HospitalInspections.org

Based on personnel record review, policy review and staff interview, it was determined the hospital failed to ensure documentation of testing and/or questioning for tuberculosis or tuberculosis symptoms, in accordance with standards, for five (5) of 42 personnel records reviewed.


The findings include:


The Department of Behavioral Health, Saint Elizabeth's Hospital Policy Number 515.03, titled, 'Tuberculosis Screening for Employees,' stipulates "Employees/Applicants shall, " ... (2) Obtain TB/PPD test annually during the employee's birth month..."


Personnel record reviews conducted on May 23, 2017 at approximately 11:00 AM lacked documented evidence of completed tuberculosis testing/screening, in accordance with the hospital policy, for Employees #3, 23, 39, 47, and 51.The hospital failed to ensure the testing and/or screening for tuberculosis for the employees.


Employee #16 reviewed, discussed, and acknowledged the findings on May 25, 2017 at approximately 1:45 PM.

Based on record review and staff interviews, it was determined the medical staff failed to ensure that quality care services were provided, as evidenced by lack of follow up for urology consult by staff, in one (1) of one (1) patient record review (Patient #3).


The findings include:


The hospital staff admitted Patient #3 with diagnoses that included Schizoaffective Schizophrenia, and a medical diagnosis of Prostate Cancer.


Review of the medical record conducted on May 22, 2017 at approximately 2:55 PM revealed that Patient #3 was being followed by an Urologist at an outside facility, with the last documented visit on November 15, 2016.


Review of the transfer of care note, documented by Employee #28, dated December 7, 2016 at 2:00 PM, revealed that the Urologist for Patient #3 was no longer seeing patients from the facility. Additionally, the note indicated that Patient #3 would require a follow up appointment with a new Urologist, in February, 2017.


Further review of the record revealed no additional follow up with a Urologist from the date of the last appointment in November 2016, to the date of the record review.


On May 24, 2017 at approximately 12:23 PM, the surveyor conducted a face-to-face interview with Employee #29, regarding Urology follow up for Patient #3. S/he stated that s/he was in constant communication with the Medical Clinic responsible for scheduling follow up appointments, and they were unable to find an Urologist to accept the patient. However, s/he went on to say the patient now has a follow up appointment scheduled.


Additionally, the surveyor conducted a face-to-face interview at approximately 2:00 PM, with Employees #71 and 72, regarding the scheduling of follow up appointments. They explained that appointments are scheduled, when the facility medical staff (for example, physicians and nurse practitioners) give them a referral. According to their records, no referral was received, for follow-up. A follow-up appointment was entered on May 24, 2017 at approximately 12:00 PM.


On the same day at approximately, the surveyor conducted a follow up face-to-face interview with Employees #6 and 8, regarding the findings and oversight for the quality of care provided by the medical staff. Both acknowledged that they have oversight over the medical staff. They acknowledged and confirmed the findings.

Based on data and record review, contract review, and staff interviews, it was determined the Governing Body failed to manage the hospital's services to establish policies to ensure safe and quality care delivery for respiratory services.


The findings include:


During the survey period, May 22, 2017 to May 25, 2017, concerns for the care and delivery of respiratory services were identified, including administration of oxygen, in the absence of orders; and failure to: establish policies and procedures for provisions of respiratory care and services; document all respiratory care services orders; ensure that all documentation and authentication of respiratory treatments, in the electronic medical administration record (eMAR), were performed by the person responsible for administering the treatment; and ensure a system of author identification that ensures the accuracy of the medical record.


On May 23, 2017 at approximately 12:00 PM, during record and contract review of respiratory services, the absence of respiratory services policies and procedures for the provision of services were identified, and Employee
#9 confirmed the absence of policy development for respiratory services. Additionally, the review of the Quality Assurance and Performance Improvement (QAPI) data lacked evidence that QAPI staff measured, analyzed or tracked quality indicators to monitor the effectiveness and safety of the delivery of respiratory services.


On May 23, 2017 at approximately 1:30 PM, the surveyor conducted a face-to-face interview with Employees #8, who confirmed s/he had oversight of respiratory services. In the presence of Employee #9, both employees were asked to provide the documented evidence of policies and procedures for the provision of respiratory care and services provided by the hospital. They could not provide the requested information, and both employees acknowledged that there were no policies for respiratory therapy services. Employee #9 added, "We are working on it."

Based on data and record review, contract review, and staff interviews, it was determined the Governing Body failed to ensure contracted respiratory services are provided in a safe and effective manner.


The findings include:


During the survey period, May 22, 2017 to May 25, 2017, concerns for the care and delivery of respiratory services were identified, including administration of oxygen, in the absence of orders; and failure to: establish policies and procedures for provisions of respiratory care and services; document all respiratory care services orders; ensure that all documentation and authentication of respiratory treatments, in the electronic medical administration record (eMAR), were performed by the person responsible for administering the treatment; and ensure a system of author identification that ensures the accuracy of the medical record.


On May 23, 2017 at approximately 12:00 PM, during record and contract review of respiratory services, the absence of respiratory services policies and procedures for the provision of services were identified, and Employee #9 confirmed the absence of policy development for respiratory services. Additionally, the review of the Quality Assurance and Performance Improvement (QAPI) data lacked evidence that QAPI staff measured, analyzed or tracked quality indicators to monitor the effectiveness and safety of the delivery of respiratory services.


On May 23, 2017 at approximately 1:30 PM, the surveyor conducted a face-to-face interview with Employees #8, who confirmed s/he had oversight of respiratory services. In the presence of Employee #9, both employees were asked to provide the documented evidence of the assessment of respiratory care, services and operations, and policies and procedures for the provision of respiratory care and services that outline quality and safe care delivery. They could not provide the requested information, and both employees acknowledged that there were no policies for respiratory therapy services. Employee #9 added, "We are working on it."

1. Based on medical record review, policy review and staff interviews, it was determined that medical staff failed to write an order for a patient, who was placed in seclusion by staff, for one (1) of 10 patient records reviewed (Patient #17).


The findings include:


The Saint Elizabeth's Hospital policy titled, 'Care of individuals in Seclusion or Restraints for Behavioral Reasons,' revised October 24, 2016 stipulates, " ...V. ORDERS FOR USE OF RESTRAINTS OR SECULSION... 1. Initiation of seclusion or restraint or physical hold requires a psychiatrist order ...A written order authorizing the seclusion or restraint shall be documented by the psychiatrist within one hour of the initiation of the episode ...2. Orders for any type of seclusion or restraint shall not exceed two (2) hours ... "


The hospital staff admitted Patient #17 with diagnoses that included Antisocial Personality.


On May 23, 2017 at approximately 3:45 PM, review of the "Initiation of Seclusion or Restraint: RN [registered nurse] Assessment, dated January 16, 2016 at 3:50 PM, revealed Patient #17 was placed in seclusion for "threatening and violent behavior towards peers or staff ...Dr. [Employee #7 ] spoke to the client after which he/[she] made decision to seclude [him/her]."


Further review of the medical progress note, dated January 16, 2016 at 4:13 PM, revealed the on-call resident was notified by nursing staff, regarding an incident with Patient #17 where, "Dr. [Employee #7] and the writer responded. Patient was placed in seclusion ..."


Ongoing review of the nursing progress note, dated January 16, 2016 at 5:31 PM, revealed Patient #17 was released from seclusion at 4:35PM, "after contracting for safety ..." However, the medical record lacked documented evidence of a physician order for the use of seclusion. The medical staff failed to follow the hospital's policy to obtain an order for the use of seclusion.


The surveyor conducted a face-to-face interview on May 25, 2017 at approximately 9:30 AM, with Employee #7, in the presence of Employee #26. Both employees were asked to provide documentation of the order for seclusion. Neither could provide the seclusion order. Employee #7 explained the process for the use of seclusion and explained the patient was placed in restraints for safety purposes, not seclusion, despite the documentation in the progress notes; however, s/he provided no evidence of this. Employee #26 explained the process for the use of seclusion and added that there was no verbal order or written order for seclusion.



2. Based on medical record review, policy review and staff interviews, it was determined that nursing staff failed to obtain an order for a patient, who was placed in seclusion by staff, for one (1) of 10 patient records reviewed (Patient #17).


The findings include:


The Saint Elizabeth's Hospital policy titled, 'Care of individuals in Seclusion or Restraints for Behavioral Reasons' revised October 24, 2016 stipulates, " ...V. ORDERS FOR USE OF RESTRAINTS OR SECULSION... 1. Initiation of seclusion or restraint or physical hold requires a psychiatrist order ...In emergency situation in which a psychiatrist is not immediately present, an individual may be placed in seclusion or restraint by a RN [registered nurse] before a psychiatrist's order is obtained. In such cases ...the RN shall request a verbal order from the psychiatrist and document the verbal order on the "Psychiatrist's Verbal Order for Seclusion or Restraint" form ...A written order authorizing the seclusion or restraint shall be documented by the psychiatrist within one hour of the initiation of the episode ...2. Orders for any type of seclusion or restraint shall not exceed two (2) hours ..."


The hospital staff admitted Patient #17 with diagnoses that included Antisocial Personality.


On May 23, 2017 at approximately 3:45 PM, review of the "Initiation of Seclusion or Restraint: RN [registered nurse] Assessment, dated January 16, 2016 at 3:50 PM, revealed Patient #17 was placed in seclusion for "threatening and violent behavior towards peers or staff ...Dr. [Employee #7 ] spoke to the client after which he/[she] made decision to seclude [him/her]."


Further review of the medical progress note dated January 16, 2016 at 4:13 PM, revealed the on-call resident was notified by nursing staff, regarding an incident with Patient #17 where, "Dr. [Employee #7] and the writer responded. Patient was placed in seclusion ..."


Ongoing review of the nursing progress note, dated January 16, 2016 at 5:31 PM, revealed Patient #17 was released from seclusion at 4:35PM, "after contracting for safety ..." However, the medical record lacked documented evidence of a physician order for the use of seclusion. The nursing staff failed to follow the hospital's policy to obtain an order for the use of seclusion.


The surveyor conducted a face-to-face interview on May 25, 2017 at approximately 9:30 AM with Employee #7, in the presence of Employee's #26. Both employees were asked to provide documentation of the order for seclusion. Neither could provide the seclusion order. Employee #7 explained the process for the use of seclusion and explained the patient was placed in restraints for safety purposes, not seclusion, despite the documentation in the progress notes; however, s/he provided no evidence of this. Employee #26 explained the process for the use of seclusion and added that there was no verbal order or written order for seclusion.

