HospitalInspections.org

Based on clinical record review and staff interviews, the facility failed to ensure services furnished under contract agreement for therapy services were provided for 2 of 11 sampled patients. (Patient #7 and Patient #22)

Findings:

Patient #7. Medical record review for Patient #7 was conducted on 2/11/13. Patient ' s clinical record indicated admitted with diagnoses to include Cerebrovascular Accident and Dysphagia (difficulty swallowing). Physician admission orders, dated 2/7/13, included orders for Physical therapy (PT), Occupational Therapy (OT) and Speech Therapy (ST). Admission physician orders, dated 2/7/13, included thickened liquids. A verbal order from attending physician was obtained on 2/8/13 to discontinue thickened liquids. The record did not include evaluation by Speech Therapist to determine if patient required thickened liquids prior to the order being changed. Clinical record revealed the PT evaluation and treatment orders were initiated on 2/8/13, but failed to reveal OT and ST evaluations had been done in accordance with the physician orders.
Interview with the facility ' s Physical Therapist on 2/12/13 at approximately 1:30pm revealed the process for notification of other therapy services ordered is for him to notify the Certified Occupational Therapy Assistant (COTA) who then in turn notifies the Speech Therapist and Occupational Therapist of need for evaluation. The Physical Therapist further identified the COTA to be the Rehabilitation Director for the facility.
In interview conducted with the facility ' s Utilization Review / Swing Bed Coordinator, on 2/12/13 at 1:40pm, it was revealed the OT/ST evaluations had not been conducted. The coordinator stated the facility process for therapy being notified of evaluations are for nursing to place a copy of the order in her box, she then notifies the in-house Physical Therapist, he notifies the COTA and the COTA notifies the OT and ST. She stated evaluations are usually done in 1-2 days. Request made for facility ' s expectation of time frame for evaluations to be conducted. Facility ' s Physical Therapist provided this surveyor with a list of patients currently on PT/ST/OT caseload. The list indicated 11 patients on PT caseload, 1 patient on OT caseload and indicated Patient #7 has a OT and ST evaluation pending.
Review of facility ' s contract for therapy services did not indicate timeframe for evaluations to be conducted. Interview with facility administrator on 2/11/13 at approximately 3:00pm revealed the expectation is for all therapy evaluations to be conducted within 48 hours; and confirmed this had not been done. The administrator further stated he was not aware of the notification process that had been relayed to me by the Physical Therapist and Utilization Coordinator.
On 2/12/13 at approximately 2:00PM, the Speech Language Pathologist arrived at facility to do the evaluation. When asked when evaluates patients for ST, she stated she comes to do the evaluation as soon as she is notified and stated she was notified of this evaluation yesterday when asked by this surveyor. The evaluation conducted on 2/12/13 (5 days after initial physician order) documented a dysphagia evaluation had been conducted at bedside on 1/31/12 stay. The 2/12/13 evaluation further documented patient safe for thin liquids. Based on this evaluation, the ST wrote treatment orders and plan of treatment related to speech/language deficits. The ST stated this patient had previous speech evaluation on prior admission and this surveyor requested this ST evaluation report. As of exit on 2/14/13, the facility had not produced the evaluation reportedly completed previous to the 2/7/13 admission.
On exit date of 2/14/13, the facility provided documentation that Occupational Therapy evaluation had been conducted on 2/13/13 (6 days after initial physician order) at approximately 5:00pm. Based on this evaluation, the OT wrote treatment orders and plan of treatment.
Patient #22. Clinical record review conducted on 2/13/13 revealed Patient #22 was admitted on 12/9/12 with a physician order for Physical Therapy and Occupational Therapy. An order was written by the Physical Therapist on 12/13/12 to "discontinue Occupational Therapy." Review of electronic record, in the presence of the Utilization Review/Case Manager failed to indicate an Occupational Therapist evaluation being conducted. The record failed to indicate why the physician orders were discontinued without obtaining the Occupational Therapy evaluation.

Based on review of the clinical record, review of facility policy and procedures, and interview with nursing staff, the facility failed to ensure physician written orders, and verbal orders/telephone orders, were verified by the physician for 3 of 15 patients in the sample (patient #11, #12 and #13).

