HospitalInspections.org

Based on admission data review, staff interviews, and document review the facility failed to be in compliance with the regulations at 42 CFR 482.1 (a)(1) because it is not "primarily engaged in providing, by or under supervision of physicians, to inpatients diagnostic services and therapeutic services for medical diagnosis, treatment and care of injured, disabled, or sick persons. The facility operates like a surgical center that primarily provides services to outpatients.

Findings include:

1. Review of Blue Valley Hospital's (BVH) utilization review data and meeting minutes dated August 23, 2017 from 3:43 PM till 3:48 PM showed that "outpatients are increasing, and inpatients are remaining about the same." The meeting minutes also showed that BVH reported "an average of 312 procedure room cases performed each month with a total of 1,874 cases performed for 1Q-2Q 2017." "Operating room procedures average 335 cases a month, with a total of 2,012 for 1Q-2Q 2017."

2. Review of BVH's utilization review data and meeting minutes dated 01/24/18 from 4:00 PM till 4:10 PM showed that BVH had "an average of 808 procedure room cases performed each quarter with a total of 3,233 cases performed for 2017." "Operating room procedures average 868 cases a quarter, with a total of 3,473 for 2017."

3. Review of the Provider Statistical and Reimbursement System data dated 04/19/18 (PS&R - a summary of all claims submitted by the provider and paid by Medicare through April 19, 2018) provided by the Medicare Administrative Contractor (MAC) Wisconsin Physicians Service Insurance Corporation (WPS) showed BVH's average daily census (ADC) (inpatients) was 0.09 in 2014, 0.21 in 2015, 0.25 in 2016, 0.22 in 2017 and dropped to 0.18 for the first quarter 2018 (01/01/18 through 03/31/18). WPS data showed BVH's average length of stay (ALOS) in 2014 was 1.5 days, in 2015 1.04 days, in 2016 1.08 days, in 2017 1.1 days and for first quarter 2018 was 2 days.

A. PS&R data also showed that BVH had a Net Reimbursement of $845,237 for Inpatients in 2017 and Net Reimbursement for the same timeframe for Outpatients of $1,723,629 (more than double the amount for inpatients).

B. PS&R data also showed that BVH had a Net Reimbursement of $67,377 for Inpatients for the first quarter of 2018 and Net Reimbursement for the same timeframe for Outpatients of $494, 586 (more than 7 times the amount for inpatients).

4. Review of the "Medicare Hospital Database Worksheet" completed by the surveyor in collaboration with Staff A, Quality Manager, on 04/23/18 showed that the facility had two operating rooms and reported it had ADC of 1.29 inpatients from 04/01/17 to 03/31/18. This data was inconsistent with the data reported by WPS in 2017/2018.

5. Review of the data provided by BVH specifying its ALOS by month from 04/01/17 through 03/31/18 showed that BVH reported an ALOS of 1.7 days.

6. During an interview on 04/25/18 at 2:45 PM, Staff A, Director of Quality stated that we have a poor electronic medical record system. In order to provide the requested monthly inpatient and outpatient lists with the average length of stay (ALOS) and average daily census (ADC) calculations, we had to go into the medical record and manually identify which patients were an inpatient or an outpatient. Staff B indicated there could be some errors.

7. Review of BVH's policy number "ADM-013" titled, "Inpatient and Outpatient Guidelines," with an effective date of January 2018, showed BVH defined which patients were included in the hospital's definition of "inpatient and outpatient admissions." "Inpatient: Can be Outpatient Observations (>24 hrs.) or Inpatient Status." "Any
patient admission with an admit and discharge date that are different (24 hours or more), who was admitted either Observation or Inpatient status to the Medical-Surgical Unit and received inpatient level care." The policy is inconsistent with the Centers for Medicare and Medicaid Services (CMS) guidance: Generally, a patient is considered an inpatient if formally admitted as inpatient with the expectation that he or she will require hospital care that is expected to span at least two midnights and occupy a bed even though it later develops that the patient can be discharged or transferred to another hospital and not actually use a hospital bed overnight.

8. Evidence of inaccurate reporting of BVH's ALOS included review of the monthly patient census sheets and medical records for Patient #6, Patient #14, Patient #13 (BVH employee), Patient #10, and Patient #35.

A. Review of the January 2018 monthly patient census sheet showed Patient #13 and Patient #10 were counted "Inpatients." Review of Patient #13's 01/02/18 medical record showed "Physician Orders" dated 01/02/18 at 12:00 PM specified Patient #13 was admitted to "outpatient observation" for monitoring. Further review showed that nursing staff inaccurately documented throughout the medical record that Patient #13 was an "inpatient." Documentation showed that Patient #13 left the hospital on 01/03/18 at 3:00 PM.

