HospitalInspections.org

Based on review of the hospital's Governing Board's meeting minutes, hopsital committee meeting minutes, hospital documents, and staff interviews, it was determined the Governing Body was not effective in carrying out the functions of the hospital to ensure compliance with the Conditions of Participation for: A-0385 Nursing Services and A-1141: Respiratory Care Services.

Findings include:

The Governing Body failed to meet on a quarterly basis as required by the medical staff bylaws and Rules and Regulations.

Employee #2 and employee #4 confirmed in an interview conducted on 9/24/2019 that the Governing Body is required to meet on a quarterly basis but the last time the Governing Body met was in August 2019.

A-0385: Nursing Services. The hospital failed to identify the following: nursing staff that was working beyond their scope of practice, and nursing staff who failed to follow physician's orders.

A-1151: Respiratory Care Services. The Governing Body failed to require Respiratory Care Practitioners to utlize hospital policies and procedures, and obtain a physician's order when caring for patients. This deficient practice poses a risk to the health and safety of the patients when the Governing Body fails to demonstrate accountability for all aspects of the hospital including Respriatory Care Services.

The cumulative effect of these systematic deficient practices resulted in the Governing Body's inability to ensure the provision of quality health care in a safe environment.

Based on review of hospital policies and procedures, patient records, and staff interviews, it was determined the hospital failed to:

A-392: Provide an acuity plan that identifies the number of nursing personnel required for the medical / surgical / and telemetry units.

A-395:
1. Test the patient's blood sugar 15 minutes after treating the patient for a blood sugar less than 60, three (3) out of (3) times for patient #1.
2. Complete the skin/wound care treatments as ordered by the physician for eight (8) of eight (8) wound care treatment documents, with instructions for "nursing to apply" the treatment.
3. Complete patient weights as required by hospital policies and procedures.
4. Require skin and wound care to be completed by licensed nursing staff for nine (9) of 17 records reviewed.

The cumulative effect of these systematic deficient practices resulted in the hospital's inability to require the provision of Nursing Services was maintained to ensure quality health care in a safe environment.

Based on review of hospital policies and procedures, patient records and staff interviews, it was determined the facility failed to:

A-1163: Require respiratory care practitioners to contact the physician with a change in patient condition, obtain a physician's order to adjust the level of oxygen being administered to the patient, and obtain orders for small volume nebulizer treatments (SVN).

The cumulative effect of these systematic deficient practices resulted in the Governing Body's inability to require Respiratory Care Services were provided as ordered to ensure the provision of quality health care in a safe environment.

Based on review of hospital documents, policies and procedures, it was determined the facility failed to require a fiber optic endoscopic eval of swallow "FEES" test be performed per facility policy within 48 hours once the test was ordered. The test was delayed for five days (patient #1). The delay in patient care posed a risk to patient health and safety that the physician would not have necessary information to maintain patient safety and provide appropriate treatment.

Findings include:

The Mobile Scope, contract, effective 6/11/2019, requires the following: "...Upon Facility receipt of a physician's order to have a FEES procedure performed for a resident and receipt of a consent form, from the resident or his/her legally responsible Party, Facility will notify Company by providing Company with a copy of the order and consent...it is the responsibility of leadership to take appropriate steps to improve the affected care, treatment and services. Leadership will monitor the quality and safety of services provided using appropriate methods, which consider risk reduction, safety, staff competence and performance improvement...Performance expectation...Responds to referral within 48 hours ...."

The "Informed Consent" policy, reviewed 10/2016, requires the following: "...A medical/surgical procedure (except if need for the procedure constitutes an emergency) cannot be performed without the consent of the patient or the patient's legal representative...The consent becomes part of the medical record and documentation regarding the patient having signed a consent should be present in the physician and/or healthcare professionals progress / narrative notes ...."

The medical record contained documentation that the patient had a history of aspiration pneumonia, and was on a pureed diet with thickened liquids prior to arrival at this hospital.

Employee #9 evaluated the patient and ordered a "FEES" (fiber optic endoscopic eval of swallow) on 9/5/2019 at 08:35.

The FEES study was conducted on 9/10/2019 at 07:32 to 07:40 am with the following results: "...Patent presents with severe pharyngeal dysphagia...aspiration of all consistencies. Physician may wish to have a conversation regarding code status, feeding status, and patient wishes with further recommendations to follow...The clinician cannot make a recommendation for an oral diet. SLP recommend patient/family/physician have a discussion regarding patient's wishes re: oral intake vs. alternative means of nutrition ...."

