HospitalInspections.org

Based on document review and interview it was determined that for 1 of 1 (Pt #2) clinical record reviewed of a patient on the 4 south east unit with a documented DNI (do not intubate) order, the Hospital failed to ensure adherence to policy.

Findings include:

1. Hospital policy entitled, "Do Not Resuscitate Policy," (approved June 3, 2003) required, "...II. Mechanism For Reaching The Decision And Resolving Conflict: D...When a patient is a candidate for partial resuscitation, a decision should be reached after consultation between the physician and the patient or...healthcare power of attorney...B. The physician should write an entry attendant to the order in the patient's progress notes which documents the following...2. Any consultation with the family, the patient, healthcare power of attorney...should be noted in the progress notes."

2. The clinical record of Pt #2 was reviewed on 1/20/15. Pt #2 was a 92 year old female admitted on 1/18/15 with diagnoses of urinary tract infection and atrial fibrillation. Pt #2's clinical record contained a spiritual screening that included Pt #1 did not have an advance directive, had a living will that did not include Pt #2's wishes, and that Pt #2 had a healthcare power of attorney. A physician's order dated 1/18/15 required a DNI for Pt #2. The physician's documentation dated 1/18/15 lacked documentation of any conversation between the physician and Pt #2 and/or Pt #2's healthcare power of attorney.

3. The manager of 2 south east unit stated that the physician's documentation failed to include a conversation between the patient and/or healthcare power of attorney regarding the decision to make Pt #2 a DNI patient.

Based on document review and interview, it was determined for 1 of 1 (Pt. #5) patient in restraints on the 5 west nursing unit, the Hospital failed to ensure a restraint order was renewed daily while the patient was restrained.

Findings include:

1. Hospital policy titled, "Use of Restraints for Medical Purposes (revised 1/6/15)" required, "If restraints are to be continued beyond the 24 hours time limit ... Renewal order is required each calendar day."

2. The clinical record of Pt. #5 was reviewed on 1/20/15. Pt. #5 was a 77 year old female admitted on 1/16/15 with the diagnosis of shortness of breath. A physicians order dated 1/17/15 at 5:00 PM included an order for medical restraints because Pt. #5 was restless and "at high risk for discontinuing their treatment." The restraint order was renewed on 1/18/15 at 5:00 PM. The clinical record lacked a renewal order for 1/19/15. Per the daily nursing documentation, Pt. #5 remained on restraints continuously through survey date of 1/20/15.

3. During an interview on 1/20/15 at approximately 10:30 AM, the unit manager stated there should have been renewal order for 1/19/15 in the chart.

A. Based on document review and interview it was determined that for 1 of 4 (Pt #1) clinical records reviewed on the 4 south east unit, the Hospital failed to ensure the patient was weighed daily as per unit protocol.

Findings include:

1. The clinical record of Pt #1 was reviewed on 1/20/15. Pt #1 was an 86 year old male admitted on 1/13/15 with a diagnosis of Acute Renal Failure. Pt #1's clinical record contained documentation of daily weights on 1/16/15 to 1/17/15, and for 1/20/15. The record lacked documentation of Pt #1's weight for 1/18 and 1/19/15.

2. The 4 south east unit manager and 4 south east charge nurse stated during an interview on 1/20/15 at approximately 11:15 AM that all patients admitted to the 4 south east unit (telemetry) are to be weighed daily and the record of Pt#1 was lacking 2 days.



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B. Based on document review, observational tour, and interview, it was determined for 1 of 1 patient (Pt. #7) observed on 7 West for a dressing change, the Hospital failed to ensure a physician's order was received prior to initiating wound care.

Findings include:

1. The Professional Staff Rules and Regulations were reviewed on 1/22/15 at 10:00 AM. The Rules required, "III Orders... C. Members of the professional staff or a licensed practitioner under an agreement with a LCMH physician shall give orders for medications and treatment..."

2. On 1/20/15 at 9:30 AM, a tour was conducted in the 7 West Unit. Pt. #7 was lying in bed and her sacral dressing change was observed. Pt. #7 had an approximately 3 inch diameter wound in her sacral area, yellow in appearance. The nurse removed the old dressing and placed a new wet dressing into the deep wound. The dressing technique was not deficient.

3. Pt. #7's clinical record was reviewed on 1/20/15 at 10:30 AM. Pt. #7 was a 89 year old female, admitted on 1/13/15, with diagnoses of multiple pressure wounds and failure to thrive. A sacral debridement procedure was performed on 1/15/15. There were no post operative wound care orders, by the physician.

4. Nursing notes documented sporadic wound assessments and dressing changes:

- 1/17/15 12:53 PM reinforced
- 1/17/15 6:45 PM changed
- 1/18/15 7:45 AM changed
- 1/19/15 12:00 AM reinforced
- 1/19/15 7:15 AM original sacral dressing
- 1/19/15 10:00 PM original sacral dressing
- 1/20/15 12:30 AM 5 x 9 dressing

5. On 1/22/15 at 9:15 AM, an interview was conducted with the Manager of Wound Care. The Manager stated there should be a physician's order for wound care after abridgement. Dressing changes after abridgement should usually be preformed 1 to 2 times per day. The Manager stated nursing should have requested a physician's order for dressing changes for Pt. #7.

