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Based on record review and interview, the hospital failed to ensure that patients were informed of the nature of their condition for which blood transfusions were ordered as required by hospital policy for 3 of 3 patients' records reviewed who received blood transfusions from a total of 31 sampled patients (#7, #18, #28). Findings:
Review of the hospital's policy titled "Consent/Informed Consent", policy number 2-160, revised 2012, reviewed 02/13, and presented by RN (registered nurse) ManagerS21 as the current policy for consent for blood administration, revealed the following:
1) Staff will comply with the attached policy titled "Informed Consent for Medical Treatment";
2) Blood transfusion consents may be obtained by the physician or other health care provider who will perform the procedure (give the transfusion);
3) A separate consent will not be required for each transfusion if the original transfusion consent states "further transfusions" or "multiple transfusions may be required";
4) A specific consent should include the specific treatment or procedure, the purpose of the treatment or procedure, the patient's diagnosis or condition for which the procedure or treatment was indicated, the risks identified by the Louisiana Medical Disclosure Panel, risks determined by the patient's physician, additional risks particular to the patient due to a complicating medical condition, and reasonable therapeutic alternatives;
5) Informed consents are required for blood/blood product administration.
Review of the "Patient Consent to Medical Treatment or Surgical Procedure and Acknowledgement of receipt of Medical Information Transfusion of Blood and Blood Components" revealed under "Treatment/Procedure" there was a blank to be filled in with a "description, nature of the treatment/procedure", and the "Purpose" had the typed reason as "to infuse the required number of units of blood/blood products to increase the patient's blood count to an acceptable level". Review of the section titled "Patient Condition" revealed a blank to be filled in for the patient's diagnosis and description of the nature of the condition or ailment for which the medical treatment was indicated and recommended. Further review revealed a blank space for risks determined by the patient's physician to be added and a blank space for additional risks particular to this patient because of a complicating medical condition to be added.
Patient #7 Review of Patient #7's medical record revealed she was a 60 year old female admitted on 02/05/13 with diagnoses of Right Foot Osteomyelitis, Right Ankle Hardware Removal, ESRD (end stage renal disease) on Peritoneal Dialysis, and Diabetes Mellitus.

Review of Patient #7's physician orders revealed an order to transfuse 1 unit of packed red blood cells on 02/05/13 at 11:30 a.m. and an order to transfuse 2 units of packed red blood cells on 02/10/13 (no documented evidence of the time the order was signed by the physician).

Review of Patient #7's "Patient Consent to Medical Treatment or Surgical Procedure and Acknowledgement of Receipt of Medical Information Transfusion of Blood and Blood Components" signed by Patient #7 and her physician on 02/05/13 at 11:00 a.m. revealed no documented evidence Patient #7 was informed of the description and nature of the treatment/procedure and her diagnosis and description of the nature of her condition or ailment for which the blood transfusion was indicated and recommended as evidenced by these two areas being blank. Further review revealed the sections titled risks determined by her physician and additional risks particular to Patient #7 were blank. There was way to determine if these two areas had been addressed by Patient #7's physician. Further review revealed no documented evidence that the consent included "further transfusions" or "multiple transfusions may be required" to cover the lack of an informed consent for the blood administered on 02/10/13.

In a face-to-face interview on 02/15/13 at 2:30 p.m., Contract RN SupervisorS15 of Unit B confirmed the blood consent for Patient #7 was incomplete.

Patient #18 Patient #18 is 62 year-old female admitted to the hospital on 02/14/13 with an admit diagnosis of symptomatic anemia.
Review of Patient #18's "Transfusion of Blood and Blood Components" consent form dated 02/14/13 revealed the consent form was incomplete. Further review revealed the description and nature of the treatment (blood transfusion) and the patient's diagnosis and description of the nature of the condition for which the blood was ordered was left blank.
In an interview on 02/15/13 at 10:50 a.m., RN Contracted SupervisorS15 confirmed that the consent for blood transfusions was incomplete.
Patient#28 Review of Patient #28's medical record revealed he was a 59 year old male admitted on 02/12/13 with a diagnosis of Lung Cancer with Right Pleural Effusion.
Review of Patient #28's "Patient Consent to Medical Treatment or Surgical Procedure and Acknowledgement of Receipt of Medical Information -Transfusion of Blood and Blood Components" revealed no documented evidence Patient #28 was informed of the description and nature of the treatment/procedure nor his diagnosis and description of the nature of his condition or ailment for which the blood transfusion was indicated and recommended as evidenced by these two areas being blank on the blood consent form. Further review of the blood consent form revealed the sections titled risks determined by your doctor and additional risks particular to Patient#28 because of a complicating medical condition were also blank. There was no way to determine if these areas had been addressed by Patient #28's physician.

An interview on 02/18/13 at 10:45 a.m. was conducted with RNS22. RNS22 was asked about the blanks on Patient #28's blood consent. RNS22 indicated those areas should have been filled out by the physician.




30172

Based on record review and interview, the hospital's governing body (Health Care Services Division) failed to ensure the performance information was reviewed by the Operational Review Committee quarterly as required by the hospital's "Divisional Strategic Plan" as evidenced by having no Operational Review Committee meeting from 05/08/12 to the current time of the survey. Findings:

Review of the Health Care Services Division's "Divisional Strategic Plan" for fiscal year 2011-2012 through 2015-2016 revealed quarterly meetings would be held to conduct operational reviews on a wide range of performance information.

Review of the meeting minutes of the Operational Review Committee revealed meetings were held on 01/31/12 and 05/08/12. Further review revealed no documented evidence a meeting was held since 05/08/12.

In a face-to-face meeting on 02/18/13 at 2:25 p.m., Director of QualityS2 indicated an Operational Review Committee meeting had not been conducted since 05/08/12 until 01/13. He further indicated the meeting minutes for the meeting held in January 2013 had not been completed yet.

Based on record reviews and interviews, the hospital failed to ensure credentialed physicians met the educational requirements according to the approved core clinical privileges or the specialty's board for
a) 1 of 1 Internal Medicine/Pulmonary Medicine credentialing files reviewed from a total of 2 Internal Medicine/Pulmonary Medicine physicians on staff (S32) and
b) 1 of 1 Anesthesiologist's credentialing file reviewed from a total of 4 anesthesiologists (S33).

The hospital failed to ensure a CRNA (certified registered nurse anesthetist) maintained ACLS (advanced cardiac life support), PALS (pediatric advanced life support), and CPR (cardiopulmonary resuscitation) certifications for 1 of 2 CRNAs' credentialing files reviewed from a total of 12 credentialed CRNAs (S34). Findings:

PhysicianS32
Review of PhysicianS32's credentialing file revealed she was reappointed on 05/25/12. Review of her "Critical Care Medicine Clinical Privileges" effective 05/2512 to 05/25/14 revealed "applicants should achieve ACLS (advanced cardiac life support) and/or advanced trauma life support (ATLS) provider status.

Review of PhysicianS32's credentialing file revealed her ACLS certification expired 08/09, and there was no documented evidence of a current ATLS certification.

In a face-to-face interview on 02/18/13 at 10:15 a.m., Medical Staff Credentialing CoordinatorS35 indicated PhysicianS32 was scheduled to attend ACLS training on 02/19/13. She offered no explanation for PhysicianS32's ACLS certification not being renewed before expiration in 08/09.

AnesthesiologistS33
Review of AnesthesiologistS33's credentialing file revealed he was reappointed 07/27/12. Further review revealed his ACLS certification expired 11/12.

Review of the "Guidelines For Delineation Of Clinical Privileges In Anesthesiology", approved by the ASA (American Society of Anesthesiologists) House of Delegates on 10/15/03 and amended 10/22/08, revealed the educational criteria to be considered for delineation of clinical privileges in anesthesiology included demonstration of competency in advanced life support.

Review of CRNAS34's credentialing file revealed no documented evidence of certification in CPR, ACLS, and PALS.

In a face-to-face interview on 02/18/13 at 10:30 a.m., Medical DirectorS18 indicated the hospital had received a letter from the emergency physician board informing them that the emergency room physicians did not have to ACLS or ATLS certified. He further indicated when the hospital changed the policy for the emergency room physicians, they included the anesthesia staff and CRNAS. Medical DirectorS18 indicated he had no communication from the anesthesiology board or state board of nursing stating that anesthesiologists and CRNAs (certified registered nurse anesthetists) did not have to be ACLS certified.

Based on record reviews and interviews, the hospital failed to meet the requirements for the Condition of Participation for Nursing Services as evidenced by:

1) Failing to ensure a registered nurse (RN) supervised and evaluated the nursing care for each patient.
a) The RN failed to assess a patient with a change in condition related to blood pressure, temperature, and blood sugar for 3 of 19 active patients reviewed for RN assessment with a change in condition from a total of 31 sampled patients (#7, #9, #10).
b) The RN failed to perform a skin assessment of pressure ulcers that included measurements and skin condition for 2 of 19 active patients' records reviewed for skin assessments from a total of 31 sampled patients (#7, #16).
c) The RN failed to assess a patient upon the patient's return from PACU (post anesthesia care unit) to determine if the care required could be delegated to the LPN (licensed practical nurse) as required by the Louisiana State Board of registered Nurses Declaratory Statement for 1 of 6 active patients' records reviewed who had surgery from a total of 31 sampled patients (#7).
d) The RN failed to assess and clarify a patient's allergies that had a discrepancy in documentation in the medical record for 1 of 19 active patients' records reviewed for allergies from a total of 31 sampled patients (#17).
e) The RN failed to ensure the physician's plan of care for each patient was implemented related to x-rays and consults for 2 of 19 active patients' record reviewed for implementation of physician orders from a total of 31 sampled patients (#11, #16) (see findings in tag A0395).