Employee #9 confirmed in an interview conducted on 9/23/2019, that the SLP who performs this test was not available until 9/10/2019 at 7:00 am. Employee #9 provided the phone messages for review. Employee #9 confirmed the other option would have been to make the patient "NPO" (nothing by mouth), and insert a duotube for nutrition until the test was performed. S/he was not convinced the patient was aspirating, and increased the diet from pureed to mechanical soft on 9/6/2019.

Employee #1 confirmed in an interview conducted on 9/23/2019, that the hospital could have sent the patient to another facility to have the test completed before 9/10/2019.

Based on review of hospital policies and procedures, Patient #1's medical record, hospital documents and staff interviews, it was determined hospital staff failed to address patient/family concerns regarding the quality of care being provided at the hospital. This deficient practice poses a potential risk to patient's health and safety when hospital staff fail to document and submit patient complaints and grievances, eliminating the opportunity to identify and correct quality of care issues.

Findings include:

The "Patient Complaint/Grievance Process" policy, revised 02/01/2016, requires the following: "...A written or verbal concern or objection from a patient or the patient's designated representative regarding the quality or appropriateness of patient care...Generally a complaint may be solved quickly by the staff member receiving the complaint...Generally a grievance would require an investigation and/or may require management level personnel to resolve the grievance...This concern cannot be resolved promptly by staff present at the time of the occurrence...Grievances are documented in the Grievance Report section of Incident Reporting / Compliance 360 by the employee as soon as the grievance is received and the report is immediately forwarded to the Department Manager / Supervisor and DQRM...At a minimum, this must be completed by the end of the working shift...."

The "Incidents" policy, reviewed 03/05/2015, requires the following: "...Major Categories of Incidents...hostility, and allegations of wrong-doing by facility personnel, etc...The supervisor in whose area an incident occurs is responsible for reporting the incident...."

Employee #13 documented the following: "...9/09/2019: 11:00...spoke with patient and son @ bedside re: care issues that patients daughter is complaining about...I ask her if she wanted to leave the hospital as the daughter was insisting and she said 'yes I guess that's what my daughter wants'. Patient does not have a written MPOA and said 'I guess my daughter will decide everything'...."

Nursing staff documented the following:

"...9/6/2019: ...1315...daughter showed up very upset about the facility and the pts past low blood sugars. I spoke with [name of employee #13] who told me s/he spoke with the family this morning and s/he refused to speak w/them again, and to find [name of employee #3] to speak w/them. When I found [employee #3] and explained the situation s/he told me s/he also spoke with them this morning and also refused to speak with the family...."

"...9/10/2019: ...pt failed FEES test...MD notified, pt NPO...spoke w/daughter, daughter very hostile, arguing, verbal abuse, CM contacted...09:00: CM spoke w/family about issues...."

"...9/11/2019...12:00...wants her mother moved to an ER for evaluation. States pt has not had proper care...Voicemail left for [name of employee #13]...Message for [name of physician #2] at 1250...awaiting information & orders...14:00: received orders from [physician #2] to transfer pt to [name of different hospital]...14:10...EMS arrived in ICU. Per [name of family member] s/he spoke with the tribe & they advised her to call 911...."

Employee #1 confirmed in an interview conducted on 9/19/2019, that an incident report was not completed prior to 9/11/2019, when the patient's family called 911.

Employee #3 documented the following: "...Late Entry: Highly requested to transfer her mom to another facility due to not satisfied of the care...9/06/2019...daughter still appears angry and demanded to have her mom transfer. Able to calm her down. Explain the process of transfer of what's involve and required...9/9/2019: Daughter calm down though still demanded her mom to be discharge from the facility. Explain again how procedure are handled informed to address concern to KPC CM...Shared with [name of employee #13] of same concerns and daughter's demeanor and dealings with staff. Request assistance as resolution in regards to daughter's request. [Employee #13] to discuss plan with daughter...."

Physician #2 confirmed in an interview conducted on 9/25/2019, s/he was notified about the family's request to transfer the patient to another hospital shortly after admission to the hospital, but was not contacted 9/6/2019 through 9/10/2019, regarding the patient/family request to transfer to another hospital.