B. During an interview on 05/03/18 at 8:52 AM, Staff A, Director of Quality, confirmed Patient #13's medical record showed the patient was an outpatient admission even though the census documents provided during the survey on 04/22/18 thru 04/25/18 showed they were an inpatient.

C. Review of Patient #10's 01/25/18 medical record showed she was admitted for intolerance to the band (a silicone device placed around the upper section of the stomach, creating a small pouch above the band and thereby restricting the amount of food that can be comfortably eaten), chronic pain, nausea can't seem to keep anything down, now just wants the band out. Review of Patient #10's record showed a handwritten order on 01/25/18 at 1:00 PM, that read, "Admit to Observation (outpatient), admit for severe nausea, vomiting and dehydration." Staff Y, Registered Nurse (RN) noted the order on 01/25/18 at 1:10 PM. Staff Z, Physician, signed the ordered 02/06/18 at 10:00 AM. The medical record lacked documentation of the type of order (how it was obtained, for example: telephone or verbal) and who wrote the order. However, throughout the medical record, nursing staff referred to Patient #10 as an "inpatient." Review of another handwritten order on 01/26/18 at 1:30 PM read, "Admit to inpatient, Staff Y, RN noted the order on 1/26/18 at 1:40 PM. Staff Z, Physician signed the order on 02/12/18 at 3:00 PM. The medical record lacked documentation of the type of order (how it was obtained, for example: telephone or verbal) and who wrote the order. Patient #10 discharged to home on 01/26/18 at 4:20 PM. The medical record did not contain any notes by Physician Staff Z regarding the medical necessity to change her admission status from Observation to Inpatient Admission.

D. Review of the March 2018 monthly patient census sheet showed Patient #6 and Patient #14 were counted as "Inpatients." Review of Patient #6's 03/04/18 medical record showed that Physician Staff H signed an order to admit to "Observation Status" (outpatient) on 03/04/18 at 10:00 PM for treatment of a migraine headache with intravenous (IV) Fentanyl (opioid narcotic). At 10:45 PM nursing staff inaccurately documented Patient #6 was an "inpatient." On 03/05/18 at 7:13 AM Staff Q, Advanced Practice Registered Nurse (APRN) placed an order in the electronic medical record "Admit to INPATIENT." The medical record did not contain any notes by Physician Staff H or APRN Staff Q regarding the medical necessity to change the patient from observation to inpatient.

E. Review of Patient #14's 03/08/18 medical record showed that she was admitted for back and leg pain, a Posterior/Transforaminal Lumbar Interbody Fusion of L4-L5 (spinal fusion procedure that joins together the front and back section of the spine). The medical record showed Physician Staff M approved an order to admit to outpatient on 03/08/18. However, throughout the medical record, nursing staff referred to Patient #14 as an "inpatient." Patient #14 discharged on 03/10/18. Further review of the record showed a handwritten order dated 03/14/18 read, "Amendment to outpatient admission order documented on 03/08/14 2104 (9:04 PM) by Staff M, amend to inpatient admission order." Staff M then signed the order on 03/14/18. The medical record lacked documentation of the type of order (how it was obtained, for example: telephone or verbal) and who wrote the amendment order. The medical record did not contain any notes by Physician Staff M regarding the medical necessity to change Patient #14's Admission from Outpatient to Inpatient Admission.

F. Review of the April 2018 monthly patient census sheet showed Patient #6 and Patient #35 were counted as "Inpatients." Review of Patient #6's medical record showed he arrived at BVH on 4/19/18 for treatment of a migraine headache. The medical record did not contain documentation specifying the patient's time of arrival, however at 3:18 PM the initial nurse's note showed "this RN assumed care from 1:50 PM to 3:15 PM." Staff Q, APRN gave a verbal order to admit Patient #6 to "Observation Status" on 04/19/18 at 12:54 PM for severe headache. However, throughout the medical record, nursing staff referred to Patient #6 as an "inpatient." Review of the "Patient Discharge Planning Needs Assessment" form dated 04/20/18 at 12:15 PM under "Admission Status" showed the Registered Nurse (RN) documented that "No order Found" - "clarifying admission status with hospitalist group." Staff Q, APRN gave a verbal order to admit Patient #6 to "INPATIENT" on 04/20/18 at 1:29 PM for severe headache. The medical record did not contain any notes by Staff H, Physician or Staff Q, APRN regarding the medical necessity to change Patient #6 from "observation status" to inpatient admission. The medical record showed Patient #6 discharged on 04/24/18 at 10:45 AM.