Based on data and record review, committee meeting minutes, and staff interviews, it was determined the hospital failed to assess processes of care and operations related to respiratory services.


The findings include:


During the survey period, May 22, 2017 to May 25, 2017, concerns for the care and delivery of respiratory services were identified, including administration of oxygen, in the absence of orders; and failure to: establish policies and procedures for provisions of respiratory care and services; document all respiratory care services orders; ensure that all documentation and authentication of respiratory treatments, in the electronic medical administration record (eMAR), were performed by the person responsible for administering the treatment; and ensure a system of author identification that ensures the accuracy of the medical record.


On May 23, 2017 at approximately 12:00 PM, during record and contract review of respiratory services, the absence of respiratory services policies and procedures for the provision of services were identified, and Employee
#9 confirmed the absence of policy development for respiratory services. Additionally, the review of the Quality Assurance and Performance Improvement (QAPI) data lacked evidence that QAPI staff measured, analyzed or tracked quality indicators to monitor the effectiveness and safety of the delivery of respiratory services.


On May 23, 2017 at approximately 1:30 PM, the surveyor conducted a face-to-face interview with Employee #8, who confirmed s/he had oversight of respiratory services. In the presence of Employee #9, both employees were asked to provide the documented evidence of the assessment of respiratory care, services and operations, and policies and procedures for the provision of respiratory care and services provided. They could not provide the requested information, and both employees acknowledged that there were no policies for respiratory therapy services. Employee #9 added, "We are working on it."

Based on quality program review, record review, and staff interview, it was determined the hospital failed to set quality priorities to ensure performance improvement for care areas formerly identified with deficient practices such as glycemic management and respiratory services. These areas were identified with practice deficits during the state licensure survey dated February 26, 2016.


The findings include:


Review of the Quality Assurance and Performance Improvement data for March 2016 through April 2017, on May 25, 2017 at approximately 1:00 PM revealed the hospital failed to recognize, monitor, measure and track care areas formerly identified with deficient practices such as glycemic management and delivery of respiratory services, to ensure safe care delivery and process improvement.


The quality program lacked documented evidence of structural, procedural or process changes to achieve sustainable remediation of repeated deficient practices and care delivery issues. In addition, the program lacked documented evidence of priorities and process improvement activities related to glycemic management and respiratory services.


On May 25, 2017 at approximately 1:00 PM, the surveyor conducted a face-to-face interview with Employee #9 to review the quality program and concerns identified during the survey. The findings were reviewed, discussed, and acknowledged by Employee #9.

1. Based on medical record review, policy review and staff interviews, it was determined the hospital failed to initate a plan of care to address the patient's need for glycemic management, for five (5) of nine (9) patients (Patients # 10, 12, 14, 31 and 60).


The findings include:


A. The physician admitted Patient #10 with diagnoses to include Schizoaffective Disorder, Bipolar Type, and Diabetes Mellitus.


The surveyor conducted a medical record review on May 22, 2017, at approximately 3:15 PM, which revealed physician orders for fingersticks, three (3) times a day, for blood glucose monitoring; and low dose correctional scale insulin coverage with Novolog. The physician ordered Novolog subcutaneous before meals, and the both orders were dated April 10, 2017, at 4:41 PM.


The nursing staff documented the blood glucose results insulin coverage on May 11, 2017, at 4:41 PM, May 12, 2017, at 4:44 PM, May 13, 2017, at 4:55 PM, and May 14, 2017 at 4:46 PM; however, the medical record lacked documented evidence of a nursing care plan to address glycemic management.


Employees #64 and 75 reviewed, discussed, and acknowledged the findings on May 22, 2017, at approximately 4:15 PM.


B. The physician admitted Patient #12 with diagnoses to include Paranoid Schizophrenia, and Diabetes Mellitus.


The surveyor conducted a medical record review on May 22, 2017, at approximately 11:00 AM, which revealed a physician order for fingersticks, three (3) times a day, for blood glucose monitoring. The order dated April 10, 2017, at 12:48 PM, included Novolog insulin, medium dose correctional scale, subcutaneous before meals.


The nursing staff documented the blood glucose levels on May 11, 2017, at 4:36 PM and administered insulin at 6:00 PM; however, the medical record lacked documented evidence of a nursing care plan to address glycemic management.


The surveyor conducted a face-to-face interview with Employees #64 and 75 on May 22, 2017 at approximately 11:30 AM, regarding the finding. Employee #75 acknowledged the finding.


C. The physician admitted Patient #14 with diagnoses to include Paranoid Schizophrenia, Diabetes Mellitus, and Hypothyroidism.


The surveyor conducted a medical record review on May 22, 2017, at approximately 2:30 PM, which revealed physician orders for fingersticks, three (3) times a day for blood glucose monitoring, and low dose correctional scale insulin coverage. The physician ordered Novolog subcutaneous before meals, and the both orders were April 10, 2017.


The nursing staff documented the blood glucose levels and administered insulin on May 12, 2017, at 4:47 PM
May 13, 2017, at 4:46 PM at 6:31 PM, May 14, 2017, at 4:44 PM, and May 20, 2017 at 4:24 PM at 6:30 PM; however, the medical record lacked documented evidence of a nursing care plan to address glycemic management.


Employees #64, 73 and 75 acknowledged the findings on May 22, 2017 at 3:30 PM.


D. The physician admitted Patient #31 with diagnoses of Schizophrenia, Undifferentiated Type, and Diabetes Mellitus.


The surveyor conducted a medical record review on May 24, 2017 at approximately 11:10 AM, which revealed a physician order for fingersticks, twice a day for blood glucose monitoring. The ordered included low dose correctional scale insulin with Novolog, dated September 24, 2016.


The nursing staff documented a blood glucose level on May 18, 2017 at 6:56 AM; however, the medical record lacked documented evidence of a nursing care plan to address glycemic management.


E. The physician admitted Patient #60 with diagnoses to include Schizoaffective Disorder and Diabetes Mellitus.


The surveyor reviewed the medical record on May 24, 2017 at approximately 11:25 AM, which revealed a physician order dated July 14, 2016 for fingersticks, before meals. In addition, the physician ordered low dose correctional scale insulin with meals on April 20, 2017.


The nursing staff documented glucose results; however, the medical record lacked documented evidence of a nursing care plan to address glycemic management.


Employees #73 and 76 on May 24, 2017 at approximately 12:00 PM. Both employees acknowledged the findings.





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2. Based on observation, interview with clinical staff and patient, review of medical records and the hospital's policy, it was determined that the hospital failed to ensure nursing staff developed and followed a current nursing care plan, in accordance with professional standards of practice, relevant to assessment and reassessment of wounds, for one (1) of one (1) medical record (Patient #26).


The findings include:


The Agency for Healthcare Policy and Research (AHCPR) Supported Clinical Practice Guidelines for 1994 recommends to "monitor progress or deterioration of the lesion, the examiner must accurately measure the length, width and depth of the ulcer and describe sinus tracts, tunneling, undermining, necrotic tissue, exudate and the presence or absence of granulation tissue or epithelialization. Reassess pressure ulcers at least weekly..."


The European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel; (EPUAP and NPUAP) Treatment of Pressure Ulcers: Quick Reference Guide for 2009, within the section titled Pressure Ulcer Assessment, Item 3 stipulates "...assess and accurately document physical characteristics such as location, Category/Stage, size, tissue type(s), wound bed and periwound condition, wound edges, sinus tracts, undermining, tunneling, exudates, necrotic tissue, odor, presence/absence of granulating tissue, and epithelialization ... select a uniform consistent method for measuring ... to facilitate meaningful comparisons of wound measurements across time..."


WOCN [Wound, Ostomy, and Continence Nurses] Society Position Statement: Pressure Ulcer Staging dated 1996, reviewed/revised April 2011 stipulates "...Recommendations: 1. Pressure ulcers should be staged according to the NPUAP staging system (NPUAP 2007; NPUAP-EPUAP, 2009). 2. Staging of Healing Pressure Ulcers: The staging system, as recommended by the NPUAP and WOCN, does not support down-staging or reverse staging of granulating pressure ulcers..."


WOCN Society Document amount - Describe in % [percentage] (example: 50% wound bed covered with soft yellow slough, 50% beefy red granulation tissue) May also use "clock system" in describing location of necrotic tissue in wound bed. Tissue Types - Slough - usually lighter in color, thinner and stringy in consistency; Color - Can be yellow, gray, white, green, brown - Eschar - usually darker in color, thicker and hard consistency black or brown in color. - Granulation Tissue - it is usually beefy red, granular, bubbly in appearance; should be differentiated from a smooth red wound bed; color of tissue - red, pink, pale pink or full dusky red - Epithelialization - can appear as deep pink, then progress to pearly pink/ light purple from the edges in full thickness wound or may form islands in the wound base with superficial wounds ..."


The hospital re-admitted Patient #26, following inpatient hospitalization at an outside acute care facility with diagnoses including Major Depression, Depression, Diabetes Mellitus, Altered Mental Status, Morbid Obesity and an outside acquired Stage 3, Sacral Wound.


On May 24, 2017 at approximately 11:15 AM, the surveyor conducted a face-to-face interview with Patient #26, in the presence of Employee #64. In response to the surveyor's query regarding the status of his/her wellbeing, the patient responded preparing for discharge. In response to the surveyor's query regarding the status of the wound, the patient reported that it healed and readily agreed to grant permission to the surveyor to view the affected area.
The surveyor observed a closed scarred area around the patient's sacrum and the inner aspect of the both gluteal regions. The surveyor's observation of the complete affected area was limited, due to the patient's size and standing position.


A review of the medical record on May 24, 2017 at approximately 11:35 AM revealed a 'Discharge/ Transfer Summary' report from the acute care facility dated January 6, 2017. The report described one (1) skin break " ...Sacral wound with superficial necrotic tissue, Stage 3-4 ..."


i. The 'RN [Registered Nurse] Return Form' dated January 6, 2017 at 7:46 PM reflected the nurse recorded the following initial wound assessment: "4 Stage full thickness Coccyx Right Gluteus wound ...measuring 6 cm [centimeters] x 8 cm x 4 cm ...The wound bed is beefy red, clean, with minimal drainage and no odor ..."


