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Based on observation, policy review and staff interviews, the CAH (Critical Access Hospital) failed to ensure health care services were furnished in accordance with written policies. This deficient practice was evidenced by failure of the CAH to develop written policies to ensure the safety and security of newborns related to measures to reduce the risk of infant abduction when the infants were in the mother's hospital room, on the Medical Surgical floor, after delivery.


Findings:


An observation was made of the CAH's Medical Surgical Unit on 11/14/16 at 11:00 a.m. The unit was not locked and was accessed by pressing a button to the side of the unit entry door. The unit exit door was locked from the outside, but could be opened from the inside by pushing on the door. The post-partum mothers and their infants were housed on the Medical Surgical Unit after delivery.

Review of the CAH's policies and procedures revealed no documented evidence that a written policy had been developed to address the safety and security of newborns relative to measures to put into place reduce the risk of infant abduction when the infants were in the mother's hospital room on the Medical Surgical Unit after delivery.

In an interview on 11/14/16 at 11:00 a.m., during the observation, S1CNO confirmed the post-partum mothers and babies were housed on the Medical-Surgical Unit after delivery. S1CNO indicated the CAH did not currently have a policy/procedure in place for reduction of the risk for infant abduction. S1CNO also confirmed there was no alarm system currently in place to alert the staff to an attempted infant abduction.

In an interview on 11/15/16 at 12:00 p.m. with S5RN (Nursing Director of Perinatal Services and the Nursery), she indicated there was no infant security system, currently in place, to reduce the risk of infant abductions when the newborns were rooming in with their mothers on the Medical Surgical Unit. S5RN agreed an infant could be removed from the mother's room on the Medical Surgical Unit if the mother was asleep and the nurses were busy.

Based on policy review and interview, the CAH (Critical Access Hospital) failed to ensure the pharmacy's policies regarding first dose review were written and implemented based on accepted professional principles. This deficient practice was evidenced by failing to ensure all prescriber's orders were reviewed for appropriateness by a pharmacist before the first dose of ordered medications were dispensed.
Findings:
Review of the Louisiana Administrative Code, Title 46 Professional and Occupational Standards, Part LIII Pharmacist, Chapter 15 Hospital Pharmacy, Section: 1511: Prescription Drug Orders, Item A. The pharmacist shall review the practitioner's medical order prior to dispensing the initial dose of medication, except in cases of emergency.
Review of the CAH's policy titled, "Dispensing: General", Policy Number: 033-1101, revealed in part: Reviews of Original or Direct Copy of Order by a Pharmacist: If the order is written when the pharmacy is closed or the pharmacist is otherwise unavailable, a healthcare professional, determined to be qualified by the organization, reviews the medication order in the pharmacist's absence. If the need arises to administer a medication prior to pharmacist review of the order, two licensed individuals with the authority to administer medication (for example two RN's) should verify the order and the medication prior to administration.
In an interview on 11/15/16 at 2:00 p.m. with S3Pharmacist, he confirmed the pharmacy hours were 8:00 a.m. - 4:30 p.m. Monday - Friday. S3Pharmacist indicated he was on call during the week and alternated weekend call with another pharmacist. S3Pharmacist reported initial doses of medications ordered on weekends were reviewed by a pharmacist on Monday. He confirmed the medication reviews that were conducted on Mondays were retrospective reviews because the initial doses of medications had already been given prior to the reviews. He indicated he was under the impression that nursing staff was qualified to review medications prior to the initial dose.

Based on record review and interview, the CAH (Critical Access Hospital) failed to ensure identified medication errors were documented in the patient's electronic medical record for 2 of 2 (Patient #R1 and Patient #R2) hospital identified medication errors reviewed.


Findings:


Review of the CAH's policy titled, "Medication Errors", Policy Number: 033-1403, revealed in part, Recording Errors in Patient's Record: The medication administered in error or omitted in error and the action taken shall be properly recorded in the patient's medical record. The entry in the patient's medical record need not indicate that an error occurred.


Review of the hospital's medication variance reports revealed Patient #R1 had received a dose of IV Nexium on 10/9/16 at 1:00 a.m. after the medication had been discontinued on 10/8/16. Review of the patient's electronic medical record revealed no evidence of documentation of the medication error in the patient's medical record.

In an interview on 11/15/16 at 12:30 p.m. with S2Compliance, she confirmed, after review of Patient #R1's medical record, that the medication error had not been documented in the patient's electronic medical record.

Patient #R2
Review of the CAH's medication variance reports revealed Patient #R2 had missed 2 ordered doses of Cefazolin 1 gram on 10/12/16 due to the medication not "showing up on the scheduled medication report". Review of Patient #R2's electronic medical record revealed no evidence that the medication errors had been documented in the patient's medical record.

In an interview on 11/15/16 at 4:35 p.m. with S2Compliance, she confirmed, after review of Patient #R2's medical record, that the medication error had not been documented in the patient's electronic medical record.

Based on record reviews, observations, and interviews the CAH (Critical Access Hospital) failed to maintain a comprehensive and ongoing Infection Control Program designed to prevent and control infections and communicable diseases as evidenced by:
1) Failing to ensure the endoscope was decontaminated in accordance with hospital policy for 1 of 1 (Patient #1) endoscopy procedures observed;
2) Failing to ensure surgical attire was laundered in a health care-accredited laundry facility in accordance with AORN Guidelines, and;
3) Failing to clean the glucometer after patient use for 1 of 1 (Patient #3) observations of glucometer use.