2) Failing to ensure that drugs and biologicals were administered according to the orders of the physician for 3 of 19 active patients' records reviewed for medication administration from a total of 31 sampled patients (#3, #10, #16).
a) Patient #10, diagnosed with right inguinal cellulitis, was administered Motrin for elevated temperature when Tylenol was ordered by the physician.
b) Patient #16, a Type 2 diabetic with physician orders for sliding scale insulin, was not administered insulin on 9 occasions (over a 3 day period) when warranted by blood glucose readings. There were 15 medication errors identified during the survey that had not been identified by the hospital (see findings in tag A0405).

Based on observation, record reviews and interviews, the hospital failed to ensure a registered nurse (RN) supervised and evaluated the nursing care for each patient.

1) The RN failed to assess a patient with a change in condition related to blood pressure, temperature, and blood sugar for 3 of 19 active patients reviewed for RN assessment with a change in condition from a total of 31 sampled patients (#7, #9, #10).
2) The RN failed to perform a skin assessment of pressure ulcers that included measurements and skin condition for 2 of 19 active patients' records reviewed for skin assessments from a total of 31 sampled patients (#7, #16).
3) The RN failed to assess a patient upon the patient's return from PACU (post anesthesia care unit) to determine if the care required could be delegated to the LPN (licensed practical nurse) as required by the Louisiana State Board of registered Nurses Declaratory Statement for 1 of 6 active patients' records reviewed who had surgery from a total of 31 sampled patients (#7).
4) The RN failed to assess and clarify a patient's allergies that had a discrepancy in documentation in the medical record for 1 of 19 active patients' records reviewed for allergies from a total of 31 sampled patients (#17).
5) The RN failed to ensure the physician's plan of care for each patient was implemented related to x-rays and consults for 2 of 19 active patients' record reviewed for implementation of physician orders from a total of 31 sampled patients (#11, #16).
Findings:

Review of the hospital policy titled "Patient Assessment and Reassessment, including Discharge Planning", policy number 6-260, revised 08/09, reviewed 10/27/12, and presented by Director of QualityS2 as the current RN assessment policy, revealed the following:
1) The assessment and reassessment of the care and/or treatment needs of the patient is continuous throughout the patient's hospitalization;
2) At the time of admission, all patients will have an initial physical, functional, and psycho-social status assessment completed by the RN to assess the patient's need for nursing care; the nursing assessment must be completed within 24 hours after patient admission;
3) The RN collects, analyzes, and documents data about the patient to determine the need for additional data and the patient's health care or treatment needs; the LPN (licensed practical nurse) may assist the RN in data collection, but the RN determines and prioritizes the patient's initial and continuing nursing care needs;
4) Any significant change in the patient's condition and/or diagnosis necessitates an immediate reassessment with changes in the plan of care reflecting the change in diagnosis or condition; and
5) Patients are reassessed after treatment, therapy, or educational sessions to determine the effectiveness of the intervention; timeframes for reassessment are dependent upon the type of treatment or therapy. Further review revealed no specific time interval was given for the reassessment to be done, and it was left to the judgment of the nurse.
Attached to the policy was the "Point of Entry Skin Assessment" that included the Braden Scale for scoring risk factors that stated a wound care consult should be ordered for all total scores of 16 or less. Further review revealed the skin assessment included the figures that were to be labeled at the anatomical site using a numbered legend for non-blanchable erythema, skin irritation, rash, abrasion, bruising, burn, edema, incision, open wound, pressure ulcer: Stage, and other. Further review revealed that "if one of the above skin assessment findings have been identified, initiate Wound Management Protocol".

Review of the Louisiana State Board of Nursing's "Delegation Decision-Making Process" revealed R.S. (revised statute) 37:913(14)(f) provides that registered nursing includes delegating nursing interventions to qualified nursing personnel in accordance with criteria established by the Board of Nursing.

Review of the Louisiana State Board of Nursing's "Administrative Rules Defining RN Practice LAC46:XLVII" revealed the following: 1) "3703. Definition of Terms Applying to Nursing Practice" revealed when delegating nursing intervention, the RN retained the accountability for the total nursing care of the individual;
2) The registered nurse shall assess the patient care situation which encompasses the stability of the clinical environment and the clinical acuity of the patient, including the overall complexity of the patient's health care problems; the assessment shall be utilized to assist in determining which tasks may be delegated and the amount of supervision which will be required;
3) Any situation where tasks are delegated should meet the following criteria: a) the person has been adequately trained for the task; b) the person has demonstrated that the task has been learned; c) the person can perform the task safely in the given nursing situation; d) the patient's status is safe for the person to carry out the task; e) appropriate supervision is available during the task implementation; f) the task is in an established policy of the nursing practice setting and the policy is written, recorded and available to all;
4) The registered nurse may delegate to licensed practical nurses (LPN) the major part of the nursing care needed by individuals in stable nursing situations, i.e. (that is), when the following three conditions prevail at the same time in a given situation: a) nursing care ordered and directed by R.N./M.D. (medical doctor) requires abilities based on a relatively fixed and limited body of scientific fact and can be performed by following a defined nursing procedure with minimal alteration, and responses of the individual to the nursing care are predictable; b) change in the patient's clinical condition is predictable; c) medical and nursing orders are not subject to continuous change or complex modification.
1) The RN failed to assess a patient with a change in condition related to blood pressure, temperature, and blood sugar:
Patient #7
Review of Patient #7's medical record revealed she was a 60 year old female admitted on 02/05/13 with diagnoses of Right Foot Osteomyelitis, Right Ankle Hardware Removal, ESRD (end stage renal disease) on Peritoneal Dialysis, and Diabetes Mellitus.

Review of Patient #7's physician's orders revealed an order on 02/08/13 at 12:25 p.m. to check her fingerstick blood glucose before meals and at bedtime. Further review revealed the Hypoglycemic Protocol was to be initiated for a blood glucose reading below 70 mg/dl (milligrams per deciliter). Further review revealed the Hypoglycemic Treatment Protocol for blood glucose less than 70 mg/dl included the following:
1) If the patient was able to manage oral intake, give 15 grams of fast-acting carbohydrate (4 ounces fruit juice or non-diet soda, 8 ounces nonfat milk, or 1 tube of glucose gel);
2) If the patient cannot manage oral intake, give 12.5 gm (grams) of 50% (per cent) Dextrose as IV (intravenous) push; if no venous access, give Glucagon 1 mg subcutaneously;
3) Re-check the finger capillary glucose in 15 minutes and repeat above if blood glucose is less than 80 mg/dl;
4) Once blood glucose is over 80 mg/dl, give the patient a meal or snack to sustain the blood glucose; and
5) Call the House Officer if glucose is still less than 70 mg/dl after two treatments.

Review of Patient #7's nurses' notes for 02/09/13 revealed the following documentation by LPNS16:
11:22 a.m. - blood sugar 60; patient given orange juice; patient asymptomatic;
12:19 p.m. (57 minutes since the previous accucheck) - blood sugar 52; patient given orange juice; no documented evidence whether Patient #7 was asymptomatic;
1:28 p.m. (59 minutes since the previous accucheck) - blood sugar 56; patient given orange juice; no documented evidence whether Patient #7 was asymptomatic;
3:06 p.m. (1 hour and 36 minutes since the previous accucheck) - blood sugar 64; patient asymptomatic; patient given orange juice;
3:48 p.m. (42 minutes since the previous accucheck) - blood sugar 93.
Review of Patient #7's nurses' notes revealed no documented evidence Patient #7's treatment was administered according to physician orders (blood glucose not rechecked in 15 minutes and treatment repeated; notify the House Officer if the glucose is still less than 70 mg/dl after two treatments). There was no documented evidence that an RN assessed Patient #7 during the episode of hypoglycemia (change in patient condition). Further review revealed Patient #7 was not assessed by an RN until 8:50 p.m., 9 hours and 28 minutes after her first episode of low blood sugar.

In a face-to-face interview on 02/15/13 at 2:30 p.m., Contract RN SupervisorS15 from Unit B offered no explanation for an RN assessment not being performed when Patient #7 became hypoglycemic. She indicated that LPNS16 was probably better than some RNs on staff. When informed that an RN assessment was required with a change in condition according to the hospital policy as well as the Louisiana State Board of Registered Nurses, Contract RN SupervisorS15 offered no comment.

Patient #9
Review of Patient #9's medical record revealed he was a 52 year old male admitted on 02/07/13 with diagnoses of Mood Disorder and Homicidal Ideation.

Review of Patient #9's "Vital Signs" record revealed his blood pressure on 02/10/13 at 8:00 p.m. was 139/110, and a second reading was documented as 121/80 (vital signs taken by mental health techs). Review of his nurses' notes revealed no documented evidence of an RN assessment after a blood pressure reading of 139/110.

In a face-to-face interview on 02/14/13 at 2:20 p.m., Clinical CoordinatorS5 of Unit A indicated the patients' vital signs were taken by the MHTs (mental health tech). She further indicated that review of Patient #9's medical record revealed no evidence of an RN assessment of Patient #9 when the MHT received the first reading of 139/110.

Patient #10
Review of Patient #10's medical record revealed he was a 1 year old male admitted on 02/11/13 with diagnoses of Reactive Inguinal Lymph Adenopathy and Right Inguinal Cellulitis.