The nurse identified and recorded the initial assessment of a second wound, located at the Left Gluteal muscle: " ...measuring 0.5 cm [centimeters] x 0.5 cm ..."


The medical record reflected conflicting assessments; the discharging facility identified one (1) wound, while the nursing readmission Initial assessment identified two (2) wounds on the same day.


The nurse recorded incomplete wound assessments which did not include the cause or type of wound, the presence or absence of tunneling or undermining, edema, or the color of wound drainage, description of surrounding skin; color, amount and consistency of wound drainage; and consistent three (3) dimensional measurements including length, width, and depth for each wound.


Having identified more than one wound, the nurse did not label the wounds to differentiate between sites or describe their location, relative to specific anatomical landmarks. Additionally, the nurse did not consistently assess and document the appearance of the wound beds.


Review of General Medical Officer's Note titled, 'Readmission Note' dated and timed January 6, 2017 at 9:36 PM reflected the physician recorded the following: " ...a pressure sore on the buttocks ...Buttocks pressure ulcer Stage III, pink granulation tissue without exudate. It extends from the mid right buttock across the midline over inferior sacrum, 2 cm [centimeters deep] ..."


According to NPUAP and WOCN Society, the practice of downstaging pressure ulcers is not supported.


A follow-up General Medical Officer's Note dated and timed January 7, 2017 at 10:48 AM reflected the physician recorded the following: " ...Sacral wound is 8 cm more than in right side, clean, no exudate and red ..."


ii. Review of the nursing staff wound assessments dated February 14, 2017 at 5:14 AM reflected the following: Wound #1, Pressure Ulcer, three (3) dimensional measurements; 5.50 x 4.0 x 3.00 centimeters; described the type of wound bed tissue; granulating, red and filled with epithelializing and granulating tissue, low exudate noted on removed dressing; peri-wound skin is healthy, wound edge is healthy.


Wound #2, dated February 14, 2017 at 5:14 AM reflected the following: Wound Location #1, Pressure Ulcer, three (3) dimensional measurements; 1.00 x 0.40 x 0.00 centimeters; described the type of wound bed tissue; epithelializing. The nurse placed an "x" in the box corresponding with "N/A" [Not Applicable] for Wound Exudate, described the peri-wound skin as healthy, and noted the wound edge is healthy.


Earlier recorded wound assessments did not include numbering of two (2) identified wound locations, and did not include evaluation of epithelialization and granulating tissue.


The nurse recorded inconsistent and incomplete wound assessments, which did not include the Stage or category of the Pressure ulcers, the anatomical locations of both wounds, the presence or absence of tunneling or undermining, presence or absence of edema, or the color of wound drainage on the removed dressing. There was no evidence that staff sought clarification from the physician relative to the stage of the pressure ulcers.


iii. Review of the nursing staff wound assessments dated February 20, 2017 at 4:50 AM reflected the following: " ...Wound Location #2, Pressure Ulcer, three (3) dimensional measurements; 3.0 x 2.50 x 0.20 centimeters. In the section of the assessment, 'Describe Length Width and Depth of wound', the nurse recorded: " ...Right Sacral wound, 3 cm x 2.2 cm x 0.2 cm ..."


The assessment included the description of the type of wound bed tissue; "Granulating", and did not include or record Wound Exudate.


In the free text section of the same assessment note dated February 20, 2017 at 4:50 AM, the nurse entered: " ...Wound Measures 3.0 x 2.50 x 0.20 cm. Wound Bed is Granulating (red). Small amount of serosanguinous drainage noted on old dressing. Wound edge well approximated. No signs and symptoms of infection."


The nursing documentation of the Right Sacral wound, identified as Location #2, included conflicting measurements for the same date and time within the same note.


The second wound, identified also as Location #2, dated February 20, 2017 at 4:50 AM reflected the following: "Wound Location #2, Pressure Ulcer, no measurements."


In the section of the assessment, 'Describe Length Width and Depth of wound', the nurse recorded: " ...Left wound resolved ..."


The nurse recorded assessments identifying both wound locations as Wound #2, and did not record other characteristics of a comprehensive wound assessment, including identification of the anatomical location of the second wound.


Nursing Staff failed to initiate a plan of care to include accurate assessment and reassessment of the patient's wound care needs.


During a follow-up review of the medical record with Employee # 18 on May 25, 2017 at approximately 9:27 AM, the surveyor conducted a face-to-face interview regarding the findings.


Employee #18 reviewed and acknowledged the findings.





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3. Based on medical record review and staff interview, it was determined the hospital failed to clarify physician orders to include oxygen saturation parameters, in order to develop a care plan to meet the needs of the patient, for one (1) of one (1) patient (Patient #1).


The findings include:


The hospital staff admitted Patient #1 with diagnoses that included Schizoaffective Disorder and Bipolar Disorder, and past medical history of Pneumothorax and Pleural Effusion.


Review of the medical record conducted on May 22, 2017 at 1:55 PM revealed a physician order, dated May 8, 2017 at 1:32 PM, for oxygen saturation to be included with the vital signs.


A review of vital signs from May 15 to 22, 2017 revealed the patient's average oxygen saturation was 96 percent. Patient #1's oxygen saturation on May 20 at 9:45 AM, May 21 at 9:35 AM, and May 22 at 8:25 AM decreased to 90 percent; and on May 21 at 8:07 PM, 91 percent. Review of the nursing notes revealed no documentation to address the decrease in oxygen saturation.


The nursing staff did not clarify the physician order to include parameters for notification or intervention for oxygen saturation to initiate a plan of care specific to the patient's needs.


On May 22, 2017 at approximately 2:15 PM, the surveyor conducted a face-to-face interview, with Employee #59, regarding assessment, intervention, and notification of the physician for the oxygen saturation levels, for Patient #1. S/he stated the nurses know to call the physician, when the patient has a "low" oxygen saturation. When asked what was considered a "low" oxygen saturation, s/he could offer no consistent percentage. Employees #57, 58, and 59 acknowledged the findings.


4. Based on medical record review and staff interview, it was determined that the nursing staff failed to assess and reassess the patient, when administering as needed (PRN) medications, to include justification for medication administration, relative to the plan of care, in one (1) of one (1) record reviewed (Patient
#34).


The findings include:


The hospital staff admitted Patient #34 with diagnoses that included Bipolar Disorder, and a past medical history of Asthma.


Review of the medical record conducted on May 23, 2017 at approximately 3:30 PM, revealed a physician order dated, April 21, 2017 at 12:34 PM, for an Albuterol Sulfate Inhaler, 90 micrograms (mcg), four (4) times a day, as needed.


Review of the Electronic Medication Administration Record (e-MAR) revealed the medication was administered to the patient on the following dates at the following times: May 13, 2017 at 6:09 AM; May 15, 2017 at 3:28 AM; May 17, 2017 at 8:14 PM; May 19, 2017 at 9:05 PM; May 20, 2017 at 2:07 PM; May 21, 2017 at 9:10 PM; May 22, 2017 at 6:38 AM; and May 23, 2017 at 9:18 PM. However, review of the nursing notes lacked evidence of assessments, consistent with the administration of PRN medications, on the aforementioned days.


Nursing staff failed to assess and reassess Patient #34 to justify the need for the medication intervention.


On May 23, 2017 at 3:40 PM, the surveyor conducted a face-to-face interview with Employees #69 and 70. Both acknowledged the findings.


5. Based on medical record review and staff interviews, it was determined that the hospital staff inconsistently performed assessments and/or failed to verify/clarify significant changes, in one (1) of one (1) medical record (Patient #9).


The findings include:


Patient #9's medical record reflected re-admission to the hospital on May 22, 2017 with new diagnoses and newly prescribed medications for treatment of the following heart and circulatory related conditions including Supraventricular Tachycardia, Atrial Flutter, and Deep Vein Thrombosis.


A review of the medical record on May 23, 2017 at approximately 10:55 AM revealed a Radiology Report from an acute care facility. The report reflected on May 19, 2017 the patient received Placement IVC (Inferior vena cava) Filter through the Right Femoral Vein; treatment for diagnosis of Lower Extremity DVT (Deep Vein Thrombosis).


Patient #9's discharge prescribed treatment for the aforementioned diagnoses included Amiodarone for Irregular Heartbeat and Levetiracetam for Seizures.


The medical record lacked documented evidence of an initial nursing care plan or IRP which addressed the patient's medical needs, relevant to the aforementioned newly identified conditions including: monitoring for symptoms of Deep Vein Thrombosis, interventions to avoid the development of additional clots, Supraventricular Tachycardia and administration of Amiodarone and Levetiracetam.


Additionally, the medical record lacked documented evidence physician's orders, reports of treatment, radiology and laboratory reports, and vital signs and other information necessary to monitor the patient's condition.


During the medical record review on May 23, 2017 at approximately 3:00 PM, the surveyor conducted a face-to-face interview with Employees #59 and 60, in the presence of Employee #2. They acknowledged the findings.

Based on medical record review, policy review, and staff interview, it was determined the nursing staff failed to ensure nursing care assignments were appropriately delegated to nursing staff, who was re-assigned from another patient unit, to meet the patient's needs.


The findings include:


Saint Elizabeth's Hospital policy number 107.05, entitled, 'Hand-Off Communication Guidelines,' revised January 14, 2015 stipulates, "A. General Standards 1. Any hand-off communication shall include information regarding the care, treatment, service, condition, and any recent or anticipated changes in individuals in care ...2. A handoff communication shall occur at each of the following times ...d. Nursing shift change B. Department Specific Guidelines 1. Nursing ...a. All oncoming RN's [Registered Nurses], Recovery Assistance and the off-going charge nurse shall attend shift report and shall use the change of shift procedures to ensure communication is thorough and accurate ..."


Saint Elizabeth's Hospital policy number 302.5-10, entitled, 'High-Risk Indicator Tracking and Review' revised May 13, 2014 stipulates, "Appendix B: Medical High Risk List ...1.Choking Aspiration ...3. Falls 4.Seizure ..."