Findings:

A review of the CAH policy titled, "Infection Control Plan 2016" provided by S7Quality as the most current, revealed proper cleaning and disinfection of equipment between patients was identified as priority on the risk assessment for the facility.

1) Failing to ensure the endoscope was decontaminated in accordance with hospital policy:

Review of the CAH policy titled, "Flexible Endoscopes, Cleaning & Processing" policy number 021-001, provided by S5RN, Surgery Manager as current policy, revealed in part the following: Transport and decontamination of endoscopes and accessories:
1. The contaminated items are transported by transport bag with personnel wearing appropriate personal protective equipment (PPE).
2. Before cleaning, perform pressure (i.e. leak) tests on flexible endoscopes with leak testing capabilities in the decontamination area before cleaning:
a. Attach the leak test system to the flexible endoscope, and then submerse the entire endoscope in water that does not contain cleaning solution.
b. Manipulate the flexible endoscope control knobs in all directions during the leak testing.
c. Check for the presence of bubbling in the water.
d. Keep the leak testing device attached to the flexible endoscope and under pressure if a leak is detected until the endoscope is removed from the water.
e. Complete the leak test before proceeding to the manual cleaning process.

Patient #1
On 11/15/16 at 10:15 a.m. an EGD (Esophagogastroduodenoscopy) was observed being performed on Patient #1. After completion of the procedure an observation was made of the decontamination of the endoscope by S6SSTech. Upon completion of the procedure and pre-cleaning at the point of use, S6SSTech bagged the endoscope and transported the scope to the decontamination room. After donning personal protective equipment, S6SSTech removed the endoscope from the bag and placed the endoscope into the sink containing enzymatic detergent solution. S6SSTech was then observed to clean the endoscope. S6SSTech did not perform a leak test prior to cleaning the endoscope.

In an interview on 11/15/16 at 11:05 a.m., S6SSTech confirmed she did not do the required leak test prior to cleaning the endoscope. S5RN (Surgery Manager) was also present for the interview and was observed to instruct S6SSTech to start the decontamination procedure over from the beginning for the endoscope that was not leak tested.



2) Failing to ensure surgical attire was laundered in a health care-accredited laundry facility in accordance with AORN Guidelines:

Review of the AORN Guidelines for Perioperative Practice, 2015 edition, revealed in part the following: Recommendation II: Only facility-approved, clean and freshly laundered surgical attire should be donned daily by all personnel entering or re-entering the semi-restricted and restricted surgical areas to decrease the possibility of cross-contamination. Surgical attire should be laundered in a health care-accredited laundry facility either on-site or through a contracted service which incorporates OSHA and CDC guidelines and professional association's recommended practices that follow industry standards through the HLAC (Healthcare Laundry Accreditation Council). Home laundering cannot be monitored for quality, consistency or safety, and laundering may not meet the specified measures necessary to achieve a reduction in microbial levels in soiled surgical attire with measures that involve mechanical, thermal, and chemical components.

Review of the CAH's policy titled, "Attire, Surgical" policy number 010-100, provided by S5RN (Surgery Manager) revealed, "All individuals who enter the semi-restricted and restricted areas of the surgical suites will wear freshly laundered surgical attire." Further review of the policy revealed provisions for home laundering of soiled surgical attire.

In an interview on 11/15/16 at 10:40 a.m., S5RN (Surgery Manager) stated the hospital did not provide scrub attire for the staff. S5RN confirmed each individual provided their own scrub attire and each individual laundered their scrub attire in their respective homes. She confirmed the surgery staff wear their scrubs from home. S5RN confirmed the CAH used AORN and AAMI guidelines as their standard of practice.

In an interview on 11/15/16 at 12:00 p.m., S5RN, Surgery Manager reviewed the AORN standards for surgical attire and confirmed the hospital was not in compliance with the standards for surgical attire since they were laundering their scrub attire at home.



3) Failing to clean the glucometer after patient use:

Review of the CAH policy titled, "HemoCue Glucose 201 DM" policy number 025-400, revealed in part the following: The HemoCue Glucose 201 test system is for the quantitative determination of glucose in whole blood....The meter is cleaned after each patient use with alcohol.

Patient #3
On 11/15/16 at 4:30 p.m. an observation was made of a finger stick blood glucose test (glucometer) on Patient #3 by S8RN. S8RN was observed to enter the patient's room with the glucometer. After performing the blood glucose check, S8RN was observed to wipe the cuvette holder only with an alcohol pad. S8RN, then removed her gloves, sanitized her hands and returned to the nurse's station with the glucometer. After returning to the nurse's station, S8RN was not observed to clean/disinfect the glucometer. S8RN was then asked what the procedure for cleaning the glucometer was. S8RN stated the glucometer was cleaned daily with a disinfectant wipe, alcohol, or soap and water. She then stated she would clean the glucometer at the end of her shift. S8RN also stated the glucometer would be cleaned if visibly soiled.

Based on observation, record review, and staff interview, the CAH (Critical Access Hospital) failed to ensure a registered nurse (RN) assigned the nursing care of each patient to other nursing personnel according to the needs of the patient and the qualifications and competence of the available staff as evidenced by:
1) The ED (Emergency Department) RN delegated the one-to-one observation of patients under a physician emergency certificate (PEC) to nursing staff (S13LPN and S14RN) and law enforcement officers who had not received training and had not been assessed for competency in crisis prevention and interventions, and;
2) The CAH assigned ICU nursing staff to provide nursing care for ICU patients and monitor telemetry patients on the medical/surgical inpatient unit simultaneously resulting in the nursing staff unable to provide continuous cardiac monitoring.