G. Review of Patient #35's medical record showed that APRN Staff Q signed an order dated 04/11/18 specifying Patient #35 was an "outpatient admission." Further review showed that nursing staff inaccurately documented throughout the medical record that Patient #35 was an "inpatient."

H. During an interview on 05/03/18 at 8:52 AM Staff A, Director of Quality, confirmed Patient #35's medical record showed the patient was an outpatient even though the census documents provided during the survey on 04/22/18 thru 04/25/18 showed they were an inpatient. Staff A stated we realize we are not always capturing the correct status in our tracking spreadsheets and are now going back to the previous weeks to verify what we have listed and that an order for inpatient or outpatient admission is present in the medical record.

9. In response to the deficiencies cited at BVH during the survey which concluded on 11/14/17, BVH outlined in its 02/12/18 plan of correction, plans to grow service lines that were focused on inpatient care to increase the ADC as well as the ALOS.

A. During an interview on 04/23/18 at 10:00 AM, Staff L, Chairman of the Board, stated he has a contractor already hired and plans were sent to the state agency for review so that the facility could add an additional 12 beds upstairs. Staff L stated they are planning to use the beds as an inpatient detox unit.

B. Tour of the second floor of the facility showed empty office spaces without construction activity in progress.

C. BVH staff failed to provide documentation supporting concrete plans and activities necessary to develop an inpatient detox unit.

D. During an interview on 04/25/18 at 1:00 PM, the State Agency Director confirmed they lacked any communications from BVH requesting review and approval of construction plans.

10. During an interview on 04/2318 at 10:00 AM, Staff L, Chairman of the Board, discussing the current status of the hospital stated that, When Medicare guidance came out (regarding "primarily engaged"), we didn't pick up on it right away...We understood with the new guidance we weren't keeping our patients long enough...Our AO (accrediting organization) granted us accreditation based on what we were planning to do in the future not the past. They did acknowledge our average length of stay was not enough...They (the State Agency surveyors) said we didn't have the average length of stay numbers and a high enough census. We agreed with them and said we would do what we need to do to meet the current regulations. We did a lot of extra surgeries to get the numbers we needed. I knew that alone wouldn't get us there. So, I offered a new benefit to all employees and their families. I told them for those that medically qualify for a gastric sleeve, we would pay what insurance didn't. Our staff has requested it for years because the insurance we have won't cover the costs for the surgery here. Unfortunately, I have a lot of obese employees and they wanted this surgery. So it was something that could help us both. We have done about 50 -60 employee/family surgeries to date with about 70 more that want it...My QA (Quality Assurance) director, Staff A came to us about a year ago and we went back and update and reviewed our policies so we would be in compliance with CMS. We spent so much time on that, we were sure we would pass a survey.

11. Staff indicated that physician staff (Staff M) and facility administration (unidentified) attempted to have the Registered Nurse (RN) Staff document symptoms or complications in the medical record that would make it look like it was medically necessary for continued hospitalization and for a patient to stay another night (thus increasing their inpatient days and average length of stay).

A. Review of BVH's policy number "ADM-013" titled, "Inpatient and Outpatient Guidelines," with an effective date of January 2018 directed, Acceptable Indications for Inpatient Hospitalization: Gastrointestinal System: Nausea/Vomiting.

B. During an interview on 04/25/18 at 10:07 AM Staff G, RN, stated that she quit working there in December 2017 because administrative staff including a doctor (Staff M, Physician) told her and the other nurses that they must enter false documentation of symptoms. This false documentation was for all patients that had a gastric sleeve (a surgical procedure used to reduce the size of the stomach to help patients with weight loss). Staff G, RN stated the nurses were expected to document that patients had complications like nausea and vomiting so that it would be appropriate to keep them for two nights.

C. During an interview on 04/25/18 at 1:15 PM, Staff C, RN, stated that administrative staff told the nurses to document all gastric sleeve patients had complications like nausea and vomiting, but stated, "None of us would do it, we rebelled and said No!"

Based on record review and staff interview, it was determined that the governing body did not ensure that patients are admitted to the hospital as an inpatient based on medical necessity for three of 27 records reviewed (Patient #6, Patient #10 and Patient #14).

The cumulative effect of this deficient practice has the potential for inpatient admissions that are not medically necessary.