On May 22, 2017 at approximately 10:30 AM, the surveyor conducted a tour of Unit 1A, in the presence of Employees #57, 58, and 59. When asked about the staffing on unit 1A for the day shift, Employee #59 explained there were three (3) nurses working, with a census of 25 patients. S/he went on to say that one nurse was administering medications, one nurse was providing treatment (for example, finger-stick blood glucose management), and one nurse was assigned team lead. The treatment and team lead nurses, also had a patient assignments.


On May 22, 2017 at approximately 10:40 AM, the surveyor conducted a face-to-face interview with Employee #61, regarding his/her nursing responsibilities on the unit, for the day. S/he stated s/he was floated from another unit, at the beginning of the shift [7:00 AM], to perform treatments. When queried about his/her patient assignment, s/he stated s/he was unaware that s/he was responsible for patients. Employee #61 stated that s/he received no patient report at the beginning of the shift.


A review of the Unit 1A day shift assignment sheet for May 22, 2017, revealed Employee #61 was assigned to the care of 10 patients. Three (3) patients were high risk falls, and one (1) patient was a high risk choking hazard.


During a subsequent interview with Employee #61 on May 22, 2017 at 12:00 PM, regarding the patient assignment, Employee #61 stated that s/he was still unaware of his/her patient assignment.


The nursing staff failed to ensure that handoff communication was performed to properly delegate nursing responsibilities to meet the patient's needs. Employees #57, 58, and 59 acknowledged the aforementioned findings.

Based on medical record review, policy review, and staff interview, it was determined that the nursing staff failed to provide necessary care and treatment, as evidence by failure to follow physicians' orders and hospital policy, relative to glycemic management, in five (5) of nine (9) records reviewed (Patients
#10, 12, 14, 31 and 60). This finding was previously identified in February 26, 2016, during the state licensure survey.


The findings include:


Saint Elizabeths Hospital policy number NPM 3-10, titled, 'Blood Glucose Monitoring', section one (1) Policy- stipulates, " ...Only registered nurse (RN) that have been trained will be authorized to use the blood glucose meter ...the results of the glucose testing will be documented in the AVATAR system ... ... IV. Documentation Requirements A. e-MAR; B. e-MAR notes-if notification of physician is necessary ..."


Saint Elizabeths Hospital policy number NPM 3-14.1, revised January 13, 2013, titled, "Insulin Administration" section (3) -H and I stipulates, "Insulin must be given within an hour of blood glucose monitor results ...I. Insulin must be given before meals (AC) and at bedtime (HS) only -except in emergencies ..."


A. The physician admitted Patient #10 with diagnoses to include Schizoaffective Disorder, Bipolar Type, and Diabetes Mellitus.


The surveyor conducted a medical record review on May 22, 2017, at approximately 3:15 PM, which revealed physician orders for fingersticks, three (3) times a day, for blood glucose monitoring; and low dose correctional scale insulin coverage with Novolog. The physician ordered Novolog subcutaneous before meals, and the both orders were dated April 10, 2017, at 4:41 PM.


The physician ordered the low dose correctional scale insulin coverage as follows:
180- 199 milligrams per deciliter (mg/dL) give one (1) unit; 200- 249 mg/dL give two (2) units;
250- 299 mg/dL, give three (3) units; 300- 349 mg/dL give four (4) units; and 350 mg/dL give five (5) units, and notify the General Medical Officer (GMO) or Nurse Practitioner (NP).


The nursing staff documented the following blood glucose results, with corresponding insulin coverage on the following dates at times:

May 11, 2017, at 4:41 PM blood glucose results 248 mg/dL, two (2) units of insulin given at 6:21 PM, one (1) hour and 40 minutes after the blood glucose result.

May 12, 2017, at 4:44 PM blood glucose 244 mg/dl, two (2) units of insulin given at 6:17 PM, 1 hour and 33 minutes after the blood glucose result.

May 13, 2017, at 4:55 PM blood glucose 252 mg/dL, three (3) units of insulin given at 6:29 PM, 1 hour and 34 minutes after the blood glucose result.

May 14, 2017 at 4:46 PM blood glucose 286 mg/dL, three (3) units of insulin given, 1 hour and 37 minutes after the blood glucose result;


The nursing staff documented the insulin administration greater than one (1) hour, after the blood glucose results.


The medical record lacked documented evidence that nursing staff administered the insulin, according to the hospital's policy.


The nursing staff failed to provide the care and necessary treatment to administer insulin with timeliness to reduce the episode of elevated blood glucose.


Employees #64 and 75 reviewed, discussed, and acknowledged the findings on May 22, 2017, at approximately 4:15 PM.


B. The physician admitted Patient #12 with diagnoses to include Paranoid Schizophrenia, and Diabetes Mellitus.


The surveyor conducted a medical record review on May 22, 2017, at approximately 11:00 AM, which revealed a physician order for fingersticks, three (3) times a day, for blood glucose monitoring. The order dated April 10, 2017, at 12:48 PM, included Novolog insulin, medium dose correctional scale, subcutaneous before meals.


The physician ordered the medium dose correctional insulin scale as follows: 180- 199 milligrams per deciliter (mg/dL) give one (1) unit; 200- 249 mg/dL give three (3) units; 250- 299 mg/dL give five (5) units; 300- 349 mg/dL give seven (7) units; and if greater than 350 mg/dL, give nine (9) units and notify the General Medical Officer (GMO) or Nurse Practitioner (NP).


The nursing staff documented the blood glucose levels as 243 mg/dL, on May 11, 2017, at 4:36 PM. The nursing staff administered three (3) units of insulin at 6:00 PM; however, the nursing staff administered the insulin one (1) hour and 24 minutes, after the blood glucose result.


The medical record lacked documented evidence that nursing staff administered the insulin, according to the hospital's policy.


The nursing staff failed to provide the care and necessary treatment to administer insulin with timeliness to reduce the episode of elevated blood glucose.


Further review of the blood glucose levels revealed the nursing staff administered insulin coverage greater than one (1) hour on the following dates and times: May 12, 2017, at 4:44 PM, blood glucose 182 mg/dL, 1 unit of insulin given at 6:13 PM; May 13, 2017, at 4:46 PM blood glucose 306 mg/dL, 7 units of insulin given at 6:33 PM; May 14, 2017, at 4:33 PM blood glucose 224 mg/dL, 3 units of insulin given at 6:41 PM; May 17, 2017, at 4:46 PM blood glucose 263 mg/dL, 5 units of insulin given at 6:03 PM; May 18, 2017, at 4:34 PM blood glucose 221 mg/dL, 3 units of insulin given at 6:04 PM and May 21, 2017, at 4:50 PM blood glucose 263 mg/dL, 5 units of insulin given at 6:12 PM.


The nursing staff documented insulin administration 1 hour (hr) and 29 minutes (min) after the blood glucose result on May 12, 2017; 1 hour and 47 minutes after the blood glucose result on May 13, 2017; 2 hours and 8 minutes after the blood glucose result on May 14, 2017; 1 hour and 17 minutes after the blood glucose result on May 17, 2017; 1 hour and 30 minutes after the blood glucose resulton May 18, 2017; and 1 hour and 22 minutes after the blood glucose result on May 21, 2017.


The nursing staff failed to provide the care and necessary treatment timely to reduce the episode of elevated blood glucose.


The surveyor conducted a face-to-face interview with Employees #64 and 75 on May 22, 2017 at approximately 11:30 AM, regarding the insulin administration. Employee #75 said the nursing staff gives the insulin when the food trays arrive.


Employees #64 and 75 reviewed, discussed, and acknowledged the findings on May 22, 2017, at approximately 11:30 AM.


C. The physician admitted Patient #14 with diagnoses to include Paranoid Schizophrenia, Diabetes Mellitus, and Hypothyroidism.


The surveyor conducted a medical record review on May 22, 2017, at approximately 2:30 PM, which revealed physician orders for fingersticks, three (3) times a day for blood glucose monitoring, and low dose correctional scale insulin coverage. The physician ordered Novolog subcutaneous before meals, and the both orders were April 10, 2017.


The physician ordered the low dose correctional scale insulin coverage as follows:
180- 199 milligrams per deciliter (mg/dL), give one (1) unit; 200- 249 mg/dL, give two (2) units;
250- 299 mg/dL, give three (3) units; 300- 349 mg/dL, give four (4) units; and 350 mg/dL, give five (5) units and notify the General Medical Officer (GMO) or Nurse Practitioner (NP).


Patient #14's blood glucose results and insulin coverage were as follows:

May 12, 2017, at 4:47 PM, 275 mg/d/L, three (3) units of insulin were given at 6:14 PM (1 hour and 27 minutes after glucose results).

May 13, 2017, at 4:46 PM, 252 mg/dL, three (3) units of insulin were given at 6:31 PM (1 hour and 45 minutes after glucose results).

May 14, 2017, at 4:44 PM, 301 mg/dL, four (4) units of insulin were given at 6:18 PM (1 hour and 34 minutes after glucose results).

May 20, 2017 at 4:24 PM, 216 mg/dL, two (2) units of insulin were given at 6:30 PM (2 hours and 6 minutes after glucose results).


The medical record lacked documented evidence that nursing staff administered the insulin, according to the hospital's policy.


The nursing staff failed to provide the care and necessary treatment to administer insulin with timeliness to reduce the episode of elevated blood glucose.


Employees #64, 73 and 75 acknowledged the findings on May 22, 2017 at 3:30 PM.


D. The physician admitted Patient #31 with diagnoses of Schizophrenia, Undifferentiated Type, and Diabetes Mellitus.


The surveyor conducted a medical record review on May 24, 2017 at approximately 11:10 AM, which revealed a physician order for fingersticks, twice a day for blood glucose monitoring. The ordered included low dose correctional scale insulin with Novolog, dated September 24, 2016.


The physician ordered the low dose correctional scale insulin coverage as follows:
180- 199 milligrams per deciliter (mg/dL), give one (1) unit; 200- 249 mg/dL, give two (2) units;
250- 299 mg/dL, give three (3) units; 300- 349 mg/dL, give four (4) units; and 350 mg/dL, give five (5) units and notify the General Medical Officer (GMO) or Nurse Practitioner (NP).


The surveyor reviewed blood glucose monitoring from May 15 through May 23, 2017. The nursing staff documented a blood glucose of 202 mg/dL on May 18, 2017 at 6:56 AM. The medical record lacked documented evidence that the nursing staff administered two (2) units of insulin, per physician's order.