Review of Patient #10's physician orders dated 02/11/13 at 9:30 p.m. revealed an order for Tylenol 120 mg (milligrams) per rectum every 6 hours as needed for temperature greater than 101 degrees Fahrenheit (F).

Review of Patient #10's "Vital Signs" on the "Nursing Care Flowsheet Pediatrics" revealed his temperature was 101.9 degrees F on 02/12/13 at 8:00 a.m., 103.6 degrees F on 02/12/13 at 7:00 p.m., and 101.9 degrees F at 8:00 a.m. on 02/13/13.

Review of Patient #10's MARs (medication administration record) revealed no documented evidence he was given Tylenol as ordered for a temperature above 101 degrees F on 02/12/13 at 8:00 a.m. and 7:00 p.m. Further review revealed Patient #10 was administered Motrin 100 mg orally as ordered for pain on 02/12/13 at 11:36am by RNS24 (3 hours and 36 minutes after Patient #10's elevated temperature was noted). Further review of the MAR revealed Patient #10 was administered Motrin 100 mg orally on 02/12/13 at 6:54 p.m. Review of the nurse's note on 02/12/13 at 8:00 p.m. revealed Patient #10's temperature was noted to be 103.6 degrees F, and RNS25 documented that Motrin was administered by the previous nurse. There was no documented evidence that Patient #10's temperature was reassessed by an RN until 10:00 p.m., 2 to 3 hours after his temperature was noted to be elevated (2 different times noted - 7:00 p.m. on the vital sign record and 8:00 p.m. on the nurse's note). Further review revealed no documented evidence Tylenol was administered on 02/13/13 at 8:00 a.m. when Patient #10's temperature was 101.9 degrees F.

In a face-to-face interview on 02/14/13 at 3:30 p.m., Unit B RN SupervisorS14 indicated Patient #10's temperature should have been reassessed one hour after the administration of medication. She further indicated Tylenol was ordered by the physician for elevated temperature and not Motrin which was administered. Unit B RN SupervisorS14 indicated after reviewing Patient #10's record that Tylenol was not administered for the elevated temperature at 8:00 a.m. on 02/13/13.

2) The RN failed to perform a skin assessment of pressure ulcers that included measurements and skin condition:
Patient #7
Review of Patient #7's medical record revealed she was a 60 year old female admitted on 02/05/13 with diagnoses of Right Foot Osteomyelitis, Right Ankle Hardware Removal, ESRD (end stage renal disease) on Peritoneal Dialysis, and Diabetes Mellitus.

Review of Patient #7's nurse's note written by LPNS16 on 02/05/13 at 5:40 p.m. upon Patient #7's arrival from PACU revealed no documented evidence of an assessment of the skin. Further review revealed an assessment was performed on 02/05/13 at 8:30 p.m. by RNS27, and she documented the skin integrity as normal and the condition as "other" with "scabs" written. Review of RNS27's narrative notes revealed no documented evidence of the assessment of the scabs that included the location, number of scabs, the size of the scabs, and the condition of the skin surrounding the scabs.

Review of Patient #7's "Intensive Care Unit 24 Hour Flowsheet" dated 02/11/13 revealed RNS29 documented at 7:45 a.m. that Patient #7's area around her buttocks and peri area was red with some small sores, and a small area around the sacrum was nonblanching. Further review revealed no documented evidence of an assessment that included the size of each sore, the size of the sacral area that was nonblanching, and the condition of the skin surrounding the affected areas. Further review revealed RNS28 documented at 7:30 p.m. redness to the perineum and buttocks with multiple small bruises and skin tears to the bilateral upper extremities. Further review revealed no documented evidence of the size of the reddened area to the perineum and buttocks and the measurements of each skin tear with the condition of the surrounding skin.

Review of Patient #7's "Intensive Care Unit 24 Hour Flowsheet" dated 02/12/13 revealed RNS29 documented at 10:20 a.m. "buttocks/peri area remain red (with) some small sores". Further review revealed no documented evidence of an assessment of the sores that included the size, whether there was drainage or odor, and the condition of the surrounding skin.

Review of the "ICU (intensive care unit) Daily Skin Assessment" form for Patient #7 revealed the assessment of her risk factors using the Braden Scale (used to predict pressure ulcer risk) revealed her score on 02/11/13, 02/12/13, and 02/13/13 was 14 (moderate risk was 13-16). Further review of the form revealed the "ICU Skin Care Protocol" for moderate risk was to obtain a wound care consult. Review of the physician orders revealed a wound care consult was not ordered until 02/12/13 at 8:23 a.m. There was no documented evidence that a physician was notified of a request for a wound care consult on 02/11/13 when Patient #7's Braden score was first documented as a moderate risk at 14.

In a face-to-face interview on 02/15/13 at 2:30 p.m., Contract RN SupervisorS15 of Unit B could offer no explanation for not having RN assessments of wounds when documented by the RN. She confirmed there was no point of entry skin assessment for Patient #7.

Patient #16
Review of Patient #16's medical record revealed she was a 62 year old female admitted on 02/09/13 with diagnoses of Urosepsis, Alzheimer's Dementia, Hypertension, and Diabetes Mellitus Type 2.

Review of Patient #16's "Nursing Care Flowsheet" dated 02/09/13 revealed RNS23 documented at 9:15 a.m. "pressure ulcer - stage 2 - buttock - sacrum - open to air". Review of her "Point of Entry Skin Assessment" performed on 02/09/13 at 6:47 a.m. by RNS30 revealed Patient #16's Braden Scale score was 8 (high risk precautions for scores less than 13), and she had 2 pressure ulcers with the anatomical figure marked at the sacral area. Further review revealed no documented evidence of an RN assessment of the pressure ulcer that included the measurement, the presence or absence of drainage and odor, presence or absence of tunneling and undermining, and the condition of the surrounding tissue.

In a face-to-face interview on 02/15/13 at 11:10 a.m., Contract RN SupervisorS15 of Unit B confirmed there was no documented evidence of an assessment of Patient #16's pressure ulcer when documented by RNS23 and RNS30.

In a face-to-face interview on 02/18/13 at 9:35 a.m., Director of QualityS2 indicated the hospital did not have a wound assessment policy. He further indicated it was addressed in the hospital's assessment policy (policy included the "Point of Entry Skin Assessment" form with no documented evidence that wound measurements were to be done). A "Wound Management Protocol" policy was never presented by Director of QualityS2 (mentioned on the point of entry skin assessment form).

3) The RN failed to assess a patient upon the patient's return from PACU:
Patient #7
Review of Patient #7's medical record revealed she was a 60 year old female admitted on 02/05/13 with diagnoses of Right Foot Osteomyelitis, Right Ankle Hardware Removal, ESRD (end stage renal disease) on Peritoneal Dialysis, and Diabetes Mellitus.

Review of Patient #7's medical record revealed she was received from PACU on 02/05/13 at 5:40 p.m. by LPNS16 after having a surgical procedure. Further review revealed the surgical procedure was a Right Ankle Incision and Drainage (status post open reduction internal fixation of a right ankle bimalleous fracture) with Hardware removal with a Right Ankle External Fixation with a Wound Vacuum Placement. Further review revealed an RN did not perform a head-to-toe assessment until 02/05/13 at 8:30 p.m. (2 hours and 50 minutes after arriving from PACU) to determine if Patient #7's care could be delegated to a LPN as required by Louisiana State Board of Nursing.

In a face-to-face interview on 02/15/13 at 2:30 p.m., Contract RN SupervisorS15 from Unit B confirmed Patient #7 was not assessed by an RN upon her arrival to Unit B from PACU.

4) The RN failed to assess and clarify a patient's allergies that had a discrepancy in documentation in the medical record:
Review of Patient #17's medical record revealed she was a 43 year old female admitted on 02/14/13 with the diagnosis of Left Tibia Osteomyelitis.

Observation on 02/15/2013 of the front of Patient #17's medical record revealed the sticker applied to the front cover of the medical record had her allergy documented as NKDA (no known drug allergies).
Review of Patient #17's history and physical dated 02/14/13 revealed her allergy listed by the physician was codeine. Further review of the history and physical documentation by the medical student revealed her allergy listed was "Codeine. Makes stomach upset (Tylenol 3)."
Review of Patient #17's hospital admission orders dated 02/14/13 revealed her allergy was listed as "Tylenol 3."
Review of Patient #17's Medication Administration Record for 02/14/13 to 02/15/13 and 02/15/13 to 02/16/13 revealed her allergy was documented as "Tylenol-Codeine #3" by pharmacy services.
Review of Patient #17's nurses' notes dated 02/14/2013 revealed the section titled "Allergies" and the nurses' narrative section were documented as "NKA" (no known allergies).
Review of 4 physician orders sheets dated 02/14/13 through 02/15/13, two sheets with orders and two blank order sheets, revealed the Drug Allergies section was documented as "NKDA" (no known drug allergies).
In an interview on 02/15/13 at 9:50 a.m., RN Contracted SupervisorS15 indicated there were inconsistencies with allergy documentation on Patient #17's medical record, and there was no documentation of further assessment and clarification of medication allergies by the nursing staff. RN Contracted SupervisorS15 further indicated there was no documentation in the chart that indicated Patient #17 was not allergic to codeine.
5) The RN failed to ensure the physician's plan of care for each patient was implemented related to x-rays and consults: Patient #11 Patient #11 is a 55 year old female admitted to the hospital on 02/13/13 with a diagnosis of left lower leg cellulitis.
Review of the physician order sheet dated 02/13/13 revealed that a routine chest x-ray was ordered for Patient #11. Further review of the medical record revealed there was no documented evidence that a chest x-ray was done for Patient #11.
In a face-to-face interview on 02/14/13 at 3:00 p.m., RN Contracted SupervisorS15 confirmed there was no order in the computer data base indicating that a chest x-ray had been entered for Patient #11. She further confirmed that there was no indication that the chest x-ray had been done, and there was no report for a chest x-ray in the medical record or the computer data base.
In a face-to-face interview on 02/14/13 at 3:15 p.m., RNS23 confirmed that Patient #11 had not been to the radiology department on her shift to obtain a chest x-ray.
Patient #16 Review of the hospital's "Bylaws, Rules and Regulations of the Medical Staff", approved on 12/13/12 and presented by administration as the current medical staff bylaws, revealed a "Consultation Form" should be completed and placed on the front of the patient's medical record, and the consulting practitioner was responsible for notifying the consultant. Further review revealed the consultant will record his/her findings and recommendations in the medical record on the "Consultation Form" that will be signed and dated by the consultant. Further review revealed routine consultations should be answered within forty-eight (48) hours of receipt either verbally or written.

