HospitalInspections.org

This condition is not met as evidenced by a lack of safe services for those services performed under a contract. Please refer to A84.

1. Based on tour, interviews and policy reviews the Governing Body failed to ensure that services performed under a contract are provided in a safe and effective manner. The finding includes the following:

a. On 11/09/12 at 12:30 PM, the surveyor was not provided with documentation by the RN # 17 Donnelly Three (3) North Nurse Manager and MGR #5, Psychiatric Nurse Manager, to indicate that the Biomedical Engineering Department had been notified when rental equipment was ordered and/or received on the Unit; so that the rental equipment would be tested and inspected before use as required in NFPA 99, Section 7-5.1.3., 7-5.2.2.1 and 7-6.2.1.2.; and as part of the Hospital ' s Department of Biomedical Engineering Medical Equipment Management Plan. Interview with RN # 17 and/or MGR # 5 indicated that the Unit had ordered rental equipment; i.e., an adjustable electric bariatric bed with companion air pump for alternating air pressure bariatric mattress, and an electric bariatric chair that was received by the Nursing Department on or before 08/31/12 for use by P # 97 in Donnelly Three (3) Patient Room #8, and that the Biomedical Engineering Department had not been notified.

2. Based on observation and interview on 11/09/12 at 12:35 PM, with the Biomedical Engineering Project Manager, RN # 17 and MGR # 5, the Unit failed to follow the Rental Bed Policy of the Biomedical Engineering Medical Equipment Management Plan as evidenced by the following:

a. The supplier technician did not fill out a quality control checklist prior to delivery of the adjustable electric bariatric bed with companion air pump for alternating air pressure bariatric mattress, and an electric bariatric chair. The supplier did not fax Bioengineering the quality control checklist for Bioengineering documentation records; i.e., no record of faxed quality control checklist available;

b. A sticker was not posted on the rental equipment to indicate electrical safety passage as required by the Biomedical Engineering Medical Equipment Management Plan; i.e., no sticker posted on the adjustable electric bariatric bed with companion air pump for alternating air pressure bariatric mattress, and an electric bariatric chair.

c. The visiting supplier technician did not register before bringing rental equipment to the floor, or for any repair, maintenance purposes; i.e., no documented registration of the visiting supplier technician with Biomedical Engineering for the delivery and set-up of the adjustable electric bariatric bed with companion air pump for alternating air pressure bariatric mattress, and an electric bariatric chair for P # 97.

This condition is not met as evidenced by an an unsafe environment for one patient with suicidal tendancies. Please refer to A144.

Based on review of the clinical record, hospital policies and procedures, and interviews for one patient reviewed for notification of responsible party/Conservator and/or informed consent for treatment, (P #65), the facility failed to ensure notification/consent. The findings include:
a. Patient #65 was admitted to the hospital Emergency Department (ED) on 08/22/12 at 6:33 PM and transferred to an inpatient unit on 08/23/12 at 3:33 AM with diagnoses that included traumatic brain injury (TBI) at age 8, psychosis, and anxiety disorder.
Review of an Inter-Agency Patient Referral Report dated 08/22/12 identified that P #65 was transferred to the hospital for a behavioral evaluation as the patient was found outside the Skilled Nursing Facility (SNF) in which he/she resided with worsening delusions and aggression, refusing medications, refusing to bathe, yelling, threatening staff and on 1:1 Constant Observation. The responsible party, Conservator #1, was identified as an attorney with address and telephone contact information documented on the form.
The hospital Facesheet identified next of kin as Conservator #1 with the relation identified by the code EO which was interpreted as significant other (E) and attorney (O) per Director #2.
Review of the clinical record identified that P #65 was evaluated in the hospital ED and assessed as having a flat affect, tangential in thought, denied suicidal or homicidal ideation with no psychotic symptoms presently. The patient was noted to have a low oxygen saturation of 88%. Diagnosis was Pneumonia and the patient was admitted to the telemetry floor on 08/23/12 at 3:33 PM.
Review of a hospital admission note documented by MD #13 on 08/23/12 at 5:52 PM identified a diagnosis of healthcare associated pneumonia with a plan that included continued treatment with Cefotan and Vancomycin, continue oxygen supplementation, hold oral hypoglycemic agents and start insulin, and initiate deep vein thrombosis prophylaxis.
A Cardiology consultation dated 08/28/12 identified that P #65, on a telemetry monitor, was found to have a Mobitz 1 with prolonged pauses which would require a permanent pacemaker. The patient refused the pacemaker and the Cardiologist left a message for Conservator #1 to assist with decision making regarding placement of the permanent pacemaker.
Interview with Conservator #1 on 10/16/12 at 12:00 PM identified that he/she had been notified by the SNF that P #65 was being transferred to the hospital for an evaluation of escalating behavior. On 08/26/12 the Conservator contacted the facility for an update on the patient ' s status and was informed that the patient had not yet returned from the hospital and that they were unaware of the patient ' s status. Conservator #1 then contacted the hospital and was informed that P #65 was not receiving care for psychiatric issues, but rather was receiving care for a medical issue. The Attending Physician, MD #13 contacted Conservator #1 a short time later and the Conservator questioned why P #65 was treated without his/her consent.
Subsequently, an informed consent and Authorization for Administration of Anesthesia and Authorization for Surgery/or Special Procedure (insertion of a permanent pacemaker) was signed by Conservator #1.
Interview with MD #13 on 10/11/12 at 1:00 PM identified that he/she had not attempted to contact the responsible party prior to Conservator #1's request for MD #13 to contact him/her and did not obtain consent to treat P #65. Additionally, MD #13 identified that P #65's contact information was not readily available. The admission Inter-Agency Patient Referral Report had been scanned into the electronic record and had been placed in the Emergency Department (ED) section of the clinical record.
Interview with Director #2 on 10/15/12 at 11:30 AM identified that the hospital did not have a specific policy regarding obtaining consent and/or authorization for treatment from the Conservator and/or responsible party.
The hospital policy for Patient's Rights identified that the patient has the right to be informed about and participate in care and treatment plans and make informed decisions.