Findings:

1) The ED RN delegated the one-to-one observation of patients under a physician emergency certificate (PEC) to nursing staff (S13LPN and S14RN) and law enforcement officers who had not received training and had not been assessed for competency in crisis prevention and interventions:

Patient #R5
Observation of Patient #R5 in the ED on 11/16/16 at 9:00 a.m. with S1CNO revealed the patient was currently under a PEC and was awaiting bed placement in a psychiatric facility. S13LPN was observed seated in a chair in the door way of the patient's room. S13LPN confirmed she was providing one-to-one observation of the patient.

Review of the patient's medical record revealed the patient had been PEC'd on 11/15/16 at 7:04 p.m. for being dangerous to self, gravely disabled, unwilling and unable to seek voluntary admission. Further review of the PEC revealed the patient was a 76 year old with a history of Schizophrenia who was brought to the ED by ambulance with bizarre behavior, confusion and paranoia. The PEC revealed the patient was currently suicidal.

In an interview on 11/16/16 at 9:10 a.m., S9RNMgr (Emergency Department) stated S13LPN was pulled from the Medical-Surgical Unit today to provide one-to-one observation of Patient #R5. S9RNMgr stated S13LPN was a former psychiatric nurse and had CPI training. S9RNMgr also stated S13LPN had not provided the hospital with documentation of her CPI certification.

Review of the personnel record for S13LPN revealed no documented evidence of CPI training or certification.

In an interview on 11/16/16 at 1:55 p.m., S2Compliance confirmed there was no documentation of CPI training in the personnel record of S13LPN and stated the employee's CPI certification expired 2 years ago.


Patient #6
Review of Patient #6's medical record revealed an admission date of 6/2/16. Further review revealed the patient's legal status was PEC due to Homicidal and Suicidal ideations. The patient's admitting diagnosis was violent. S14RN (OB nurse) was documented as providing observations of the patient on 6/02/16 at 11:15 p.m.

Review of the personnel record for S14RN revealed no documented evidence of training and competency in crisis prevention and interventions.

In an interview on 11/16/16 at 3:45 p.m. with S2Compliance, she confirmed S14RN had no documented evidence of training and competency in crisis prevention and interventions in her personnel file.


Patient #16
Review of Patient #16's medical record revealed the patient's legal status was PEC, CEC, and Judicial Commitment. Further review revealed the patient was documented as having Suicidal and Homicidal Ideations. The patient was held pending placement in an acute psychiatric hospital, in the hospital's ED from 5/19/16 (admission) through 6/23/16 (discharged to an acute inpatient psychiatric hospital). Area law enforcement officers were utilized instead of hospital staff to provide observation of the patient in the capacity of a sitter and not in a law enforcement capacity throughout his stay in the hospital's ED.

Review of the CAH's orientation training provided to area law enforcement officers (being utilized in the capacity of sitters/security detail) revealed no documented evidence of training and competency in crisis prevention and interventions.

In an interview on 11/15/16 at 1:50 p.m. with S2Compliance, she confirmed the area law enforcement officers (being utilized in the capacity of sitters) had not received training, from the CAH, in crisis prevention and interventions. She indicated the officers had been invited to participate in the CAH's crisis prevention and interventions training and they had declined.

In an interview on 11/15/16 at 2:30 p.m. with S1CNO, he indicated the area law enforcement officers were utilized to provide supervision of PEC/CEC patients in the ED who were exhibiting hostile or threatening behaviors . He confirmed they were not being utilized in a law enforcement capacity. S1CNO confirmed the CAH had not trained the law enforcement officers in crisis prevention and interventions. S1CNO also confirmed the CAH had not determined whether the law enforcement officers had received any type of crisis prevention intervention training in their law enforcement training.



2) The CAH assigned ICU nursing staff to provide nursing care for ICU patients and monitor telemetry patients on the medical/surgical inpatient unit:

Review of the CAH policy titled, "Nursing Provision of Care/Scope of Practice" policy number 055-012 revealed in part the following: Intensive Care Unit: The ICU nurse is responsible for monitoring the 10-channel telemetry system for Med/Surg as ordered by the attending physician.

Review of the CAH policy titled, "Telemetry Monitoring" policy number 006-010, revealed in part the following: Purpose: To provide continuous monitoring and early detection of cardiac dysrhythmia and/or condition abnormalities while at rest and/or engaged in activities. Telemetry monitoring will be established by the nurse as soon as possible after being ordered by attending physician....Call ICU nurse with patient information and monitor number. Fax telemetry orders to ICU....Telemetry recordings will be documented by the ICU nurse and brought to Med/Surg at the end of each shift....Note: When the ICU nurse calls for the nurse to check on a telemetry patient, please do so as soon as possible.

On 11/14/16 at 1:00 p.m. an observation and interview was conducted with S11RN. S11RN was observed seated at the nursing station in front of a cardiac monitor on the Medical-Surgical unit. S11RN stated she was the ICU nurse but there were no ICU patients today. S11RN stated the ICU nurses are assigned to cardiac monitoring for the telemetry patients. She stated if they do not have ICU patients they will monitor at the desk in the med/surg unit. She stated if they do have ICU patients they monitor the telemetry patients from the ICU. S11RN stated Patients #10, #11, and #12 were current telemetry patients on the med/surg unit. She stated there was a 4th rhythm on the monitor, but that rhythm was for an ED patient. S11RN stated the ED patient cardiac monitoring shows on their monitors but the ICU nurses are not responsible for monitoring the ED patients.