Review of Patient #16's medical record revealed she was a 62 year old female admitted on 02/09/13 with diagnoses of Urosepsis, Alzheimer's Dementia, Hypertension, and Diabetes Mellitus Type 2.

Review of Patient #16's admission orders dated 02/09/13 at 5:00 a.m. revealed an order for a wound care consult.
Review of Patient #16's "Wound Care Nurse Consult/Referral Form" revealed the date of request was 02/09/13 at 8:36 a.m., and the wound care nurse performed the assessment on 02/13/13 at 10:00 a.m. The assessment was performed 96 hours after ordered rather than within 48 hours as required by the medical staff bylaws.
In a face-to-face interview on 02/15/13 at 11:10 a.m., Contract RN SupervisorS15 from Unit B confirmed Patient #16's wound care consult was not completed within 48 hours as required by the medical staff bylaws.

Based on record reviews and interviews, the hospital failed to ensure the nursing staff developed and kept current a nursing care plan for each patient.
1) The nursing staff failed to ensure the "Master Treatment Plan" was completed by the third day of admission as required by hospital policy for 1 of 2 psychiatric treatment plans reviewed for treatment plan implementation from a total of 31 sampled patients (#3).
2) The nursing staff failed to ensure a patient's treatment interventions were implemented according to the patient's treatment plan for 1 of 2 psychiatric patients' records reviewed from a total of 31 sampled patients (#9).
3) The nursing staff failed to revise a patient's treatment with changes in patient behavior for 1 of 2 psychiatric patients' records reviewed for care plan revision from a total of 31 sampled patients (#3).
Findings:

Review of the hospital policy titled "Master Treatment Plan Acute Care Psychiatric Unit", policy number P-129, revised 11/06, reviewed 01/13, and presented as the current policy by Director of QualityS2, revealed each discipline would complete their assessments within the respective time frames, report their findings, and state their recommendations on the Interdisciplinary Assessment and in the treatment team meetings. Further review revealed the unit Psychiatrist would direct all care plan discussions and development of the treatment plan. Further review revealed the Master Treatment Plan would be completed and initiated under the Psychiatrist's guidance by the third day of admission.

Review of the hospital policy titled "Interdisciplinary Treatment Team and Treatment Plan Acute Care Psychiatric Unit", policy number P-105, revised 08/10, reviewed 01/13, and presented by Director of QualityS2 as a current policy, revealed the following:
1) The Master Treatment Plan is developed by the third day of admission; goals are prioritized and should be realistically achievable by discharge;
2) Master Treatment goals will include short-term hospital goals, intermediate treatment goals, long-term life goals; all goals should be measurable and described in behavioral terms;
3) The Treatment Plan shall include specific interventions suggested by the treatment team and ordered by the staff psychiatrist or his designee; the responsible discipline and frequency of each intervention shall be indicated;
4) Any changes to the patient's treatment plan shall be recorded in the Interdisciplinary Progress Notes under the heading "Treatment Team" and the Master Treatment Plan.

Review of the hospital policy titled "Group Therapy/Psycho-education", policy number P-124, revised 01/13, and presented as a current policy by Director of QualityS2, revealed the counseling staff will attempt to follow the Program Schedule outlining days/times for group sessions as the demands of the work day will allow. Further review revealed appropriate documentation by the staff member in each of the patient's charts should include participation and/or refusal, behavior, intervention, response, and plan for follow-up.

1) The nursing staff failed to ensure the "Master Treatment Plan" was completed by the third day of admission as required by hospital:
Review of Patient #3's medical record revealed she was a 30 year old female admitted on 02/10/13 with diagnoses of Bipolar Disorder and Manic Recent Episode.

Review of Patient #3's "Interdisciplinary Treatment Plan" on 02/13/13, the third day after admission, revealed no documented evidence that the following items had been addressed as evidenced by areas being blank or not checked:
a) Diagnoses including Axis I, II, III, IV, and V and estimated length of stay;
b) Patient's strengths
c) Patient's weaknesses;
d) Discharge planning;
e) Target date for achievement for problems identified: Psychosis, Elevated Mood, Poor Impulse Control, Pain, Fall Risk;
f) Clinical interventions for the nursing staff and counseling.

In a face-to-face interview on 02/13/13 at 2:15 p.m., Clinical CoordinatorS5 for Unit A indicated the treatment plan was completed in the treatment team meeting which would be conducted the next day (fourth day after admission). She further indicated the target dates were filled in on the initial treatment plan by Unit A Program ManagerS12 (a licensed clinical social worker). Clinical CoordinatorS5 for Unit A indicated the clinical intervention was selected by the nurse only if it was a physical problem, otherwise it was selected by Unit A Program ManagerS12. She confirmed that Patient #3's nursing interventions should have been completed by the nurse as of this time.

In a face-to-face interview on 02/14/13 at 2:30 p.m., Unit A Program ManagerS12 confirmed Patient #3's treatment plan was not completed in 3 days of admission.

2) The nursing staff failed to ensure a patient's treatment interventions were implemented according to the patient's treatment plan:
Review of Patient #9's medical record revealed he was a 52 year old male admitted on 02/07/13 with diagnoses of Mood Disorder and Homicidal Ideation.

Review of Patient #9's treatment plan revealed his identified problems on 02/07/13 were altered thoughts as evidenced by ideas of reference, disorganized speech, and decreased concentration and mood disturbance as evidenced by mood swings, sleep disturbance, and decreased concentration. Further review revealed the problem of inability to remain drug/alcohol free as evidenced by inability to maintain sobriety despite negative consequences and labile emotions was identified on 02/08/13. Further review revealed the clinical intervention for all 3 problems was that Patient #9 was to attend group psychotherapy once a day for one hour 1 to 5 days a week.

Review of Patient #9's narrative notes revealed Patient #9's psychosocial assessment was conducted on 02/08/13 at 8:38 a.m. Further review revealed Patient #9 attended a group psychotherapy session on 02/08/13 at 10:30 a.m. and 02/13/13 at 4:48 p.m. There was no documented evidence of the attempt at participation or the refusal to attend group sessions in Patient #9's medical record.

In a face-to-face interview on 02/14/13 at 1:45 p.m., Unit A Program ManagerS12 indicated it was ideal for a patient to attend group psychotherapy 5 days a week. She further indicated the staff used a range in frequency to cover the days that attendance did not occur.

In a face-to-face interview on 02/14/13 at 2:30 p.m., PsychiatristS31 indicated he doesn't order group therapy, because every patient receives group therapy. He further indicated group therapy was offered daily, and patients were exempt for attendance for the first 24 hours of admission. He further indicated after the initial 24 hours, there should be documentation of the patient's attendance daily or the attempt and refusal of the patient.

3) The nursing staff failed to revise a patient's treatment with changes in patient behavior:
Review of Patient #3's medical record revealed she was a 30 year old female admitted on 02/10/13 with diagnoses of Bipolar Disorder and Manic Recent Episode.

Review of Patient #3's nurses' narrative notes revealed the following:
02/10/13 at 1:00 p.m. - speech rapid, pressured, frequent cursing, and sexually inappropriate statements;
02/11/13 at 6:35 a.m. - patient flirtatious with staff and peers;
02/11/13 at 10:30 p.m. - flirtatious with males and females; required frequent redirection;
02/12/13 at 5:40 a.m. - hypersexual with no documented evidence of specific behaviors exhibited by Patient #3;
02/12/13 at 10:00 p.m. - needs frequent redirection to not touch males;
02/13/13 at 2:40 a.m. - needing frequent redirection for sexually inappropriate statements;
02/13/13 at 10:05 a.m. - hypersexual hypersexual with no documented evidence of specific behaviors exhibited by Patient #3.

Review of Patient #3's treatment plan on 02/13/13 revealed one of her identified problems initiated on 02/10/13 was elevated mood as evidenced by labile affect, pressured speech, racing thoughts, flight of ideas, and grandiosity. Further review revealed one of the goals was that Patient #3 would decrease her impulsivity by 90% (per cent) with examples being not engaging in self-destructive behaviors, physical aggression, hyper-sexual behavior, and use of profanity. Further review revealed the elevated mood treatment plan was pre-printed, and there was no documented evidence of hand-written behaviors and clinical interventions specific to Patient #3 relating to hyper-sexual behavior. Review of Patient #3's treatment plan for poor impulse control revealed it was initiated 02/11/13 and included the addition of "pulled object down from ceiling on prior shift". There was no documented evidence that Patient #3's treatment plan had been revised to include her hypersexual behaviors from 02/10/13 through 02/13/13.