Further review of the medical record revealed, on May 21, 2017, at approximately 6:57 AM, the nursing staff failed to document blood glucose results. Employees #73 and 76 reviewed the medical record, in the presence of the surveyor and acknowledged the finding.


The nursing staff failed to provide the care and necessary treatment to administer insulin, as per physician order, to reduce the episode of elevated blood glucose.


Employees #73 and 76 acknowledged the findings on May 24, 2017 at approximately 12:00 PM.


E. The physician admitted Patient #60 with diagnoses to include Schizoaffective Disorder and Diabetes Mellitus.


The surveyor reviewed the medical record on May 24, 2017 at approximately 11:25 AM, which revealed a physician order dated July 14, 2016 for fingersticks, before meals. In addition, the physician ordered low dose correctional scale insulin with meals on April 20, 2017.


The physician ordered the low dose correctional scale insulin coverage as follows:
180- 199 milligrams per deciliter (mg/dL), give one (1) unit; 200- 249 mg/dL, give two (2) units;
250- 299 mg/dL, give three (3) units; 300- 349 mg/dL, give four (4) units; and 350 mg/dL, give five (5) units and notify the General Medical Officer (GMO) or Nurse Practitioner (NP).


The surveyor reviewed glucose results on May 15, 2017 through May 22, 2017. On May 15, 2017, at 11:29 AM, the medical record lacked documented evidence that a fingerstick was completed. The nursing staff documented a time without a glucose result.


Further review of the medical record on May 17, 2017, at 5:12 PM revealed the nursing staff documented glucose results of 186 mg/dL. However, the medical record lacked documented evidence the nursing administered the insulin coverage of one (1) unit, as ordered by the physician.


The nursing staff failed to follow the physician orders and provide necessary care and treatment for Patient #60, relative to glucose monitoring and insulin administration.


The surveyor discussed the findings with Employees #73 and 76 on May 24, 2017 at approximately 12:00 PM. Both employees acknowledged the findings.



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2. Based on medical record review and staff interview, it was determined the nursing staff failed to assess and monitor patients that received as needed (PRN) medication, in one (1) of two (2) patient records reviewed (Patient 34).

The findings include:


The hospital staff admitted Patient #34 with diagnoses that included Bipolar Disorder, and a past medical history of Asthma.


Review of the medical record conducted on May 23, 2017 at approximately 3:30 PM, revealed a physician order dated, April 21, 2017 at 12:34 PM, for an Albuterol Sulfate Inhaler, 90 micrograms (mcg), four (4) times a day, as needed.


Review of the Electronic Medication Administration Record (e-MAR) revealed the medication was administered to the patient on the following dates at the following times: May 13, 2017 at 6:09 AM; May 15, 2017 at 3:28 AM; May 17, 2017 at 8:14 PM; May 19, 2017 at 9:05 PM; May 20, 2017 at 2:07 PM; May 21, 2017 at 9:10 PM; May 22, 2017 at 6:38 AM; and May 23, 2017 at 9:18 PM. However, review of the nursing notes lacked evidence of assessments, consistent with the administration of PRN medications, on the aforementioned days.



Nursing staff failed to assess and reassess Patient #34, to monitor the patient's status and effectiveness of care.


On May 23, 2017 at 3:40 PM, the surveyor conducted a face-to-face interview with Employees #69 and 70. Both acknowledged the findings.


2. Based on medical record review and staff interview, it was determined the nursing staff failed to administer medication, in accordance with physician orders, for one (1) of one (1) patient record reviewed (Patient #3).


The findings include:


The hospital staff admitted Patient #3 with diagnoses that included Schizoaffective Schizophrenia, and a medical diagnosis of Prostate Cancer.


Review of the medical record conducted on May 22, 2017 at approximately 2:55 PM revealed a physician order dated April 10, 2017 at 8:10 AM, for Casodex 50 milligrams (mg), once a day, to be started, after a Prostate-Specific Antigen (PSA) level was drawn. Additionally, physician orders included PSA levels to be drawn on April 19, 2017 at 1:53 PM and on April 20, 2017 at 2:55 PM.


Further review of the record revealed that a PSA level was drawn on April 21, 2017 at 5:40 AM. The result was reported on April 23, 2017 at 8:26 AM.


Review of the Electronic Medical Record (e-MAR) revealed that Patient #3 received Casodex everyday beginning April 10, 2017, the initial order date to April 21, 2017, when the labs were drawn. However, the record lacked documented evidence that staff obtained the ordered lab work, prior to medication administration.


Nursing staff failed to follow physician orders in the administration of a medication that required recent lab work prior to administration.


The surveyor conducted a face-to-face interview on May 22, 2017 at approximately 3:30 PM, with Employees #57, 58, and 59. They acknowledged and confirmed the aforementioned findings.

Based on record review and staff interviews, it was determined the hospital staff failed to ensure a system of author identification that ensures the accuracy of the medical record, in two (2) of nine (9) records (Patients #4 and 34).


The findings include:


A. The hospital staff admitted Patient #4 with diagnoses that included Bipolar Disorder, and a past medical history of Chronic Obstructive Pulmonary Disease.


A review of the medical record conducted on May 23, 2017 at approximately 10:50 AM revealed a physician order, dated April 10, 2017 at 10:08 AM, for Albuterol nebulizer treatment, 2.5 milligrams (mg), twice a day.


Review of the Electronic Medication Administration Record (e-MAR) revealed the patient received nebulizer treatments on the following dates, at the following times: May 20, 2017 at 9:25 AM and at 1:35 PM, May 21, 2017 at 1:30 PM, May 22, 2017 at 8:25 AM, and May 23, 2017 at 8:30 AM and at 2:15 PM.


The signatures of the respiratory therapy staff who administered the nebulizer treatments are listed at the bottom of the e-MAR; however, in the section titled, "Administration Event," the selection indicates, "Nurse Administered Voluntarily."


The surveyor conducted a face-to-face interview on May 23, 2017 at approximately 11:15 AM, with Employee #48, regarding the documentation of the administration of respiratory treatments, performed by respiratory therapy staff. S/he stated that there are no options in the "Administration Event" to identify that the medication is administered by Respiratory Therapy staff.


Hospital staff failed to ensure a system of author identification that allowed Respiratory Therapy staff to appropriately identify the discipline, who administered the medication, to ensure accuracy of the medical record.


The surveyor conducted a face-to-face interview on May 23, 2017 at approximately 11:30 AM, with Employees #8 and 41. They acknowledged the aforementioned findings.


B. The hospital staff admitted Patient #34 with diagnoses that included Bipolar Disorder, and a past medical history of Asthma.


A review of the medical record conducted on May 23, 2017 at approximately 3:30 PM revealed a physician order, dated April 21, 2017 at 12:33 PM, for Ipratropium Bromide nebulizer treatment, 500 micrograms (mcg), once a day.


Review of the Electronic Medication Administration Record (e-MAR) revealed the patient received medication, from May 14, 2017 to May 23, 2017.


The signatures of the respiratory therapy staff, who administered the nebulizer treatments are listed at the bottom of the e-MAR; however, in the section titled, "Administration Event," the selection indicates, "Nurse Administered Voluntarily."

The surveyor conducted a face-to-face interview on May 23, 2017 at approximately 4:00 PM, with Employee #70, regarding the documentation of the administration of respiratory treatments, performed by respiratory therapy staff. S/he stated that there are no options in the "Administration Event" to identify that the medication is administered by Respiratory Therapy staff.


Hospital staff failed to ensure a system of author identification that allowed Respiratory Therapy staff to appropriately identify the discipline, who administered the medication, to ensure accuracy of the medical record.


The surveyor conducted a face-to-face interview on May 23, 2017 at approximately 11:30 AM, with Employees #8 and 41. They acknowledged the aforementioned findings.

Based on medical record review and staff interviews, it was determined the hospital failed to ensure that all medical records contained information to justify and support care and treatment; and/or describe the patient's progress and response to medications, care, and treatment, in two (2) of two (2) of patient records (Patients #1 and 34).


The findings include:


A. The hospital staff admitted Patient #1 with diagnoses that included Schizoaffective Disorder and Bipolar Disorder, and past medical history of Pneumothorax and Pleural Effusion.


Review of the medical record conducted on May 22, 2017 at 1:55 PM revealed a physician order, dated May 8, 2017 at 1:32 PM, for oxygen saturation to be included with the vital signs.


A review of vital signs from May 15 to 22, 2017 revealed the patient's average oxygen saturation was 96 percent. Patient #1's oxygen saturation on May 20 at 9:45 AM, May 21 at 9:35 AM, and May 22 at 8:25 AM decreased to 90 percent; and on May 21 at 8:07 PM, 91 percent. Review of the nursing notes revealed no documentation to address the decrease in oxygen saturation.


There was no evidence that nursing staff ensured the medical record contained a complete physician's order to include parameters for notification or intervention for oxygen saturation.


On May 22, 2017 at approximately 2:15 PM, the surveyor conducted a face-to-face interview, with Employee #59, regarding assessment, intervention, and physician notification to justify care and treatment relative to saturation levels for Patient #1. S/he stated the nurses know to call the physician, when the patient has a "low" oxygen saturation. When asked what was considered a "low" oxygen saturation, s/he could offer no consistent percentage. Employees #57, 58, and 59 acknowledged the findings.


B. The hospital staff admitted #34 with diagnoses that included Bipolar Disorder, and a past medical history of Asthma.


Review of the medical record conducted on May 23, 2017 at approximately 3:30 PM, revealed a physician order dated, April 21, 2017 at 12:34 PM, for an Albuterol Sulfate Inhaler, 90 micrograms (mcg), four (4) times a day, as needed.


Review of the Electronic Medication Administration Record (e-MAR) revealed the medication was administered to the patient on the following dates at the following times: May 13, 2017 at 6:09 AM; May 15, 2017 at 3:28 AM; May 17, 2017 at 8:14 PM; May 19, 2017 at 9:05 PM; May 20, 2017 at 2:07 PM; May 21, 2017 at 9:10 PM; May 22, 2017 at 6:38 AM; and May 23, 2017 at 9:18 PM. However, review of the nursing notes lacked evidence of assessments, consistent with the administration of PRN medications, on the aforementioned days.


Nursing staff failed to assess and reassess Patient #34 to justify the need for the medication intervention.