Review of the medical records for Patients #10, #11, and #12 revealed the physician had ordered continuous cardiac monitoring for the patients.

On 11/14/16 at 4:45 p.m. and observation was made of the telemetry monitor on the Medical/Surgical unit. There was no one observed to be monitoring the telemetry monitor.
At 4:55 p.m. S10RNSup was observed putting a patient record in order and not observing the telemetry monitor. She stated she was watching the monitor and she did not know where the ICU nurse was. S10RNSup stated they had just received a new admission and confirmed she was not watching the monitor.
At 5:00 p.m. an observation was made in ICU. S11RN was observed seated in front of a cardiac monitor. S11RN was asked how she monitors the telemetry patients when she has patients in ICU. S11RN stated if she is in a room with a patient and can't watch the monitor, the ward clerk will call and ask her to look at the monitor if an alarm goes off. She stated the nurse at the desk on the medical/surgical unit will call also. S4RNMgr (Med-Surg and ICU) joined the interview and stated if there are 2 patients in the ICU, the ICU is still responsible to monitor the telemetry patients. She stated the ward clerk is not trained to read cardiac monitor rhythms. She stated if an alarm goes off the nurses go check the patient. She stated S10RNSup was trained to monitor rhythms but was not sure if the nurses on the floor had been trained.

On 11/15/16 at 8:00 a.m., S19RN was observed seated in front of a cardiac monitor in ICU. There were no current patients in ICU. When asked how she monitors the telemetry monitors when she has two patients in ICU. She stated, "If you have patients, you keep the doors open and listen for alarms." She stated she notifies the nursing supervisor if she is going to be "tied up" in a patient room. She stated, "You do a lot of going back and forth." S19RN stated they do not get a second ICU nurse until they have three patients or two one-to-one patients.

In an interview on 11/16/16 at 3:20 p.m., S1CNO confirmed the ICU nurses are responsible for monitoring the telemetry patients on the Medical-Surgical unit. He also confirmed the ICU nurses are not responsible for monitoring the ED patients on cardiac monitors. S1CNO confirmed arrhythmias and recording of changes in the patient's rhythms could be missed when nurses responsible for telemetry monitoring have other assignments. S1CNO stated they are in the process of developing training and competencies for the LPN staff to monitor the telemetry monitors.


30984

Based on record reviews and interview, the CAH (Critical Access Hospital) failed to ensure the registered nurse (RN) supervised and evaluated the nursing care for each patient as evidenced by:

1) Failure to ensure orders relative to the initiation and titration of continuous Propofol infusions were clarified prior to implementation by nursing staff as evidenced by failing to obtain dosing increments and intervals for initiation and titration for 2 of 2 (#R3, #R4) sampled patient records reviewed for continuous medication infusions out of a total sample of 20 (#1-#20) and 5 (#R1-#R5) random patient records reviewed;

2) Failure to document the dose and rationale for titration of Propofol continuous infusions for 2 of 2 (#R3, #R4) sampled patient records reviewed for continuous Propofol infusions out of a total sample of 20 (#1-#20) patient records and 5 (#R1-#R5) random patient records reviewed, and;

3) Failure to document an interpretation of the cardiac monitoring telemetry readings for medical surgical patients for 2 of 2 (#10, #12) sampled patients reviewed for telemetry out of a total sample of 20 (#1-#20) patient records.

Findings:

1) Failure to ensure orders relative to the initiation and titration of continuous Propofol infusions were clarified prior to implementation by nursing staff:

Review of the hospital policy titled, "Orders: Titrating" policy number 033-1013, revealed in part the following: Titrate orders must meet the following: The prescriber must specifically order the minimum and maximum dose. The parameter used to titrate (e.g. blood pressure) must be available on the patient care unit where the patient is being treated, and the nurse must be competent in reading and/or interpreting the parameter. The dosage increment used to titrate the medication must be written.

Patient #R3
Review of the medical record for Patient #R3 revealed the patient brought to the CAH's ED on 06/06/16 with a diagnosis of being unresponsive. Review of the record revealed the patient was intubated and placed on a ventilator on 06/6/16. Review of the physician's orders revealed an order for a Propofol continuous infusion as follows:
06/06/16 at 5:49 p.m. Propofol 10 mg/100 ml titrate IVP.
There was no documented evidence of any physician orders indicating the starting dose, the minimum or maximum dose, intervals or dose to titrate the infusion by, and there was no parameter for titration ordered by the physician.

Review of the Medication Record revealed the following: Propofol 10 mg/ml 100 ml vial titrate. Further review of the patient's medical record revealed the following Intravenous Fluids entries: start time: 5:24 p.m.: Diprivan (Propofol) 100mg/100ml; rate: 8 mcg; site: left wrist. 9:45 p.m.: Diprivan (Propofol) 100mg/100ml; rate: 15 mcg; site: left wrist. Additional review revealed no documented evidence of orders for increasing the rate of the Propofol from 8 mcg to 15 mcg.

In an interview on 11/16/16 at 11:09 a.m., S4RNMgr confirmed the Propofol order was incomplete and the nurse should have clarified the order to include a starting dose, increments and dose for titration and the parameter to titrate the medication to. S4RNMgr confirmed the policy and procedure for titrating orders had not been followed.