Based on observation, review of clinical records, hospital policies and procedures, and interviews for one of four Patients reviewed for patterns of self harm, Patient #97 (P #97), the hospital failed to ensure that the patient received care in a safe setting. The findings include:
a. P #97 was admitted to the hospital on 08/31/12 with diagnoses that included schizoaffective disorder, borderline personality disorder, and history of prior suicide attempts with ligature, morbid obesity and chronic obstructive pulmonary disease (COPD). P #97 had a legally appointed Conservator of Person (COP).
i. Review of a Psychiatric Consultation and Discharge Summary documented by Acute Care Hospital #1 dated 08/24/12 identified that P #97 had been evaluated in the hospital Emergency Department (ED) on 08/10/12 after reporting that he/she had overdosed on prescribed medications, and, while in the ED, wrapped an oxygen tubing around his/her neck in a tight ligature. P #97 subsequently, presented to Acute Care Hospital #1 on 08/23/12 acting erratically, screaming, and banging his/her head against the side rails and on the walls. Impression included that P #97 was at high risk for self-injurious behaviors and unable to care for him/her self in the community. The patient was placed on a Physician ' s Emergency Certificate (PEC) to be transferred to a psychiatric hospital when a bed was available.
Review of a Psychiatric Intake Evaluation dated 08/31/12 at 9:59 PM identified that P #97 denied suicidal ideation (SI) and/or homicidal ideation (HI). A Suicide Assessment dated 08/31/12 identified Risk Factors that included Key Symptoms of anxiety and physical pain; Suicidal Behavior that included history of picking at skin, history of placing ligature around neck, overdose of medications, ice pick to face; and access to firearms/other lethal means that included pills and cords. Suicide Risk Level was determined to be high and treatment interventions included inpatient hospitalization with an observation status of every 15 minute checks (q 15 min checks)
A Physician ' s Examination dated 08/31/12 at 11:00 PM Part1-Suicide Assessment identified that P #97 denied suicidal ideation, denied suicidal plan, denied suicidal behavior, and denied suicidal intent. Suicidal Risk Level was identified as low with a low risk for violence.
A Physician ' s order dated 08/31/12 directed supplemental oxygen via nasal cannula at 3 liters (l) per minute (l/min) to maintain percentage of oxygen greater than 92%.
An Interdisciplinary Treatment Plan dated 08/31/12, identified the problem of Suicide Risk with interventions that included, in part, to observe the patient ' s behavior and perform a Safe-T assessment and to remove potential dangerous objects per unit guidelines.
Suicide Risk assessments were conducted by Physicians, Clinicians, and Nursing staff at least daily that identified that P #97 denied suicidal intent, plan, and/or means and continued on q 15 minute checks.
A Nursing Progress note dated 09/15/12 at 6:01 PM identified that P #97 was extremely agitated, swearing at staff, and screaming and could not be redirected despite many attempts. At 6:30 PM the On Call MD ordered administration of intramuscular (IM) medications. The Nursing Progress note identified an ongoing plan to assess and monitor per Interdisciplinary plan. At 9:40 PM a Resident On-Call note identified that P #97 was assessed for self injurious behavior that included scratching his/her skin on the abdomen and scalp with a plan that included to cleanse wounds and apply Bacitracin, call if self injurious behaviors recur and consider 5 min checks if concerned.
A Physician On-Call note dated 09/16/12 at 11:00 AM identified that he/she was called secondary to P #97 ' s persistent behavioral agitation, verbal aggression, and self harm behavior (banging head against the bed). Patient #97 was unable to be redirected, would not take oral medications, but would agree to take IM. IM medications were ordered and administered.
A Physician ' s On-Call note dated 09/16/12 at 6:45 PM identified that he/she was called for a medical emergency. P #97 had requested to have hour of sleep (HS) medication administered early. The Registered Nurse (RN) identified that it was too early to receive the medications. The Patient was observed to have the nasal cannula around his/her neck and became cyanotic and unresponsive. With airway protection, the Patient became alert and responsive within 10 minutes from the event. Patient #97 was transferred to the Hospital ' s Emergency Department (ED) for further evaluation with a plan to increase observation to 1:1 upon return.
A Physician ' s On-Call note dated 09/16/12 at 9:45 PM identified that Patient #97 had returned from the ED with no acute findings or new interventions but with a plan to continue treatment per Interdisciplinary Treatment Plan and start 1:1 observation.
ii. A Suicide Assessment documented on 09/27/12 at 10:35 AM by MD #25 identified that P #97 ' s Risk Factors included Suicidal Behavior of putting nasal cannula around his/her neck and scratching his/her skin on 09/16/12; Precipitants/Stressors that included medical conditions and changing environment; and access to lethal means that P #97 denied. Additionally P #97 denied suicidal ideation, plan, behavior, or intent. Suicidal Risk Assessment was determined to be moderate and treatment interventions included a change from 1:1 (continuous) observation to every 5 minute checks.
A Progress Note documented by a Psychiatric Resident on 10/07/12 at 1:55 PM identified that P #97 exhibited continued agitation with multiple episodes of yelling, hitting, scratching, attempting to bang his/her head, and bite staff. Additionally, P #97 threw a tray on the floor, moved him/herself from the wheelchair to the floor and required multiple staff members to lift him/her back to bed. Assessment included persistent behavioral disregulation and increased agitation that required 4 point restraint. Plan included, in part, continuous supervision while in restraints then resume q 5 minute checks.
A nursing note dated 10/07/12 at 10:00 PM identified that the patient continued to have poor impulse and behavioral control and remained on q 5 minute checks for safety. He/she remained threatening, aggressive, vulgar, and demanding of staff. P #97 refused scheduled medications but complained of physical discomforts such as chest pain, shortness of breath and pain but refused as needed (prn) treatments. The patient denied suicidal ideation and homicidal ideation. Plan was for the patient to remain on q 5 min checks until reassessed by treatment team in the morning.
A Nursing Note dated 10/08/12 at 2:45 AM and a Physician On-Call note dated 10/08/12 at 2:46 AM identified that the patient remained on q 5 min checks and, at approximately 2:35 AM, the patient was noted to have the oxygen tubing wrapped around his/her neck. The tubing was immediately removed and the patient was unresponsive with vital signs that included a normal oxygen saturation of 99% on 3 liters of oxygen, continuously, normal pulse rate of 83 beats per minute (BPM), normal respiratory rate of 22 breaths per minute (BPM), and normal temperature of 97 degrees Fahrenheit (F). The patient kept his/her eyes closed and remained non-verbal during the assessment, but was noted to wince during painful stimuli. Patient #97 was transported to hospital ED to evaluate potential head/neck trauma.
A Nursing Note dated 10/08/12 at 2:45 PM identified that P #97 returned from the ED at 7:00 AM and was placed on continuous 1:1 observation.
Review of the clinical record identified that P #97 had remained on continuous 1:1 observation since 10/08/12 without further episodes of self injurious behavior with oxygen tubing used as a ligature.
Observation of P #97 on 10/11/12 at 3:15 PM identified that the patient resided in a private room near the nursing station, seated in a bariatric wheelchair with a portable oxygen tank affixed to the handle grips and approximately 3 feet of tubing extending from the tank to the nasal cannula placed in his/her nostrils and looped over each ear. An oxygen concentrator was visible that was plugged into a wall socket behind the bed by an approximately 3-4 foot cord and had oxygen tubing and cannula that extended to the bed. An electric bariatric bed and companion alternating air pressure bariatric mattress were plugged into an electrical socket with standard length electrical cords. A CPAP machine with mask attached by 3-4 feet of accordion tubing and an electrical cord were on a bedside table. Additionally, the room contained a large bariatric lift chair that had a standard electrical cord and a 3 foot coiled cord that attached a remote controller to the chair to be used independently by the patient.
Review of the clinical record and interview with Unit Manager, RN #17, on 10/11/12 at 3:30 PM identified that the staff were aware of the equipment on admission and included the additional risk factors as part of the Suicide Risk Assessments conducted daily by the nursing staff, psychiatrists, physicians, and/or other clinicians.
Review of the clinical record from 09/15/12 through 09/16/12 at 6:35 PM and interviews with MD #27 and Acting Medical Director, MD #26 on 10/12/12 identified that the transition from q 15 min checks to 1:1 continuous observation would require a comprehensive assessment and there was an inherent dilemma with the borderline personality that would have to be considered in the use of 1:1 that would have risks, including regressive behavior, as well as benefits. These issues were, most likely considered. There may have been a lack of documentation of the assessment, but not a lack of assessment itself.
Observation, and interviews on 11/09/12 at 11:15 AM identified that P #97 continued to reside in the same private room and had his/her observation status changed from 1:1 observation to q 15 minute observation following a period of improved behavioral control as assessed and documented by the interdisciplinary team. Interview with MD #27 on 11/09/12 at 12:20 PM identified that, following a hearing related to discharge on 11/09/12; every 5 minute checks were resumed as a cautionary measure as P #97 was not satisfied with the outcome of the hearing. Observation of the room identified that all oxygen tubing, electrical cords, accordion tubing initially observed on 10/11/12 were still present in the room. Additionally, the bariatric bed, 3 1/4 side rails, bariatric lift chair, and handicap support bar in the bathroom contained multiple tie off areas suitable for ligature placement as well as areas of entrapment.
Review of a Weekly Environmental Rounds form identified that rounds did not include observing for cords, tubing, areas of entrapment and/or ligature tie off points.
Review of Written Guidelines for Adults and Geriatric Units Potentially Dangerous Items (PDI) identified that PDI ' s include all items with electrical cords, CPAP machines, and oxygen and should be kept in the Nursing Station and signed out per policy and/or staff to supervise patient use of potentially dangerous items.
Subsequent to surveyor investigation on 11/09/12, an Immediate Plan of Correction to address the identified, ongoing safety issues was requested. An acceptable Plan was provided.

Based on a review of the clinical record, staff interviews and a review of the facility policy for one sampled patient (Patient #38), the facility failed to provide requested medical information in accordance with the facility policies. The findings included:
a. Patient #38 was admitted to the hospital on 4/15/12 with complaints of fatigue, and a decreased appetite. Patient #38's diagnoses included non-insulin diabetes mellitus, and recent surgery for retinal detachment. Patient #38 was noted to experience myoclonic seizures secondary to hypoxic ischemic injury. Patient #38 was successfully extubated on 5/13/12 and was transferred to palliative care and expired on 5/16/12. The certificate of death identified the cause of death as acute respiratory failure as a consequence of aspiration pneumonia. Review of the clinical record identified Patient #38 requested a copy of his/her medical record on 5/4/12. The hospital record was issued on 6/5/12 to the family. Interview and review of the clinical record with the Director of Performance Improvement on 10/16/12 at 3:45 PM identified that it is a policy of the hospital to release medical records after discharge; however the record may be viewed with the patient during hospitalization in the presence of the attending physician. Further interview with the Director of Performance Improvement indicated the clinical record did not identify the patient was informed of the hospital policy and/or the process by which he/she could view their medical record while hospitalized. The hospital policy for release of protected health information directed in part patients may request copies of their medical record after discharge by completing an authorization form and submitting it to Health Information Management. The policy further directed patients who are hospitalized may review their medical records only in the presence of their attending physician. An authorized form should be obtained from the patient or personal representative and filed into the record. The policy failed to identify the time interval in which the medical record would be released to the patient.

This condition is not met based on the nursing staffs failure to identify and/or address safety hazards in the resident's environment for a patient with known suicide behavior. Please refer to F395

14528


1. Based on medical record reviews, review of facility policies and interviews for 1 patient identified as being at risk for aspiration (Patient #22), the facility failed to develop and/or follow the plan of care per speech therapy (ST) recommendations. The finding includes:

Patient #22 was admitted to the hospital on 1/18/12 with diagnoses of dementia, altered mental status, and a history of refusing to eat over the last few days. The ST evaluation dated 1/20/12 recommended, in part, small sips/bites, upright posture, and to monitor for aspiration. ST notes dated 1/23/12 indicated that the patient refused assistance with feeding, assist with oral intake, tray set-up, and aspiration precautions. ST notes dated 1/25/12 identified that the patient remained at increased risk for aspiration, and to continue aspiration precautions and assist with tray set-up. Documentation by Person #2 dated 1/30/12 noted that a sign was posted above the patient's bed that directed staff to be present during meals in case of choking and that staff were not observed in the patient's room when the patient's tray was left in front of the patient. Meal intake documentation and or nursing outcome notes dated 1/20/12 through 1/30/12 lacked documentation that the patient was observed and/or assisted during meals. Although interview with ST #1 on 10/11/12 at 2:10 PM indicated that the patient was at risk for aspiration and diet modification minimized the need for 1:1 observation, the facility policy for aspiration precautions directed to provide verbal cuing while feeding and observe for coughing, choking, gagging and drooling.
In addition, although the nursing plan of care for Patient #22 dated 1/18/12 identified malnutrition with an intervention to promote oral nutrition, a nutritional consult was not documented during the patient's hospitalization from 1/18/12 to 1/30/12. Interview with Dietician #2 on 10/16/12 at 8:20 AM noted that the patient was at low nutritional risk and should have had a nutritional screen within 5-7 days after admission. The facility policy for documentation of nutritional information identified four nutritional status levels with the least risk level requiring a brief nutritional screen and diet review in the medical record by day 7- 10.