Findings include:

- Review of the January 2018 monthly patient census sheet showed Patients #10 was counted as "Inpatient." Review of Patient #10's 01/25/18 medical record showed she was admitted for intolerance to the band (a silicone device placed around the upper section of the stomach, creating a small pouch above the band and thereby restricting the amount of food that can be comfortably eaten), chronic pain, nausea can't seem to keep anything down, now just wants the band out. Review of Patient #10's record showed a handwritten order on 01/25/18 at 1:00 PM, that read, "Admit to Observation (outpatient), admit for severe nausea, vomiting and dehydration." Staff Y, RN noted the order on 01/25/18 at 1:10 PM. Staff Z, Physician, signed the ordered on 02/06/18 at 10:00 AM (11 days later). The medical record lacked documentation of the type of order (how it was obtained, for example: telephone or verbal) and what licensed practitioner wrote the order. Additionally, throughout the medical record, nursing staff referred to Patient #10 as an "inpatient." Review of another handwritten order on 01/26/18 at 1:30 PM read, "Admit to inpatient, Staff Y, RN noted the order on 01/26/18 at 1:40 PM. Staff Z, Physician signed the order on 02/12/18 at 3:00 PM (17 days later). The medical record lacked documentation of the type of order (how it was obtained, for example: telephone or verbal) and what licensed practitioner wrote the order. Patient #10 discharged to home on 01/26/18 at 4:20 PM. The medical record did not contain any notes by Physician Staff Z regarding the medical necessity to change her admission status from Observation to Inpatient Admission.

- Review of the March 2018 monthly patient census sheet showed Patient #14 was counted as "Inpatient." Review of Patient #14's 03/08/18 medical record showed that she was admitted for back and leg pain, a Posterior/Transforaminal Lumbar Interbody Fusion of L4-L5 (spinal fusion procedure that joins together the front and back section of the spine). The medical record showed Physician Staff M approved an order to admit to outpatient on 03/08/18. However, throughout the medical record, nursing staff referred to Patient #14 as an "inpatient." Patient #14 discharged on 03/10/18. Further review of the record showed a handwritten order dated 03/14/18 read, "Amendment to outpatient admission order documented on 03/08/14 2104 (9:04 PM) by Staff M, amend to inpatient admission order." Staff M then signed the order on 03/14/18 (four days after Patient #14's discharge). The medical record lacked documentation of the type of order (how it was obtained, for example: telephone or verbal) and what licensed practitioner wrote the amendment order. The medical record did not contain any notes by Physician Staff M regarding the medical necessity to change Patient #14's Admission from Outpatient to Inpatient Admission.

- Review of the April 2018 monthly patient census sheet showed Patient #6 was counted as an "Inpatient." Review of Patient #6's medical record showed he arrived at BVH on 04/19/18 for treatment of a migraine headache. The medical record did not contain documentation specifying the patient's time of arrival, however at 3:18 PM the initial nurse's note showed "this RN assumed care from 1:50 PM to 3:15 PM" Staff Q, APRN gave a verbal order to admit Patient #6 to "Observation Status" on 04/19/18 at 12:54 PM for severe headache. However, throughout the medical record, nursing staff referred to Patient # 6 as an "inpatient." Review of the "Patient Discharge Planning Needs Assessment" form dated 04/20/18 at 12:15 PM under "Admission Status" showed the Registered Nurse (RN) documented that "No order Found" - "clarifying admission status with hospitalist group." Staff Q, APRN gave a verbal order to admit Patient #6 to "INPATIENT" on 04/20/18 at 1:29 PM for severe headache. The medical record did not contain any notes by Staff H, Physician or Staff Q, APRN regarding the medical necessity to change Patient #6 from "observation status" to inpatient admission. The medical record showed Patient #6 discharged on 04/24/18 at 10:45 AM.

1. During an interview on 04/24/18 at 10:00 AM Patient #6, stated that I am a fall risk when I have migraines because sometimes it causes me to pass out. I get "ice pick" headaches with cold sweats, weakness, and dry heaves. When I am admitted here they give me pain medications every four hours until the migraine goes away.

2. During an interview on 04/25/18 at 10:07 AM Staff G, Registered Nurse (RN), stated that Patient #6 thought he could just walk in and say he had a headache and get admitted as an inpatient. Once he looked at the board (patient tracker dry erase board mounted on the wall near the nurse's station) and said, "We don't have enough patients. I need to be admitted." Another time he walked in to the facility in his pajamas and said he had a headache and wanted to be admitted. Staff G stated these things happened after surveyors were there in November 2017. Staff G said that she could not remember the dates that this occurred, but that he did end up getting admitted.

3. During an interview on 04/25/18 at 1:15 PM, Staff C, RN, stated that Patient #6 had come into the hospital in his pajamas and walked down the hallway and said he had a headache and needed to be admitted. Staff C confirmed that Patient #6 had also came on to the unit one day and looked at the patient board and commented that the census was too low, and then he said he had a headache and needed to be admitted. Staff C does not recall the exact dates this happened but remembered that he ended up being admitted.

