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Based on record review and interview, the hospital failed to ensure the nursing staff developed and kept current individualized and comprehensive care plans, addressing all active patient problems, for 8 (#4, #5, #6, #8, #9, #19., #20, #21) of 30 patient records reviewed for care plans from a total patient sample of 30.

Findings:

Review of the hospital policy titled, "Nursing Process-Care Plan", revealed in part: I. Purpose: It is the responsibility of every nurse to actively contribute to the plan of care on each assigned patient. Care plans must be initiated by a Registered Nurse within twenty-four (24) hours of admission. III. Procedure: The admission assessment data is the basis for the selection and individualization of the patient's plan of care. Patients receive care based upon assessment of their needs. 4. The patient's plan of care will be personalized to meet individual needs. 5. Additional problems unique to the patient may be included and needs reassessed whenever warranted by the patient's condition. 6. Collaborative input from the other health care providers contribute to a comprehensive patient assessment. III. A. Patient care planning will include interventions, therapy, and education specific to the patient's health care needs, discharge planning, continuing care needs, and potential referral/consultations. B. The plan of care goals will be reviewed each shift and revised as necessary or as indicated by the changing needs of the patient. C. Plan of care goals will be individualized. D. Evaluation: Reassessment: 1. Patient outcomes and response to treatment/implementation of patient care planning is evaluated and documented daily.


Patient #4
Review of Patient #4's medical record revealed an admission date of 11/24/18 with admission diagnoses of Diabetes Mellitus Type II, Pneumonia, and End Stage Renal Disease. Further review revealed the patient was receiving Hemodialysis, had an open wound located on the lower back and pelvis, and was on contact precautions for ESBL(extended spectrum beta lactamase) - a resistant bacteria.

Review of Patient #4's current care plan revealed End Stage Renal Disease, treatment with Hemodialysis, Arteriovenous fistula site care, impaired skin integrity related to a back wound, actual infection- Pneumonia, Diabetes Mellitus, and Contact Isolation for ESBL bacterial infection were not identified as current problems to be addressed on the plan of care. S11RN, electronic medical record navigator, confirmed the findings during Patient #4's electronic medical record review.


Patient #5
Review of Patient #5's medical record revealed an admission date of 11/25/18 with admission diagnoses of being a Non-compliant End Stage Renal Disease patient with elevated potassium, BUN (blood, urea, nitrogen), and creatinine levels and Diabetes Mellitus Type II. Additional review revealed Patient #5 had a central venous catheter access in her left neck for hemodialysis.

Review of Patient #5's current care plan revealed central venous catheter site care and Diabetes Mellitus were not identified as current problems to be addressed on the plan of care. S11RN, electronic medical record navigator, confirmed the findings during Patient #5's electronic medical record review.


Patient #6
Review of Patient #6's medical record revealed and admission date of 11/24/18 with admission diagnoses of Fatigue and SOB. Further review revealed the patient had diagnosis of Diabetes Mellitus, Bipolar disorder, Acute Congestive Heart Failure, Hyponatremia, and an Acute Urinary Tract Infection.

Review of Patient #6's current care plan revealed impaired mobility with a plan to improve physical mobility and prevent complications of immobility. Diabetes Mellitus, Bipolar disorder, Acute Congestive Heart Failure, Hyponatremia, and an Acute Urinary Tract Infection were not identified as current problems to be addressed on the plan of care. S11RN, electronic medical record navigator, confirmed the findings during Patient #6's electronic medical record review.


Patient #8
Review of Patient #8's medical record revealed an admission date of 9/8/18 with admission diagnosis of Hypoglycemia. Further review revealed the patient had a diagnoses of Diabetes Mellitus, Bilateral Pneumonia, Urinary Tract Infection, and Peripheral Vascular Disease with Bilateral Amputations. Further review revealed a discharge date of 9/12/18.

Review of Patient #8's care plan revealed knowledge deficit of current medical condition with a plan to initiate necessary lifestyle changes and to participate in therapeutic regime. Diabetes Mellitus, Bilateral Pneumonia, Urinary Tract Infection, and Peripheral Vascular Disease with Bilateral Amputations were not identified as problems to be addressed on the plan of care. S11RN, electronic medical record navigator, confirmed the findings during Patient #8's electronic medical record review.