15482


2. Based on a review of clinical records, policy review, and interview, for 3 of 3 patient's reviewed for nursing services, (#39, #71 and #40) the hospital failed to ensure that patient weights were obtained and/or that a nutritional consult was obtained and/or that abnormal findings were communicated to the physician. The findings nclude:

a. Patient #39 was admitted on 10/6/12 with difficulty swallowing/dysphagia. A swallowing evaluation completed on 10/8/12 identified the need for a low residue and thin liquid diet secondary to low motility. Review of the admission assessment dated 10/6/12 identfied the patient's weight was 170 pounds and that a nutritional consult was not indicated. On 10/9/12, the patient's weight was 160 pounds, a ten (10) pound loss in three days. Interview with staff on 10/10/12 identified that when the nursing admission assessment is completed a nutrition consult will be initiated if certain questions "trigger" based on a scoring system. The hospital failed to ensure that the Registered Dietician and/or MD were notified of the patient's weight loss. The clinical record failed to reflect that interventions to prevent further weight loss was initiated as of 10/10/12.


b. Patient #71 was admitted on 9/25/12 with dementia, and an elevated BUN and creatinine with a history of renal transplant. Review of the clinical record failed to identify that the patients weight had been obtained on admission and/or for the period of 9/25/12 through 10/11/12.


c. Patient #40 was admitted on 10/4/12 with a left hip fracture and a right heel pressure ulcer that was identified as unstageable. Review of the wound evaluation completed on 10/7/12 identified that the patient had a 2.2 cm by 1.2 cm pressure ulcer on the right heel. Review of the wound assessment identified that a nutrition consult was ordered. Review of the clinical record with the Dietician on 10/11/12 failed to identify that a dietary consult had been completed. Interview with staff on 10/11/12 at 2:30 PM identified that a nutrition consult had not been completed and staff were unable to locate a request for a nutritional consult. Review of the Pressure Ulcer policy indicated that patients at risk for breakdown meet the criteria for a nutrition consult.




26703


3. Based on clinical record review and interviews for 1 (P#31) of 3 patients reviewed for alteration in skin integrity, the facility failed to document nursing assessments according to facility protocol.
P#31 arrived in the Emergency Department (ED) on 7/21/12 by ambulance with symptoms of bradycardia (low heart rate) and hypothermia (low body temperature). Diagnoses included mental retardation, hypothermia, diabetes mellitus and peripheral vascular disease (PVD) A nursing assessment and physician physical exam completed in the ED on 7/21/12 identified P#31 had no acute rash or other skin issues. Following evaluation in the ED P#31 was admitted to the hospital. A wound evaluation dated 7/26/12 indicated P#31 had an intact coccyx and a small serous blister in his/her right medial thigh. The thigh blister assessment was not assessed and documented according to facility policy. Skin assessments dated 7/27/12 to 8/2/12 identified intermittent episodes when P#31 had a red area on his/her coccyx however, the assessments failed to identify monitoring of the right thigh blister daily. P#31 was discharged to his/her previous residence at a group home on 8/2/12.
During an interview with RN #9 on 10/16/12 at 12:00PM, RN# 9 indicated he/she did recall P#31 having a blister but did not recall further details of P#31's skin assessment. Upon surveyor inquiry RN# 9 identified that skin assessments are documented in the medical record every shift.
Facility Pressure Ulcer Protocol indicated when a wound is identified the area must be staged according to National Pressure ulcer Advisory Panel (NPUAP) staging guidelines. Documentation should include measurements and characteristics of the wound. According to the NPUAP staging guidelines a stage II pressure ulcer may present as an intact or open/ruptured serum filled blister. The protocol further indicated skin assessments were to be completed and documented daily.


27691


4. Based on observation of care, review of clinical records, review of hospital policies and procedures and interviews for one patient who resided on an adult inpatient psychiatric unit with a history of self injurious behavior, required continuous oxygen therapy, and required Continuous Positive Airway Pressure (CPAP), the hospital failed to ensure appropriate delivery of care. The findings include:

a. P #97 was admitted to the hospital on 08/31/12 with diagnoses that included schizoaffective disorder, borderline personality disorder, and history of prior suicide attempts with ligature, morbid obesity, chronic obstructive pulmonary disease (COPD), history of congestive heart failure (CHF), and sleep apnea. P #97 had a legally appointed Conservator of Person (COP).
i. Review of a Psychiatric Consultation and Discharge Summary documented by Acute Care Hospital #1 dated 08/24/12 identified that P #97 had been evaluated in the hospital Emergency Department (ED) on 08/10/12 after reporting that he/she had overdosed on prescribed medications, and, while in the ED, wrapped an oxygen tubing around his/her neck in a tight ligature. P #97 subsequently, presented to Acute Care Hospital #1 on 08/23/12 acting erratically, screaming, and banging his/her head against the side rails and on the walls. Impression included that P #97 was at high risk for self-injurious behaviors and unable to care for him/her self in the community. The patient was placed on a Physician ' s Emergency Certificate (PEC) to be transferred to a psychiatric hospital when a bed was available.
Review of a Psychiatric Intake Evaluation dated 08/31/12 at 9:59 PM identified that P #97 denied suicidal ideation (SI) and/or homicidal ideation (HI). A Suicide Assessment dated 08/31/12 identified Risk Factors that included Key Symptoms of anxiety and physical pain; Suicidal Behavior that included history of picking at skin, history of placing ligature around neck, overdose of medications, ice pick to face; and access to firearms/other lethal means that included pills and cords. Suicide Risk Level was determined to be high and treatment interventions included inpatient hospitalization with an observation status of every 15 minute checks (q 15 min checks)
A Physician ' s Examination dated 08/31/12 at 11:00 PM Part1-Suicide Assessment identified that P #97 denied suicidal ideation, denied suicidal plan, denied suicidal behavior, and denied suicidal intent. Suicidal Risk Level was identified as low with a low risk for violence.
A Physician ' s order dated 08/31/12 directed supplemental oxygen via nasal cannula at 3 liters (l) per minute (l/min) to maintain percentage of oxygen greater than 92%.
An Interdisciplinary Treatment Plan dated 08/31/12, identified the problem of Suicide Risk with interventions that included, in part, to observe the patient ' s behavior and perform a Safe-T assessment and to remove potential dangerous objects per unit guidelines.
Suicide Risk assessments were conducted by Physicians, Clinicians, and Nursing staff at least daily that identified that P #97 denied suicidal intent, plan, and/or means and continued on q 15 minute checks.
A Nursing Progress note dated 09/15/12 at 6:01 PM identified that P #97 was extremely agitated, swearing at staff, and screaming and could not be redirected despite many attempts. At 6:30 PM the On Call MD ordered administration of intramuscular (IM) medications. The Nursing Progress note identified an ongoing plan to assess and monitor per Interdisciplinary plan. At 9:40 PM a Resident On-Call note identified that P #97 was assessed for self injurious behavior that included scratching his/her skin on the abdomen and scalp with a plan that included to cleanse wounds and apply Bacitracin, call if self injurious behaviors recur and consider 5 min checks if concerned.
A Physician On-Call note dated 09/16/12 at 11:00 AM identified that he/she was called secondary to P #97 ' s persistent behavioral agitation, verbal aggression, and self harm behavior (banging head against the bed). Patient #97 was unable to be redirected, would not take oral medications, but would agree to take IM. IM medications were ordered and administered.
A Physician ' s On-Call note dated 09/16/12 at 6:45 PM identified that he/she was called for a medical emergency. P #97 had requested to have hour of sleep (HS) medication administered early. The Registered Nurse (RN) identified that it was too early to receive the medications. The Patient was observed to have the nasal cannula around his/her neck and became cyanotic and unresponsive. With airway protection, the Patient became alert and responsive within 10 minutes from the event. Patient #97 was transferred to the Hospital ' s Emergency Department (ED) for further evaluation with a plan to increase observation to 1:1 upon return.
A Physician ' s On-Call note dated 09/16/12 at 9:45 PM identified that Patient #97 had returned from the ED with no acute findings or new interventions but with a plan to continue treatment per Interdisciplinary Treatment Plan and start 1:1 observation.
ii. A Suicide Assessment documented on 09/27/12 at 10:35 AM by MD #25 identified that P #97 ' s Risk Factors included Suicidal Behavior of putting nasal cannula around his/her neck and scratching his/her skin on 09/16/12; Precipitants/Stressors that included medical conditions and changing environment; and access to lethal means that P #97 denied. Additionally P #97 denied suicidal ideation, plan, behavior, or intent. Suicidal Risk Assessment was determined to be moderate and treatment interventions included a change from 1:1 (continuous) observation to every 5 minute checks.
A Progress Note documented by a Psychiatric Resident on 10/07/12 at 1:55 PM identified that P #97 exhibited continued agitation with multiple episodes of yelling, hitting, scratching, attempting to bang his/her head, and bite staff. Additionally, P #97 threw a tray on the floor, moved him/herself from the wheelchair to the floor and required multiple staff members to lift him/her back to bed. Assessment included persistent behavioral disregulation and increased agitation that required 4 point restraint. Plan included, in part, continuous supervision while in restraints then resume q 5 minute checks.
A nursing note dated 10/07/12 at 10:00 PM identified that the patient continued to have poor impulse and behavioral control and remained on q 5 minute checks for safety. He/she remained threatening, aggressive, vulgar, and demanding of staff. P #97 refused scheduled medications but complained of physical discomforts such as chest pain, shortness of breath and pain but refused as needed (prn) treatments. The patient denied suicidal ideation and homicidal ideation. Plan was for the patient to remain on q 5 min checks until reassessed by treatment team in the morning.
A Nursing Note dated 10/08/12 at 2:45 AM and a Physician On-Call note dated 10/08/12 at 2:46 AM identified that the patient remained on q 5 min checks and, at approximately 2:35 AM, the patient was noted to have the oxygen tubing wrapped around his/her neck. The tubing was immediately removed and the patient was unresponsive with vital signs that included a normal oxygen saturation of 99% on 3 liters of oxygen, continuously, normal pulse rate of 83 beats per minute (BPM), normal respiratory rate of 22 breaths per minute (BPM), and normal temperature of 97 degrees Fahrenheit (F). The patient kept his/her eyes closed and remained non-verbal during the assessment, but was noted to wince during painful stimuli. Patient #97 was transported to hospital ED to evaluate potential head/neck trauma.
A Nursing Note dated 10/08/12 at 2:45 PM identified that P #97 returned from the ED at 7:00 AM and was placed on continuous 1:1 observation.
Review of the clinical record identified that P #97 had remained on continuous 1:1 observation since 10/08/12 without further episodes of self injurious behavior with oxygen tubing used as a ligature.
Observation of P #97 on 10/11/12 at 3:15 PM identified that the patient resided in a private room near the nursing station, seated in a bariatric wheelchair with a portable oxygen tank affixed to the handle grips and approximately 3 feet of tubing extending from the tank to the nasal cannula placed in his/her nostrils and looped over each ear. An oxygen concentrator was visible that was plugged into a wall socket behind the bed by an approximately 3-4 foot cord and had oxygen tubing and cannula that extended to the bed. An electric bariatric bed and companion alternating air pressure bariatric mattress were plugged into an electrical socket with standard length electrical cords. A CPAP machine with mask attached by 3-4 feet of accordion tubing and an electrical cord were on a bedside table. Additionally, the room contained a large bariatric lift chair that had a standard electrical cord and a 3 foot coiled cord that attached a remote controller to the chair to be used independently by the patient.
Review of the clinical record and interview with Unit Manager, RN #17, on 10/11/12 at 3:30 PM identified that the staff were aware of the equipment on admission and included the additional risk factors as part of the Suicide Risk Assessments conducted daily by the nursing staff, psychiatrists, physicians, and/or other clinicians.
Review of the clinical record from 09/15/12 through 09/16/12 at 6:35 PM and interviews with MD #27 and Acting Medical Director, MD #26 on 10/12/12 identified that the transition from q 15 min checks to 1:1 continuous observation would require a comprehensive assessment and there was an inherent dilemma with the borderline personality that would have to be considered in the use of 1:1 that would have risks, including regressive behavior, as well as benefits. These issues were, most likely considered. There may have been a lack of documentation of the assessment, but not a lack of assessment itself.
A re-visit, observation, and interviews on 11/09/12 at 11:15 AM identified that P #97 continued to reside in the same private room and had his/her observation status changed from 1:1 observation to q 15 minute observation following a period of improved behavioral control as assessed and documented by the interdisciplinary team. Interview with MD #27 on 11/09/12 at 12:20 PM identified that, following a hearing related to discharge on 11/09/12; every 5 minute checks were resumed as a cautionary measure as P #97 was not satisfied with the outcome of the hearing. Observation of the room identified that all oxygen tubing, electrical cords, accordion tubing initially observed on 10/11/12 were still present in the room. Additionally, the bariatric bed, 3 1/4 side rails, bariatric lift chair, and handicap support bar in the bathroom contained multiple tie off areas suitable for ligature placement as well as areas of entrapment.
Review of a Weekly Environmental Rounds form identified that rounds did not include observing for cords, tubing, areas of entrapment and/or ligature tie off points.
Review of Written Guidelines for Adults and Geriatric Units Potentially Dangerous Items (PDI) identified that PDI ' s include all items with electrical cords, CPAP machines, and oxygen and should be kept in the Nursing Station and signed out per policy and/or staff to supervise patient use of potentially dangerous items.
Subsequent to surveyor investigation on 11/09/12, an Immediate Plan of Correction to address the identified, ongoing safety issues was requested. An acceptable Plan was provided.
b. A Physician ' s Order dated 08/31/12 directed Supplemental Oxygen (O2) at 3 liters (l) per minute (min) to a maximum of 3 L/Min, maintain % O2 greater then (>) or equal to (=) 92%, wean to room air, obtain SPO2 within 15 minutes of each rate change, patient may use face mask or cannula for supplemental Oxygen depending on nostril discomfort. The order was modified on 09/27/12.
An Interdisciplinary Treatment Plan dated 08/31/12 identified the problem of Oxygen Therapy, O2 at 3liters continuous, plan to taper to room air when resting/sitting. An updated intervention dated 09/22/12 included O2 at 3 liters/min via nasal cannula (nc) and O2 saturation as needed.
Review of Nursing Progress Notes and/or the electronic medication administration record (e-mar) for the time frame of 08/31/12 through 10/19/12 identified that oxygen usage and oxygen saturation was not consistently documented. Documented oxygen saturation range was 94% to 100% and did not consistently identify the liter flow at the time of assessment. The clinical record lacked documentation of attempts to taper to room air.
ii. A Physician ' s orders dated 09/01/12 directed patient can use own CPAP machine.
An Interdisciplinary Treatment Plan dated 08/31/12 identified the problem of sleep apnea with interventions that included will use CPAP when machine arrives.
Review of the clinical record lacked documentation of CPAP settings, safety check, usage, tolerance, and/or cleaning schedule.
Observation of P #97 on 10/11/12 at 3:15 PM identified that the patient was seated in a bariatric wheelchair with a portable oxygen tank affixed to the handle grips and approximately 3 feet of tubing extending from the tank to the nasal cannula placed in his/her nostrils and looped over each ear. An oxygen concentrator was visible that was plugged into a wall socket behind the bed by an approximately 3-4 foot cord and had oxygen tubing and cannula that extended to the bed. Additionally, a CPAP machine with mask attached by 3-4 feet of accordion tubing and an electrical cord was observed on a bedside table.
Observation and interview with P #97 on 11/09/12 at 11:15 AM identified that he/she was seated in a wheelchair without benefit of oxygen. A portable tank was not visible in the room, however, a concentrator with oxygen tubing and cannula attached was observed. A CPAP mask and tubing was on the bed. P #97 identified that he/she did not always use oxygen when he/she first got up and, further, he/she had brought the CPAP machine from home and used it both day and night.
Interview with MD #27 on 11/0912 at 12:20 PM identified that he/she had contacted P #97 ' s primary care physician (PCP) who had directed that the oxygen should be used at night and as needed and that there was no intent to wean to room air and both the portable oxygen tank and the concentrator need to be readily accessible.
Interview with RN #17 on 11/09/12 at 12/25/12 identified that he/she had discussed the CPAP usage with P #97 and determined that the concentrator was connected to the CPAP machine for delivery of oxygen when CPAP was in use.