Based on record review and staff interview, the medical record failed to include nursing documentation of medication administration on the medication administration record for four records of 27 records reviewed (four admissions for Patient #6), the medical record failed to include practitioner's orders following standards of practice for one of 27 records reviewed (Patient #9), and the medical record included an operative report for one of one record reviewed of patients having their surgery cancelled (Patient #9). Failure to document medication administration has the potential for medication errors including overdose, and ineffective medication management. Failure to write orders and verify orders in a manner consistent with accepted guidelines has the potential for medical errors and omissions. Failure to have an accurate medical record that reflects the treatments, procedure and care a patient receives has the potential for a patient to have an inaccurate medical history and follow up care.

Findings include:

1. Review of Patient #6's 02/22/18 through 02/26/18 medical record showed the following: Admit to Inpatient for pain management and management of urinary retention. Medication Reconciliation (Med Rec) documents showed, Home Meds Reviewed: Staff R, Registered Nurse (RN) on 02/22/18 at 12:00 AM. The patient brought home medications to the facility. Home medications are not verified for administration.

Patient #6's inpatient medication orders approved by Staff Q, Advanced Practice Registered Nurse (APRN) on 02/22/18 at 10:38 AM read, Patient may continue home meds as documented on the Med Rec form. Review of medication administration record showed, [Hold] Indomethacin (nonsteroidal anti-inflammatory drug (NSAID) used to treat pain, swelling, and joint stiffness caused by arthritis, gout, and bursitis) 25 mg capsule, Medication unavailable on 02/23/18 at 12:11 PM; [Hold] Crestor (helps lower cholesterol) 20 mg, Medication unavailable on 02/23/18 at 12:10, 02/24/18 at 8:55 AM and 02/25/18 at 9:17 AM; [Hold] Tizanidine (helps treat muscle spasms) 4 mg tablet, Medication unavailable on 02/23/18, 02/24/18, and 02/25/18. Nursing staff failed to document a reason for holding the medication and the medical record lacked documentation that nursing staff attempted to contact the physician, APRN, and/or the pharmacist regarding the unavailability of the medication.


2. Review of Patient #6's 03/04/18 through 03/07/18 medical record showed the following. Admission diagnosis auditory neuropathy, acute sinusitis (infection in the sinus), pain management.

A. Staff T's, Registered Nurse (RN) Nurses Notes dated 03/04/18 at 11:15 AM, showed pain medication given at 11:15 PM after IV (intravenous) started. Nursing staff failed to document the administration of pain medication on the medication administration record.

B. Staff T's, RN Nurses Notes dated 03/05/18 at 5:42 AM, showed, did vs (vital signs), gave pain medication. Nursing staff failed to document the administration of pain medication on the medication administration record.

C. Staff U's, RN Nurses Notes dated 03/05/18 at 2:07 PM, showed, Assumed care at 6:00 AM. PT (patient) resting in bed on RA (room air). Oriented x4, assessment done, WNL (within normal limits). Denies nausea. C/O (complains of) pain, PRN (as needed) pain med (medication) given. Nursing staff failed to document the administration of pain medication on the medication administration record.

D. Staff R's, RN Nurses Notes dated 03/06/18 at 5:00 AM, showed, Pain to ears, up 8/10 and treated with Fentanyl and Benadryl (treats itching). This am pt (patient) reported better. Pain still 8/10 but more tolerable as he reported. Nursing staff failed to document the administration of the pain medication and the Benadryl on the medication administration record.

E. Staff U's, RN Nurses Notes dated 03/06/18 at 2:47 PM, showed, C/O head pain, multiple PRN meds given. Nursing staff failed to document the kind of PRN medications and what time the PRN medications were given on the medication administration record.

F. Staff R's, RN Nurses Notes dated 03/07/18 at 4:50 AM, showed, Pain treated with Fentanyl IV and Benadryl. Nursing staff failed to document the administration of the pain medication and the Benadryl on the medication administration record.

G. Staff U's, RN Nurses Notes dated 03/07/18 at 10:33 AM, showed, feels better and pain level is at a 5. Asked for Valium (treats anxiety) to keep pain at bay. Nursing staff failed to document the administration of pain medication on the medication administration record.

H. Review of Patient #6's Medication Reconciliation showed, Home Meds Reviewed: Staff T, on 03/05/18 at 1:28 AM. The patient brought home medications to the facility. Home medications are not verified for administration.