Patient #9
Review of Patient #9's medical record revealed an admission date of 9/21/18 with admission diagnosis of Wound Infection. Further review revealed a discharge date of 9/22/18.

Review of Patient #9's care plan revealed no care plan during the hospital stay. S11RN, electronic medical record navigator, confirmed the findings during Patient #9's electronic medical record review.


Patient#19
Review of Patient #19's medical record revealed an admission date of 11/24/18 as an observation for status post fall- surgery. Patient #19's admission was changed to inpatient on 11/26/18. Further review revealed the patient had diagnosis of closed fracture of the right tibia plateau, closed intertrochanteric fracture of the right hip, Dementia, falls, hip pain-swelling and COPD (Chronic Obstructive Pulmonary Disease) type A.

Review of Patient #19's current care plan revealed Dementia, falls, hip pain-swelling and COPD type A were not identified as current problems to be addressed on the care plan. S4Regulatory, electronic medical record navigator, confirmed the findings during Patient #19's electronic medical record review.


Patient #20
Review of Patient #20's medical record revealed an admission date of 11/21/18 with a diagnosis of dehydration. Further review revealed the patient had diagnosis of bladder outlet obstruction, benign prostatic hyperplasia, COPD, Diabetes mellitus - borderline diet control now, E. Coli urinary tract infection and back pain.

Review of Patient #20's current care plan revealed bladder outlet obstruction, benign prostatic hyperplasia, COPD, E. Coli urinary tract infection and back pain were not identified as current problems to be addressed on the care plan. S4Regulatory, electronic medical record navigator, confirmed the findings during Patient #20's electronic medical record review.


Patient #21
Review of Patient #21's medical record revealed and admission date of 11/18/18 with a diagnosis Mastitis R breast post mastectomy. Further review revealed the patient had diagnosis of
acute diarrhea, COPD, diabetes, methicillin resistant Staphylococcus infection, back pain and sleep apnea.

Review of Patient #21's current care plan revealed acute diarrhea, COPD, diabetes, methicillin resistant Staphylococcus infection, and sleep apnea were not identified as current problems to be addressed on the care plan. S4Regulatory, electronic medical record navigator, confirmed the findings during Patient #21's electronic medical record review.





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Based on record reviews, observations, and interviews the hospital failed to ensure drugs and biologicals were administered in accordance with physician orders and hospital policy as evidenced by:
1) failure of the nurse to obtain a clarification order for the titration of Dopamine for 2 (#10, #29) of the 2 patient records reviewed for Dopamine titration orders from a sample of 30 patients;
2) failure of the nurse to document the medication error in the patient's medical record, and/or failure of the nurse to notify the physician of the medication error for 2 (#8, #9) of 2 patient records reviewed for medication administration errors from a sample of 30 patients; and
3) failure to follow the hospital's policy by not dating opened multi-use vials.
Findings:

1) Failure of the nurse to obtain a clarification order for the titration of Dopamine

Review of the hospital policy titled Physician Orders presented as current policy revealed in part, all orders must be entered into the electronic system or written on a Doctor's Order Form.
Verbal order is an order given orally to a licensed personnel by an individual licensed to write orders, which is written/entered in the patient's medical record and read back to the individual giving the order.
In areas of physician oversight, when "repeat-back" of verbal orders are allowed by policy (example: codes, ER, OR), verbal orders may be entered directly into electronic medical record (EMR) and a paper copy is not required.
The order procedure: Nursing will read the complete set of doctor's orders; Scan EMR for importance of orders. STAT orders are always transcribed and completed first; and Nursing will review orders for accuracy and thoroughness.

Patient #10
Review of Patient #10's orders dated 11/3/18 revealed a verbal order from S14MD for Dopamine 800 mg/ 250 ml premix 800 mg rate Titrate taken by S13RN. There was no documented evidence of parameters, such as a titration rate or goal for maintaining Patient #10's blood pressure. There was no documented evidence of a clarification order written by S13RN.

S4Regulatory, electronic medical record navigator, confirmed the findings during Patient #10's electronic medical record review.

Patient #29
Review of Patient #29's orders dated 10/13/18 revealed a STAT order entered by S15MD for Dopamine 800 mg/ 250 ml premix 800 mg rate Titrate. There was no documented evidence of parameters, such as a titration rate or goal for maintaining Patient #29's blood pressure. There was no documented evidence of a clarification order.