5. Based on observation, review of the clinical record, hospital policies and procedures, and interviews for one sampled resident who required oxygen therapy, P #97 and one of two Patients who required Continuous Positive Airway Pressure (CPAP), P #97, the hospital failed to ensure that the patient's care needs, health status, and response to interventions were assessed in accordance with accepted standards of nursing practice. The Condition of Nursing is not met. The findings include:
a. P #97 was admitted to the hospital on 08/31/12 with diagnoses that included schizoaffective disorder, borderline personality disorder, and history of prior suicide attempts with ligature, morbid obesity, chronic obstructive pulmonary disease (COPD), and sleep apnea.
i. A Physician ' s order dated 08/31/12 directed Supplemental Oxygen (O2) at 3 liters (l) per minute (min) to a maximum of 3 L/Min, maintain % O2 greater then (>) or equal to (=) 92%, wean to room air, obtain SPO2 within 15 minutes of each rate change, patient may use face mask or cannula for supplemental Oxygen depending on nostril discomfort. The order was reviewed on 09/27/12.
An Interdisciplinary Treatment Plan dated 08/31/12 identified the problem of Oxygen Therapy, O2 at 3liters continuous, plan to taper to room air when resting/sitting. An updated intervention dated 09/22/12 included O2 at 3 liters/min via nasal cannula (nc) and O2 saturation as needed.
Review of Nursing Progress Notes and/or the electronic medication administration record (e-mar) for the time frame of 08/31/12 through 10/19/12 identified that oxygen usage and oxygen saturation was not consistently documented. Documented oxygen saturation range was 94% to 100% and did not consistently identify the liter flow at the time of assessment. The clinical record lacked documentation of attempts to taper to room air.

ii. A Physician ' s orders dated 09/01/12 directed patient can use own CPAP machine.
An Interdisciplinary Treatment Plan dated 08/31/12 identified the problem of sleep apnea with interventions that included will use CPAP when machine arrives.
Review of the clinical record lacked documentation of CPAP settings, safety check, usage, tolerance, and/or cleaning schedule.
Observation of P #97 on 10/11/12 at 3:15 PM identified that the patient was seated in a bariatric wheelchair with a portable oxygen tank affixed to the handle grips and approximately 3 feet of tubing extending from the tank to the nasal cannula placed in his/her nostrils and looped over each ear. An oxygen concentrator was visible that was plugged into a wall socket behind the bed by an approximately 3-4 foot cord and had oxygen tubing and cannula that extended to the bed. Additionally, a CPAP machine with mask attached by 3-4 feet of accordion tubing and an electrical cord was observed on a bedside table.
Observation and interview with P #97 on 11/09/12 at 11:15 AM identified that he/she was seated in a wheelchair without benefit of oxygen. A portable tank was not visible in the room, however, a concentrator with oxygen tubing and cannula attached was observed. A CPAP mask and tubing was on the bed. P #97 identified that he/she did not always use oxygen when he/she first got up and, further, he/she had brought the CPAP machine from home and used it both day and night.
Interview with MD #27 on 11/0912 at 12:20 PM identified that he/she had contacted P #97's primary care physician (PCP) who had directed that the oxygen should be used at night and as needed and that there was no intent to wean to room air and both the portable oxygen tank and the concentrator needed to be readily accessible.
On 11/09/12 at 12/25/12 RN #17 identified that he/she had checked with R #97 and determined that the concentrator was connected to the CPAP machine for delivery of oxygen when the CPAP was in use.
Refer to A084, A144, A338, A385, A701, and A710