Patient #R4
Review of the medical record for Patient #R4 revealed the patient was a 60 year old admitted to the hospital on 09/25/16 with a diagnosis of Sepsis, Pneumonia, and Dehydration. Review of the record revealed the patient was intubated and placed on a ventilator on 09/30/16. Review of the physician's orders revealed a verbal order for a Propofol continuous infusion as follows:
09/30/16 at 6:19 p.m. Propofol 10 mg/100 ml titrate IVP.
There was no documented evidence of any physician orders indicating the starting dose, the minimum or maximum dose, intervals or dose to titrate the infusion by, and there was no parameter for titration ordered by the physician.

Review of the Medication Record revealed the following: Propofol 10 mg/ml 100 ml vial titrate continuous.

Further review of the record revealed the Propofol infusion was started on 09/30/16 at 7:30 p.m. and continued until the patient was transferred to another hospital on 10/01/16 at 8:15 p.m.

In an interview on 11/16/16 at 11:10 a.m., S4RNMgr (ICU Manager) reviewed the electronic medical record and confirmed the only order for the Propofol infusion was the verbal order on 09/30/16 at 6:19 p.m. S4RNMgr confirmed the verbal order was incomplete and the nurse should have clarified the order to include a starting dose, increments and dose for titration and the parameter to titrate the medication to. S4RNMgr confirmed the policy and procedure for titrating orders had not been followed.



2) Failure to document the dose and/or rationale for titration of Propofol continuous infusions:

Patient #R3
Review of the medical record for Patient #R3 revealed the patient was intubated and started on a Propofol infusion on 06/06/16 at 5:49 p.m. in the CAH's ED.
There was no documented evidence of any physician orders indicating the starting dose, the minimum or maximum dose, intervals or dose to titrate the infusion by, and there was no parameter for titration ordered by the physician.

Review of the Medication Record revealed the following: Propofol 10 mg/ml 100 ml vial titrate. Further review of the patient's medical record revealed the following Intravenous Fluids entries: start time: 5:24 p.m.: Diprivan (Propofol) 100mg/100ml; rate: 8 mcg; site: left wrist. 9:45 p.m.: Diprivan (Propofol) 100mg/100ml; rate: 15 mcg; site: left wrist. Additional review revealed no documented evidence of orders for increasing the rate of the Propofol from 8 mcg to 15 mcg and no documentation of the parameter used to titrate the medication.

In an interview on 11/16/16 at 11:09 a.m., S4RNMgr (ICU Manager) confirmed the nurse had not documented the reason the dose was increased and there was no documentation of the parameter used to titrate the infusion to.


Patient #R4
Review of the medical record for Patient #R4 revealed the patient was a 60 year old admitted to the hospital on 09/25/16 with a diagnosis of Sepsis, Pneumonia, and Dehydration. Review of the record revealed the patient was intubated and placed on a ventilator on 09/30/16. Review of the physician's orders revealed a verbal order for a Propofol continuous infusion as follows:
09/30/16 at 6:19 p.m. Propofol 10 mg/100 ml titrate IVP.

Review of the Medication Record revealed the following: Propofol 10 mg/ml 100 ml vial titrate continuous.

Review of the nursing documentation revealed the following:
09/30/16 at 7:30 p.m. - "Propofol drip started for sedation while on ventilator." The entry was documented by S15RN. There was no documented evidence of the dose the Propofol infusion was started at, there was no documentation of the rationale or patient behavior that warranted the use of the medication, and there was no parameter indicated for titration.
Further review of the nursing documentation from 09/30/16 at 7:30 p.m. to 10/01/16 at 6:47 a.m. revealed no documented evidence of the dose or patient response to the Propofol infusion.

Review of the nursing documentation by S16RN on 10/01/16 from 7:00 a.m. to 6:48 p.m. revealed the following:
7:00 a.m. - Propofol drip at 20 mcg/Kg/min at 7.8 cc/hr....Propofol adjusted as needed.
10:00 a.m. - Propofol increased to 30 mcg/Kg/min.
11:00 a.m. - Propofol increased to 40 mcg/Kg/min.
Review of the nursing documentation revealed no documented evidence of why the Propofol infusion was increased. There was no documentation of the parameter used to titrate the medication.

In an interview on 11/16/16 at 11:10 a.m., S4RNMgr (ICU Manager) reviewed the electronic medical record and confirmed S15RN failed to document the dose and rate of administration of the Propofol infusion that was started on 09/30/16 at 7:30 p.m. S4RNMgr confirmed the Propofol infusion was titrated up by S16RN at 10:00 a.m. and 11:00 a.m. S4RNMgr confirmed the nurse had not documented the reason the dose was increased and there was no documentation of the parameter used to titrate the infusion to.



3) Failure to document an interpretation of the cardiac monitoring telemetry readings for medical surgical patients:

Patient #10
Review of the medical record for Patient #10 revealed the patient was admitted to the hospital on 11/10/16 with a diagnosis of Anoxic Brain Injury. Review of the record revealed the patient was discharged from acute care and admitted to swing bed status on 11/14/16. Review of the record revealed the patient was on continuous cardiac monitoring since admission on 11/10/16 to present day (11/16/16).

Review of the telemetry rhythm strips recorded in the patient's record revealed strips were printed every 6 hours but there was no documented evidence of any interpretation of the rhythm.