In a face-to-face interview on 02/13/13 at 2:40 p.m., Clinical CoordinatorS5 for Unit A confirmed Patient #3's treatment was not implemented or revised to address her hypersexual/sexually inappropriate behaviors exhibited from 02/10/13 through the time of the record review on 02/13/13.

Based on record reviews and interviews, the hospital failed to ensure that drugs and biologicals were administered according to the orders of the physician for 3 of 19 active patients' records reviewed for medication administration from a total of 31 sampled patients (#3, #10, #16). Patient #10, diagnosed with right inguinal cellulitis, was administered Motrin for elevated temperature when Tylenol was ordered by the physician. Patient #16, a Type 2 diabetic with physician orders for sliding scale insulin, was not administered insulin on 9 occasions (over a 3 day period) when warranted by blood glucose readings. There were 15 medication errors identified during the survey that had not been identified by the hospital. Findings:

Review of the hospital policy titled "Timely Administration of medications", policy number 5-209, revised 11/12, and submitted by Director of QualityS2 as a current medication administration policy, revealed that missed doses of medications due to patient refusal must be documented on the MAR (medication administration record), and the prescriber must be notified.

Patient #3
Review of Patient #3's medical record revealed she was a 30 year old female admitted on 02/10/13 with diagnoses of Bipolar Disorder and Manic Recent Episode.

Review of Patient #3's physician admit orders dated 02/10/13 at 9:00 a.m. revealed an order for a Nicotine Transdermal Patch 21 mg (milligrams) every 24 hours.

Review of Patient #3's MARs revealed she refused the Nicotine patch on 02/10/13, 02/11/13, and 02/12/13. Further review revealed LPNS6 documented that a Nicotine patch was removed and a Nicotine 21 mg patch was applied to the right chest on 02/13/13 at 8:51 a.m. Review of the nurses' notes and MARs revealed no documented evidence the physician was notified of Patient #3's refusal of the Nicotine patch for 3 days as required by hospital policy.

In a face-to-face interview on 02/13/13 at 2:55 p.m., LPNS6 indicated she applied a Nicotine patch to Patient #3's chest, but she did not remove a patch. She further indicated she must have pushed the "yes" button on the hand-held "patient touch" device used during medication administration.

Patient #10
Review of Patient #10's medical record revealed he was a 1 year old male admitted on 02/11/13 with diagnoses of Reactive Inguinal Lymph Adenopathy and Right Inguinal Cellulitis.

Review of Patient #10's physician orders dated 02/11/13 at 9:30 p.m. revealed an order for Tylenol 120 mg (milligrams) per rectum every 6 hours as needed for temperature greater than 101 degrees Fahrenheit (F).

Review of Patient #10's "Vital Signs" on the "Nursing Care Flowsheet Pediatrics" revealed his temperature was 101.9 degrees F on 02/12/13 at 8:00 a.m., 103.6 degrees F on 02/12/13 at 7:00 p.m., and 101.9 degrees F at 8:00 a.m. on 02/13/13.

Review of Patient #10's MARs (medication administration record) revealed no documented evidence he was given Tylenol as ordered for a temperature above 101 degrees F on 02/12/13 at 8:00 a.m. and 7:00 p.m. Further review revealed Patient #10 was administered Motrin 100 mg orally as ordered for pain on 02/12/13 at 11:36am by RNS24 (3 hours and 36 minutes after Patient #10's elevated temperature was noted). Further review of the MAR revealed Patient #10 was administered Motrin 100 mg orally on 02/12/13 at 6:54 p.m. Review of the nurse's note on 02/12/13 at 8:00 p.m. revealed Patient #10's temperature was noted to be 103.6 degrees F, and RNS25 documented that Motrin was administered by the previous nurse. Further review revealed no documented evidence Tylenol was administered on 02/13/13 at 8:00 a.m. when Patient #10's temperature was 101.9 degrees F.

In a face-to-face interview on 02/14/13 at 3:30 p.m., Unit B RN SupervisorS14 indicated Tylenol was ordered by the physician for elevated temperature and not Motrin which was administered. Unit B RN SupervisorS14 indicated after reviewing Patient #10's record that Tylenol was not administered for the elevated temperature at 8:00 a.m. on 02/13/13. She further indicated no medication variance report had completed for the incorrect medication being administered and for the medication not being administered when Patient #10's temperature was elevated.

Patient #16
Review of Patient #16's medical record revealed she was a 62 year old female admitted on 02/09/13 with diagnoses of Urosepsis, Alzheimer's Dementia, Hypertension, and Diabetes Mellitus Type 2.

Review of Patient #16's "Physician Order Set - Subcutaneous Insulin" dated 02/09/13 at 9:30 a.m. revealed fingerstick blood glucose checks were to be done before meals and at bedtime. Further review revealed Patient #16 was to be administered Novolog Insulin subcutaneously according to the following sliding scale:
70-159 mg/dl (milligrams per deciliter) - 0 units
160-199 mg/dl - 1 unit
200-239 mg/dl - 2 units
240-269 mg/dl - 3 units
270-299 mg/dl - 4 units
Greater than 299 mg/dl - 5 units

Review of Patient #16's MARs and nurses' notes revealed the following blood glucose results that warranted insulin administration according to physician orders that was not administered:
02/11/13 at 4:00 p.m.- blood glucose 183; no insulin administered; 1 unit Novolog Insulin should have been administered according to physician order;
02/12/13 at 6:00 a.m. - blood glucose 191; no insulin administered; 1 unit Novolog Insulin should have been administered according to physician order;
02/12/13 at 10:59 a.m. - blood glucose 169; no insulin administered; 1 unit Novolog Insulin should have been administered according to physician order;
02/12/13 at 15:39 p.m. - blood glucose 170; no insulin administered; 1 unit Novolog Insulin should have been administered according to physician order;
02/12/13 at 9:54 p.m. - blood glucose 161; no insulin administered; 1 unit Novolog Insulin should have been administered according to physician order;
02/13/13 at 5:32 a.m. - blood glucose 189; no insulin administered; 1 unit Novolog Insulin should have been administered according to physician order;
02/13/13 at 10:39 a.m. - blood glucose 186; no insulin administered; 1 unit Novolog Insulin should have been administered according to physician order;
02/13/13 at 3:11 p.m. - blood glucose 186; no insulin administered; 1 unit Novolog Insulin should have been administered according to physician order;
02/13/13 at 9:30 p.m. - blood glucose 169; no insulin administered; 1 unit Novolog Insulin should have been administered according to physician order.

In a face-to-face interview on 02/15/13 at 11:10 a.m., Contract RN SupervisorS15 from Unit B confirmed Patient #16 did not receive Novolog Insulin according to the sliding scale ordered by her physician.

Based on record reviews and interviews, the hospital failed to ensure blood was administered according to hospital policy. The nurse failed to monitor blood administration according to hospital policy for 2 of 3 patients' records reviewed for blood administration from a total of 31 sampled patients (#7, #18). Findings:

Review of the hospital policy titled "Blood and Blood Components, Administration of", policy number NA-03-004, revised 02/13, reviewed 2007, and presented by Contract RN (registered nurse) SupervisorS15 from Unit B, revealed the following:
1) The RN may not delegate the function of administration of Blood and Blood Components;
2) Obtain baseline assessment and vital signs including temperature, pulse, respirations, and blood pressure;
3) Check for physician's order;
Infuse slowly for the first 15 minutes, observing patient for adverse reactions and assessing thereafter as appropriate;
4) Adjust infusion rate based on clinical condition of the patient, blood component being transfused, and physician orders;
5) Infuse in 4 hours or less from the time the blood was obtained from the blood bank;
6) Assess vital signs and record on the "Transfusion Flowsheet" every 15 minutes times 4, every 30 minutes times 2, then every hour until the transfusion is complete; repeat this sequence for each unit administered.

Review of the Louisiana State Board of Nursing's "Administrative Rules Defining RN Practice LAC46:XLVII" revealed the registered nurse may delegate to licensed practical nurses (LPN) the major part of the nursing care needed by individuals in stable nursing situations, i.e. (that is), when the following three conditions prevail at the same time in a given situation: a) nursing care ordered and directed by R.N./M.D. (medical doctor) requires abilities based on a relatively fixed and limited body of scientific fact and can be performed by following a defined nursing procedure with minimal alteration, and responses of the individual to the nursing care are predictable; b) change in the patient's clinical condition is predictable; c) medical and nursing orders are not subject to continuous change or complex modification.

Patient #7
Review of Patient #7's medical record revealed she was a 60 year old female admitted on 02/05/13 with diagnoses of Right Foot Osteomyelitis, Right Ankle Hardware Removal, ESRD (end stage renal disease) on Peritoneal Dialysis, and Diabetes Mellitus.