29049


6. Based on a review of the clinical record, staff interviews, and a review of the facility documentation for one patient (Patient #59), the facility failed to conduct a newborn assessment and/or a breastfeeding assessment in accordance with the hospital policy. The findings included:
a. Patient #59 was born on 10/6/12 via a cesarean section birth. Interview and review of the clinical record with RN #16 on 10/9/12 at 11:30 AM identified the newborn assessment was not completed on 10/9/12 within an eight hour period. Interview with Nurse Manager #3 indicated a newborn assessment should have been documented once a shift in accordance with the hospital policy and was not. The hospital ' s guidelines for well newborn care directed in part to assess newborn parameters every shift.
b. Interview and review of the clinical record with RN # 16 on 10/9/12 at 11:40 AM identified a breastfeeding assessment was not completed for Patient #59 on 10/8/12 and 10/9/12 within an eight hour period. Interview with Nurse Manager #3 indicated a breastfeeding assessment should have been completed and documented once a shift in accordance with the hospital policy. The hospital breastfeeding policy, directed in part, that mother-infant dyads are to have a breastfeeding assessment at least once every eight hours after delivery.
7. Based on a review of the clinical record, staff interviews, patient interview and a review of the facility policy for one patient (Patient #58), the facility failed to encourage the mother-infant dyad stay together in accordance with the hospital policy and/or failed to identify the location of the infant. The finding included:
During a tour of the post-partum unit on 10/9/12 at 1:15 PM an interview was conducted with Patient #58 who indicated on 10/7/12 during the hours of 12:00 AM and 7:00 AM the nurse caring for her encouraged the patient to return her infant to the nursery so she could rest. Patient #58 identified the nurse did not encourage rooming in and did not provide education regarding the importance of the mother-infant dyad remaining together. In addition upon review of the newborn flow sheet the location of the infant was only identified at the time of the feeding. Interview with Nurse Manager #3 indicated not separating the mother and infant was an area that was lacking and needed improvement. Further interview with Nurse Manager #3 indicated the location of the infant should be identified in the clinical record at all times and was not. The hospital breastfeeding policy, directed in part, that all mother-infant dyads would be encouraged to remain together and should not be separated for greater than one hour unless medically indicated. The well newborn guidelines failed to identify the location of the infant must be documented in the clinical record.
8. Based on a review of the clinical record, staff interviews and a review of the facility policy for one patient (Patient #27), the facility failed to provide oral care and/or range of motion in accordance with the plan of care. The finding included:
a. Review of the clinical record identified Patient #27 diagnoses included a history of pneumonia, status post right upper lobectomy (9/25/11), secondary to a congenital lung anomaly. On 11/27/11 Patient #27 developed seizures. A subsequent Magnetic Resonance Imaging (MRI) of the brain showed findings consistent with global anoxic brain injury. Patient #27 remained in a persistent vegetative state with an unknown etiology related to the onset of the seizure activity.
i. Interview and review of the patient care associate (PCA) flow sheets with RN #17 on 10/16/12 at 2:00 PM identified between 12/20/11 and 1/13/12 mouth care was not provided and/or documented on five occasions and should have been documented every eight hours per the plan of care. RN #17 could not identify why mouth care was not completed, and/or documented. The hospital policy for knowledge based charting and clinical documentation guidelines, directed in part, each patient would have a plan of care, assessment, intervention, education record and goal/outcome evaluation. The plan of care would serve as a communication tool between disciplines to assure continuity of individualized care. Regularity of assessments and interventions are based on an eight hour interval.

ii. Interview and review of the critical care nursing assessments with RN #17 on 10/16/12 at 3:00 PM identified between 11/27/11 and 12/19/11 range of motion was not provided and/or documented on ten occasions. Although the hospital critical care flow sheet identified range of motion as an assessment the hospital guidelines for the use of the critical care flow sheet failed to identify that a comprehensive musculoskeletal assessment must be completed with an interval of frequency in which the assessment/intervention should be completed.

9. Based on a review of the clinical record, staff interviews and a review of the facility policy for one of two sampled patients (Patient #38), the facility failed to follow the physician's order and/or speech therapy recommendations for assistance with feedings. The findings included:
a. Patient #38 was admitted to the hospital on 4/15/12 with complaints of fatigue, and a decreased appetite. Patient #38 ' s diagnoses included non-insulin diabetes mellitus, and recent surgery for retinal detachment. Upon admission to the emergency room Patient #38 was found to be in acute renal and respiratory failure. Patient #38 was intubated and admitted to the intensive care unit. Patient #38 was transferred to a medical floor once he/she was stabilized. During the hospital course the patient was thought to have multiple episodes of aspiration. Speech therapy was consulted and a modified barium swallow was performed on 4/30/12 which showed aspiration with honey thickened liquids and penetration with nectar consistency. Significant pooling of fluid in the vallecular and piriform sinuses was noted with decreased peristalsis and tipping of the epiglottis. Further review of the clinical record identified on 5/6/12 after eating lunch the patient had an episode of hypoxia leading to respiratory arrest. Cardio-pulmonary resuscitation was administered and circulation was restored. Subsequent to the event on 5/6/12 Patient #38 was noted to experience myoclonic seizures secondary to hypoxic ischemic injury. Patient #38 was successfully extubated on 5/13/12 and was transferred to palliative care and expired on 5/16/12. The certificate of death identified the cause of death as acute respiratory failure as a consequence of aspiration pneumonia. Patient #38 had been receiving enteral feedings via a nasogastric tube for severe dysphagia and was followed by speech therapy. Patient #38 was identified as a silent aspirator and at risk for aspiration pneumonia. Patient #38 had diet advancements when improvements were noted with swallowing evaluations. Review of the clinical record indicated on 5/3/12 speech therapy recommended feeding techniques that included small sips/bites, no straws, double swallow with each bolus. On 5/4/12 the nutrition note identified Patient #38 as a high aspiration risk due to non-compliance with swallow strategies and required supervision throughout meals. Physician ' s orders dated 5/6/12 directed a no concentrated sweets, no added salt, honey thickened National Dysphagia Diet level one, puree with aspiration precautions and nursing instruction directed double swallow with oral intake. Interview and review of the nursing assessment/intervention sheets with RN #18 on 10/16/12 at 11

1. Based on medical record review, review of facility policies and interviews for 4 of 4 patients (Patient #95, #44, #71, #36), the facility failed to develop a comprehensive nursing plan of care. The finding includes:

a. Patient #95 was admitted to the hospital on 10/6/12 with a diagnosis of congested heart failure. Interview with the patient's nurse on 10/9/12 at 1:50 PM indicated that the patient was incontinent of urine, had an open area on the inner left ankle with a Mepilex dressing in place, and had swallowing difficulties. Review of the patient's record with Director #4 on 10/9/12 at 1:55 PM indicated that a nursing plan of care had not been developed to address the patient's problems of incontinence, difficulty swallowing, or skin integrity to include goals and interventions. The facility care plan policy entitled Knowledge Based Charting (KBC) Clinical Documentation Guidelines for Nursing identified that a Clinical Practice Guideline (CPG) included care planning and that each patient will have at least one CPG within 2 hours of admission. The policy also directed that all licensed clinical disciplines are accountable to update the plan of care (POC) by adding CPGs to the POC and adding interventions and goals.
b. Patient #44 was admitted on 10/2/12 with dementia, renal failure, diabetes and anxiety. The clinical record identified that the patients weight on 10/2/12 was 80.2 pounds (lbs), 95.2 lbs. on 10/8/12 and 86.8 lbs. on 10/9/12. The nutrition note dated 10/9/12 identified that the patient was underweight with a BMI of 15.1. The note requested a stand scale weight related to the inconsistency of the previous weights. Review of the care plan failed to identify an active problem related to nutrition.

c. Patient #71 was admitted on 9/25/12 with dementia, alcohol abuse and an elevated BUN and creatinine with a history of renal transplant. Review of the clinical record failed to identify a weight for the patient during the period of 9/25/12 through 10/11/12. Review of the careplan with the Nurse Manager on 10/11/12 failed to identify that the patient had an active plan of care in place. The clinical record indicated that on admission the plan of care had one active problem in place for acute renal failure however the problem was discontinued on 10/1/12 and no active problems were identified. Interview with staff on 10/11/12 at 11:40 AM indicated that the patient's BUN and creatinine had improved, however, placement was an issue.

The facility care plan policy entitled Knowledge Based Charting (KBC) Clinical Documentation Guidelines for Nursing identified that a Clinical Practice Guideline (CPG) included care planning and that each patient will have at least one CPG within 2 hours of admission. The policy also directed that all licensed clinical disciplines are accountable to update the plan of care (POC) by adding CPGs to the POC and adding interventions and goals.
d. Patient #38 was admitted to the hospital on 4/15/12 with complaints of fatigue, and a decreased appetite. Patient #38's diagnoses included non-insulin diabetes mellitus, and recent surgery for retinal detachment. Upon admission to the emergency room Patient #38 was found to be in acute renal and respiratory failure. During the hospital course the patient was thought to have multiple episodes of aspiration. Speech therapy was consulted and a modified barium swallow was performed on 4/30/12 which showed aspiration with honey thickened liquids and penetration with nectar consistency. Significant pooling of fluid in the vallecular and piriform sinuses was noted with decreased peristalsis and tipping of the epiglottis. Further review of the clinical record identified on 5/6/12 after eating lunch the patient had an episode of hypoxia leading to respiratory arrest. Cardio-pulmonary resuscitation was administered and circulation was restored. Subsequent to the event on 5/6/12 Patient #38 was noted to experience myoclonic seizures secondary to hypoxic ischemic injury. Patient #38 was successfully extubated on 5/13/12 and was transferred to palliative care and expired on 5/16/12. The certificate of death identified the cause of death as acute respiratory failure as a consequence of aspiration pneumonia. Patient #38 had been receiving enteral feedings via a nasogastric tube for severe dysphagia and was followed by speech therapy. Patient #38 was identified as a silent aspirator and at risk for aspiration pneumonia. Patient #38 had diet advancements when improvements were noted with swallowing evaluations. Review of the clinical record indicated on 5/3/12 speech therapy recommended feeding techniques that included small sips/bites, no straws, double swallow with each bolus. On 5/4/12 the nutrition note identified Patient #38 as a high aspiration risk due to non-compliance with swallow strategies and required supervision throughout meals. Physician's orders dated 5/6/12 directed a no concentrated sweets, no added salt, honey thickened National Dysphagia Diet level one, puree with aspiration precautions and nursing instruction directed double swallow with oral intake. Interview and review of the nursing assessment/intervention sheets with RN #18 on 10/16/12 at 11:00 AM identified on 5/1/12 and 5/6/12 at 7:41 AM Patient #38 fed him/herself. Further interview with RN #18 indicated the nursing care plan should have identified supervision/assistance with all meals that included the feeding recommendations from speech therapy. Further review of the clinical record identified on 5/6/12 at 12:00 PM Patient #38 was found unresponsive. A subsequent bronchoscopy dated 5/6/12 identified evidence of decomposed material which appeared to be food. Interview with MD #16 on 10/16/12 at 11:50 AM identified the RN on duty informed her that Patient #38 was found with food in his/her mouth when the incident occurred on 5/6/12 at 12:00 PM. Interview with MD #14 on 10/16/12 at 4:30 PM identified the unresponsive event on 5/6/12 at 12:00 PM led to anoxic injury.