Employee #3 confirmed in an interview conducted on 9/25/2019, that s/he spoke to the patient and family "at least three (3) times" regarding the family's concern regarding the quality of care, prior to 9/11/2019, but did not complete an incident report. Employee #3 confirmed that incident reports should have been completed when the family reported ongoing concerns with the quality of patient care.

Based on review of hospital documents, policies and procedures, it was determined the facility failed to require hospital staff obtain informed consent prior to the Flexible Endoscopic Evaluation of Swallowing (FEES) study for 2 of 2 patients (#1 and #25). This deficient practice poses the risk to patient health and safety when patient's do not receive adequate information to make an informed decision.

Findings include:

The Mobile Scope, contract, effective 6/11/2019, requires the following: "...Upon Facility receipt of a physician's order to have a FEES procedure performed for a resident and receipt of a consent form, from the resident or his/her legally responsible Party, Facility will notify Company by providing Company with a copy of the order and consent...it is the responsibility of leadership to take appropriate steps to improve the affected care, treatment and services. Leadership will monitor the quality and safety of services provided using appropriate methods, which consider risk reduction, safety, staff competence and performance improvement...Performance expectation...Responds to referral within 48 hours ...."

The "Informed Consent" policy, reviewed 10/2016, requires the following: "...A medical/surgical procedure (except if need for the procedure constitutes an emergency) cannot be performed without the consent of the patient or the patient's legal representative...The consent becomes part of the medical record and documentation regarding the patient having signed a consent should be present in the physician and/or healthcare professionals progress / narrative notes ...."

The medical records for patient #1 and patient #25 were reviewed and contained orders and results for FEES testing. The medical records did not contain a consent form to perform the test.

Employee #2 confirmed in an interview conducted on 9/23/2019, that informed consent was not being obtained prior to this test.

Based on direct observation, review of policies and procedures, hospital documents and staff interviews, it was determined nursing service failed to require an acuity plan was established, documented, and implemented to determine the type and the number of nursing personnel required for the hospital. This practice poses the potential risk for inadequate unit staff, assigned to meet the needs of patients with varying acuities and co-morbidities.

Findings include:

Direct observation conducted on 9/18/2019, of the medical/surgical telemetry unit, revealed patient #28 with his/her legs starting to go between the bed rails. Employee #1 assisted the patient after the surveyor directly asked if the patient needed assistance. Employee #1 confirmed the patient had pulled their intravenous line out. The patient's call light was off and hospital staff were not in the area until Employee #1 asked for assistance.

Patient #25 had a visitor at the nurses station who asked for water that was requested "40 minutes ago". Patient #25 and the visitor confirmed that the call light was answered by intercom approximately 40 minutes ago, but the water was never brought to them.

The "Acuity Staffing Process, Nursing" policy, approved 12/15/2016, requires the following: "...To provide acuity based nurse staffing system to: ...predict nursing care requirements of individual patients and assure that staffing hours reflect the volume of patients, acuity and intensity of nursing services provided while managing workload resources...Utilizing the acuity score information, along with any additional pertinent information such as the probability of early/late discharges, expected admits not arriving or unexpected admits arriving, geography, nursing staff competencies and experience, the House Supervisor / Charge Nurse (HSCN) determines the number of actual nursing staff needed to deliver care per nursing unit, and make patient / staff assignments...."The nurse patient ratio on the (High Observation Unit) HOU is 1:1 to 1:3 based on the patient acuity...Patients requiring hourly assessments and interventions are staffed at a 1:1 or 1:2 ratio...."

The "Level of Care Matrix/Acuity Tool" requires the following: "...The Acuity level is determined by the highest Level in which the patient achieved a score of three (3) or more. If the patient has scoring in Levels higher than the classified Acuity Level, the scores should be added together. If those scores total 3 or more, the patient is scored at the next Acuity Level from the one previously determined...." The patient is assigned a score of Level I through Level V, with level V being the most acute.

The Nursing Assignment sheet, 9/18/2019, identified a census of 14 medical, surgical and or telemetry patients, with four RN's and one CNA on this unit.

Employee #1 confirmed in an interview conducted on 9/23/2019, the Acuity Staffing Process does not identify the number of nursing assistants or registered nurses required for the medical/surgical/telemetry units based on the acuity of the patients.