S11RN, electronic medical record navigator, confirmed the findings during Patient #29's electronic medical record review.


2) Failure of the nurse to document the medication error in the patient's medical record, and/or failure of the nurse to notify the physician of the medication error

Review of the hospital policy titled Medication Administration, presented as current policy, revealed in part, Medications omitted and the reason for omission are to be documented in the electronic medical record.

Review of the hospital policy titled Reporting of Medication Errors, presented as current policy, revealed in part, all medication errors identified will be reported immediately upon detection to the attending physician; and documentation of physician notification and any new orders from the physician will be noted in the EMR.

Patient #8
Review of Patient #8's medical record revealed an admission date of 9/8/18 with admission diagnosis of Hypoglycemia.

Review of the physician's orders revealed an order dated 9/9/18 at 9:16 a.m. of D5 Lactated Ringers infusion at 75 ml/hour.

Review of the eMAR revealed D5 Lactated Ringers infusion at 75 ml/hour started on 9/9/18 at 8:54 p.m.

Review of Medication Error Event Report documented 9/9/18 revealed Patient #8 had a delay in the administration of fluids.

Review of Patient #8's medical record with the guidance of S11RN revealed no documented evidence of the delay in administration documented in the medical record nor the physician was notified of this delay.

Patient #9
Review of Patient #9's medical record revealed an admission date of 9/21/18 with admission diagnosis of Wound Infection.

Review of the physician's orders revealed an order 9/21/18 for Vancomycin (an antibiotic) 1 gm IVPB every 12 hours.

Review of the eMAR revealed a dosage of Vancomycin administered on 9/21/18 at 1:16 p.m.

Review of Medication Error Event Report documented 9/22/18 revealed Patient #9 had a missed dosage of Vancomycin on 9/22/18 at 2:00 a.m.

Review of Patient #9's medical record with the guidance of S11RN revealed no documented evidence of the missed dosage of Vancomycin documented in the medical record nor the physician was notified of the missed dosage of Vancomycin.


3) Failure to follow the hospital's policy by not dating opened multi-use vials.

Review of the hospital policy titled Medication Administration, presented as current policy, revealed in part, medications omitted and the reason for omission are to be documented in the electronic medical record.

On 11/26/18 at 3:00 p.m. an observation of the mediation refrigerator with S2CNO and S6LPN, revealed #2 three (3) ml bottles of Humalog were opened and unlabeled [both bottles with Lot #C838932A and expiration 10/19]. S2CNO verified the above findings.

Based on observations and interview, the hospital failed to have working call lights on the siderails for 3 out of 36 hospital beds observed.

Findings:

An observation was made on 11/26/18 at 3:00 p.m. of patient rooms 234, 311 and 321 having hospital beds in the rooms with nonfunctioning call lights on the siderails.

On 11/26/18 at 3:00 p.m. S1Admin confirmed the above findings.

Based on observations, record review, and interview, the hospital failed to ensure the infection control program was implemented to prevent and control infections and communicable diseases as evidenced by:
1) failing to maintain a sanitary environment in the hospital and perform hand hygiene for 1(#6) of 1 current patient receiving accuchecks out of a total paitent sample of 30.
2) failing to ensure gowns were worn during provision of hemodialysis/assessment of the patient, failing to ensure biohazardous waste bags were available for discarding contaminated gloves/gowns/waste, and failing to disinfect reusable equipment in the patient's room for 1(#4) of 1 current patients in contact isolation, observed receiving hemodialysis, from a sample of 2 hemodialysis patients (#4,#5) out of a total patient sample of 30.

Findings:

1) Failure to maintain a sanitary environment in the hospital and perform hand hygiene during accucheck.

Review of the hospital policy titled Hand Hygiene presented as current policy revealed in part, appropriate times to use hand washing and /or hand sanitizer:
7. Decontaminate hands after contact with a patient's intact skin and/or patient surroundings (example-when taking a pulse or blood pressure and lifting a patient).
9. Decontaminate hands after removing gloves and other PPE.

