HospitalInspections.org

Based on record review and staff interview, the Hospital failed to follow their policy and procedure for initiating a Do Not Resuscitate (DNR) Order as evidenced by:
1) the nurse failing to have the DNR order authenticated by the physician within 12 hours of the order for 1 (#13) of 2 (#13, #14) patients reviewed with a DNR out of a total of 31 sampled medical records; and
2) the physician failing to document in the progress notes the DNR discussion with the family, Power of Attorney and/or patient before DNR status was implemented for 1 (#13) of 2 (#13, #14) patients reviewed with a DNR out of a total of 31 sampled medical records.
Findings:

Review of the policy titled Advance Directives (Living Will, Durable Power of Attorney, DNR, Withdrawing/Withholding) presented as current policy revealed in part beginning on page 11 of 17: ...A. Physicians should discuss, with patient or his/her appropriate designee representative, the possibility of cardiopulmonary arrest ...C. Institution of DNR will occur only upon the physician's order. In the presence of a living will from the patient requesting to not be resuscitated, the physician shall be allowed to give a telephone order, until he/she can reasonably get to the hospital to authenticate the order, within 12 hours if this situation presents itself in the nighttime .... O. Operating Room Some patients with DNR status become candidates for surgical procedures that may provide them with significant benefit even though the procedure may not change the natural history of the underlying disease ...The DNR status of such patients during the operative procedure and during the immediate postoperative period may need to be modified prior to the operation ...The patient and the physicians who will be responsible for the patient's care should discuss the new risks and the approach to potential life-threatening problems during the perioperative period. The results of these discussions should be documented in the record.
Responsibility: A. Attending Physician: Document the medical facts and condition of the patient in the progress notes indicating the basis for the DNR determination and consultation and consent of the patient and/or family.
Procedure: ...Physician writes order and notes in progress note.

1) The nurse failed to have the DNR order authenticated by the physician within 12 hours of the order as evidenced by:

Review of Patient #13's medical record revealed an admission date of 01/30/19 with and admission diagnoses of COPD Exacerbation, Peripheral Artery Disease, Right Foot Ulcer, and Sepsis.

Review of the Physician Orders revealed on 01/30/19 at 2:00 p.m. a RBTO by S7LPN: "Activate Advanced Directive. Pt is DNR". This order was not authenticate by a physician.

On 02/19/19 at 8:15 a.m. an interview with S5NM and S4QA verified the above findings.


2) The physician failed to document in the progress notes the DNR discussion with the family, Power of Attorney and/or patient before DNR status was implemented as evidenced by:

Review of the History and Physical dictated 01/30/19 and progress note dated 01/31/19 revealed no documented evidence of discussion with the patient/family/significant other related to the DNR.

On 02/18/19 at 4:30 p.m. a review of the medical records of Patient #13 with S5NM and S7LPN verified there were no notes of a discussion with the patient/family/significant other related to the DNR.

On 02/19/19 at 8:15 a.m. an interview with S5NM and S4QA verified the above findings.

Based on record review and interview, the hospital failed to ensure the Emergency Department (ED) direct care staff received the education, training and demonstrated knowledge in the use of non-physical intervention skills for 3 (S9IC, S11RN, S13RT) of 4 (S9IC, S11RN, S12RT, S13RT) emergency department employee files reviewed.

Findings:

On 2/20/2019 at 8:30 a.m. a review of the personnel files for S9IC, S11RN and S13RT failed to reveal documented current education, training and demonstration in the use of non-physical intervention skills.

On 2/20/19 at 8:30 a.m. S10AA verified the above staff work in the emergency department and their personnel files did not contain documented current education, training and demonstration in the use of non-physical intervention skills.

Based on record review and interview, the hospital's Governing Body failed to ensure the QAPI program reflected the complexity of the hospital's services as evidenced by failing to include all hospital services in the QAPI program. This deficient practice was evident by failing to include the following contracted services: linen, physical therapy, anesthesia, biohazard waste and Mobile Cataract Surgery services.

Findings:

On 2/20/19 at 10:45 a.m. a review of the QAPI Plan failed to reveal the following contracted services were included: linen, physical therapy, anesthesia, biohazard waste and Mobile Cataract Surgery.

A review of the Oakdale Community Hospital Contract Log services confirmed the linen, physical therapy, anesthesia, biohazard waste and Mobile Surgery services were contracted.

In an interview on 2/20/19 at 10:50 a.m. S4QA verified he was the person responsible for coordination of the hospitals Quality Assurance Program. He further confirmed the above services were contracted and not included in the QAPI Plan.

39791

Based on record review, interview, and observation, the hospital failed to ensure the nursing staff developed and kept current individualized and comprehensive nursing care plans. This deficient practice was evidenced by failure of the nursing staff to include all identified medical diagnoses and failure to include nursing interventions for for 5 (#13, #16, #18, #20, #31) of 15 (#1-#5, #11-#20, and #31) sampled patients reviewed for care plans of a total sample of 31.