Review of Patient #7's physician orders revealed an order to transfuse 2 units of packed red blood cells on 02/10/13 (no documented evidence of the time the order was signed by the physician).
Review of Patient #7's "Transfusion Flowsheet" and the nurse's notes dated 02/10/13 revealed all documentation of the blood administration and monitoring was by LPNS16 (licensed practical nurse) except for the RN's signature as the person initiating each unit of blood. Further review revealed the first unit of blood was started at 10:00 a.m. and completed at 1:05 p.m. Further review revealed no documented evidence the blood was infused slowly for the first 15 minutes and assessed by an RN for adverse reactions as required by hospital policy. Further review revealed no documented evidence of Patient #7's vital signs at 1:00 p.m. as required by hospital policy (one hour after the second 30 minute assessment). Further review revealed the second unit of blood was started at 1:30 p.m. and completed at 3:30 p.m. Review of Patient #7's blood pressure at the start of the second unit revealed it was 131/50 and at 2:00 p.m. it was 89/52. There was no documented evidence of an RN assessment when Patient #7's blood pressure dropped from 131/50 at 1:30 p.m. to 97/70 at 1:45 p.m. and to 89/52 at 2:00 p.m.

In a face-to-face interview on 02/15/13 at 2:30 p.m., Contract RN SupervisorS15 indicated LPNS16 was probably a better nurse than some RNs. When told of Louisiana State Board of Nursing's declaratory statement on the RN delegating to the LPN, Contract RN SupervisorS15 had no comment to offer. She confirmed the nursing documentation for Patient #7's blood administration and monitoring was by LPNS16.

Patient #18 Patient #18 is a 62 year old female admitted to the hospital on 02/14/13 with an admit diagnosis of symptomatic anemia. Further review revealed additional diagnoses of congestive heart failure (CHF) and coronary artery disease (CAD).
Review of Patient #18's physician order dated 02/14/13 for transfusion of blood products revealed an order to transfuse 2 units of PRBC's (packed red blood cells) and to premedicate the patient with Tylenol 650 mg (milligrams) and Benadryl 25 mg po (by mouth) times 1.
Review of Patient #18's nurse's note and "Transfusion Flowsheet" revealed no documented evidence the blood was infused slowly for the first 15 minutes and assessed by an RN for adverse reactions as required by hospital policy.
In a face-to-face interview on 02/14/13 at 10:50 a.m., RN Contracted SupervisorS15 indicated that there was not a specified duration of time for the transfusion of the blood ordered by the physician.

Based on record reviews and interviews, the hospital failed to ensure patient medical records were promptly completed within 30 days from the patient's date of discharge as required by the hospitals' medical staff bylaws. The hospital had 173 delinquent patient records with the longest date being from 08/12. Findings:

Review of the hospital's "Bylaws, Rules and Regulations of the Medical Staff", approved on 12/13/12 and presented by administration as the current medical staff bylaws, revealed the attending physician was responsible for the preparation of a medical record for each patient and for having the entire record completed within 30 days from the date of the patient's discharge from the hospital.

Review of the "Medical Record Delinquency Report" dated 02/15/13, provided as the current delinquency list by RHIAS17 (registered health information administrator), revealed the hospital had 173 delinquent patient records. Further review revealed 44 practitioners had delinquent medical records. Further review revealed 3 practitioners had patient records delinquent as far back as 08/12.

In a face-to-face interview on 02/15/13 at 3:00 p.m., RHIAS17 indicated the hospital's delinquency rate was currently 7% (per cent). When asked how the medical record delinquencies were handled, RHIAS17 indicated a delinquent chart notice was sent to the physician every other week, and an update was sent weekly to the Administrator, Medical Director, Department Heads, the Medical Staff over the residents, the Director of Nursing, and the Director of Quality. She further indicated the hospital did not suspend physicians for delinquent medical records.

In a face-to-face interview on 02/18/13 at 5:00 p.m., Medical DirectorS18 indicated when he recognized an increase in a physician's delinquent record count, he (Medical DirectorS18) would speak with the physician. He further indicated he did not have documentation of his verbal conversations with any of the physicians. When asked about his having the greatest number of delinquent medical records, Medical DirectorS18 indicated the majority of his delinquencies were related to his signature needed on the wound care nurse's notes.

Based on record reviews and interviews, the hospital failed to ensure medical records entries were complete, dated, timed, and authenticated by the person responsible for providing the service for 7 of 19 active patient records reviewed for complete medical record entries from a total of 31 sampled patient records (#3, #8, #10, #12, #13, #14, #15). Findings:

A review of the hospital policy titled "Medical Record Content", revised 02/02/09 and provided by Director of QualityS2 as being the most current policy, revealed that all medical record entries shall be timed, dated, have identified author of the entry, and be authenticated. Further review revealed the Brief Operative Note shall be written immediately after surgery, and the Operative Report was to be dictated immediately following surgery.
A review of the Brief Operative Note revealed a one sheet form with spaces to document the following: date of operation, pre-operative diagnosis, post-operative diagnosis, operations, surgeons, first assistant, staff, operative findings, specimens, anesthesia, complications, estimated blood loss, fluids, drains, and comments. The bottom right hand of the form had a boxed area with 4 options with #4 option requiring further documentation. Underneath the 4 options was another small boxed area with the word "initials" typed under it. The bottom left of the form had a space for the provider's signature, the date, and the time. Next to the provider's signature to the right there was another space for the staff signature, the date, and the time. Underneath the signature lines was a space for the dictation number.
Patient #3
Review of Patient #3's medical record revealed she was a 30 year old female admitted on 02/10/13 with diagnoses of Bipolar Disorder and Manic Recent Episode.

Review of Patient #3's "Acute Psychiatric Unit Patient Flow Sheet" revealed no documented evidence of the date on the flow sheet. Further review revealed the flow sheet included the nursing assessment, suicidal/homicidal assessment, physical assessment, fall assessment, activity and activities of daily living, and the observations made by the mental health techs.

In a face-to-face interview on 02/13/13 at 2:45 p.m., Unit A Clinical CoordinatorS5 indicated the flow sheet should have included the date of 02/10/13. She confirmed the date was not documented on the flow sheet.

Patient #8
A review of the Brief Operative Note for Patient #8 revealed the bottom right hand boxed area had #4 option checked with no initials present in the smaller boxed area underneath. The signature section at the bottom of the form revealed the staff signed, dated, and timed the form prior to the provider completing the form.

Patient #10
Review of Patient #10's medical record revealed he was a 1 year old male admitted on 02/11/13 with diagnoses of Reactive Inguinal Lymph Adenopathy and Right Inguinal Cellulitis.

Review of Patient #10's "Consult/Referral Form" for urology revealed no documented evidence of the date and time the consult was written. Further review revealed no documented evidence of the signature of the physician who wrote the consult.

In a face-to-face interview on 02/14/13 at 3:20 p.m., RN (registered nurse) Quality Management Program CoordinatorS13 confirmed the urology consult for Patient #10 was not dated, timed, and authenticated.

Patient #12
A review of the Brief Operative Note for Patient #12 revealed in the signature section at the bottom of the form, the staff signed, dated, and timed the form prior to the provider completing the form.
Patient #13
A review of the Brief Operative Note for Patient #13 revealed the bottom right hand boxed area had #4 option checked with further documentation noted and no initials present in the smaller boxed area underneath. The space on the bottom of the form for the dictation number was blank.
Patient #14
A review of the Brief Operative Note for Patient #14 revealed in the signature section on the bottom of the form had no staff signature. The space on the bottom of the form for the dictation number was blank.
Patient #15
A review of the Brief Operative Note for Patient #15 revealed the bottom right hand boxed area had #4 option checked with no further documentation noted and no initials in the smaller boxed area underneath. The signature section of the form further revealed the staff had signed, dated, and timed the form prior to the provider completing the form.
An interview on 02/18/13 at 5:00 p.m. was conducted with Medical DirectorS18. Medical DirectorS18 was asked about the requirements for completing the Brief Operative Note form. After Medical DirectorS18 reviewed the Brief Operative Note forms for Patients #8, #12, #13, #14, and #15, he confirmed the forms were not completed as required by the medical record policy. Medical DirectorS18 indicated the staff should sign the form after the provider had completed the form verifying the information was correct. He also indicated whenever option #4 was checked in the boxed area to the right, further documentation should be present. He further indicated a detailed operative report should be dictated following surgery, and the dictation number should be included on the form when signed by the staff. Medical DirectorS18 indicated the smaller boxed area in the larger boxed area with the initials typed under it was no longer required to be initialed and had not been changed in the policy.

Based on observations, record reviews, and interviews, the hospital failed to ensure medical equipment was maintained to ensure an acceptable level of safety and quality. The hospital failed to calibrate a scale and manual sphygmomanometers according to hospital policy and manufacturer's guidelines. Findings:

Review of the hospital policy titled "Accuracy Testing Sphygmomanometer, Non-Electrical", policy number 5-ME-PM48A, revised 08/94, reviewed 01/12, and presented as the current policy by Director of QualityS2, revealed the non-electrical sphygmomanometer would receive operational checks for accuracy and cleaning annually by the Biomedical Engineering department. Further review revealed the policy was regarding mercury non-electrical sphygmomanometers.

Review of the manufacturer guidelines for the "Welch Allyn Wall and Mobile Aneroid Sphygmomanometer", presented by Support Services DirectorS7, revealed Welch Allyn recommended a full check of calibration at least every 2 years or according to local law and after maintenance and repair.

Review of the hospital policy titled "Verification of Functionality and Accuracy of Scales (Calibration)", policy number 5-ME-PM 59, reviewed 01/12, and presented by Support Services DirectorS7 as the hospital's current policy for scale inspections, revealed hospital scales would receive an operational check for accuracy and electrical safety annually by the Biomedical Engineering department.

Observation of the supply room on Unit A on 02/13/13 at 11:40 a.m. revealed a standing scale and a manual sphygmomanometer with no documented evidence that they had been inspected for accuracy and safety.