The hospital policy for knowledge based charting directed in part that a plan of care including an assessment, intervention, and goal/outcome evaluation will be documented in the clinical record and the plan of care will serve as a communication tool between disciplines to assure continuity of care. The policy further directed all licensed individuals would be accountable to update the plan of care and a nursing outcome summary statement would be documented with each handoff and/or any significant change in the patient's condition.





15482









27691


Based on review of the clinical record, hospital policies and procedures, and interviews for one of two Patients who resided on an adult psychiatric unit reviewed for medication administration, (P #66), the hospital failed to ensure that medications were administered in accordance with physician ' s orders and hospital policy. The findings include:
a. P #66 was admitted to the hospital on 09/29/12 with diagnoses that included Major Depression with psychotic features.
Review of a Physician's On Call Note dated 10/07/12 at 5:00 PM documented by MD #11 identified that P #66 had an episode of agitation and verbal and physical aggression directed towards staff in response to a room search. Security and staff restrained P #66 in a safety suit, brought the patient to a side room, and applied 4 point restraints. Additionally, MD #11 directed to administer Zyprexa 5 milligrams (mg) intramuscularly (IM) and Benadryl 50 mg IM as the patient was allergic to Haldol.
A follow-up Incident Note dated 10/07/12 at 5:30 PM documented by MD #11 identified that P #66 was given Ativan 2 mg IM in addition to Zyprexa 5 mg IM and Benadryl 50 mg IM in error due to a miscommunication regarding the verbal order. The patient was initially going to be given Haldol, Ativan, and Cogentin, but when the Haldol allergy was noted, the order was changed to Zyprexa 5 mg IM and Benadryl 50 mg IM only. Once it was noted that the Ativan was given with the Zyprexa, MD #11 directed that the patient ' s vital signs were to be taken and monitored every ? hour times 2 hours, if stable checked every hour after that between 7:00 PM and 12:00 AM then every 4 hours until the morning of 10/08/12. Patient #66 was on Constant Observation during this time period.
Review of the hospital electronic Order Summary for the time period of 10/07/12 at 4:07 PM through 10/07/12 at 6:13 PM identified an order for a room search was documented at 4:07 PM, Zyprexa injection Administer 5 mg IM now documented by MD #11 at 4:46 PM, Benadryl administer 50 mg IM now, documented at 4:47 PM by MD #11, and Ativan administer 2 mg IM now documented at 05:36 PM by Registered Nurse (RN) #14, as requested by MD #11 by way of a verified, verbal order. Additionally, on 10/07/12 at 5:43 PM MD #11 documented that Ativan administer 2 mg IM now had been refused.
Review of an electronically generated medication administration record (e-MAR) identified that the Zyprexa, Benadryl, and Ativan were administered on 10/07/12 at 4:44 PM by RN #14.
Review of a hospital incident report with the Nursing Director of Psychiatry, Director #6 on 10/12/12 at 2:30 PM identified that RN #14, had received a verbal order from MD #11 to administer Haldol, Benadryl, and Ativan. When MD #11 read that P #66 was allergic to Haldol as documented in the Electronic Medical Record (EMR), he/she verbally directed RN #14 to administer Zyprexa 5 mg IM instead. There was a miscommunication between RN #14 and MD #11 and Ativan 2 mg IM was given in error. RN #14 repeated the orders to another RN; however the error was not caught due to high commotion on the unit at the time.
Interview with MD #11 on 10/15/12 at 10:00 AM identified that he/she had communicated to RN #14 that Ativan could not be administered with Zyprexa, but did not communicate the reason for the decision. RN #14 repeated the Zyprexa and Benadryl order to MD #11. MD #11 identified that he/she had documented the orders after the discussion and it was not until after the Ativan was administered that RN #14 reported to MD #11 that he/she had not documented the order for Ativan, that the error was identified. MD #11 further identified that RN #14 had explained that he/she thought MD #11 was referring to not mixing Zyprexa and Ativan in the same syringe during administration rather then not administering the Ativan at all due to a possible adverse reaction.
Interview with RN #14 on 10/15/12 at 10:45 PM identified that he/she had administered all medications based on MD #11 ' s verbal order. MD #11had changed the original Haldol order to Zyprexa when allergies were reviewed and RN #14 identified that he/she repeated the change in orders including the Ativan to MD #11. When MD #11 directed no Ativan, it was RN #14 ' s understanding that the directive was related to not mixing Ativan and Zyprexa in the same syringe prior to administration rather then not administering Ativan at all due to a potential adverse interaction with Zyprexa.
Hospital Written and Verbal Order Policy and Procedure identified, in part, that all verbal orders will be entered into the Electronic Medical Record (EMR) by the professional receiving the order and the receiver must verify the verbal order. The receiver should write down, or enter the order into the EMR first, then read it back to the prescriber for verification.





29049

Based on review of facility documentation, review of facility policies and interviews, the hospital failed to ensure that protected health information (PHI) was adequately safeguarded. The finding includes:
Facility documentation identified that Patients #11 through #20 had received treatment at the facility during 2009 to 2011 related to their diagnosis of congestive heart failure (CHF). The contract with Corporation #1 dated 12/28/11 identified a goal to seek out and provide analytical insight related to CHF to improve patient outcomes, reduce re-admissions and discover additional insights. The contract further indicated that Corporation #1 would make all data needed available to Subsidiary #1 to solve selected problems. Facility documentation dated 8/13/12 identified that on or about 6/6/12, patient data was transferred to a Corporation #1 server by the facility. The facility documentation also noted that on 6/22/12, a Data Scientist from Corporation #1's subsidiary brought a laptop computer home. The laptop was unencrypted, contained PHI (social security number, birth date, diagnosis etc.) of Patients #11 through #20 and the laptop was stolen from the Data Scientist's home. Interview with the Facility Deputy General Council on 8/30/12 at 1:00 PM noted that the stolen laptop computer also contained, in part, the PHI of 2,087 additional patients who had received treatment related to CHF at the facility during 2009 to 2011. S/he further indicated that although the information sent to Corporation #1's server was encrypted, the stolen laptop was not encrypted and it was Corporation #1's policy to ensure that every computer was encrypted. The Facility Deputy General Council on 8/30/12 at 1:00 PM indicated that the facility did not have a policy or procedure in place (at the time of the breach) to ensure the safety and confidentiality of PHI once the information was transferred to a contracted vendor. Subsequent to the event, the facility developed a contract policy and procedure dated July 2012 to include a pre-contract questionnaire for vendors to better ensure patient privacy and security.

Based on medical record reviews, review of hospital policies and interviews for one patient (Patient #22), the facility failed to maintain a complete and/or accurate record. The findings include:

Patient #22 was admitted to the hospital on 1/18/12 with altered mental status and urinary tract infection. The plan of care dated 1/18/12 identified that the patient required the skin precaution protocol and interventions included repositioning and incontinent care every 2 hours. Facility documentation dated 2/2/12 indicated that Person #2 visited that Patient almost daily and often found the Patient incontinent of urine. A review of patient care assistant (PCA) and intake and output records and nursing outcome summary documentation from 1/19/12 to 1/30/12 was conducted on 10/17/12. The review identified that documentation for the provision of incontinent care and/or the assessment for incontinence was lacking for a period of greater than 5 hours on the evening and/or night shifts on 1/19/12, 1/20/12, 1/25/12, a period of greater than 8 hours on 1/24/12 from 9:20 PM to 6 AM on 1/25/12, and incontinent episodes or I/O was not documented for the night shift on 1/24/12. Interview with Director #5 on 10/11/12 at 10:25 AM noted that s/he spoke to staff regarding care provided to Patient #22 and staff indicated that staff was in the Patient's room frequently to provide care. The facility policy for perineal care directed to document the procedure in the patient's record. The facility I/O policy directed to calculate any output from incontinence and record the amount on the I/O record.
In addition, Patient #22 was diagnosed with dysphagia on 1/20/12. Facility documentation dated 2/2/12 indicated that Person #2 observed Patient #22 with a meal tray and dentures were not in the patient's mouth on 1/22/12. Facility documentation dated 2/10/12 noted that staff was spoken to by the Nurse Manager regarding the complaint. Although Patient #22's admission valuables record lacked documentation of the dentures despite the form's direction to denote if the dentures were with the patient, the Speech Therapy evaluation dated 1/20/12 identified that the patient had upper and lower dentures. The plan of care dated 1/18/12 indicated that the patient had a problem with malnutrition and although an intervention directed to promote oral nutrition, the interventions did not include ensuring denture placement prior to meal consumption.

1. Based on review of clinical records, review of hospital policies and interviews with hospital personnel for one patient, Patient #24, who required cardiac telemetry during hospitalization, the clinical record lacked documentation to reflect that cardiac rhythm strip documentation was completed in accordance with hospital policy. The findings include:


Patient #24 was admitted to the hospital on 3/18/12 with diagnoses that included a new onset atrial fibrillation. Review of physician orders dated 3/18/12 and subsequent interview with MD #24 on 10/15/12 at 11:40 AM identified that cardiac telemetry was ordered upon the patient's admission and was discontinued on 3/30/12. Review of the Telemetry Criteria and Use Guidelines directed that cardiac rhythm strips be documented in the patient's permanent record every 8 hours. Review of Patient #24's Electrocardiogram (ECG) Rhythm Log dated 3/18/12 through 3/30/12 lacked documentation to reflect that rhythm strip documentation from 3/23/12 through 3/27/12 was completed every 8 hours as per guidelines.