I. Review of Patient #6's inpatient admission orders approved by Staff Q, APRN, on 03/05/18 at 7:13 AM showed, Patient may continue home meds as documented on the Med Rec form.

J. The Medication Administration Record failed to include these home medications. The Medical Record showed no evidence nursing staff administered Patient #6's home medications as documented on the Med Rec form including, oxycodone (a narcotic medication given for pain) 10 milligrams (mg) every six hours as needed (PRN) for pain; Fluticasone nasal (a medication uses to prevent seasonal allergies) twice a day, tizanidine 4mg twice daily, Crestor 20 mg once daily, and Isoniazid (an antibiotic uses to treat tuberculosis) 300 mg once daily. The medical record lacked documentation that nursing staff attempted to contact the physician, APRN, and/or the pharmacist regarding the medication discrepancy.


3. Review of Patient #6's 03/16/18 through 03/20/18 medical record showed the following.

A. Staff S's, Registered Nurse (RN) Nurses Notes dated 03/17/2018 08:10 AM, read, Pain meds administered. Nursing staff failed to document the administration of pain medication on the medication administration record. It is unknown what kind and how much pain medication the patient received.

B. Agency Nurse 5's, Registered Nurse (RN) Nurses Notes dated 03/17/2018 11:15 PM, read, Pt given Percocet 7.5/325 (schedule II narcotic pain medication) two tablets po (by mouth) prior to shower. Nursing staff failed to document the administration of pain medication on the medication administration record.

C. Agency Nurse 5's, Registered Nurse (RN) Nurses Notes dated 03/18/2018 00:30 AM, read, Pt had had 3 large diarrhea after dinner...Zofran (treats nausea) 4 mg (milligrams) IV (through the vein) and Toradol (non-steroidal anti-inflammatory pain medication) 30 mg IV offered for relief. Nursing staff failed to document the administration of anti-nausea medication and the pain medication on the medication administration record.

D. Agency Nurse 5's, Registered Nurse (RN) Nurses Notes dated 03/18/2018 01:40 AM, read, Physician Staff H notified about episode of diarrhea pt has had. Immodium (anti-diarrheal) ordered, pt had family bring in Immodium for him. The nurse documented in her notes that the physician ordered Immodium, however, the medical record did not contain a verbal or written order for Immodium and the medication administration record lacked documentation of administration of the medication. Additionally, the medical record lacked approval by the Physician or the Pharmacist for use as a home medication .

E. Agency Nurse 5's, Registered Nurse (RN) Nurses Notes dated 03/18/2018 02:40 AM, read, Pt reports relief with use of Immodium 2 caplets. The medical record did not contain a verbal or written order for Immodium and the medication administration record lacked documentation of administration of the medication. Additionally, the medical record lacked approval by the Physician or the Pharmacist for use as a home medication.

F. Staff S's, Registered Nurse (RN) Nurses Notes dated 03/18/2018 11:31 AM, read, Assessed pain level and administered pain meds as well as AM meds. Nursing staff failed to document the administration of pain medication on the medication administration record. Nursing staff failed to document the administration of two "AM" medications : Eliquis (used to prevent blood clots) 5 mg twice a day and Neurontin (treats nerve pain) 100 mg twice a day on the medication administration record.

G. Agency Nurse 5's, RN Nurses Notes dated 03/19/18 04:01 AM read, he had diarrhea again and administered himself Immodium he brought from home...Continues to complain of "ice pick" headache and states the toradol does nothing to help the pain. After 2 percocet, pt (patient) is sleeping soundly and drowsy when awake. The medical record did not contain a verbal or written order for Immodium and the medication administration record lacked documentation of administration of the medication. Additionally, the medical record lacked approval by the Physician or the Pharmacist for use as a home medication. Nursing staff failed to document administration of Toradol and/or Percocet on the Medication Administration Record.

H. Staff J's, Registered Nurse (RN) Nurses Notes 03/19/18 7:56 AM read, pt walks to nurses station, states he's ready for pain meds, percocet given to pt.states headache pain 7/10...pt recently had a valium and wanting to rest. Nursing staff failed to document the administration of the percocet or the valium on the Medication Administration Record.

I. Staff J's, Registered Nurse (RN) Nurses Notes 03/19/18 2:43 PM read, pt been laying in bed most of day...Pain meds given as needed. Nursing staff failed to document the administration of any pains meds on the Medication Administration record.

J. Staff J's, Registered Nurse (RN) Nurses Notes 03/19/18 5:52 PM read, pt continues to rest in bed. toradol given for pain. Nursing staff failed to document the administration of the pains medication on the Medication Administration record.