Observation of Unit F on 02/14/13 at 10:05 a.m. revealed a manual sphygmomanometer with no documented evidence that they had been inspected for accuracy and safety.

Review of the "Medical Scale Inventory (Calibration List)" presented by Support Services DirectorS7 revealed Unit A's scale was listed as being inspected on 02/13.

In a face-to-face interview on 02/14/13 at 9:00 a.m., Support Services DirectorS7 indicated the Welch Allyn sphygmomanometer should be calibrated every 2 years, and the sphygmomanometers at the hospital had never been calibrated. When Support Services DirectorS7 presented the "Medical Scale Inventory (Calibration List)", she indicated she didn't know which day in February the Unit A scale had been calibrated.

In a face-to-face interview on 02/14/13 at 11:10 a.m., Support Services DirectorS7 indicated Unit A's scale had not been calibrated until the lack of calibration was identified during the survey on 02/13/13.

Based on record review and interview, the hospital failed to ensure the person designated as the infection control officer had acquired specialized training in infection. The designated nurse had no prior experience or specialized training in infection control (S20). Findings:

Review of Infection Control OfficerS20's personnel file revealed her prior nursing experience was in the neonatal intensive care unit, pediatrics, and the inpatient surgery unit. There was no documented evidence of experience in infection control.

Review of a list presented by Infection Control OfficerS20 of the items she had reviewed with the former Infection Control Officer within the previous month revealed no documented evidence of the signature of and evaluation by the former Infection Control Officer.

Review of the "Initial Sill/Competency Validation" presented by Director of QualityS2 revealed competency evaluations had been performed by Director of QualityS2 (not the experienced infection control officer) on 01/28/13, 02/04/13, 02/05/13, and 02/08/13.

In a face-to-face interview on 02/18/13 at 1:30 p.m., Infection Control OfficerS20 Indicated her previous experience was mostly with high-risk neonates. She further indicated she had no experience in infection control other than her basic nursing experience, and she had not had any specialized training in infection control.

Based on observation, record reviews, and interviews, the infection control officer failed to investigate, report, and control infections and communicable diseases.
1) The infection control officer failed to investigate 2 catheter-associated urinary tract infections and 2 central line infections identified by the Infection Control department in December 2012.
2) The infection control officer failed to ensure the maintenance of a sanitary physical environment as evidenced by patient mattresses on Unit A and Unit E with tears that prevented the surface from being disinfected properly.
3) The infection control officer failed to mitigate the risks of infection as evidenced by staff on Unit E wearing the same mask used as personal protective equipment when going from the restricted zone to the semi-restricted zone and back to the restricted zone.
4) The infection control officer failed to ensure hand hygiene practices in Unit G were implemented as evidenced by breaches in hand hygiene on 02/14/13 by PhlebotomistS8, Medical TechnologistS9, and Blood Bank SupervisorS10.
Findings:

1) The infection control officer failed to investigate 2 catheter-associated urinary tract infections and 2 central line infections identified by the Infection Control department in December 2012:
A review of the hospital policy titled "Department Guidelines: Infection Control Department", policy number IC-14-004, revised 04/03, reviewed 0612, and presented as the current policy by Director of QualityS2, revealed the purpose of the Infection Control department was to reduce the risk of transmission of infections by performing specific monitoring of device-related infections, identifying nosocomial infections and determining measures to decrease their occurrence, taking action to prevent and control infections based upon evaluation of surveillance reports of infections and infection potential, and reviewing focuses on those infections that present the potential for prevention or intervention to reduce the risk of future occurrence.
A review of the hospital's Infection Prevention and Control Report for December 2012 provided by Director of QualityS2 and prepared by Infection Control OfficerS20 revealed the central line infection rate for July, August, September, October and November 2012 was 0% (per cent). The central line infection rate for December was 12.35%. Further review revealed the catheter-associated urinary tract infection rate for September and October 2012 was 0%. Further review revealed the catheter-associated urinary tract infection rate was 7.81% in November 2012 and 8.30% in December . Review of the Infection Prevention and Control Report for December 2012 revealed no documented evidence of any investigation into the increase in the infection rates for the central line infections or the catheter-associated urinary tract infections.
An interview on 02/18/13 at 1:35 p.m. was conducted with Infection Control OfficerS20. She was asked for the investigations done in relation to the increase in the catheter-associated urinary tract infection rate and the central line infection rate that were reported by the Infection Control department in December 2012. She indicated since the infection control rate for catheter-associated urinary tract infection was 0% in September and October 2012 and had a slight increase from November to December, she did not do an investigation. She further indicated sine the infection control rate for central lines were 0% for the last 5 months, she did not do any investigations. Infection Control OfficerS20 further indicated she had the tracking information in her data base, but had not performed any trending.
An interview on 02/18/13 at 4:30 p.m. was conducted with Director of Quality RNS2. He was asked about the investigations for the increase in the catheter-associated urinary tract infection and central line infection rates that were reported by the Infection Control department in December 2012. Director of Quality RNS2 confirmed that no investigations were performed for these 2 increases in infection rates, since they were not significantly high enough and had been 0% for some of the prior months. He further indicated the infection control department would investigate the catheter-associated urinary tract infections and the central line infections if an increase was noted in subsequent months.
2) The infection control officer failed to ensure the maintenance of a sanitary physical environment as evidenced by patient mattresses on Unit A and Unit E with tears that prevented the surface from being disinfected properly:
Observation in the restraint room on Unit A on 02/13/13 at 11:20 a.m. revealed the mattress on the restraint bed had a tear in the seam and the top surface had large areas of the mattress that was peeled from wear.

In a face-to-face interview on 02/13/13 at 11:20 a.m., Unit A Clinical CoordinatorS5 indicated she probably never noticed the condition of the mattress, because a sheet was covering the mattress. She further indicated the condition of the mattress was never reported to her by the housekeeping staff. Unit A Clinical CoordinatorS5 confirmed the tear and wear of the mattress presented an infection control issue for disinfection and prevention of infection.

An observation on 02/14/13 at 10:25 a.m. in the presence of RN SupervisorS19 from Unit E and RN ManagerS21 revealed a fracture table used for patients having orthopedic surgery in Unit E. Further observation revealed the mattress pads had tears and holes in it that were covered with clear tape that was peeling with a sticky residue remaining.
An interview on 02/14/13 at 10:30 a.m. was conducted with RN SupervisorS19 from Unit E in the presence of RN ManagerS21. RN SupervisorS19 from Unit E was asked about the tape used on the fracture table to cover the tears and the holes. She indicated she was aware of the condition of the mattress pad. She further indicated the mattress pad had been torn and had a couple of holes in it, and it was repaired with tape that was peeling off. RN SupervisiorS19 from Unit E was asked how she could assure the part of the mattress pad under the tape was properly cleaned and disinfected between patient use. She indicated she was unable to assure the mattress pad under the tape was properly cleaned and disinfected between patient use. She further indicated the mattress pads should be replaced.
3) The infection control officer failed to mitigate the risks of infection as evidenced by staff on Unit E wearing the same mask used as personal protective equipment when going from the restricted zone to the semi-restricted zone and back to the restricted zone: Review of the hospital policy titled "Dress Code, Operating Room", revised by the hospital on 01/13 and provided by Director of QualityS2 as the most current policy, revealed the purpose of the policy was to comply with the recommended standards of AORN. The policy revealed the unrestricted zone included the operating room front desk, the lounges, restrooms, supervisor's office, and manager's office and housekeeping room. The semi-restricted zone included the corridors behind the warning signs, the storage rooms and the scrub area. The restricted zone included the operating room suites, the sterile core, minor room and the cystoscopy room. The policy further revealed all persons entering the semi-restricted and restrictive zone should be in surgical attire to include surgical masks that covered the nose and mouth only when in the restricted area. Further review revealed surgical masks should not be worn hanging around the neck.
Review of the AORN "Peri-Operative Standards and Recommended Practices" 2012 Edition revealed a section titled "Recommended Practice for Surgical Attire". Review of this section revealed recommendation #6 stated all individuals entering the restricted surgical area should wear a surgical mask when open sterile supplies and equipment are present. A clean surgical mask should be worn for every procedure and masks should not be worn around the neck as the filter portion of the surgical mask harbors bacteria from the nasopharyngeal airway and is considered contaminated and could lead to cross contamination.
Observations were made on 02/14/13 between 9:50 a.m. and 11:00 a.m. within Unit E in the presence of RNSupervisorS19 from Unit E and RNManagerS21. Observations of breaches in the surgical attire during this time interval included staff with surgical masks hanging from their necks when going from the restricted zone to the semi-restricted zone and pulling the same masks back up when re entering the restricted zone.
An interview on 02/18/13 at 1:00 p.m. was conducted with RNSupervisorS19 from Unit E. She indicated she was the supervisor for Unit E and was involved with the development of the policies for Unit E. RNSupervisorS19 from Unit E was asked about non-scrubbed staff wearing their surgical masks hanging around their necks. She indicated she allowed staff to pull their masks down when going from a restricted zone to a semi-restricted zone and pull the masks back up again when returning to the restricted zone. She further indicated staff were allowed to hang their masks around their necks and only had to remove their masks when leaving Unit E or when masks were soiled. RNSupervisorS19 from Unit E was asked if she was aware of the AORN Recommended Practice that stated that masks are not to be worn around the neck. She indicated "No". RNSupervisorS19 from Unit E was asked if she was aware that the hospital policy titled "Dress Code, Operating Room" that was approved by RNSupervisorS19 from Unit E stated that masks were not to be worn hanging around the neck. She reviewed the policy presented to her and had no response.
4) The infection control officer failed to ensure hand hygiene practices in Unit G were implemented as evidenced by breaches in hand hygiene on 02/14/13: Observation in Unit G on 02/14/13 at 9:25 a.m. revealed PhlebotomistS8 drew a blood specimen from a patient with gloved hands, discarded the needle in the sharps container, wrote information on the stickers with a pen, and labeled the vacutainers. Wearing the same gloves, she taped gauze to the patient's hand, brought the lab tubes to the tube holder on the counter on the other side of the room, and removed her gloves. PhlebotomistS8 then got a label from a shelf and called the next patient to Unit G. She applied gloves and began to draw blood from the second patient. Continuous observation revealed PhlebotomistS8 did not wash her hands or use sanitizing gel after removing her gloves, before reapplying gloves, and between each patient's lab draw.
In a face-to-face interview on 02/14/13 at 9:25 a.m., Unit G ManagerS36, who was present during the above observation, confirmed PhlebotomistS8 did not perform hand hygiene after removing her gloves and between patient contact.
Observation in Unit G on 02/14/13 at 9:40 a.m. revealed Medical TechnologistS9 removed her gloves when she left her work station and went to get her policy book. Continuous observation revealed Medical TechnologistS9 did not wash her hands or use sanitizing gel when she removed her gloves.
In a face-to-face interview on 02/14/13 at 9:40 a.m., Medical TechnologistS9 indicated she was supposed to wash her hands or use sanitizing gel after she removed her gloves. She confirmed that she did not wash her hands or use hand sanitizing gel.
Observation in Unit G on 02/14/13 at 9:55 a.m. revealed Blood Bank SupervisorS10 left her work station, removed her gloves, went to her desk, and opened a file cabinet in her office area. Continuous observation revealed she did not wash her hands or use sanitizing gel after she removed her gloves before going to her office area and the file cabinet.
In a face-to-face interview on 02/14/13 at 9:55 a.m., Blood Bank SupervisorS10 indicated she usually washed her hands when she left her work area and went to her office area. She confirmed she did not wash her hands or use sanitizing gel when observed, because she had just put her gloves on.
In a face-to-face interview on 02/14/13 at 10:00 a.m., Unit G ManagerS36 indicated they only observe the phlebotomists for hand washing surveillance and not all Unit G staff.