In an interview on 11/16/16 at 11:50 a.m., S4RN (Manager of Medical-Surgical Unit and ICU) reviewed the patient's telemetry rhythm strips and confirmed there was no documentation of an interpretation of the rhythm. S4RN confirmed the ICU nurses were responsible for monitoring the telemetry patients also and the ICU nurses do not document anything regarding the telemetry monitoring. S4RN confirmed the ICU nurse prints the strips, but they do not document an interpretation of the patient's rhythm.


Patient #12
Review of the medical record for Patient #12 revealed the patient was admitted to the hospital on 11/12/16 with a diagnosis of Systolic Congestive Heart Failure. Review of the record revealed the patient was on continuous cardiac monitoring since admission on 11/12/16 to present day (11/16/16).

Review of the telemetry rhythm strips recorded in the patient's record revealed strips were printed every 6 hours but there was no documented evidence of any interpretation of the rhythm.

In an interview on 11/16/16 at 10:00 a.m., S4RN (Manager of Med Surg and ICU) reviewed the patient's telemetry rhythm strips and confirmed there was no documentation of an interpretation of the rhythm. S4RN confirmed the ICU nurses were responsible for monitoring the telemetry patients also and the ICU nurses do not document anything regarding the telemetry monitoring.

In an interview on 11/15/16 at 10:38 a.m. with S9RNMgr (ED Nurse Manager) she confirmed patients in the ED were placed on continuous telemetry monitoring. She indicated there are no monitor techs and no set staff assignment to continuously observe the cardiac monitors for ED patients on telemetry. S9RNMgr indicated ED patients on telemetry had backup monitoring in the ICU, by the ICU nurses, when the ED nurses were pulled away from observing the cardiac monitors. S9RNMgr reported the ED staff does not call the ICU nurses to ask them to assume responsibility for monitoring of the ED telemetry patients when the ED nurse is called away from observing their patients' cardiac monitors. S9RNMgr further reported they take for granted someone either in ICU or on the Medical Surgical Unit is observing the ED telemetry patients' cardiac monitors.

In an interview on 11/16/16 at 3:20 p.m., S1CNO confirmed the nurses do not document an interpretation of the cardiac rhythm for telemetry patients. He confirmed the ICU nurse was responsible for the monitoring of telemetry patients on the medical-surgical unit. He also confirmed the ICU nurses were not responsible for monitoring the cardiac monitors for ED patients.










30984

30984


Based on record reviews and interviews, the CAH (Critical Assess Hospital) failed to ensure the assignment of nursing personnel for patient care services was done in accordance with nursing personnel competence. This deficient practice was evidenced by failure of the CAH to ensure competency evaluations for Propofol infusion administration were documented for 4 of 4 (S15RN, S17RN, S18RN, S19RN) personnel reviewed who had administered Propofol.
Findings:

Review of the Louisiana State Board of Nursing, "Declaratory Statement on the Role and Scope of Practice of the Registered Nurse in the Administration of Medication and Monitoring of Patients During the Levels of Procedural Sedation (Minimal, Moderate, Deep, and Anesthesia) as Defined Herein" revealed in part the following: Position Statement, March 17, 2004.....The Registered nurse (non-CRNA) (Certified Registered Nurse Anesthetist) shall have documented education and competency to include: A. Knowledge of sedative drugs and reversal agents, their dosing and physiologic effects. Advanced Cardiac Life Support....Skill in establishing an open airway, head-tilt, chin lift, use of bag-valve-mask device, oral and nasal airways, and emergency procedures. This includes rescuing a patient that may progress beyond deep sedation. Demonstration of the acquired knowledge of anatomy, physiology, pharmacology, and basic cardiac arrhythmia recognition; recognize complications of undesired outcomes related to sedation/analgesia; demonstrated appropriate interventions in compliance with standards of practice, emergency protocols, or guidelines....
B. Competencies will be measured initially during orientation and on an annual basis....

Patient #R3
Review of Patient #R3's medical record revealed S17RN and S18RN had administered Propofol to the patient, in the CAH's ED, on 6/6/16.
Review of the personnel files for S17RN (ED nurse) and S18RN (ED Nurse) revealed no documented evidence of competencies for administration of Propofol.
In an interview on 11/15/16 at 10:38 a.m. with S9RNMgr (ED) she confirmed registered nurses administered Propofol to intubated patients in the ED. S9RNMgr also confirmed there were no documented competencies for S17RN and S18RN for administration of Propofol.


Patient #R4
Review of Patient #R4's medical record revealed S15RN had administered Propofol to the patient, in the CAH's ICU, on 09/30/16.
Review of the personnel files for S15RN (ICU nurse) revealed no documented evidence of competencies for administration of Propofol.

In an interview on 11/16/16 at 11:10 a.m., S4RNMgr (ICU Manager) confirmed S15RN had administered Propofol by infusion to Patient #R4 and had no documented competency for administration of Propofol.

S19RN
In an interview on 11/15/16 at 8:00 a.m., S19RN, ICU confirmed Propofol was administered in the ICU to patients on ventilators by the ICU nurses. S19RN confirmed she had administered Propofol to ICU patients. S19RN indicated they ICU did not have protocols for continuous infusions of Propofol, Levophed, or Dopamine, but stated the physician writes specific orders for titrating.

Review of the personnel record for S19RN revealed no documented evidence of competency in Propofol infusion administration.

In an interview on 11/15/16 at 5:00 p.m., S1CNO confirmed there were no competencies done for administration of Propofol infusions in the ED or ICU.