On May 23, 2017 at 3:40 PM, the surveyor conducted a face-to-face interview with Employees #69 and 70. Both acknowledged the findings.

Based on medical record review and staff interviews, it was determined the hospital staff failed to ensure that all documentation and authentication of respiratory treatments, in the electronic medical record, were performed by the person responsible for administering the treatment, in three (3) of five (5) records (Patients #4, 16 and 34).


The findings include:


Saint Elizabeths policy number NPM 3-8-4, revised March 11, 2013, entitled, 'Utilizing E-MAR [electronic medical administration record] and Pyxis-Medication Administration', section V. Procedures, stipulates, "...C. eMAR Screen Checks: The filter section of the e-MAR screen (located at the top), shall be checked prior to use. Make sure the following are checked for accuracy before administering medications: The correct unit is selected, The correct date and time medications are to be given indicated, The correct individual had been selected form the drop down menu ... Ensure the pharmacy, nutrition and lab [laboratory] boxes are all checked (no empty boxes The "Show All" box located to the right of the filter screen) is selected and checked ..."


A. The hospital staff admitted Patient #4 with diagnoses that included Bipolar Disorder, and a past medical history of Chronic Obstructive Pulmonary Disease.


A review of the medical record conducted on May 23, 2017 at approximately 10:50 AM revealed a physician order, dated April 10, 2017 at 10:08 AM, for Albuterol nebulizer treatment, 2.5 milligrams (mg), twice a day.


Review of the Electronic Medication Administration Record (e-MAR) revealed the patient received nebulizer treatments on the following dates, at the following times: May 20, 2017 at 9:25 AM and at 1:35 PM, May 21, 2017 at 1:30 PM, May 22, 2017 at 8:25 AM, and May 23, 2017 at 8:30 AM and at 2:15 PM.


The signatures of the respiratory therapy staff who administered the nebulizer treatments are listed at the bottom of the e-MAR; however, in the section titled, "Administration Event," the selection indicates, "Nurse Administered Voluntarily." There was no documented evidence that respiratory staff ensured proper author authentication of nebulizer treatments administered.


The surveyor conducted a face-to-face interview on May 23, 2017 at approximately 11:15 AM, with Employee #48, regarding the documentation of the administration of respiratory treatments, performed by respiratory therapy staff. S/he stated that there are no options in the "Administration Event" to identify that the medication is administered by Respiratory Therapy staff.


Hospital staff failed to ensure a system of author identification that allowed Respiratory Therapy staff to appropriately identify the discipline, who administered the medication, to ensure accuracy of the medical record.


The surveyor conducted a face-to-face interview on May 23, 2017 at approximately 11:30 AM, with Employees #8 and 41. They acknowledged the aforementioned findings.


B. The physician admitted Patient #16 with diagnoses to include Paranoid Schizophrenia, Uncontrolled, Hyperglycemia and status post Viral Bronchitis.


The surveyor conducted a medical record review on May 23, 2017, at approximately 10:30 AM. The record review reflected a physician order for Ipratropium inhalation (nebulizer), twice a day, by respiratory therapy, on April 14, 2017, at 1:34 PM.


The surveyor completed a review the e-MAR and clinical staff notes for May 8 through May 22, 2017, for completion and authentication of respiratory treatments. The nursing staff signed the e-MAR, indicating administration of respiratory treatments on May 8, 2017 at 8:43 AM; May 9, 2017 at 8:57 AM; May 13, 2017 at 8:34 AM; May 14, 2017 at 8:57 AM; and May 20, 2017 at 8:20 AM.


Further review revealed, the respiratory staff documented notes on May 8, 2017 at 10:00 AM and May 9, 2017 at 10:20 AM that reflected the nursing staff signed for the respiratory treatments time slot; therefore, respiratory documented treatments at a different time.


The surveyor queried Employees #64, 73, and 75, regarding nursing staff administration of the nebulizer treatments. Employees #64 and 75 explained that the nursing staff does not administer nebulizer treatment and nursing staff signed the treatments, unintentionally, when they checked the medication boxes on the e-MAR. Employee #73 confirmed the statement.


Nursing staff failed to ensure the correct individual appropriately documented the administration of nebulizer treatments to ensure accuracy of the medical record.


Employees #64, 73 and 75 acknowledged the findings on May 23, 2017 at approximately 11:00AM.


C. The hospital staff admitted Patient #34 with diagnoses that included Bipolar Disorder, and a past medical history of Asthma.


A review of the medical record conducted on May 23, 2017 at approximately 3:30 PM revealed a physician order, dated April 21, 2017 at 12:33 PM, for Ipratropium Bromide nebulizer treatment, 500 micrograms (mcg), once a day.


Review of the Electronic Medication Administration Record (e-MAR) revealed the patient received medication, from May 14, 2017 to May 23, 2017.


The signatures of the respiratory therapy staff, who administered the nebulizer treatments are listed at the bottom of the e-MAR; however, in the section titled, "Administration Event," the selection indicates, "Nurse Administered Voluntarily." There was no documented evidence that respiratory staff ensured proper author authentication of nebulizer treatments administered.


The surveyor conducted a face-to-face interview on May 23, 2017 at approximately 4:00 PM, with Employee #70, regarding the documentation of the administration of respiratory treatments, performed by respiratory therapy staff. S/he stated that there are no options in the "Administration Event" to identify that the medication is administered by Respiratory Therapy staff.


Hospital staff failed to ensure a system of author identification that allowed Respiratory Therapy staff to appropriately identify the discipline, who administered the medication, to ensure accuracy of the medical record.


The surveyor conducted a face-to-face interview on May 23, 2017 at approximately 11:30 AM, with Employees #8 and 41. They acknowledged the aforementioned findings.

1. Based on interviews with staff, and review of medical records, it was determined that the hospital staff inconsistently performed assessments and/or failed to verify/clarify significant changes, in one (1) of one (1) re-admission record (Patient #9).


The findings include:


Patient #9's medical record reflected re-admission to the hospital on May 22, 2017 with new diagnoses and newly prescribed medications for treatment of the following heart and circulatory related conditions including Supraventricular Tachycardia, Atrial Flutter, and Deep Vein Thrombosis.


A review of the medical record on May 23, 2017 at approximately 10:55 AM revealed a Radiology Report from an acute care facility. The report reflected on May 19, 2017 the patient received Placement IVC (Inferior vena cava) Filter through the Right Femoral Vein; treatment for diagnosis of Lower Extremity DVT (Deep Vein Thrombosis).


Patient #9's discharge prescribed treatment for the aforementioned diagnoses included Amiodarone for irregular heartbeat and Levetiracetam for seizures.


The medical record lacked documented evidence of an initial nursing care plan or ICP [interdisciplinary care plan], which addressed the patient's medical needs relevant to the aforementioned newly identified conditions including: monitoring for symptoms of Deep Vein Thrombosis, interventions to avoid the development of additional clots, Supraventricular Tachycardia and administration of Amiodarone and Levetiracetam.


Additionally, the medical record lacked documented evidence of physician's orders, reports of treatment, radiology and laboratory reports, and vital signs and other information necessary to monitor the patient's condition.


During the medical record review on May 23, 2017 at approximately 3:00 PM, the surveyor conducted a face-to-face interview with Employees #59 and 60, in the presence of Employee #2. They acknowledged the findings.


2. Based on 61 medical record reviews and staff interview, it was determined that the medical staff failed to follow hospital policy, relative to Tuberculosis Screening for individuals in care, for one (1) patient with a documented history of Positive Tuberculin Skin Test (Patient #24).


The findings include:


The hospital's policy, number 101.04, titled, 'Tuberculosis Screening for Individuals in Care', recently revised February 16, 2017 stipulates " ...It is the policy of [Hospital's Name] that all individuals in care shall be screened for tuberculosis and if applicable, appropriate follow-up initiated to promote safety and well-being ...a. Upon admission, all individuals in care shall be screened by the GMO [General Medical Officer or Physician]/ NP [Nurse Practitioner] for the presence of infection with M.[Mycobacterium] Tuberculosis using the Mantoux TST [Tuberculin Skin Test] skin test ..."


The hospital admitted Patient #24, whose diagnoses included Seizure disorder, Hypertension, Diabetes Mellitus Type II, Paranoid Schizophrenia, Hypo-osmolality and Hyponatremia.


A review of the medical record on May 22, 2017 at approximately 10:40 AM revealed Employee #28 recorded findings of the patient's history and physical examination, dated December 29, 2016.


The section of the 'History and Physical Examination' report titled, 'History of Present Illnesses' reflected, " ...Current PPD Status: Hx (history) of positive PPD ..."


Additional review of the medical record lacked documented evidence of the source of the information, the patient's refusal to take the test, interventions for follow-up skin test or chest radiograph, at the time of the record review.


During review of the medical record, the surveyor conducted a face-to-face interview with Employees #28 and 67 on May 22, 2017 at approximately 11:30 PM. They both reviewed and acknowledged the findings.


Following the medical record review, on May 24, 2017, Employee #28 provided the surveyor with an un-titled report dated May 24, 2017. The report reflected that upon admission, the patient reported a history of positive PPD.


Further, the report reflected, " ...presented without Tuberculosis related symptoms and none were reported ...PPD planted on May 22, 2017, results read on May 24, 2017, results: 0 mm [millimeters] ...Chest x-ray on May 23, 2017: no active Pulmonary disease- No evidence of active Tuberculosis ..."


Employees #28 and 67 acknowledged the findings.

Based on observation, record review and staff confirmation, it was determined the hospital failed to ensure the accuracy of records of scheduled drugs.


The findings include:


On February 24, 2016, a seventy-two (72) hour All Station Event Report generated by the facilities' Pyxis Automated Dispensing Machine (ADM) for controlled substances schedule II-V. The report was generated for all patients receiving a controlled substance from May 20, 2017, at 10:51 to May 23, 2017, at 10:51. The report was printed for Patient Care Units; 1 A, 1 B, 1 C, 1 D, 1 E, 1 F, 1 G, 2 A, 2 B, 2 C, and 2D. Patients were randomly selected for this audit from each unit. There were no patients on House 1 D that were prescribed any controlled substances, during the report's time block.The patient's physician orders and eMAR were also requested for review. The survey of records was started at approximately 14:30, on May 23, 2017, and completed on May 24, 2017, at 16:30.