The findings are:

A record review was conducted for patient #11 of the sample on 2/11/13. The record review revealed an order dated 2/8/13 for "CBC & BMP" (complete blood count and basic metabolic panel). On the same line as the order, it is indicated by the circled letters "RA". The order was noted by the first initial and last name of the LPN (Licensed Practical Nurse), with the date of 2/8/13 and the time of "1300" (1:00 p.m.). There was not indication on the order that it was a telephone or verbal order, and the physician had not signed the order, nor initiated it as being accurate. On 2/11/13 at approximately 3:00 p.m., and interview was conducted with the charge nurse. The nurse confirmed that this order was not signed by the physician, and that it appeared to have been written by the physician, and not be a telephone or verbal order.

A record review was conducted for patient #12 of the sample on 2/11/13. The record review revealed an order written on 2/8/13 at 1:15 p.m. for "EKG NOW & fax to MD". The order was written as a "V.O (verbal order) "physician's name/nurse's name, LPN". The order was "noted" by the same nurse on 2/8/13 at 1:15 p.m.. Written in the order space on the order sheet was also the note "To Pharmacy/2/8/13 @ 1622 and a circled set of initials. The order did not contain the initials of the physician to verify the order. On 2.11.13 at approximately 3:50 p.m., and interview was conducted with the DON (Director of Nursing). The DON confirmed that the order had not been initialed the physician and that the order had been written approximately 3 days ago.

A record review was conducted for patient #13 of the sample on 2/12/13. The record review revealed the following orders:

2/5/13 @ 2100: Amlodipine 10 mg po (by mouth) daily, Coreg 12.5 mg po BID (twice a day), Doxepin 75 mg @ HS (hour of sleep), Remeron 15 mg po @ HS, Protonix 40 mg po daily, Lasix 40 mg po daily, KCL (potassium) 10 meq (milliequivalents) po daily - disregard duplicate order, Prednisone 10 mg po daily. The order was written as 'VORB" (verbal order read back) "physician name/first initial of name and last name RN". The order was noted without nursing initials on 2/5/13 @ 2100. The order also had been stamped "SCANNED" 2/6/13 @ 0555 to Pharmacy and a circled set of initials. The order had not been initialed by the physician. Another order, separately written at the same date/time, for Ambien 10 mg po at bedtime. The order was written as a TORB (telephone order read back) with the physician's name/nurses name. The order was also marked as "SCANNED" @ 0555 to Pharmacy, with a circled set of initials. These orders did not contain the initials of the physician to verify the orders. Order dated 2/6/13 was written for "NS (normal saline) 60 cc/hr (cubic centimeters per hour) as a TORB with the physicians name/nurses name LPN. This order was "noted" and initiated by the nurse on 2/6/13 @ 1730. The order did not contain the initials of the physician to verify the orders.. On 2/12/13 at approximately 9:05 a.m., and interview was conducted with the unit nurse (a Registered Nurse). The nurse looked at the order sheet, and confirmed the physician had not counter-signed the orders. The nurse stated she believed the policy to be that the physician must counter-sign the orders within 24 hours.

The hospital's written policy and procedure for "Verbal and Telephone orders", reviewed by the hospital on 1/28/12, was reviewed by the surveyor on 2/12/13. The policy states (in part): "Verbal and telephone orders are allowed, however in an effort to reduce medication errors, the use of these types of orders is discouraged". Under the paragraph entitled "Procedure" it is stated "The prescribing practitioner must sign the written record of the verbal/telephone order within a reasonable time frame".



27622

Based upon observation of patients, interview with patients and staff, and review of the clinical patient records, it was determined the facility failed to develop a nursing plan of care for problem care areas requiring specific nursing interventions for 5 of 20 patients in the sample (#11, #12, #6, #7, #8)

The findings are:

The plan of care was reviewed for patient #11. The patient was admitted with a decline in both physical and mental condition, and lung congestion. The patient also has a diagnosis of mental retardation (down's syndrome). The plan of care noted the identified problem of "Insufficient physiological or psychological energy to endure or complete required or desired daily activities. Goals for this problem were listed on the plan of care as "muscle strength, muscles endurance, cardiovascular function, and respiratory function". There were no approaches/interventions identified for this problem identified and contained in the plan of care. The patient was observed to have an indwelling (Foley) urinary catheter. The catheter bag was noted to be hanging from the side rail of the bed. The plan of care did not contain any identified problem or care need for the indwelling catheter.