Based on review of the clinical record for one patient (#37), review of hospital policy and interviews, the hospital failed to ensure that the patient's discharge summary included all patient diagnoses, the disposition of care upon discharge and subsequent provisions for follow-up care. The finding includes:
Review of the clinical record for Patient #37 identified that the patient was brought to the hospital on 2/9/12 secondary to increased somnolence at adult day care. The patient was known to wear oxygen at home secondary to chronic respiratory failure (COPD) and to be non-compliant with wearing CPAP at home for obstructive sleep apnea (OSA) due to a poor fitting facial mask. Review of the Discharge Summary (called STAT Transfer Summary) dated 2/17/12, identified the patient's hospital course included rescue BPAP, adjustment of medications, and review of laboratory data. The summary failed to address the diagnoses of OSA and how that was being treated in the hospital (which included a change in mode to BPAP, a change in mask to nasal pillows and daily use while sleeping) as well as expectations for discharge treatment for that diagnosis. Review of the patient's discharge W-10 identified that the patient should wear BPAP (inspiratory pressure 14/expiratory pressure 4) as directed (and written) by the physician. The Discharge Summary and/or the W-10 failed to identify that the patient had successfully worn BPAP treatment during sleep hours while hospitalized and should continue that treatment upon discharge.
During interview on 10/16/12 at approximately 10:05 AM, MD #18, attending hospitalist, stated that although the Discharge Summary had been authored by a resident, it was the attending's responsibility to review and approve what was written. MD #18 stated that hospitalization was the time to treat acute issues of the patient, such as this patient's acute on chronic hypercapnic respiratory failure and that post hospitalization, the patient should return to whatever treatment (CPAP in this case) s/he was getting in the community prior to hospitalization. The physician stated that no interference with home settings of CPAP would occur. The hospital failed to ensure that a complete accounting of the patient's diagnoses and hospital experience was documented including plans for discharge treatments in the correct mode of non-invasive positive pressure ventilation during sleep.

1. Based on medical record reviews, review of facility policies and interviews for one of three patients reviewed for laboratory blood work documentation (Patient #22), the facility failed to ensure that blood work was completed as ordered. The finding includes:

Patient #22 was admitted to the hospital on 1/18/12 with a diagnosis of dementia, altered mental status, urinary tract infection and a history of refusing to eat over the last few days. Physician orders dated 1/18/12 directed blood work to include albumin and prealbumin. Although computerized results for all other blood work ordered on 1/18/12 was completed and available, the computerized laboratory results for albumin and prealbumin dated 1/18/12 noted "specimen not received, auto cancelled by laboratory." Review of the patient's record with RN #12 on 10/12/12 at 11:00 AM noted the albumin and prealbumin were not completed by the laboratory per the physician's order and the order was not discontinued by a physician. Interview with Laboratory Staff on 10/17/12 at 8:55 AM indicated that blood work that has not been completed will automatically be cancelled after a certain time period in the electronic system.

The Hospital failed to ensure that the physical environment was designed and constructed to maintain the safety of patients with suicidal tendencies and/or tendencies to cause harm to themselves or others. The Hospital failed to implement immediate safety interventions to correct the environmental safety issues. The finding includes the following: see A 084, A 701 and A710.

The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured.

Based on observation on 10/10/12 at 2:00 PM, the surveyor while accompanied by the facility Fire Marshal, a Representative of the Engineering Department, and the Nurse Manager of Bliss 5, observed that the plastic end caps of the corridor handrails of Bliss 5 were missing and/or damaged exposing sharp and jagged edges of plastic and metal. Some end caps were covered with black tape that did not provide a surface that was cleanable and promoted the maintenance of a sanitary condition.

Based on tours of the facilities, staff interviews, and documentation review, the hospital did not ensure that applicable provisions of the Life Safety Code of the National Fire Protection Association (NFPA 101, 2000 edition) were met.

See K tags K 014, K 015, K 018, K 020, K 104, K 050, K 062, K 071, K 072, K 075, K 077, K 147 and K 130 from the Life Safety Code Survey conducted 10/09/12 through 11/09/12.

Based on observation during tour, interviews and review of facility policy and procedure, the facility failed to ensure that daily checks of emergency equipment were completed in accordance with the hospital policy. The findings include:
a. A tour of the labor and delivery unit on 10/9/12 at 9:45 AM identified the emergency cart and defibrillator log was not signed on seven occasions dated 9/1/12 to 9/30/12. Interview with RN #15 on 10/9/12 at 10:00 AM indicated documentation was required daily to ensure emergency equipment was readily available and functioned properly in the event of an emergent situation. The hospital policy for checking locked emergency supplies, directed in part, a designated individual will check emergency supplies daily on each patient care area for lock integrity of the crash cart, emergency medication, and intubation boxes. The policy further directed the defibrillator will be checked daily to verify it is plugged in, charged, and energy checks would be completed daily by a validated staff person.
b. A tour of the ambulatory surgery unit on 10/9/12 identified that the emergency cart and defibrillator log was not checked on 7/15/12, 7/30/12, and 7/24/12 to ensure operational readiness according to the stipulation of the hospital policy. During interview, Quality Person #1 stated that although the unit was not open on weekends, all weekday cart checks should be documented as completed in the log.

1. Based on observation in the surgical and central sterile arena, review of hospital policy and/or interview, the hospital failed to ensure that infection control practices were followed. The findings include:
a. During tour of the surgical center satellite on 10/10/12 with the Operating Room Practice Director and Manager of the unit, numerous intravenous fluid bags were observed to be spiked with tubing inserts in the bottom drawer of the anesthesia machine. The bags failed to be dated as to when the bags were spiked. During interview on 10/10/12, both the Director and Manager stated that the IV bags were not to be made up in advance of a procedure and should always be dated when the bag is entered.
b. During tour of the surgical satellite, observation was made in one OR of multiple files and clutter atop the desk in the OR that remained between cases, impeding the ability to clean the room according to terminal cleaning policy. Review of the terminal cleaning policy reflected that all rooms should be cleaned daily including the horizontal surfaces of all furniture.
c. During tour of the OR Suite with the Director and Peri-op Quality staff member, on 10/9/12, several personal briefcases/backpacks were observed lying atop a table in a clean supply room in the semi-restricted area of the operating suite. During interview on 10/9/12, the Quality and Education staff member for the OR stated that the hospital did not have a policy governing introducing surgical staff/vendor personal packs into the perioperative practice setting. Review of the AORN Standards and Practice Recommendations 2010, identified that a transition zone, such as lockers rooms, act as a filter through which staff can enter in street clothing (and with personal items) and emerge in the appropriate surgical attire ready to enter the semi-restricted areas of the OR Suite.
d. A review of the steam sterilizer biological testing log on 10/10/12, identified a failure to document biological test results at the end of the three (3) hour incubation period for orthopedic instrumentation processed at another site. For the dates of 8/20, 8/27, 9/25, 9/26, 9/28 and 9/29/12, the resulting test reading failed to be documented in the log reflecting the efficacy of the steam sterilization process. During interview on 10/10/12, the Manager of Central Sterile stated that a portion of orthopedic instrumentation was sterilized at another location in the hospital and sent the Attest biological indicator to central sterile for incubation. S/he stated that although test results were also documented in the computer, there lacked a process for electronically documenting the results from orthopedic instrumentation area for greater than one year. Review of the hospital policy for the rapid readout biological indicator directed that following the three (3) hour incubation period, the test should be read and documented.
e. During tour of the interventional radiology rooms on 10/11/12, it was observed that for two rooms, the doors were propped open and the tables were setup with sterile fields which were covered. During interview with interventional staff members waiting the arrival of the patients for each of these rooms on 10/11/12, it was identified that "the OR" coached them to cover the sterile fields on the tables as it was done "all the time" in the OR. Review of the hospital policy for the principles of aseptic technique identified that the sterile field should be set up as close as possible to the procedure time, closely monitored and never covered. Room doors should be kept closed to ensure effectiveness of the positive pressure air exchanges. During interview on 10/11/12 at approximately 1:47 PM, the Director of OR Professional Practice and Peri-operative Quality RN reiterated that practice within the OR follows the above referenced policy.
f. Tour of the wound clinic on 10/11/12 identified that cubicle curtains were hung in a manner that they were touching the floor.

g. Tour of the Dental clinic on 10/11/12 identified that the clean utility room contained dirty items. Interview with staff indicated that although the room was identified as the "clean" utility room it was used as a "soiled" room, containing garbage bags and specimens.

h. Tour of the Brownstone clinics on 10/11/12 identified cracked exam tables throughout the the building rendering them unable to be adequately cleaned..

i. Tour of the acute dialysis unit identified white fistula clamps hanging from the IV poles attached to the hemodialysis machines prior to treatments.

j. Tour of the Brownstone clinic on the third floor identified a cabinet utilized for the administration Pentamindine. The seat located in the cabinet was dirty and had white buildup. Interview with the staff on 10/11/12 at 11:00 AM identified that they were unsure who was responsible to clean the cabinet after use. In addition the oxygen concentrator used to provide aerosolization for the cabinet was dirty.




14528


2. Based on medical record review, observation and interview the facility failed to store thickener per facility practice to prevent the possibility of cross contamination of infection. The finding includes:

During a tour of the N9 unit on 10/11/12 at 11:00 AM, a can of dietary thickener was observed on the bedside table in an occupied patient room. Interview with an N9 RN on 10/11/12 at 11:00 AM noted that there was one can of thickener somewhere on the unit for use for all patients as needed. Interview with the N9 Nurse Manager via phone on 10/11/12 at 10:40 AM noted that the unit did not presently have thickener stored on the unit (pantry) and would order the thickener as needed. Interview with the Dietary Supervisor on 10/11/12 at 10:50 AM indicated that there were five patients on the N9 unit who required thickened liquids, some liquids on the unit were pre-thickened, and if the nurse required additional liquids to be thickened, dietary would send a can of thickener for single patient use upon request. Interview with the Dietary Director on 10/11/12 at 12:15 PM indicated that once a can of thickener is in a patient's room, it is to be used solely for that patient and nursing must order more thickener as required for other patients. The facility did not have a policy related to thickened liquid deliver, storage or unit par level requirements.