In the presence of hospital Employee #19, the physician order and eMAR were reviewed for accuracy; medication withdrawals from the ADM; administration times of medication to the patient; and the documentation for the dispositioning of controlled substances. Out of thirteen (13), Patient Care Units surveyed, there were seven (7) Patient Care Units that had findings. Twenty-eight (28) patients were randomly chosen for this portion of the survey. For fourteen (14) out of twenty-eight (28) patients surveyed, it was found that criteria were not met in either the documentation of administration of controlled substances, the documentation of the wasting of controlled substances, or the timeliness of administration of controlled substances, and failure to document the actual time the medication was administered on eMAR.


A. On April 12, 2017, at 23:50, Patient #6, on Patient Care Unit 1 A, was ordered Zolpidem 5 mg (milligrams) by mouth, every night, at bedtime. On May 22, 2017, at 19:31, Zolpidem was removed from the ADM and not administered to the patient, until 20:59 (over 1 hour after removal from the ADM).


B. On April 12, 2017, at 13:04, Patient #7, on Patient Care Unit 1 A was ordered Lorazepam 1 mg by mouth every day. On May 21, 2017, Lorazepam 1mg tablet was removed from the ADM at 15:44 and administered to the patient at 16:55 (over one (1) hour late).


C. On May 9, 2017, at 11:17, Patient #10, on Patient Care Unit 1 B was ordered Clonazepam 0.5mg, twice a day (at 8:00 AM and 09:00 PM). On May 22, 2017, at 19:15 Clonazepam 0.5mg was removed from the ADM and administered to the patient at 20:40 (over one (1) hour late).


D. On May 1, 2017, at 10:47, Patient #11, on Patient Care Unit 1 B was ordered Lorazepam 2mg by mouth, three times a day. On May 22, 2017, at 19:42 Lorazepam 2mg was removed from the ADM; with no record of administration and no record of return or wasting.


E. On May April 23, 2017, Patient #12, on Patient Care Unit 1 B was ordered Tramadol 50mg by mouth, two times a day. On May 21, 2017, at 07:29, Tramadol 50mg was removed from the ADM and administered at 08:50 (over one hour late).


F. On April 19, 2017, Patient #18, on Patient Care Unit 1 C was ordered Zolpidem 10mg by mouth, at bedtime. On May 21, 2017, at 23:38, Zolpidem 10mg was removed from the ADM and per eMAR documentation, it was administered at 23:00 (30 minutes before removal from the ADM).


On April 19, 2017, at 14:56, Patient #18 was ordered Lorazepam 3mg by mouth, two times a day. On May 23, 2017, at 08:50, three (3) Lorazepam 1mg tablets were removed from the ADM and per eMAR documentation, it was administered at 08:20 (30 minutes before removal from the ADM).


G. On May 19, 2017, at 11:53, Patient #19, on Patient Care Unit 1 C was ordered Lorazepam 2mg by mouth, four times a day. On May 22, 2017, Lorazepam 2mg was removed from the ADM at 08:27. There is no record of administration, waste, or return.


H. On May 4, 2017, at 20:00, Patient #23, on Patient Care Unit 1 E was ordered Clonazepam 0.5mg by mouth two times a day. On May 22, 2017, at 07:37, Clonazepam 0.5mg was removed from the ADM and administered at 09:00 (over an hour late).


I. On May 4, 2017, at 06:18, Patient #28, on Patient Care Unit 1 F was ordered Lorazepam 2mg/ml[milligrams/milliter], intramuscularly every morning. On May 21, 2017, at 07:39 Lorazepam 2mg/ml was removed from the ADM and administered at 09:00 (about one and one half hours later).


J. On April 18, 2017, at 12:12, Patient #31, on Patient Care Unit 2 A was ordered Lorazepam 1mg by mouth, every day at noon. On May 20, 2017, at 12:55, Lorazepam 1mg was removed from the ADM; however, the eMAR indicates that Lorazepam was administered at 12:00 (almost an hour before it was removed from the ADM).


K. On April 20, 2017, at 17:01, Patient #32, on Patient Care Unit 2 A was ordered Lorazepam 1mg by mouth, two times a day. On May 20, 2017, at 19:36 Lorazepam 1mg was removed from the ADM and administered to the patient at 20:57 (over one hour late). On May 21, 2017, at 19:31 Lorazepam 1mg was removed from the ADM and administered to patient at 20:53 (over one hour late).


L. On April 20, 2017, at 15:57, Patient #37, on Patient Care unit 2 A was ordered Lorazepam 2mg by mouth, three times a day. On May 21, 2017, the eMAR indicates that 2mg of lorazepam were administered to the patient at 06:32; however, there is no record on the ADM that the Lorazepam was removed.


M. On May 22, 2017, at 11:55, Patient #43, on Patient Care unit 2 D was ordered Clonazepam 1mg by mouth every evening. On May 22, 2017, at 21:37 Clonazepam 1mg tablet was removed from the ADM and administered to the patient at 20:54 (administration was one half hour before the medication was removed from the ADM).


N. On April 21, 2017, at 14:02 Patient #45, on Patient Care Unit 2 D was ordered Clonazepam 1mg by mouth, every night at bedtime. On May 21, 2017, at 19:58, Clonazepam 1mg was removed from the ADM; however, there is no record of waste, return, or administration of this dose.


Employee #19 acknowledged the findings.

Based on observations during the dietary survey, it was determined dietary services were not adequate to ensure that foods are prepared and served in a safe and sanitary manner.


The findings include:


1. Trays of tapioca pudding were stored, in the walk-in refrigerator, beyond the expiration date of May 21, 2017, in six (6) of six (6) tray observations at 10:20 AM on May 22, 2017.


2. The slat surfaces on the soiled side of the dishwasher were soiled with debris, in one (1) of one (1) observation at 11:45 AM on May 22, 2017.


3. The interior and bottom surfaces of sheet pans, washed in the Pot and Pan Wash Area, were soiled with leftover foods and pans were not allowed to dry, before stacking on racks for re-use, in 15 of 26 observations at 11:30 am on May 22, 2017.


4. The top and bottom surfaces of chinaware plates were soiled and stained with leftover food, in 20 of 25 observations at 1:30 PM on May 22, 2017.


5. Apple juices, and tapioca puddings were stored in the Nutritional Room refrigerator, beyond the use by date of May 19, 2017, in eight (8) of eight (8) observations on May 19, 2017.


Employee #23 observed and acknowledged the findings.

A Federal Life Safety Code survey was conducted on 5-23-17 through 5-24-17 to determine compliance with applicable provisions of the 2012 edition of the Life Safety Code. Based on observation, staff interview, and review of documentation, it was determined that the life safety code requirement was not met on the Condition Level. The facility's fire alarm system had devices (sprinkler heads) that had the potential to not function as designed. The facility had dust laden and corroded sprinkler heads.


Based on observation, the facility fire department connection caps one (1) of 10 is not hand tight.

The findings include:

It was observed at approximately 10:30am through 1:30pm on May 23 through May 24, 2017, the facility fire department connection caps are not hand tight. Posing as a potential hazard in an event of an emergency.

Based on observation, the facility sprinkler caps one (1) of 2 is not operable.

The findings include:

It was observed at approximately 10:30am through 1:30pm on May 23 through May 24, 2017, the facility sprinkler cap inside of refrigerator K54 is covered with the manufactures plastic covering. Creating a potential hazard in an event of an emergency.

Based on observation, the facility sprinkler heads sixteen (16) of 220 are dust laden.

The findings include:

It was observed at approximately 10:30 am through 1:30pm on May 23 through May 24, 2017, the facility sprinkler heads in the following areas are dust laden:

1. Nurse station 1F13
2. Room 1D12
3. Nurse station (Franz House)
4. Room 2A67
5. Room 227
6. Room 115
7. Room 146.02
8. Butterfly corridor
9. Loading dock by room 159.01
10. Room 149.01

Posing as a potential hazard in an event of an emergency.

Based on observation, the facility sprinkler head rings eleven (11) of 220 are corroded.

The findings include:

It was observed at approximately 10:30am through 1:30pm on May 23 through May 24, 2017, the facility sprinkler head rings in the following areas are corroded:

1. Nutrition service room
2. Room 149.01

Posing as a potential hazard in an event of an emergency.

Based on observation, the facility sprinkler heads thirteen (13) of 220 are corroded.

The findings include:

It was observed at approximately 10:30am through 1:30pm on May 23 through May 24, 2017, the facility sprinkler heads in the following areas are corroded:

1. Room 225
2. Room 220
3. Room 210
4. Room 208.03
5. Room 208
6. Room 114
7. Post Office

Posing as a potential hazard in an event of an emergency.

Based on observations during the survey, it was determined that housekeeping and maintenance services were not adequate to ensure that the facility is maintained in a safe and sanitary manner.


The findings include:


1. The following findings were observed, during a tour of Unit 1E, at 3:45 PM on May 24, 2017.


A. The interior surfaces of exhaust vents were soiled with dust, in 1E141 Seclusion Room.


B. Multiple outlet strips were on floors, instead of mounted on walls; the interior areas of exhaust vents were soiled with dust; electrical wall outlets lacked covers; floor surfaces were marred and soiled, in the rear of equipment, in four (4) of four (4) observations, in Room 1E21.


C. Floor surfaces were soiled, in Room 1E20.


D. Walls and door surfaces were soiled and stained, in 1E19 Comfort Room; wooden shelves, in the hallway at the entrance to 1C, were soiled with dust; and wall surfaces were soiled, above the backrest of sofas, in area 1C, in three (3) of three (3) observations.


E. Paint was peeling in the shower ceiling, in Room 1E52.


F. The interior surfaces of exhaust vents were soiled with dust, in 1E53.


G. The floor drain cover was soiled with debris, in Room 1E54.


H. Residual adhesive was left on walls near the toilet, in 1E55.


I. Floor surfaces were damaged and the horizontal surfaces of the patients bed frame were soiled, in Room 1E60.


J. The inner surfaces of the ice machine and water chutes were soiled with debris, in the 1E Nutrition Service Area.


K. The bottom shelf surfaces of large carts were soiled with dust, in Room 1E05.


L. Caulking located around the bottom of the toilet was soiled and damaged; the access panel door was rusty and the exhaust vent was soiled, on the interior, in the Staff Restroom, in three (3) of three (3) observations.