The plan of care was reviewed for patient #12. The patient was admitted with weakness, urinary tract infection, and gastroenteritis. The patient was observed to have an indwelling (Foley) catheter. The catheter bag was noted to be hanging from the side rail of the bed. The patient was interviewed on 2/11/13 at approximately 4:00 p.m. The resident was asked why she had the Foley catheter. She stated she was not sure, but thought it was because she had been dehydrated when she arrived in the emergency room. The patient could not describe what nursing care was provided for the catheter care (when it was cleaned or how often it was emptied). The plan of care was reviewed for this patient. The plan of care was noted to have identified problems of: "Deficient fluid volume, decreased intravascular, interstitial, and/or intracellular fluid. This refers to dehydration, water loss alone without change in sodium. Goals for this identified care problem were multiple, and measurable. However, there were no approaches/interventions listed in the plan of care for this identified care area. Impaired urinary elimination was identified on the plan of care as a problem care area, with goals of "symptom control". The approaches/interventions listed for this problem care area are defined as urinary elimination management, medication management, fluid management, and fluid monitoring. Additionally, the problem care area of "disturbance in urine elimination" is identified in the plan of care. Multiple, measurable goals are contained in the plan of care. However, there were no approaches/interventions listed in the plan of care for this identified care area problem. The plan of care did not identify or include any identified care area problem for the patient with an indwelling (Foley) catheter, did not establish any goals with such care area, and provided no nursing approaches/interventions to manage this nursing care problem area.

On 2/11/13 at approximately 3:50 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated they have been using the electronic plan of care format for about 2 years now, and they acknowledge there are problems with the program and some care plans come out " incomplete " . The DON also stated that Foley catheter care is a standard of nursing care, and she was not aware that it required a specific plan of care in order to provide the care for the catheter. The DON could not further explain the lack of interventions for other identified care areas in the plan of care.



27622

Patient #6. Clinical record review was conducted on 2/11/13. Record revealed Patient #6 admitted on 2/5/13 with primary diagnosis of pneumonia. Nursing admission assessment conducted documented gastrostomy tube feedings, urinary and bowel incontinence; and dependence on all Activities of Daily Living. Patient observed on 2/11/13 at approximately 2:45pm to have indwelling urinary catheter in place and a Peripherally Inserted Central Catheter (for intravenous infusions) in place to left upper arm. Review of electronic document titled " comprehensive care plan " noted " ineffective breathing pattern " with measurable goals and interventions noted. The plan of care failed to include additional patient problems that were identified on the initial assessment or interventions initiated after admission. The care plan failed to include the use of indwelling urinary catheter, care of the central line, care of the gastrostomy tube, care of skin related to immobility and incontinence, and provision of Activities of Daily Living.
In interview conducted with the Assistant to the Director of Nursing on 2/11/13 at approximately 3:00pm, she stated the care plan is based on medical necessity for admission only and use what is most pertinent to the admission diagnosis.
In interview conducted with the facility's Utilization Review/Case Manager on 2/11/13 at approximately 3:05pm, she stated this resident should have several problems indicated on plan of care. She stated the plan of care is utilized for acute and swing bed (SNF) care; and that she and the nurses would update care plans. Stated any problems identified on nursing admission assessments and/or ongoing nursing assessments would be care planned as care plans are reviewed daily.