15482



3. Based on review of facility documentation and interview the facility failed to ensure that "flash" sterilization was utilized on a limited basis. The finding includes the following:

a. Review of the sterilization logs at the outpatient surgical center for the period of 9/1/12 through 10/10/12 identified that flash sterilization was completed 10-20 times per day on each of four autoclaves. Interview with staff on 10/10/12 at 10:00 AM indicated that although the facility does utilize flash sterilization often, there has been a decrease in flashing with a plan to purchase additional items to further decrease the use of flash sterilization.

b. Tour of the dental clinic on 10/11/12 identified that in the processing area there was a check list that identified "weekly cleaning" and "monthly cleaning" of the autoclave. Interview with staff indicated that on a weekly basis an Attest biological is processed in the autoclave and sent, with an unprocessed Attest indicator to the hospital microbiology lab. Review of the manufacturers guideline indicated that the biological indicator must be incubated within two (2) hours or be refrigerated, if not spores will die off and a sterilization failure could go undetected.

Review of the clinic policy indicated that weekly autoclave maintenance is performed and general cleaning monthly. The policy indicated that an Attest indicated will be processed on a normal cycle after each weekly clearing and one processed and one unprocessed indicator are taken to the hospital lab for testing. The facility policy failed to identify the time parameters and/or the need for refrigeration prior to transport to the lab.

1. Based on review of the clinical record, review of hospital policy and interviews, the hospital failed to ensure that the discharge plan was reassessed prior to discharge for one patient (#37) who required BiPAP (Bi-level Positive Airway Pressure) as directed by the physician. The finding includes:
Patient #37 was admitted to the hospital on 2/9/12 secondary to exhibiting non-arousable lethargy at adult day care. Review of the admission history and physical (H&P) dated 2/9/12 identified that the patient had diagnoses that included, in part, chronic respiratory failure, secondary to chronic obstructive respiratory disease (COPD) and obstructive sleep apnea with the use of oxygen and Continuous Positive Airway Pressure (CPAP) at home. Review of the Discharge Planning Assessment identified that the patient utilized a CPAP machine at home, however, the plan failed to reflect that the patient's non-invasive positive pressure ventilation pressures changed from CPAP to BiPAP per physician order while hospitalized.
The patient was discharged to a skilled nursing facility (SNF) on 2/17/12. Review of the Inter-Agency Patient Referral Report (W-10) directed that the patient use BiPAP at bedtime (settings: I-PAP 14, E-PAP 4, nasal pillows with 3 liters of oxygen).
During interview on 10/22/12 at 10:20 AM, MD #17 (pulmonologist) stated that Patient #37 was non compliant with wearing CPAP secondary to the pressure mode and comfort of the mask. The physician stated that ultimately changing the delivery mode to BiPAP and nasal pillows during the hospital stay, allowed the patient to be more comfortable and compliant with wearing the equipment while sleeping. The physician stated that the patient's home machine should have been set by the company to the settings of BPAP at discharge.
During interview on 10/15/12 at approximately 11:20 AM, the Director of Discharge Planning stated that s/he spoke to the rehab facility Administrator who had agreed to take the patient provided that the patient would be receiving CPAP.
During interview on 10/15/12 at approximately 2:00 PM, Case Coordinator #2 (CC#2) stated that s/he did not arrange for the patient's CPAP machine be changed to BiPAP settings for discharge because s/he thought it was the responsibility of the nursing home evaluator to notify the family to bring in the patient's own (CPAP) machine. CC#2 stated she thought CPAP and BiPAP were the same thing and did not arrange for the machine to have the correct settings and be available to the patient upon discharge.
Review of the clinical record dated 2/17/12 identified that the patient returned to the ED at 7:07 PM, approximately four (4) hours following discharge from the hospital for lethargy and fluctuating level of consciousness. Review of the history of present illness identfied that the patient was sent to a SNF after admission for hypercapnic respiratory failure. While at the SNF, the patient fell asleep and the staff did not apply CPAP, and were unable to wake the patient up. The patient was evaluated in the ED and discharged back to the SNF on 2/18/12 at 12:27 AM. The W-10 identified that the patient must wear CPAP when sleeping.
On 2/18/12 at 5:57 AM, Patient #37 was transferred from the SNF to the ED for evaluation. Review of the triage note identified a chief complaint quote: patient was sent back to the nursing home and the SNF does not have the correct set-up for CPAP, patient became confused and combative after being asleep with oxygen saturation of 68%. The History and Physical identified that the patient was discharged from the hospital with no arrangements for BiPAP having been made. The patient was treated with rescue BPAP while in the ED and returned to the SNF on 2/18/12 at 5:11 PM.

1. Based on a review of the clinical record, staff interviews, and a review of facility documentation for one patient (Patient #60), the facility failed to document that a time out was conducted prior to the placement of an epidural catheter. The finding included:
a. Patient #60 was admitted to the hospital on 10/8/12 in labor and requested the administration of an epidural for pain management. Interview and review of the clinical record with RN #15 on 10/9/12 at 10:45 AM identified the verification of correct patient, site/side and procedure for catheter placement was not completed. Further interview with RN #15 indicated the documentation was required prior the administration of the epidural to ensure the safety of the patient who received the procedure and subsequent administration of medication through the catheter. The hospital policy for verification of correct patient, side/site, and procedures, directed in part, that a time out is to be conducted prior to the start of the procedure, to include the name of the procedure, verification of the correct patient, verification of the procedure to be performed, verification of the correct site including site marking (by a licensed practitioner who is credentialed to perform the procedure), safety precautions based on patient history and/or medication used and the time out would be documented in the medical record.

1. Based on clinical record review, interview and review of the facility documentation, for one of two dental surgery records, the facility failed to ensure that an informed consent had been completed. The finding includes the following:

Review of Patient #78's clinical record indicated that the patient was seen in the dental clinical on 10/3/12 for the removal of a tooth. Review of the clinical record failed to identify that an informed consent had been completed. Review of the record with staff on 10/11/12 at 10:30 AM indicated that the consent is completed and scanned into the computer however review of the computerized record failed to identify that the back page of the consent was present.

Review of the facility policy indicated an informed consent should be completed prior to any procedure.

1. Based on clinical record review, review of hospital policies and interviews with hospital personnel for one patient, Patient #25, who underwent a Central Venous Catheter (CVC) insertion preoperatively, the facility failed to ensure that the policy for CVC insertion was followed by the physician and/or that the facility had a policy for CVC insertion by anesthesia specific to their role. The findings include:

Patient #25 was admitted to the facility on 1/24/11 for an elective surgery of a benign hepatic adenoma. Review of the clinical record, review of hospital documentation and interviews with the Director of Risk and the Director of Quality on 10/10/12 identified that on 1/24/11, Patient #25 had a right Internal Jugular (IJ) CVC incorrectly placed by the anesthesiology resident, MD #9, at the beginning of the surgical case, just prior to the incision at 9:09 AM. Review of the anesthesia record dated 1/24/11 and subsequent interview with the attending anesthesiologist, MD #7, on 10/15/12 at 11:00 AM indicated that during a critical surgical moment of the operative procedure on 1/24/11, at approximately 10:20 AM, MD #7 attempted to transduce the CVC for a central pressure and an arterial wave form was intermittently noted on the monitor. Arterial blood gases verified arterial blood and the right IJ CVC was subsequently not utilized for fluid and/or medication administration. MD #7 indicated that he/she informed the surgeon of the CVC misplacement later, during surgical closure. Interview with MD #9 on 10/12/12 at 9:30 AM indicated that the CVC was inserted utilizing ultrasound guidance and that catheter placement confirmation by x-ray was not conducted as a standard of practice. MD #9 indicated that he/she removed the right IJ CVC at 12:15 PM and that pressure at the site was held for five minutes. Patient #25 was stable upon transfer to the Post Anesthesia Care Unit (PACU) at 12:36 PM. The clinical record identified that on 1/24/11 at 3:35 PM, Patient #25 neurologically deteriorated when a left-sided facial droop and left upper extremity weakness were noted. The stroke team was notified immediately. Review of the head Computerized Tomography Scan (head CT) report dated 1/24/12 at 4:35 PM identified an acute thrombosis and thromboembolism in the right common carotid artery. Review of the clinical record identified that Patient #25 had sustained a right hemispheric Cerebrovascular Accident (CVA). Interview with the Perioperative Performance Improvement nurse, RN #1, on 10/16/12 and review of the facility's CVC Insertion Policy indicated that an x-ray to confirm placement was required for IJ CVC insertion. Although the policy referenced a preoperative CVC insertion with sedation and anesthesia policy, RN #1 identified that no anesthesia CVC insertion policy was in place at the time of the incident. Interview with the Assistant Director of Anesthesia, MD #8, on 10/12/12 at 10:00 AM identified that the post procedure x-ray was not performed for central line placement verification in the Operating Room and that no anesthesia policy addressing central line placement was in effect at the time of the incident.

1. Based on clinical record review, interview and policy review the facility failed to ensure that a post anesthesia note was dated. The finding includes the following:

Patient #40 was admitted on 10/5/12 with a left hip fracture requiring surgery on 10/6/12. Review of the clinical record on 10/9/12 identified that a post anesthesia note had been completed however the note failed to reflect a date and time it had been completed. Interview with staff on 10/9/12 at 10:30 AM identified that the note should have been completed with in 48 hours and should be dated and timed.

Review of the facility policy indicated that all entries in the clinical record should be dated and timed.