Findings:

Review of the hospital policy titled Plan of Care presented policy revealed, in part: the plan of care will be developed and implemented based on Nursing Diagnoses/Patient Problem or Need and will be discussed with patient/family, whenever possible, and as desired by the patient.
The nursing care provided is based on established standards of patient care and standards of nursing practice that has been reviewed and approved by the Chief Nursing Officer. Nursing Diagnoses and these standards will guide the RN and other nursing staff members in the provision of nursing care.
Continuing care needs are assessed on admission and are re-evaluated as necessary; appropriate referrals are made through consultation with Social Services/Discharge Planner.

Patient #13
Review of Patient #13's medical record revealed an admission date of 01/30/19 with and admission diagnoses of COPD Exacerbation, Peripheral Artery Disease, Right Foot Ulcer, and Sepsis.

Review of her medical history revealed a medical diagnoses of Type 2 Diabetes.

Review of Patient #13's orders revealed an order for glucometer checks every 6 hours.
Further review revealed an order for contact isolation.

Review of Patient #13's MAR revealed Lantus Insulin 58 units SQ every night.
Further review of Patient #13's MAR revealed two antibiotics (Zosyn 3.375 mg IVPB every 6 hours and Vancomycin 1 Gm IVPB every 24 hours).

Review of Patient #13's labs revealed on 02/12/19 Urine Culture results with ESBL (resistant bacterial infection) and contact precautions.

Review of Patient #13's current care plan revealed nutrition-less than body requirements; altered electrolytes imbalance; altered comfort level related to surgical procedure; altered tissue perfusion related to peripheral perfusion; and safety.

On 02/18/19 at 3:00 p.m. Patient #13's current care plan was reviewed with the guidance of S5NM. S5NM verified diabetes and infection were not identified as current problems to be addressed on the plan of care.

An observation on 02/18/19 of Patient #13's door revealed a sign stating contact isolation and PPE supplies hanging on her door.


Patient #16
Review of the Medical Record for patient #16 revealed the patient was admitted to swing bed on 02/15/19 for Resolving Pyelonephritis and Resolving Dehydration.

Review of patient #16's care plan revealed identified problems to include Urinary Tract Infection and Safety.

The care plan did not reflect the patient's other diagnosis of Diabetes, Hypertension, Alzheimer's, and Atrial Fibrillation.


Patient #18
Review of the Medical Record for patient #18 revealed the patient was admitted to swing bed on 01/08/19 for Resolving CHF, COPD, and A-Fib.

Review of patient #18's care plan revealed identified problems to include Increased Knowledge and Ability to Self-Care, Mobility, Safety, and Alteration in Comfort.

The care plan did not reflect the patient's cardiac and respiratory issues, or the order for continued telemetry monitoring.


Patient #20
Review of the Medical Record for patient #20 revealed the patient was admitted to swing bed on 01/26/19 for Resolving Pyelonephritis.

Review of patient #20's care plan revealed identified problems to include Understanding Disease Process, Mobility, Safety, Activity, and Urinary Tract Infection.

The care plan did not reflect the patient's other diagnosis of Diabetes's, and Hypertension.

The patient had orders for Accuchecks AC & HS per S/S, and Lantus 20 units SQ q HS.


Patient #31
Review of the Medical Record for patient #31 revealed the patient was admitted to swing bed on 02/14/19 for Resolving Pneumonia.

Review of patient #31's care plan revealed identified problems to include Mobility, Knowledge Deficit, Safety, and Impaired Gas Exchange.

The care plan did not reflect the patient's other diagnosis of Diabetes's and Hypertension.

The patient had orders for Accuchecks AC & HS per S/S, and Lantus 25 units SQ q day.


Interview on 02/19/19 at 2:45 p.m. with S2CNO confirmed that the nursing staff should be care planning all of the patient's diagnosis.

Based on interview, the hospital failed to ensure the organization of the medical record service was appropriate and complied with the requirements of State regulations as evidenced by failure to have a RHIT or RHIA designated as responsible for the medical record department.
Findings:

Interview on 02/19/19 at 2:00 p.m. with S3CFO confirmed the hospital did not currently have employed or contracted RHIA or RHIT since February 1st. She further indicated that she was assuming responsibility for medical records until someone was hired, but did not have any medical records or health information training.

Based on record review and interview the hospital failed to ensure the clinical records system was maintained in accordance with written policies and procedures as evidenced by failure to ensure medical records of patients were promptly completed as set forth in the hospital's policies for completion of medical records.

Findings:

Review of the hospital's policy titled Documentation of Health Information revealed in part:
Procedure: 7. All signatures should be on the chart within 30 days of discharge.
Procedure: 10. The Hospital conducts an ongoing review of records ...