Patient #7. Clinical record review was conducted on 2/11/13. Record revealed Patient #7 was admitted on 2/7/13 with primary diagnoses of cerebral vascular accident, diabetes, hypertension and left sided paralysis. Physician admission orders note aspiration, Decubitus and fall precautions. Physician History and Physical documented CVA, coronary artery disease, hypertension and kidney disease. Nursing admission assessment documented presence of Foley catheter, diabetes, and dependent on all Activities of Daily Living. Review of electronic document titled " comprehensive care plan " noted " risk for aspiration " and " risk for falls. " Goals and interventions were noted for both. The care plan failed to include any other problems identified on admission assessment.
Swing bed admission physician orders, dated 2/7/13, included orders for Physical therapy .Interview with Physical Therapist on 2/12 13 at approximately 1:20PM revealed patient has not been able to participate in therapy since evaluation done on Friday due to blood pressure elevations. Physician orders were noted on 2/8/13 to initiate a blood pressure medication, on 2/9/13 to increase the blood pressure medication, on 2/11/13 to decrease the blood pressure medication. The comprehensive plan of care failed to include the problem related to blood pressure which was identified after admission.
On further review of the clinical record on 2/12/13 at approximately 2:30pm, it was noted Xeroxed plans of care had been added for hypertension, Cerebrovascular accident, and diabetes. An interview was conducted with the Director of Nursing on 2/12/13 at approximately 3:00pm. She stated she went through all the patient records after survey team left and added the care plans they had used prior to instituting electronic records as did not like the options the computerized electronic system offered. She further stated she was not aware the appropriate plans of care were not being generated electronically with their electronic medical records.
Patient #8. Clinical record review was conducted on 2/11/13. Record revealed Patient #8 was admitted 2/2/13 with diagnosis of chronic obstructive pulmonary disease and failure to thrive. Nursing admission assessment documented depression, poor fluid intake, and poor food intake . Physician History and Physical documentation included multiple compression fractures of spine, hypertensive retinopathy of both eyes, hard of hearing, and anxiety neurosis. Review of electronic document titled " comprehensive care plan " noted " Activity Intolerance " and failed to include nursing interventions. The plan of care failed to include any other problems, goals or interventions.
On further review of the clinical record on 2/12/13 at approximately 2:30pm, it was noted that Xeroxed plans of care had been added for COPD and fall risk. The plans of care added were noted to include measurable goals and nursing interventions.
The hospital policy and procedure for the Nursing Department was reviewed. The "purpose" of the policy is stated, in part, "Each patient shall receive appropriate nursing care/interventions, relevant to meet the patient's needs, given the current state of knowledge. Each patient will receive nursing care/interventions in an effective manner, given the current state of knowledge, in order to achieve the desired/projected outcome for the patient. Nursing care will be provided by nursing staff that are competent to fulfill their assigned responsibilities". The policy further states, in part, "Each patient will be assessed for biophysical, functional, psychosocial, environmental, cultural, spiritual, developmental, self-care, nutritional risk, education, abuse/neglect risk, and discharge care needs/state. Have a plan of care that prescribes individualized interventions to attain expected outcomes and reflects recognized standards of care and practice as well as respects patient rights. Have his/her needs/state reassessed and the plan of care evaluated and revised, based on assessment data. Each patient will have nursing care/interventions available to meet his/her needs. Each patient (and or family, as appropriate) will receive individualized care/interventions based on identified needs

Based on observations, record review and staff interviews, the facility failed to ensure medical record documentation was accurate as evidenced by documenting a central line dressing had been changed without the dressing change occurring for 1 of 2 patients sampled. (Patient #6).

Findings:

On 2/11/13 at approximately 12:45pm, Patient #6 was observed to have a Peripherally Inserted Central Catheter (PICC) to left upper arm. The gauze under the tegaderm was noted to have approximately 3cm area of what appeared to be dried blood; and there was no date on the dressing indicating when it was last changed .
Physician orders, dated 2/8/13, include PICC Line care per protocol. Request made for facility policy and procedure related to PICC line dressing changes.
An interview was conducted with the Registered Nurse (RN #1) providing care on 2/11/13 at approximately 1:15pm. She stated the PICC dressing should have date indicating date to be changed, stated it might have fallen off and stated believes due to be changed today. Interview with Registered Nurse (RN#2) was conducted at approximately 1:20pm. She demonstrated where she inserted the PICC on 2/5/13 , demonstrated the PICC dressing changes are documented on Medication Administration Record (MAR); and stated the MAR would prompt for dressing to be changed on 2/12/13.
On 2/13/13 at 9:20am, patient was observed to have same PICC dressing in place as observed on 2/11/13. There was no indication the dressing had been changed on 2/12/13. RN #2 approached this surveyor on 2/13/13 at 10:22 am and stated "I know you looked at the PICC dressing this morning and it was not changed." Stated she was supposed to change the dressing yesterday, but forgot to. Stated she has now changed the dressing. Request made for a copy of the Medication Administration Record that indicates PICC dressing change. The MAR documented the dressing as have been done on 2/12/13 at 2:00pm as indicated by initials of nurse assigned to the patient. RN #2 confirmed the dressing had not been changed as was documented on the MAR, stated the assigned nurses sign off on the MAR, but herself and another licensed nurse who insert the PICC Lines perform the dressing changes.
Review of facility Policy and Procedure titled " Peripherally Inserted Central Catheters (PICC) Care and Maintenance " documented to change dressing every 7 days or when loose, soiled or dampened.

Based on clinical record review, quality assurance program review and interviews, the facility failed to evaluate all patient care services affecting patient health and safety as evidenced by failure to include therapy services in the quality assurance program.