Based on document review and interview it was determined that for 1 of 2 (Pt #1) clinical records reviewed of patients that were receiving an anti-coagulant medication, the Hospital failed to ensure the drug was administered as ordered.

Findings include:

1. The clinical record of Pt #1 was reviewed on 1/20/15. Pt #1 was an 86 year old male admitted on 1/13/15 with a diagnosis of Acute Renal Failure. Pt #1's clinical record contained a physician's order dated 1/14/15 that required Lovenox 30 milligrams subcutaneouly daily. Pt #1's medication administration record dated 1/17/15 indicated that Pt #1's Lovenox was not given. In the comment section the nurse documented it was not administered due to a hemoglobin of 7.9. The record lacked documentation of a physician's order to hold the medication.

2. The 4 south east unit manager stated during an interview on 1/20/15 at approximately 11:30 AM that the reason the Lovenox was not given was unclear. The 4 south east unit manager stated no physician's order or documentation was found in the chart that indicated to hold Lovenox if hemoglobin was 7.9.

Based on document review, it was determined that , the Hospital failed to ensure that medical records were completed within 30 days after discharge. This potentially affected all patients associated with the 595 delinquent records.

Findings include:

1. The Hospital's Professional Staff Rules and Regulations approval date November 4, 2014 required, "M. Delinquent Medical Records: 1. Any medical record shall be considered delinquent when it has been incomplete for more that 30 days following discharge of the patient."

2. On 1/22/15 at approximately 2:45 PM the Hospital presented an attestation letter that indicated the Hospital had a total of 595 delinquent records past 30 days.

A.Based on document review, observation and interview it was determined that for 1 of 2 (Pt #2) patients observed during glucose testing, the Hospital failed to ensure adherence to infection control policy and procedure.

Findings include:

1. Hospital policy entitled, "Infection Control," (reviewed 1/9/15) required, "I. Contact Precautions: G. When possible, dedicate the use of non critical patient care equipment ...Items must be adequately cleaned and disinfected by nursing...before use on another patient."

2. The clinical record of Pt #2 was reviewed on 1/20/15. Pt #2 was a 92 year old female admitted on 1/18/15 with diagnoses of urinary tract infection and atrial fibrillation. Pt #2 was in Contact Precautions related to a history of MRSA (methicillin resistant staphylococcus aureus). Pt #2's clinical record contained a physician's order dated 1/19/15 that required bedside glucose monitoring 4 times a day.

3. On 1/20/15 at approximately 11:15 AM Pt #2 was observed having a bedside glucose test performed by the Care Partner (E #1). E #1 laid the bottle of testing strips on Pt #2's bed. E #1 failed to disinfect the bottle prior to leaving Pt #2's room.

4. The 4 south east unit manager confirmed during an interview on 1/20/15 at approximately 11:00 AM that the bottle was not disinfected and should have been prior to leaving the room.




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B. Based on observation, staff interview, and document review, it was determined that for 1 of 1 (E #2) staff observed, the Hospital failed to ensure septic technique was maintained when drawing medications from vials, as required by Hospital policy.

Findings include:

1. An observational tour was conducted on 1/21/15 between 7:15 and 8:00 AM. In OR 6, E #2 was observed drawing and preparing medications for the next surgical case. E #2 failed to wipe clean the rubber top of each vial before inserting a needle and drawing the medication.

2. The OR Service Coordinator was interveiwed on 1/21/15 at approximately 7:45 AM and stated that the vial top is supposed to be cleaned with an alcohol pad before inserting the needle and drawing up the medication referencing standard nursing practice based on "Clinical Nursing Skills"

3. The Hospital policy titled, "Multiple Dose Containers and Vials" (revised 3/6/13), reviewed on 1/21/15, required, "Aseptic technique will be used to withdraw medication from a multidose vial."

4. The Hospital presented the reference book, 7th edition "Clinical Nursing Skills" and high lighted page 603 under Medication Administration which required, "for drawing medication from a Vial... 1. Remove the vial cap. 2. Open antimicrobial wipe and cleanse the rubber top of the vial. Rationale: Manufacturer does not guarantee sterility of rubber top.

Based on observation, interview and document review it was determined that for 1 of 1 (E #2) staff observed setting up for the next surgical case, the Hospital failed to ensure cleaning between cases in the OR was completed before placing clean supplies on the OR bed; thus contaminating the supplies..

Findings include:

1. An observational tour of the surgical suite was conducted on 1/21/15 between 7:20 and 7:45 AM. The turnover cleaning was observed in OR 6. E #2 was observed setting up for a new case before the cleaning staff arrived to clean and disinfect the bed. E #2 placed a clean, newly opened oxygen mask tubing on the surgical table that had not been cleaned from a previous case.

2. The OR Service Coordinator, interviewed on 1/21/15 at approximately 7:45 AM, acknowledged that E #2 placed the clean tubing on the unclean OR bed, contaminating the tubing.

3. The Environmental Service Schedule for Surgery, reviewed on 1/21/15, required, " Assignment: Surgical "OR" suites-Between Cases: Daily-Clean and Disinfect Bed/OR cart."