F).

Based on record review, interview, and policy review, the provider failed to ensure staff followed blood administration procedures that included the following:
*One of one sampled patients (21) had vital signs (temperature, pulse, and blood pressure) checked more than pre and post- infusion.
*Two of two sampled patients (19 and 21) had dual verification of two nurses signatures prior to a blood transfusions.
*One of One sampled patients (22) had a dual verification signatures prior to the removal of the blood product from the laboratory.
*Two of two sampled patients (19 and 21) had an initial transfusion rate at fifty milliliter (ml) per hour.
*One of one sampled patients (19 ) had an informed consent signed prior to their blood transfusion.
Findings include:

1. Record review of patient 21's electronic medical record (EMR) revealed:
*The patient had received two units of packed red blood cells (PRBC) on 3/2/23.
*The transfusion had begun at 1:47 p.m. started by RN L at a rate of seventy-five ml per hour with the first set of vital signs.
*The first unit of PRBC's completed at 4:45 p.m. with the last set of vital signs had been obtained by RN K.
-No other vital signs had been obtained during the transfusion.
*The second unit PRBC's only had one signature by RN L for verification prior to transfusion.
-The infusion rate for the second unit had been started at one hundred ml per hour by RN K.
-Vital signs had been obtained at 4:45 p.m. and again at 7:34 p.m. by RN M when the PRBC's infusion was completed.
--The second unit of PRBC's had not had dual verification of two nurses prior to the transfusion.

2. Record review of patient 22's EMR revealed:
*He had received one unit of PRBC's on 5/23/23.
*There was no documentation of dual signature verification of the blood product prior to leaving the laboratory for patient infusion.

3. Record review of patient 19's EMR revealed:
*He had received two units of PRBC's on 5/26/23.
*There was no documentation of informed consent for the blood products prior to transfusion.
*His first unit of PRBC's was started at 12:10 p.m. by RN P at a rate of seventy-five ml per hour and was completed at 2:43 p.m.
-The start rate for the transfusion was to be at fifty ml per hour.
*The second unit of packed red blood cell had been started at 2:47 p.m. by RN P.
-There was no documentation of dual signature verification prior to the patient transfusion.

Interview on 6/1/23 at 3:45 p.m. with director of nursing (DON) B regarding record reviews of blood transfusions revealed:
*Her expectation would have been that staff had followed the provider's policy for blood products administration.
*Blood transfusion should have never been started at seventy-five ml per hour.
*The patient's vital signs should have been obtained more than two times during a transfusion.
-Vital signs should have been checked after the first fifteen minutes of the transfusion, then hourly until completed.
*Blood products required dual signature verification prior to the removal from the laboratory and prior to the start of the blood transfusion.
*Informed consent for blood products should have been obtained prior to transfusion.

Review of the provider's January 2023 Blood and Blood Product Administration revealed:
*"Verification by two healthcare members ( one person from lab and one the following RN, licensed practical nurse) is required when blood/blood products are dispensed from laboratory."
*"Verification by two individuals (RN, LPN, or Medical Staff provider) is required prior to administration of blood/blood products."
*"Via infusion pump: Begin at a rate of 50 ml per hour for the first fifteen minutes, if no signs or symptoms of reaction the infusion rate may be increased."
*"Monitor vital signs before starting the transfusion, after first fifteen minutes, then at least hourly during the transfusion, and then when the transfusion is completed.

Based on interview, and job description review, the provider failed to ensure that anesthesia medications for patient conscious sedation procedures had not been administered by one of one paramedic. Findings include:

Interview on 5/30/23 at 7:40 a.m. and again on 6/1/23 at 3:00 p.m. with paramedic G regarding his role during patient conscious sedation procedures revealed:
*He received his paramedic license in 2019.
-During that training he had been trained on sedation.
--Medication administration for rapid sequential intubation which would sedate a patient.
*He would draw up the medication midazolam (Versed) and Fentanyl and then administer those medications to patient's intravenously during the procedure.
*He was usure of how many conscious sedation procedures he had administered those medications.

Telephone interview on 6/1/23 at 3:30 p.m. with South Dakota board of medical and osteopathic examiners J regarding a paramedic's ability to administer conscious sedation medication revealed:
*Administration of conscious sedation medication would not have been within the scope of practice for paramedic G.
*Paramedics would have been able to administer medication for rapid sequence intubation in emergent situations.
*The provider would have been able to petition the board to increase paramedic G's scope of practice.

Interview on 6/1/23 at 4:10 p.m. with medical director C and chief executive officer A regarding paramedic G's scope of practice revealed:
*They had been informed that paramedic G had received training in paramedic school to perform conscious sedation for patients.
*Medical director C had been informed that paramedic G had received a special certification for the administration of conscious sedation medication.
-A request had been made to director of nursing B to review paramedic G's certification.
--No certification was received prior to the exit of the survey.

Review of the provider's paramedic job description revealed:
*To provide quality emergency medical service in a rapid, safe, and effective manner to all patient's requesting care.
*To maintain current certification and/or licensures as required for your level of training.