K. Staff R's, RN Nurses Notes dated 03/20/2018 05:28 AM, read, c/o (complaint of) pain to Left ear, Pain treated with Percocet. This am pain down to a 4/10 (scale of 0-10 with 0 being no pain to 10 being excruciating). Nursing staff failed to document the administration of pain medication on the medication administration record.


4. Review of Patient #6's 04/19/18 through 04/24/18 medical record showed the following:

A. Staff D's, RN Nurses Notes dated 04/22/18 at 11:40 PM, showed Pt. (Patient) complaining of HA (headache) after his shower, will medicate and continue to monitor. The medication administration record lacked documentation pain medication was given. Nursing staff failed to document the administration of pain medication on the medication administration record.

B. Staff D's, RN Nurses Notes dated 04/23/18 at 2:38 AM, showed Medicated for HA (headache) at this time, will continue to monitor. Nursing staff failed to document the administration of pain medication on the medication administration record.

C. Staff R's, RN Nurses Notes dated 04/24/18 at 5:24 AM, showed Pt alert and oriented x4, reporting c/o headache at 8/10 feeling like an ice pick to his ears. Pain treated with Fentanyl PRN, nausea reported x1 Phenergan (a medication given to prevent vomiting) given PRN. Nursing staff failed to document the administration of the Fentanyl or Phenergan on the Medication Administration Record on 04/24/18.

D. Medication Reconciliation showed, Home Meds Reviewed: Staff V, Pharmacist on 04/19/18 at 12:08 PM. The patient brought home medications to the facility. Home medications are not verified for administration.

E. Review of Patient #6's medication administration record showed, [Hold] Crestor 20 mg, Medication not brought in from home, med not available on 04/21/18 at 1:10 PM, 04/22/18 at 12:12 PM and [Hold] Tizanidine 4 mg tablet, Medication not brought in from home, med not available on 04/19/18 at 8:59 PM, 04/21/18 at 1:10 PM and 8:46 PM, 04/22/18 at 12:12 PM and 9:09 PM. The medical record lacked documentation that nursing staff attempted to contact the physician, APRN, and/or the pharmacist regarding the unavailability of the medication.


5. Review of Patient #9's 02/15/18 through 02/18/18 medical record showed the following.

A. Staff W, RN's nurse's note dated 02/15/18 at 12:54 PM read, 02/16/18 at 10:35 AM this RN spoke with Physician Staff H and received orders to admit pt. (patient) for acute renal injury.

B. An order written on 02/15/15 at 10:35 showed, Admit to obs. (observation) status secondary to prerenal/azotemia (abnormally high levels of nitrogen-containing compounds (such as urea, creatinine, various body waste compounds, and other nitrogen-rich compounds in the blood) with likely dehydration. The order does not indicate what practitioner gave the order and what type of order it was (verbal or telephone). A late entry signature by Physician Staff H on 02/27/17 at 1335 (1:35 PM)(9 days after the patient discharged).

C. An admit to INPATIENT order was approved 02/15/18 at 16:03 by Staff Q, APRN, with diagnosis of Acute Renal Injury.

D. Further review of the record showed a nurse note written by Staff AA, RN on 02/15/18 at 12:00 PM, read Patient lab work indicates a creatinine level trending upward. iSTAT (An advanced, easy-to-use blood analyzer that provides healthcare professionals with access to lab-quality results in minutes) drawn per orders, Creatinine (Cr) level is 2.7 (normal 0.6 to 1.2). Surgery cancelled per MD and pt. admitted for IV hydration and monitoring of creatinine level.

E. Even though there is documentation in the record indicating that Patient #9's surgery was canceled, the medical record contains a Physician Operative Report that read:

Operative Report: Sleeve w/o hernia
PREOPERATIVE DIAGNOSIS:
1. Morbid Obesity, diabetes, hypertension
Morbid obesity with a BMI: 64.4
POSTOPERATIVE DIAGNOSIS:
1. Morbid Obesity
PROCEDURE: Laparoscopic sleeve gastrectomy and EGD
SURGEON: Physician Staff BB
FIRST ASSISTANT: None.
BLOOD LOSS: 20 cc ' s
COMPLICATIONS: None.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room. After adequate
general endotracheal anesthesia, the abdomen was scrubbed, prepped, and draped in the usual sterile
fashion. Then, 0.25% Marcaine was injected at all intended port sites and against countertraction, a
5 Visiport was placed several centimeters above the umbilicus. The abdomen was insufflated to 15
mm Hg with CO2 gas. One 5mm trocar was placed in the left midclavicular line and then another 5
in the left anterior axillary line. A right midclavicular 15 mm trocar was placed under direct vision.
A small trocar incision placed in the epigastrium for a Nathanson Retractor to lift the left lateral lobe
of the liver anteriorly. We used the Covidien LigaSure device to then start taking down the greater
curvature. Once we got up passed the short gastrics, the left crus was identified, we had anesthesia
placed the calibration tubing and had no evidence of hiatal hernia. Anesthesia placed a 40 bougie
oral down through the gastroesophageal junction to make sure it was not too tight. With this, we
took down the vessels greater curvature all the way to 4-5 cm from the pylorus. Using the black
stapling load the linear staple cutter was used to divide the stomache longitudinally along the bougie
to the GE junction. We made sure to not be too close to the GE junction and left a bit of an "Elves
ear" shape there. Once that portion of the stomach was excised, it was removed thru the 15 mm
trocar site. That was then closed with a transfascial o vicryl suture. The patient was placed in
Trendelenburg position and the stomach was insufflated with air from the gastroscope. The upper
abdomen had been filled up with water. There were no air bubbles. There was good passage of the
scope down into esophagus. No hiatal hernia was seen during endoscopy. It was then advanced to
the area of antrum/incisura down towards the pylorus and duodenum. There was no internal
bleeding from the staple line, and no air leaks with this. We took pictures of all this and then the air
was aspirated. I scrubbed back in. We sucked out the majority of the fluid, the Nathan Retractor was
removed, all the other trocar sites were closed with 3-0 Vicryl, Steri-Strips and dermabond.
Sponge and needle counts were correct.
There were no complications.

G. The medical record showed an order that read: Operation cancelled due to ARF (Acute Renal Failure) with Cr 2.7. Physician Staff BB signed the order with a late entry on 02/22/18 at 0700 (4 days after the patient discharged). The late entry failed to indicate the date and time the operation was canceled.

H. Review of document titled, "Blue Valley Hospital Medical Staff Rules and Regulations," revised by the Medical Staff 09/28/2016 read, All orders for treatment and medication shall be in writing with date and time. Verbal orders may be substituted for a written order if dictated by the responsible practitioner to authorized personnel, these must be date and time by the authorized personnel and signed by the responsible practitioner. Authorized personnel accepting verbal orders shall enter the order on the physician order sheet: the date, time, sign their name and the dictating practitioner. Orders which are illegible or improperly written shall not be carried our until they are written or properly understood by the person responsible for carrying out the order...All medical record entries shall be entered in a timely, legible, authenticated and permanent manner.

Based on document review and staff interview, the facility failed to have organized dietary services that provides food and food menus that meets the nutritional needs of their patients and failed to ensure the food they deliver is at a safe temperature. The facility failed to show evidence of a contracted service that can provide therapeutic dietary services consistent with those provided to inpatients at a hospital. This deficient practice has the potential to cause patients to receive inappropriate diet options and potentially contaminated foods that could lead to foodborne illness.

Findings include:

1. During an interview on 4/25/18 at 5:50 PM, Staff A, Quality Director, stated that we use Hy-Vee foods to supply meals for all our patients. Our Dietician is in contact with them and makes sure we can get what we need including specialty diets like diabetic diets and cardiac diets. We have thermometers and after we reheat the food, we take the temperature and document it on a log.

2. During an interview on 04/30/18 at 1:55 PM Staff N, food catering services manager, stated that they have not been in contact with the dietician from Blue Valley Hospital and have not provided the facility their recipes nor do they have carbohydrate counts, low sodium options, or pureed items listed on their catering guide. Staff N confirmed they did not provide a patient menu but stated the items listed on the "Hy-Vee Kitchen Menu Selections" document are consistent with items from their catering catalog.

3. Review of the document titled "Hy-Vee Kitchen Menu Selections" on 04/25/18 showed a sample of the Hy-Vee menu options from their catering guide. The menu provided to patient's lists breakfast, lunch, dinner, and side dish options. Some heart healthy selections are marked with a heart symbol and a notation on the bottom indicating, "Diabetic Diet will consist of sugar-free options, if applicable" the facility provides a patient menu to their patients without knowledge of the nutritional value of its offerings.

4. Review of contract for Hy-Vee services failed to identify the type of services they agreed to provide. The contractual agreement was for setting up the facilities charge account.

5. Review of two documents titled "Diet Service Quality on 04/25/18 at 9:03 AM revealed staff documented only 7 temperatures on 1/22/16, 12/07/16, 04/04/17, 05/03/17, 05/22/17, 01/06/18, and 03/03/18 for microwaved foods in a period of more than two years.