Based on record review and staff interview, the CAH (Critical Access Hospital) failed to ensure the Quality Assurance program was effective as evidenced by the Quality Assurance program failing to:
1) identify problems regarding Propofol administration in the ED and ICU as a focus area in need of improvement in the CAH ' s QA plan.;
2) identify ED and ICU nursing staff ' s lack of competency assessments for administration of Propofol as a focus area in need of improvement in the CAH ' s QA plan ; and
3) identify problems related to Telemetry Monitoring/interpretation of rhythm strips on the ED, ICU, and Medical-Surgical Units as a focus area in need of improvement in the CAH ' s QA plan.

Findings:

Review of the CAH's policy titled,"Quality Improvement Plan", Policy Number: 056, revealed in part: III: Purpose: The Quality Improvement Program is designed to provide a systematic and organized mechanism to promote safe and quality patient care services. Through an integrated interdisciplinary process, patient care and services shall be continuously monitored and evaluated to promote optimum outcomes. D. ACT: Opportunities for improvement are identified by continuously assessing and measuring the services and processes provided. The organization ' s improvement initiatives will focus primarily on systems and processes as they relate to priority focus areas and clinical service groups. Appropriate actions will be taken to make changes that improve performance and patient safety and reduce the risk of sentinel events.

1) Failure to identify problems regarding Propofol administration in the ED and ICU as a focus area in need of improvement in the CAH ' s QA plan.

Patient #R3
Review of the medical record for Patient #R3 revealed the patient brought to the CAH's ED on 06/06/16 with a diagnosis of being unresponsive. Review of the record revealed the patient was intubated, placed on a ventilator and started in a continuous infusion of Diprovan (Propofol) at 5:24 p.m. on 06/6/16. There was no documented evidence of any physician orders indicating the starting dose, the minimum or maximum dose, intervals or dose to titrate the infusion by, and there was no parameter for titration ordered by the physician. Further review revealed no documented evidence that the RN had clarified the order prior to initiating the infusion.

In an interview on 11/16/16 at 11:09 a.m., S4RNMgr confirmed the Propofol order was incomplete and the nurse should have clarified the order to include a starting dose, increments and dose for titration and the parameter to titrate the medication to. S4RNMgr confirmed the policy and procedure for titrating orders had not been followed.

Patient #R4
Review of the medical record for Patient #R4 revealed the patient was admitted to the hospital on 09/25/16 with a diagnosis of Sepsis, Pneumonia, and Dehydration. Further review of the record revealed the patient was intubated, placed on a ventilator and started on a continuous infusion of Propofol (per physician verbal order) on 09/30/16. Patient #R4 was an ICU patient.
Review of the nursing documentation revealed the following: 09/30/16 at 7:30 p.m. - "Propofol drip started for sedation while on ventilator." The entry was documented by S15RN.
There was no documented evidence of any physician orders indicating the starting dose, the minimum or maximum dose, intervals or dose to titrate the infusion by, there was no parameter for titration ordered by the physician and there was no documentation of the rationale or patient behavior that warranted the use of the medication.

In an interview on 11/16/16 at 11:10 a.m., S4RNMgr (ICU Manager) reviewed the electronic medical record and confirmed the only order for the Propofol infusion was the verbal order on 09/30/16 at 6:19 p.m. S4RNMgr confirmed the verbal order was incomplete and the nurse should have clarified the order to include a starting dose, increments and dose for titration and the parameter to titrate the medication to. S4RNMgr confirmed the policy and procedure for titrating orders had not been followed.

2) Failure to identify ED and ICU nursing staff administering Propofol infusions lacked competency assessments for administration of Propofol as a focus area in need of improvement in the CAH ' s QA plan.

Patient record review and staff interviews revealed S15RN (ICU), S17RN (ED), S18RN(ED), and S19RN (ICU) had administered Propofol infusions in the CAH ' s ED and ICU. Review of the personnel files for S15RN (ICU), S17RN (ED), S18RN (ED), and S19RN (ICU) revealed no documented evidence of competency evaluations for Propofol infusion administration.

In an interview on 11/15/16 at 10:38 a.m. with S9RNMgr (ED) she confirmed registered nurses administered Propofol to intubated patients in the ED. S9RNMgr also confirmed there were no documented competencies for S17RN and S18RN for administration of Propofol infusions.

In an interview on 11/16/16 at 11:10 a.m., S4RNMgr (ICU Manager) confirmed S15RN had administered Propofol by infusion and had no documented competency for administration of Propofol.

In an interview on 11/15/16 at 5:00 p.m., S1CNO confirmed there were no nursing competency evaluations for administration of Propofol infusions in the ED or ICU.


3) Failure to identify problems related to Telemetry Monitoring on the Medical-Surgical, ICU and ED Units.

Patient #10
Review of the medical record for Patient #10 (currently a swing bed patient on the Med/Surg Unit) revealed the patient was admitted to the hospital on 11/10/16. The patient had been on continuous cardiac monitoring from admission to present day (11/16/16). Additional review revealed telemetry rhythm strips were printed every 6 hours but there was no documented evidence of any interpretation of the rhythm.

In an interview on 11/16/16 at 11:50 a.m., S4RN (Manager of Medical-Surgical Unit and ICU) reviewed the patient's telemetry rhythm strips and confirmed there was no documentation of rhythm interpretation. S4RN confirmed the ICU nurses were responsible for monitoring the telemetry patients also and the ICU nurses do not document anything regarding the telemetry monitoring. S4RN confirmed the ICU nurse prints the strips, but they do not document an interpretation of the patient's rhythm.