M. Floor surfaces were soiled, in the staff break room.


N. Penetrations were observed in ceiling surfaces, around seven (7) conduit pipes, in the patient clothing storage area.


O. Floor surfaces were soiled and stained and the top surfaces of cleaning equipment was soiled with dust, in the Janitors Room.


P. The exhaust vent, located above the washer and dryer, was soiled with dust, in the Laundry Room.


Q. The top surfaces of the ice machine were soiled with dust, in the Nutritional Services Area.


R. The bottom shelf surfaces of the soiled linen cart were soiled with dust, in room 1E05.


2. The following findings were observed, during a tour of Unit 1A, between 3:55 PM and 4:20 PM on May 23, 2017.


A. The bottom shelf surfaces of two (2) carts in the Soiled Utility Room (1A05) were soiled with dust.


B. Excessive patient belongings were on the floor, in Room 1A07.


C. Cleaning supplies, such as mops and brooms were improperly stored on floor surfaces, in Room 1A09.


D. Shower curtains were soiled and stained and floor tiles were damaged and uneven, in Room 1A53, in two (2) of two (2) observations.


E. The horizontal surfaces of bed frames were dusty, in rooms,1A58 and 1A62, in two (2) of two (2) observations.


F. The interior surfaces of the sink were soiled and stained, in the 1A Day Room.


G. Shower curtain surfaces were soiled and stained, in Room 1A48.


H. Urine odor was present, in the Room 1A47.


I. The top surfaces of the patient's wardrobe, was soiled with dust, in Room 1A45.


J. Floor tile surfaces were separated and the horizontal surfaces of the bed frame were soiled, in two (2) of two (2) observations, in Room 1A40.


K. The interior surfaces of exhaust vents were soiled with dust, in Laundry Room 1A66.


L. The horizontal surfaces of the bed frame were soiled with dust, in Room 1A42.


3. The following findings were observed, during a tour of Unit 1B, between 4:27 PM and 4:55 PM on May 23, 2017.


A. Shower curtain surfaces were soiled and stained, in Room 1B53.


B. The entrance door was marred and floor surfaces were marred, in Room 1B62.


C. A urine odor was detected in the patients clothing and in Room, 1B61.


D. The main entrance door to Unit 1B was marred and scarred on the frontal surfaces.


4. The following findings were observed, during a tour of Unit 2B, between 10:45 AM and 11:30 AM on May 24, 2017.


A. The threshold ,at the entrance to Group Room 2A02, was missing and the wooden finished surfaces of chair armrest were worn, in two (2) of two (2) observations.


B. Door jamb surfaces were marred at the entrance to the Multi-Purpose Room, 2A67.


C. Cleaning supplies were observed on floor surfaces, in the Janitorial Closet.


D. Exhaust vent surfaces were soiled in the staff bathroom.


E. Shower curtain surfaces were soiled with dust, in Room 2A52.


F. Wall surfaces were soiled and stained, in room 2A53.


G. The top of the closet was soiled with dust; spillages were observed on the desk, and the exhaust vent cover was rusty, in three (3) of three (3) observations, in room 2A64.


H. Exhaust vent louver surfaces were soiled with dust, in Room 2A55.


I. The top surfaces of the cabinet were soiled with dust, in Room 2A57.


J. Wall surfaces were marred and scarred; and floor and wall surfaces were soiled in the rear of the Pyxis Area, in the Medication Room.


5. The following findings were observed, during a tour of Unit 2B, between 12:15 PM and 12:45 PM on May 24, 2017.


A. Wall surfaces were marred and chair armrest surfaces were worn in, the Group Room, near the entrance to Unit 2B.


B. The lower surfaces of three (3) linen carts were soiled, on the lower surfaces, in Room 2B05.


C. The interior surfaces of the mop sink were soiled with debris; and dark stains were observed on floor surfaces, in the Janitorial Closet.


D. The ice machine motor was making a loud noise, during operation in the Pantry Room.


E. The lower wall surfaces were soiled and stained and privacy curtain hooks were missing, in the Room 2B53.


F. The drain cover, under the sink, was soiled and stained; the faucet was not secured to the sink,when examined; and the exhaust vent was soiled with dust, in Room 2B54.


G. Floor surfaces were marred and damaged, in Room 2B60 and the Group Room.

H. Hallway walls were marred, in the center hallway areas of unit 2B.


6. The following findings were observed, during a tour of Unit 1F, between 3:15 PM and 4:15 PM on May 24, 2017.


A. The base surfaces of two (2) of three (3) soiled linen carts were soiled with dust, in Room 1F05.


B. Residual tape was observed on wall surfaces, in Room 1F07.


C. Cleaning equipment was improperly stored on the floor, in Room 1F08.


D. Floor surfaces were stained and the bottom shelf surfaces of the cabinet were dusty, in Room 1F08.


E. The frontal surfaces of the door and jambs were marred at entrance to the Nurses Station.


F. Wall and floor surfaces were soiled and marred, and a tank of C02 [Carbon Dioxide] was not secured, to prevent accidental tip over, in the Treatment Room.


G. Wall surfaces were marred and stained, in the 1F Comfort Room.


H. Floor tiles were damaged at the entrance to Room 1F23.


I. The shower outlet drips water continuously, after the faucet is turned off, in Room 1F24.


J. Rust was observed on the frontal areas of the access panel; and paint was peeling in the ceiling over the toilet, in Room in 1F26.


K. Wall surfaces were marred in the Material Management Processing Areas.


L. The following findings were observed in the Gymnasium Transitional Unit at 10:30 AM on May 24, 2017.


M. The end cap was missing on a wall guard near the door; entrance door surfaces were marred; and ceiling surfaces were soiled near the supply vent, in the Gymnasium.


Employees #21 and 24 observed and acknowledged the findings.

Based on QAPI program review and staff interview, it was determined the hospital s failed to establish policies and procedures to ensure provisions of procurement services for potential donors.


The findings include:


During the entrance conference for the federal and annual licensure survey conducted on May 22, 2017 at approximately 10:30 AM, Employee #9 was asked to provide the list or report of statistical data for compliance, regarding organ donation, and the written agreement with an Organ Procurement Organization. S/he explained that in the instance of an emergency, the facility sends the "individuals in care (IIC)" out for emergency services, at a higher level of acute care; thus, s/he was unaware that this requirement applied to their psychiatric hospital. S/he added that s/he would check with hospital staff to confirm her statement.


On May 24, 2017 at approximately 10:00 AM, review of hospital policies, and the Quality Assurance and Performance Improvement data for March 2016 through April 2017, revealed the hospital lacked documented evidence of policies and procedures to address its responsibilities, relative to organ donation for potential donors.


On May 24, 2017 at approximately 10:30 AM, the surveyor conducted a face-to-face interview with Employee #9, regarding the findings. S/he acknowledged the findings.

Based on the Quality Assurance and Performance Improvement (QAPI) program review and staff interview, it was determined the hospital staff failed to ensure the requirements for provisions for Organ, Tissue and Eye Procurement were met; as evidenced by failure to establish written agreement with Organ Procurement Organization (OPO) for potential donors.


The findings include:


During the entrance conference for the federal and annual licensure survey conducted on May 22, 2017 at approximately 10:30 AM, Employee #9 was asked to provide the list or report of statistical data for compliance, regarding organ donation, and the written agreement with an Organ Procurement Organization. S/he explained that in the instance of an emergency, the facility sends the "individuals in care (IIC)" out for emergency services, at a higher level of acute care; thus, s/he was unaware that this requirement applied to their psychiatric hospital. S/he added that s/he would check with hospital staff to confirm her statement.


On May 24, 2017 at approximately 10:00 AM, Review of the Quality Assurance and Performance Improvement data for March 2016 through April 2017, revealed the hospital lacked documented evidence of statistical data for compliance and reporting of organ donation. Additionally, no documented evidence of a written agreement with an OPO was provided, as requested.


On May 24, 2017 at approximately 10:30 AM, the surveyor conducted a face-to-face interview with Employee #9, regarding the findings. S/he acknowledged the findings.

Based on medical record review and staff interview, it was determined the respiratory therapy staff failed to administer respiratory treatments and medications, in accordance with acceptable standards, as evidence by the administration of oxygen, in the absence of a physician order, for one (1) of one (1) patients (Patient #1).


The findings include:


The hospital staff admitted Patient #1 with diagnoses that included Schizoaffective Disorder and Bipolar Disorder, and past medical history of Pneumothorax and Pleural Effusion.


A review of the medical record conducted on May 22, 2017 at 1:55 PM, reflected Patient #1 received oxygen therapy, initiated by respiratory therapy staff, on the following dates, at the following times: May 17, 2017 at 9:45 AM; May 18, 2017 at 9:25 AM; May 19, 2017 at 9:50 AM; and May 22, 2017 at 2:00 PM. However, the record lacked documented evidence of an order from an authorized, licensed provider for the administration of oxygen for Patient #1.


The surveyor conducted a face-to-face interview on May 23, 2017 at approximately 11:30 AM, with Employee #48, in the presence of Employee #8, regarding oxygen administration for Patient #1. Employee #48 stated, " ...when the patient needs oxygen, we give it;" and added that s/he was unaware that an order was needed. Employee #8 acknowledged the findings.

Based on medical record review and staff interview, it was determined the respiratory therapy staff failed to document all respiratory care services orders, in the medical record, for one (1) of one (1) record (Patients #1).


The findings include:


The hospital staff admitted Patient #1 with diagnoses that included Schizoaffective Disorder and Bipolar Disorder, and past medical history of Pneumothorax and Pleural Effusion.


A review of the medical record conducted on May 22, 2017 at 1:55 PM, reflected Patient #1 received oxygen therapy, initiated by respiratory therapy staff, on the following dates, at the following times: May 17, 2017 at 9:45 AM; May 18, 2017 at 9:25 AM; May 19, 2017 at 9:50 AM; and May 22, 2017 at 2:00 PM. However, the medical record lacked evidence that respiratory therapy staff obtained and documented an order for the administration of oxygen for Patient #1.


The surveyor conducted a face-to-face interview on May 23, 2017 at approximately 11:30 AM, with Employee
#48, in the presence of Employee #8, regarding oxygen administration for Patient #1. Employee #48 stated, " ...when the patient needs oxygen, we give it;" and added that s/he was unaware that an order was needed. Employee #8 acknowledged the findings.