Based on review of hospital policies and procedures, patient medical records, and staff interviews, it was determined a registered failed to supervise, evaluate and require nursing staff follow the physician's order for the following:

1. Test patient #1's blood sugar level 15 minutes after treating the patient for low blood sugar three (3) out of three (times). This deficient practice poses a potential risk to patient health and safety when the nurse fails to confirm the patient's glucose level is in a safe range.

2. Skin and wound care to be completed for eight (8) of eight (8) patient records reviewed (#7, 8, 11, 12, 16, 18, 19, 20, and 21). This deficient practice poses a potential risk to patient health and safety when nursing staff fail to provide appropriate care to patients with compromised skin integrity.

3. require skin and wound care to be completed by licensed nursing staff for nine (9) of 17 records reviewed. This deficient practice poses a potential risk to patient health and safety when unlicensed staff perform skin and wound care on patients without proper training and supervision

Findings Include:

#1

The medical record contained the following physician's order: "...moderate sliding scale insulin...BS<60 give 50 mls D 50 W, RECHECK BLOOD GLUCOSE IN 15 MINUTES, MAY REPEAT IF NECESSARY THEN CALL PHYSICIAN FOR FURTHER ORDERS.... "

Patient #1's medical record contained documentation that the patient's blood sugar level dropped below 60, three times between 9/5/2019 and 9/6/2019. Nursing staff failed to check the glucose level 15 minutes after treating the low blood sugar three (3) out of three (3) times.

Patient #1's blood sugar readings were documented as follows:

9/5/2019 at 1730: The patient's glucose level was 50. The RN administered 50 mls of D 50 W at 17:30. The glucose level was not checked until 18:30.

9/5/2019 at 2200: The glucose level was 58. The RN documented that the patient received orange juice x 2 and ice cream. The next glucose level was not checked until 22:50.

9/6/2019 at 0600. The patient's glucose level was 50. The RN administered 50 mls of D 50 W. The next glucose level was not checked until three (3) hours later, at 09:00.

Employee #1 confirmed in an interview conducted on 9/25/2019, the nurses did not check the blood glucose level 15 minutes after treating the low blood sugar as required by physician's order.

#2

The Wound Dressing Change / Applications" policy, reviewed 10/2016, requires the following: "...Wound dressings at [name of hospital] are changed by licensed healthcare professionals in a consistent manner according to physician order and/or if soiled or compromised...."

Wound care treatment documents, with an order date ranging from 8/16/2019 through 9/21/2019, were reviewed. Eight of eight wound care treatments with instructions for "nursing to apply" the treatment, did not contain documentation of the treatment being completed (patient #1, 10, 11, 12, 15, 29, 30 and 31).

Employee #2 and employee #3 confirmed in an interview conducted on 9/24/2019, that the treatment orders were not sent to pharmacy, therefore did not appear on the medication administration record for nursing staff to complete.

Employee #23 confirmed in an interview conducted on 9/24/2019, that s/he is not responsible for the treatments in the "treatment book" because the wound care nurses take care of these treatments.

Employee #15 confirmed in an interview conducted on 9/24/2019, that the wound care nurses do not complete the treatments when the instructions include "nursing to apply". The nurses directly responsible for caring for the patients are to complete these treatments.

Hospital staff were unable to provide documentation for wound care treatments with instructions for "nursing to apply" the treatment, for eight (8) of eight (8) patient records (#1, 10, 11, 12, 15, 29, 30, and 31).

#3

The Wound Dressing Change / Applications" policy, reviewed 10/2016, requires the following: "...Wound dressings at [name of hospital] are changed by licensed healthcare professionals in a consistent manner according to physician order and/or if soiled or compromised...."

The "Wound Care Tech" job description requires the following: "...The Wound Care Tech will assist the Wound Care Coordinator with patients receiving wound and/or lymphedema care. The Wound Care Tech is responsible for applying wound dressing as directed by the Therapist or RN ...."

The "Wound Care Nurse" job description requires the following: '...Must be a graduate of an accredited school of nursing...Must hold a current state license and must maintain license renewal in accordance with the standards of the State Board of Nursing...Certification in wound care preferred...Certification in sharp debridement procedures preferred ...."

The wound care treatment book contained documentation confirming that Employee #15 completed the wound care on 9/24/2019 for nine (9) of 17 records reviewed (#7, #8, #11, #12, #16, #18, #19, #20, #21).