Based on observations, record reviews, and interviews, the hospital failed to ensure the surgical care of patients was performed in a manner designed to assure the achievement and maintenance of a high standard of medical practice and patient care as required by hospital policy and the AORN (Association of peri-Operative Registered Nurses) standards of practice. 1) Observation revealed staff did not conform to the dress code established by hospital policy and the AORN standards of practice related to head covering, surgical masks and warm-up jackets. 2) The hospital failed to have the means to ensure the temperature of warmed fluids was not above 98.6 degrees F (Fahrenheit) when used for patient irrigation as evidenced by the temperature of the warmer containing fluids being set at 104 degrees F and having no means to check the temperature of fluids before patient irrigation other than by touch.
Findings:
1) Observation revealed staff did not conform to the dress code established by hospital policy and the AORN standards of practice related to head covering, surgical masks and warm-up jackets: Review of the hospital policy titled "Dress Code, Operating Room", revised by the hospital on 01/13 and provided by Director of QualityS2 as the most current policy, revealed the purpose of the policy was to comply with the recommended standards of AORN. The policy revealed the unrestricted zone included the operating room front desk, the lounges, restrooms, supervisor's office, and manager's office and housekeeping room. The semi-restricted zone included the corridors behind the warning signs, the storage rooms and the scrub area. The restricted zone included the operating room suites, the sterile core, minor room and the cystoscopy room. The policy further revealed all persons entering the semi-restricted and restrictive zone should be in surgical attire to include: hospital acquired scrubs, disposable head covering, designated shoes or shoe coverings, and surgical masks that covered the nose and mouth only when in the restricted area. Further review revealed the staff were required to wear long blue cover gowns (provided by the hospital and available in the operating room) when leaving the operating room area. Further review revealed cloth hats may be worn only if covered by a disposable head covering, and surgical masks should not be worn hanging around the neck.
Review of the AORN "Peri-Operative Standards and Recommended Practices" 2012 Edition revealed a section titled "Recommended Practice for Surgical Attire". Review of this section revealed recommendation #3 stated that all individuals who enter a semi-restricted or restricted surgical area should wear appropriate surgical attire to include non-scrubbed personnel wearing a freshly laundered or single use long sleeved warm-up jacket. The warm-up jacket should be snapped closed with cuffs down to the wrist so as to prevent the edges of the front of the jacket from contaminating a prep area or the sterile surgical field and to help contain skin squames shed from bare arms. Further review revealed recommendation #6 stated all individuals entering the restricted surgical area should wear a surgical mask when open sterile supplies and equipment are present. A clean surgical mask should be worn for every procedure and masks should not be worn around the neck as the filter portion of the surgical mask harbors bacteria from the nasopharyngeal airway and is considered contaminated and could lead to cross contamination.
Observations were made on 02/14/13 between 9:50 a.m. and 11:00 a.m. within Unit E in the presence of RNSupervisorS19 from Unit E and RNManagerS21. Observations of breaches in the surgical attire during this time interval included the following: 1.Staff in the restricted area with a cloth hat not covered with a disposable head covering; 2. Staff with surgical masks hanging from their necks when going from the restricted zone to the semi-restricted zone and pulling the same masks back up when re entering the restricted zone; 3. Staff wearing untied long blue cover gowns in the restricted zone; no non-scrubbed staff observed wearing snapped warm-up jackets as recommended by AORN; 4. Staff in a surgical procedure with bed sheets wrapped around themselves.
An interview on 02/18/13 at 1:00 p.m. was conducted with RNSupervisorS19 from Unit E. She indicated she was the supervisor for Unit E and was involved with the development of the policies for Unit E. RNSupervisorS19 from Unit E was asked about staff being observed wearing long blue cover gowns (designated by their policy for use when leaving Unit E) in the semi-restricted and restricted zones of Unit E. She indicated she allowed staff to wear them in the semi-restricted and restricted zones as warm-up jackets and also to be worn when leaving Unit E. RNSupervisorS19 from Unit E was asked if staff were allowed to wrap bed sheets around themselves in the sterile rooms during a procedure. She indicated this was not acceptable, and she would in service staff. RNSupervisorS19 from Unit E was asked if she was aware of the AORN Recommended Practice that only snapped warm-up jackets were to be worn by staff in the restricted zone. She indicated "No". RNSupervisorS19 from Unit E was asked about non-scrubbed staff wearing their surgical masks hanging around their necks. She indicated she allowed staff to pull their masks down when going from a restricted zone to a semi-restricted zone and pull the masks back up again when returning to the restricted zone. She further indicated staff were allowed to hang their masks around their necks and only had to remove their masks when leaving Unit E or when masks were soiled. RNSupervisorS19 from Unit E was asked if she was aware of the AORN Recommended Practice that stated that masks are not to be worn around the neck. She indicated "No". RNSupervisorS19 from Unit E was asked if she was aware that the hospital policy titled "Dress Code, Operating Room" that was approved by RNSupervisorS19 from Unit E stated that masks were not to be worn hanging around the neck. She reviewed the policy presented to her and had no response. She was asked about the wearing of cloth hats in Unit E and indicated all cloth hats needed to be covered by a disposable head covering according to their policy. When RNSupervisorS19 from Unit E was informed of the surveyor's observations of staff in the restricted area wearing cloth hats without any disposable head covering over the cloth hats, she indicated she would in service staff regarding this policy.
2) The hospital failed to have the means to ensure the temperature of warmed fluids was not above 98.6 degrees F when used for patient irrigation: A review of the hospital policy titled "Warmers, Blankets and Solution Warmers", revised by the Hospital on 01/13 and provided by Director of QualityS2 as the most current policy, revealed the warmers containing solutions and linens for patient use will not be set higher than 104 degree F, and warmer temperature readings would be monitored daily.
Review of the AORN "Peri-Operative Standards and Recommended Practices" 2012 Edition revealed a section titled "Recommended Practice for a Safe Environment of Care" revealed recommendation #8 stated that fluids used for patient irrigation should not exceed 98.6 degrees F. The recommendation also stated that fluids warmed to higher temperature should be cooled to 98.6 degrees F before patient use by measuring the temperature of the irrigating fluid on the sterile field by using a sterile thermometer or a commercially available intra operative irrigation warming bath to ensure the temperature does not exceed 98.6 degrees F.
Observations were made on 02/14/13 between 9:50 a.m. and 11:00 a.m. within Unit E in the presence of RNSupervisorS19 from Unit E and RNManagerS21. Observations included fluid warmers with patient irrigating fluids set at 104 degree F and no means of monitoring the fluid temperatures on the sterile field.
An interview on 02/18/13 at 1:00 p.m. was conducted with RNSupervisorS19 from Unit E. She indicated she was the supervisor for Unit E and was involved with the development of the policies for Unit E. She was asked how staff monitored the temperature of the irrigating fluid used for patients during procedures. RNSupervisorS19 from Unit E indicated the warmers containing the irrigating fluids were all set at 104 degree F. She was asked if staff checked the irrigating fluid temperature before the irrigating fluids were used on a patient. She indicated staff do not have sterile thermometers available on the sterile field and would test the fluid by touch alone. She was asked if she was aware of the AORN Recommended Practice that stated fluids used for patient irrigation should not exceed 98.6 degree F and she indicated "No".