Findings:

Patient #7. Medical record review for Patient #7 was conducted on 2/11/13. Patient ' s clinical record indicated admitted with diagnoses to include Cerebrovascular Accident and Dysphagia (difficulty swallowing). Physician admission orders, dated 2/7/13, included orders for Physical therapy (PT), Occupational Therapy (OT) and Speech Therapy (ST). Admission physician orders, dated 2/7/13, included thickened liquids. A verbal order from attending physician was obtained on 2/8/13 to discontinue thickened liquids. The record did not include evaluation by Speech Therapist to determine if patient required thickened liquids prior to the order being changed. Clinical record revealed the PT evaluation and treatment orders were initiated on 2/8/13, but failed to reveal OT and ST evaluations had been done in accordance with the physician orders.
Interview with the facility ' s Physical Therapist on 2/12/13 at approximately 1:30pm revealed the process for notification of other therapy services ordered is for him to notify the Certified Occupational Therapy Assistant (COTA) who then in turn notifies the Speech Therapist and Occupational Therapist of need for evaluation. The Physical Therapist further identified the COTA to be the Rehabilitation Director for the facility.
In interview conducted with the facility ' s Utilization Review / Swing Bed Coordinator, on 2/12/13 at 1:40pm, it was revealed the OT/ST evaluations had not been conducted. The coordinator stated the facility process for therapy being notified of evaluations are for nursing to place a copy of the order in her box, she then notifies the in-house Physical Therapist, he notifies the COTA and the COTA notifies the OT and ST. She stated evaluations are usually done in 1-2 days. Request made for facility ' s expectation of time frame for evaluations to be conducted. Facility ' s Physical Therapist provided this surveyor with a list of patients currently on PT/ST/OT caseload. The list indicated 11 patients on PT caseload, 1 patient on OT caseload and indicated Patient #7 has a OT and ST evaluation pending.
Review of facility ' s contract for therapy services did not indicate timeframe for evaluations to be conducted. Interview with facility administrator on 2/11/13 at approximately 3:00pm revealed the expectation is for all therapy evaluations to be conducted within 48 hours; and confirmed this had not been done. The administrator further stated he was not aware of the notification process that had been relayed to me by the Physical Therapist and Utilization Coordinator.
On 2/12/13 at approximately 2:00PM, the Speech Language Pathologist arrived at facility to do the evaluation. When asked when evaluates patients for ST, she stated she comes to do the evaluation as soon as she is notified and stated she was notified of this evaluation yesterday when asked by this surveyor. The evaluation conducted on 2/12/13 (5 days after initial physician order) documented a dysphagia evaluation had been conducted at bedside on 1/31/12 stay. The 2/12/13 evaluation further documented patient safe for thin liquids. Based on this evaluation, the ST wrote treatment orders and plan of treatment related to speech/language deficits. The ST stated this patient had previous speech evaluation on prior admission and this surveyor requested this ST evaluation report. As of exit on 2/14/13, the facility had not produced the evaluation reportedly completed previous to the 2/7/13 admission.
On exit date of 2/14/13, the facility provided documentation that Occupational Therapy evaluation had been conducted on 2/13/13 (6 days after initial physician order) at approximately 5:00pm. Based on this evaluation, the OT wrote treatment orders and plan of treatment.
Patient #22. Clinical record review conducted on 2/13/13 revealed Patient #22 was admitted on 12/9/12 with a physician order for Physical Therapy and Occupational Therapy. An order was written by the Physical Therapist on 12/13/12 to "discontinue Occupational Therapy." Review of electronic record, in the presence of the Utilization Review/Case Manager failed to indicate an Occupational Therapist evaluation being conducted. The record failed to indicate why the physician orders were discontinued without obtaining the Occupational Therapy evaluation.
On 2/14/13 at approximately 8:30am, an interview was conducted with the facility's Director of Nursing/Risk manager and the Assistant to the DON/Quality Improvement Coordinator. Review of facility-wide quality assurance program failed to include therapy services provided on contractual agreement to include Physical Therapy, Speech Therapy and Occupational Therapy.

Review of facility's document titled "Performance Improvement Plan - Quality Assurance" states the Performance Improvement Director will ensure that Support Services and Department Heads are conducting ongoing monitoring of the quality and appropriateness of patient care. Review of facility's document titled "Performance Improvement - Facility Wide" states the facility-wide program has the responsibility for monitoring every aspect of patient care, from the time the patient enters the facility through diagnosis, treatment, recover and discharge in order to identify and resolve any breakdowns that may result in suboptimal patient care and safety, while striving to continuously improve and facilitate positive patient outcomes."