Based on interview, record review, and policy review, the provider failed to ensure two of two sampled swing bed patients (7 and 8) closed records who required a weekly care conference, had the documentation in their electronic medical record (EMR) to support a care conference was held weekly.
Findings include:

1. Interview and record review on 5/31/23 at 1:00 p.m. with registered nurse (RN) F regarding patient chart reviews of patients (7 and 8) who received swing bed services revealed:
*Patient 7 was admitted on 4/14/23 and discharged on 5/3/23.
*Patient 8 was admitted on 4/13/23 and discharged on 4/25/13.
*RN F was unable to find documentation for weekly care conferences for the above patients.
*She had been employed at the hospital for 25 years and was familiar with the hospital policies and procedures.
*Care conferences were to have been held weekly for every patient who had received swing bed services.
*Nursing staff were responsible to document the care conferences in the EMR.
*The care conference section was a check system.
*A box was to have been checked that the care conference had taken place, checks were then placed next to the interdisciplinary team members that attended the care conference, and there was another area to add notes for updates or changes for the patient.
*It was her expectation and the policy and procedure to document weekly when the care conference had taken place, who had attended the care conference, and note any changes regarding the patient.

Interview on 6/1/23 at 9:23 a.m. with director of nursing (DON) B regarding swing bed care conferences revealed:
*She had overseen the patient swing bed services.
*She thought the care conferences were held weekly on Wednesdays.
*There were no current swing bed patients.
*The nurses should have documented care conferences had taken place for patients 7 and 8.
*She could not confirm that care conferences were held for patients 7 and 8.
*If those patients had care conferences conducted, it should have been documented.
*It was her expectation that the policy would have been followed by the nursing staff.

Interview on 6/1/23 at 9:54 a.m. with RN I regarding swing bed patient care conferences revealed:
*The swing bed patient care conferences were to have been held weekly on Wednesdays.
*The nursing staff were responsible to ensure that the care conferences were documented in the EMR.
*Their computer system included an area to check that the care conference had taken place, who attended, and an area for charting information that was discussed.
*It was their policy and procedure to ensure the care conference information was documented in the patient's EMR.

Interview on 6/1/23 at 3:25 p.m. with chief executive officer A regarding the above findings revealed:
*She was unaware that patients 7 and 8 had missing documentation for their care conferences.
*She had agreed that the expectation for patient care conferences were for nursing staff to have documented in the patient's EMR when it had taken place, who attended, and any noted changes to the patient's care or updates.
*She agreed the hospital nursing staff had not followed the policy and procedure for documentation of weekly patient care conferences.

Review of the provider's January 2023 Swingbed Nursing Services policy revealed:
*"9 c. Care conferences will be attended as appropriate by staff from nursing, nutrition services, pharmacy, therapy (OT, ST, PT), activities, and home health/hospice. Others may also attend as appropriate and may include the physician. Patients and/or family members will be invited to formal care conferences one weekly on Wednesdays or whenever indicated and/or possible."
*"9 g. After care conference has been held documentation will be entered into the Swing bed Care Conference Intervention in (computer application). Care conferences will be scheduled at a Minimum of every 7 days."

Based on record review, interview, and policy review, the provider failed to ensure two of two closed record swing bed patients sampled (7 and 8) had received a notice of Medicare non-coverage within two days of their coverage ending.
Findings include:

1. Review of patient 7's electronic medical record (EMR) revealed:
*She was admitted to skilled swing bed on 4/14/23 due to repeated falls.
*She was discharged on 5/3/23 to her home.
*The notice of Medicare Non-Coverage form had not been found within her EMR.
*There had been no documentation to support that the patient had received the notice or had been advised of her Medicare rights.

2. Review of patient 8's EMR revealed:
*He was admitted to skilled swing bed on 4/13/23 due to a urinary tract infection and repeated falls.
*He was discharged to his home on 4/25/23.
*The notice of Medicare Non-Coverage form had not been found within his EMR.
*There had been no documentation to support that he had received the notice or had been advised of his Medicare rights.

Interview on 6/1/23 at 4:00 p.m. with director of nursing B and RN F regarding the above patient charts revealed:
*They confirmed the Medicare Non-Coverage forms were missing for patients 7 and 8.
*The nursing staff, discharge planners, and the hospital unit clerks were responsible to ensure all required forms were completed for the patients.
*There had been confusion as to who ensured the forms were completed and included in the EMR.
*There was a computer upgrade on 11/1/22.
*When that upgrade had taken place, a new electronic signature system had been started.
*There were challenges with the transfer of the forms with signatures within the EMR.

Interview on 6/1/23 at 3:15 with chief executive officer A regarding patients 7 and 8's EMR chart revealed:
*She had not been aware patients 7 and 8 had not received a Medicare Non-Coverage notification.
*She agreed the forms should have been completed and given to the patients.
*She agreed patients should have been informed of their end date of Medicare covered service.
*The nursing staff, hospital unit clerks, and discharge planners should have followed the policy and procedure.

Review of the provider's May 2022 Hospital Discharge and Medicare Appeal Rights policy revealed:
*"A followup written notice is to be given to the beneficiary prior to discharge. This notice will be given as far in advance of discharge as possible but no more than 2 calendar days before discharge."