Review of the CDC's "Guideline for hand Hygiene in Health-Care Settings" revealed hands should be washed or an alcohol-based hand rub should be used before having direct contact with patients before inserting an invasive device, after contact with a patient's intact skin, after contact with inanimate objects in the immediate vicinity of the patient, and after removing gloves.

On 11/26/18 at 3:15 p.m. an observation of S6LPN perform an accucheck on Patient #6 revealed S6LPN placed the multi-patient use glucometer on Patient #6's over-bed table containing Patient #6's opened dietary tray. Further observation revealed following the glucose check, S6LPN did not perform hand hygiene after removal of gloves and used her computer on wheels keypad to enter patient information.

On 11/28/18 at 9:00 a.m. in an interview with S12RN verified the findings of the glucometer check on Patient #6.


2) Failing to ensure gowns were worn during provision of hemodialysis/assessment of the patient, failing to ensure biohazardous waste bags were available for discarding contaminated gloves/gowns/waste, and failing to disinfect reusable equipment in a contact isolation patient's room who was receiving hemodialysis.


Review of the Hospital policy titled,"Transmission Based Precautions", Policy Number: IV- B.3, last reviewed: 8/2018, revealed in part: Contact Precautions: V. In addition to standard precautions: 3. Wear gloves and gowns when entering the patient room.

Review of the hospital policy titled,"Standard Precautions", Procedure Number: 602, revealed in part: Standard precautions will be utilized by personnel in areas, and during procedures, where there is a risk of exposure to blood, body fluids, secretions, excretions, non-intact skin, mucous membranes. 1. Hand hygiene will be practiced at all times. 2. Personal Protective Equipment (PPE) will be used at all times when the nature of anticipated care or cleaning of environmental surfaces and/or equipment indicates that contact with blood or body fluids may occur. 11. Equipment and supplies, if not single use, will be properly disinfected using standard precautions. Procedure- Key Points: Regular cotton, non-fluid resistant lab coats are not considered PPE and should be removed or should be worn under a fluid resistant gown. Gowns should cover the front, at least to the mid-thigh, have long sleeves and cover the front of the body.
Dialysis personnel will adhere to the following: 3. The outside surface of the machine, chair, bedside table, blood pressure cuff, and any ancillary equipment will be cleaned after each patient use with a 1:100 bleach solution.

On 11/28/18 at 7:50 a.m. an observation was made of Patient #4. Signage indicating Patient #4 was on contact isolation precautions was noted upon entry into the patient's room. Patient #4 was observed in the bed with hemodialysis in progress. S9MD was observed at the patient's bedside with his lab coat on, open down the front leaving his clothing exposed, with gloves on and no gown. S10RN was also observed in the room with no gown on or PPE of any type. No red bags were noted in the trash cans in the patient's room for discarding used PPE. No linen cart was noted for disposal of used patient linens.

In an interview on 11/28/18 at 8:50 a.m. with S8LPN, she confirmed Patient #4 was on contact isolation precautions. S8LPN reported the patient was on contact precautions due to an ESBL (Extended Beta Spectrum Lactamase- resistant bacteria) infection.

On 11/28/18 at 9:59 a.m. an observation was made of S10RN removing Patient #4 from hemodialysis treatment. S10RN removed the needles (with attached sections of tubing) that had been used for cannulation of the patient's vascular access. S10RN placed the 2 dirty needles with the attached extensions of the blood line tubing on the patient's bedside table with no barrier between the surface of the table and the used needles/tubing. The used tubing that was attached to the dirty, used needles was observed to contain a residual amount of blood tinged fluid. A beverage cup and a plastic container of fruit was also noted on the table. S10RN removed and discarded the dirty needles and the tubing. S10RN failed to disinfect the patient's bedside after discarding the used equipment. Further observation of S10RN revealed he placed the used hemodialysis tubing with the attached dialyzer, noted to contain residual blood tinged fluid, on the floor prior while opening a red biohazard bag that had been on the floor in the patient's room. S10RN discarded his gown and gloves in the trash can in the patient's room that contained a clear, non biohazardous plastic bag.

In an interview on 11/28/18 at 10:38 a.m. with S5VPCompliance, she confirmed gowns should be worn when entering a patient's room that was on contact isolation precautions. She also confirmed there should have been red biohazard bags in the trash cans in the patient's room. S5VPCompliance agreed the above referenced observed actions were breaches in infection control practices.



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