Patient #12
Review of the medical record for Patient #12 (currently a swing bed patient on the Med/Surg Unit) revealed the patient was admitted to the hospital on 11/12/16. The patient had been on continuous cardiac monitoring from admission to present day (11/16/16). Additional review revealed telemetry rhythm strips were printed every 6 hours but there was no documented evidence of any interpretation of the rhythm.

In an interview on 11/16/16 at 10:00 a.m., S4RN (Manager of Med Surg and ICU) reviewed the patient's telemetry rhythm strips and confirmed there was no documentation of rhythm interpretation. S4RN confirmed the ICU nurses were responsible for monitoring the telemetry patients also and the ICU nurses do not document anything regarding the telemetry monitoring.

In an interview on 11/15/16 at 10:38 a.m. with S9RNMgr (ED Nurse Manager), she confirmed patients in the ED were placed on continuous telemetry monitoring. She indicated there are no monitor techs and no set staff assignment to continuously observe the cardiac monitors for ED patients on telemetry. S9RNMgr indicated ED patients on telemetry had backup monitoring in the ICU, by the ICU nurses, when the ED nurses were pulled away from observing the cardiac monitors. S9RNMgr reported the ED staff does not call the ICU nurses to ask them to assume responsibility for monitoring of the ED telemetry patients when the ED nurse is called away from observing their patients' cardiac monitors. S9RNMgr further reported they take for granted someone either in ICU or on the Medical Surgical Unit is observing the ED telemetry patients' cardiac monitors.

In an interview on 11/16/16 at 3:20 p.m., S1CNO confirmed the nurses do not document an interpretation of the cardiac rhythm for telemetry patients. He confirmed the ICU nurse was responsible for the monitoring of telemetry patients on the Medical-Surgical Unit. He also confirmed the ICU nurses were not responsible for monitoring the cardiac monitors for ED patients.

Review of the Hospital-wide Quality Plan, presented as current by S7Quality, revealed no documented evidence that problems regarding Propofol administration in the ED and ICU, lack of ED and ICU nursing staff competency assessments for administration of Propofol infusions, and problems related to Telemetry Monitoring/interpretation of rhythm strips in the ED, ICU, and Medical-Surgical Units had been identified as problem prone, focus areas in need of improvement in the CAH ' s hospital wide QA plan.

In an interview on 11/16/16 at 4:30 p.m. with S7Quality, she confirmed problems regarding Propofol administration in the ED and ICU, lack of ED and ICU nursing staff competency assessments for administration of Propofol infusions, and problems related to Telemetry Monitoring/interpretation of rhythm strips on the ED, ICU, and Medical-Surgical Units had not been identified as problem prone, focus areas in need of improvement in the CAH ' s hospital wide QA plan.

Based on observation, record review and interview, the CAH (Critical Access Hospital) failed to ensure 1) the Patient Activities Program included large and small group activities designed to meet the interests and the physical, mental, and psychosocial well-being of each swing bed patient;and
2) the swing bed patient activity care plans were individualized for 3 ( #3,#11,#13) of 3 swing bed patients reviewed out of a total patient sample of 20 (#1-#20) and a random patient sample of 5 (#R1-#R5).

Findings:

1) Failed to ensure the Patient Activities Program included large and small group activities.

On 11/14/16 at 11:00 a.m. an observation was made of the CAH's Medical/Surgical/Swing Bed Unit. No calendar of activities or postings of any type were noted to indicate the hospital was providing Group Activities for the CAH's swing bed patients.

Review of the policy titled,"Job Duties of the Patient Activity Coordinator" (presented as the only policy referencing the CAH's Patient Activities Program) revealed in part: Patient Care: 4. Coordinates therapeutic recreation activites in small and large groups to observe and encourage socialization, interpersonal relationships between patients, and stimulating patient interest in leisure activities. Also to observe patients' reaction in small and large group situations.

In an interview on 11/15/16 at 4:00 p.m. with S12ActDir, he confirmed there was no Activities Calendar and no group activities. S12ActDir indicated he had an activity cart with playing cards, crossword puzzles, coloring sheets and small packs of crayons that were distributed to patients. S12ActDir indicated the patient activities were individual activities and usually consisted of reading the newspaper and watching television.

2) Failed to ensure swing bed patients' activity care plans were individualized for each swing bed patient.

Patient #3
Review of Patient #3's medical record revealed the patient was re-admitted to swing bed status on 11/4/16.

Review of Patient #3's swing bed plan of care revealed the following: Patient weekly goals: Patient will participate in at least 3 activities per week. Participated in: Patient viewed television, read paper, and visited with family.

Patient #11
Review of Patient #11's medical record revealed the patient was admitted to swing bed status on 11/4/16.

Review of Patient #11's swing bed activity plan of care revealed the following: Patient weekly goals: Patient will participate in at least 3 activities per week. Participated in: Patient viewed television, read paper, and visited with family.

Patient #13
Review of Patient #13's medical record revealed the patient was admitted to swing bed status on 11/9/16.

Review of Patient #13's swing bed Activity plan of care revealed the following: Patient weekly goals: Patient will participate in at least 3 activities per week. Participated in: Patient viewed television, read paper, and visited with family.

In an interview on 11/15/16 at 3:00 p.m. with S2Compliance, she agreed the swing bed patient's activity care plans needed some work and could be more specific.