Employee #15's personnel file contained documentation that confirmed s/he is a certified nursing assistant and not a licensed healthcare professional.

Employee #3 and Employee #15 confirmed in an interview conducted on 9/24/2019, employee #15 performed the wound care without RN supervision.

Employee #2 confirmed in an interview conducted on 9/24/2019 that Employee #15 was not qualified to perform wound care without the RN being present.

Based on review of hospital policies and procedures, hospital documents, Patient #1's medical record, and staff interviews, it was determined the facility failed to require that Respiratory Therapists have a physician's order for the following:

1. Administering oxygen to patient # 1,
2. BiPAP was utilized as ordered by the physician.
3. Administering Albuterol SVN treatment to patient #1.

These deficient practices pose a risk to the health and safety of patients when hospital staff fail to obtain a Physician's order when administering oxygen or SVN treatments.

Findings include:

The "Protocols for Respiratory Therapy" document requires the following: "...Respiratory protocols will be initiated when: ...Any respiratory therapy modality is ordered...A physician order is placed for Respiratory Therapy to 'assess and treat' and/or evaluate...The RCP will facilitate provision of physician orders based on the respiratory therapy algorithm protocols by placing the Select Physician Orders RT/RT Plan of Care form in the physician orders section of the medical record for physician verification through physician signature and date...During the course of therapy, the physician will be called by the RCP if the patient's clinical status deteriorates, or if an adverse event occurs...Changes will be recorded on the Select Physician Orders for RT/RT Plan of Care for physician verification of care management...When indications for therapy have been resolved, the physician will be notified by the RCP for an order regarding discontinuance of therapeutic respiratory care management...

The medical record contained the following physician orders:

9/4/2019 at 19:10: "...Oxygen Therapy:...Mode: NC...LPM: 2...Continuous...BIPAP: Insp: 12...Exp: 6...FIO2:30 ...HS...PRN...Pulse Oximeter: Continuous...ABG PRN...."
9/5/2019: Continue BiPAP at HS as tolerated
9/10/2019 (0310): Wean O2 keeping sats 92%
9/10/2019 (place BiPap on)
9/11/2019: Wean O2 keeping O2 sats 90%

#1

The medical record contained documentation that the RT increased the amount of oxygen being administered to the patient without a physician's order as follows:

9/5/2019 at 03:35: oxygen was increased from 2 liters to 3 liters when the patient's oxygen level decreased to 88% with "continuous grunting".

9/5/2019 at 08:00: oxygen was increased from 3 liters to 5 liters.

9/7/2019: High flow nasal cannula at 10 liters per minute

9/9/2019: Oxygen was changed to 15 liters per minute via High flow nasal cannula "bubbler" at 21:45.

Employee #8 confirmed in an interview conducted on 9/19/2019, the medical record did not contain a physician's order to increase the oxygen.

#2

Patient #1's medical record contained the following orders for BiPAP:

9/4/2019 at 19:10: "...Oxygen Therapy:...Mode: NC...LPM: 2...Continuous...BIPAP: Insp: 12...Exp: 6...FIO2:30 ...HS...PRN...Pulse Oximeter: Continuous...ABG PRN...."
9/5/2019: "...Continue BiPAP at HS as tolerated...."

BiPAP was not used at "HS", 9/4/2019 at 19:10 through 9/7/2019 at 14:30 as required by the physician's order on 9/4/2019.

9/8/2019: BiPAP Fio2 increased to 50% at 02:00

9/9/2019: Bipap FiO2 increased to 55% at 19:50 "...D/T ABG PO2 66...."

The medical record did not contain an order to increase FIO2 to 50% or 55%.

Employee #8 confirmed in an interview conducted on 9/19/2019, that "HS" means that the patient is to wear the BiPAP while sleeping, as tolerated, and the medical record did not contain a physician's order to increase the oxygen level.

#3

The medical record did not contain an order for Albuterol SVN on 9/5/2019 at 03:35.

The medical record contained documentation that the RT administered an Albuterol small volume nebulizer on 9/5/2019 at 03:35 without a physician's order.

Employee #8 confirmed in an interview conducted on 9/19/2019, the medical record did not contain a physician's order to administer the Albuterol SVN on 9/5/2019.