Review of the hospital's Medical Staff By-laws, Medical Records 28. The attending physician shall be responsible for the preparation of a complete medical record for each of his inpatients, outpatients, or emergency patients. This record shall include: a. identification data ...n. An autopsy report should be included when applicable or available.
All medical records should be completed within 30 days from the date of discharge. Those medical records not completed within 30 days of discharge shall be considered delinquent. Notification of delinquent records will be sent to the physician and non-completion with-in 15 days from notification will necessitate notification of the Chief of Staff for intervention.

Review of the hospital's Deficiency Report by Physician dated 02/19/19 revealed there were 19 delinquent records due past 30 days with 14 records delinquent over 60 days.

During an interview on 02/19/19 at 10:10 a.m., S3CFO stated the hospital has not followed the by-laws by involving the Chief of Staff for completion of medical records.

Based on record review and interview, the hospital failed to ensure a person qualified by education and experience and competency in infection control practices was designated as the infection control officer as evidenced by failure to have documented evidence of education, prior experience, and competency in infection control practices for S9IC who was designated infection control officer.
Findings:

Review of personnel file for S9IC revealed no documented evidence of education, prior work experience, and competency in infection control practices.

On 02/19/19 at 3:00 p.m. in an interview with S9IC, she indicated she had no prior work experience in infection control and had not received infection control education related to developing and implementing an effective infection control program.

39791


Based on record reviews, observations, and interviews, the infection control officer failed to develop and/or implement a system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel as evidenced by:
1) failed to ensure hand hygiene practices were implemented in accordance with CDC guidelines as evidenced by observation of breaches in hand hygiene during the performance of 1 (Patient 1) of 1 capillary blood glucose test observed; and
2) failed to ensure all staff adhered to current CDC (Centers for Disease Control) guidelines related to TB (tuberculosis) screening as evidenced by 2 (S13RT, S14CNA) of 8 personnel records review for TB screenings.

Findings:

1) The infection control officer failed to ensure hand hygiene practices were implemented in accordance with CDC guidelines as evidenced by:

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 including medical equipment, and after removing gloves.

Review of the hospital policy titled Hand Hygiene presented as current policy revealed in part, it is recommended to decontaminate hands: ...After removing gloves ...

An observation on 02/19/19 at 4:00 p.m. of a blood glucose test on Patient #R1 revealed S16LPN donned gloves, performed the blood glucose testing, removed the gloves, donned another pair of gloves, used her computer on wheels to document, then administered an oral medication to the patient. S16LPN did not perform hand hygiene during these observations.

In an interview on 02/19/19 at 4:15 p.m. with SF5NM, the above observations were verified.


2) The infection control officer failed to ensure all staff adhered to current CDC (Centers for Disease Control) guidelines related to TB (tuberculosis) screening as evidenced by:

Review of the " Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005 " published by the CDC (Centers for Disease Control) revealed, in part, " ...HCWs (health-care workers) refer to all paid and unpaid persons working in health-care settings who have the potential for exposure to M. tuberculosis through air space shared with persons with infectious TB disease. Part time, temporary, contract, and full-time HCWs should be included in TB screening programs. All HCWs who have duties that involve face-to-face contact with patients with suspected or confirmed TB disease (including transport staff) should be included in a TB screening program. The following are HCWs who should be included in a TB screening program: Administrators or managers ...Nurses ...Physicians (assistant, attending, fellow, resident, or intern) ... " .

Review of the personnel record of S14CNA on 02/20/19 at 10:00 a.m. failed to reveal a current documented TB screening.

Review of the personnel record of S13RT's on 02/20/19 at 10:00 a.m. failed to reveal a current documented TB screening.

On 02/20/19 at 10:30 a.m. in an interview with S10AA verified the above findings in the personnel records.

Based on record review and interview, the hospital failed to ensure that an Activity Assessment was completed for activities for 2 (#16, #18) of 5 (#16, #18-#20, #31) patients who were admitted to Swing Bed status in a total sample of 31.

Findings:

Review of the hospital policy titled "Plan For Providing Care Swing Program Management", revised 10/2011 revealed in part: The Patient Activities Coordinator will complete an initial assessment within 72 hours of admit and will provide appropriate activities at a minimal of 2 times per week or more if desired.

Patient #16
Review of the medical record for patient #16 revealed that she was admitted to Swing Bed status on 02/15/19 with a diagnosis of Resolving Pyelonephritis and Dehydration. Further review of the record revealed no documented evidence that an activity assessment was provided to the patient.

Patient #18
Review of the medical record for patient #18 revealed that she was admitted to Swing Bed status on 01/08/19 with a diagnosis of Resolving CHF, COPD, and A-Fib. Further review of the record revealed no documented evidence that an activity assessment was provided to the patient.

Interview on 02/19/19 at 10:20 a.m. with S5NM confirmed there were no activity assessments documented on patient #16 and Patient #18.

Interview on 02/19/19 at 2:50 p.m. with S2CNO stated that there should have been an activity assessment documented on all swing bed patients.