HospitalInspections.org

Based on findings from document review and interview, in 3 of 6 credentials files reviewed for the hospital's medical staff members, the governing body did not ensure implementation of appropriate policies requiring delineation of clinical privileges for its established medical staff.

Findings include:

--Per review of the hospital's document entitled "Bylaws of the Medical Staff of Clifton-Fine Health Care Corporation," last approved 5/30/08, it states under section 6.2-2 Medical Staff Action "...All recommendations for appointment must also specifically recommend the staff category, clinical service if applicable, and clinical privileges to be granted ..."

--Per review of credentials files on 10/21/10 for Physicians #1, #2, and #3, each contained a form entitled "Clifton Fine Hospital ED Delineation of Privileges." When completed properly during the credentialing process, information on the form describes the specific privileges requested and granted for 12 potential categories of clinical services. However, although the document was signed by the Medical Director for each physician, the specific privileges granted were not indicated.

--During interview with the Manager of Quality Improvement & Risk Management on 10/21/10 at 1:00 p.m., the above findings were verified.

Based on findings from document review and interview, in 1 of 1 medical records reviewed involving a medication error, although hospital staff identified that a medication error occurred (when a patient, Patient A, was administered 4 incorrect doses of an antihypertensive medication), the medication error was not reported and investigated to identify causative factors (and implement corrective actions) to prevent recurrences. The lack of a report would also preclude effective tracking of medication errors to identify trends warranting attention.

Findings include:

--Per review of Patient A's medical record, on 9/14/10 at 9:00 a.m., a physician ordered "coreg 12.5 mg by mouth (PO) twice daily." Entered on the pharmacy printed medication administration record (MAR) was "med: carvedilol 3.125 mg tablet WF: coreg 3.125 mg tablet, take 1/2 tablet (1.5625 mg.) by mouth twice daily. Tabs already cut in half." The above dosages were crossed out in handwriting, and written in was "12.5 mg 2 x daily" (date of change not noted). The medication was initialed by nursing as being administered on 9/15/10 at 9:00 a.m. and 8:00 p.m. and on 9/16/10 at 9:00 a.m. and 8:00 p.m.

On 9/17/10 at 8:20 a.m., a physician documented in the progress notes, "Patient did receive several doses of coreg at 1.25 mg. instead of 12.5 mg. This was corrected last pm..."

--Per review of the hospital's policy and procedures (P&Ps) entitled "Medication Errors," dated October 1996, it states "...A medication error will be considered to have occurred when:...The patient receives the wrong dose of a medication...When an error has been discovered the following will ensue:...Completion of a medication error report must be accomplished as soon as possible, after the error is discovered...A copy of the initiated form(s) will be sent to the NSA (nursing services administration). After investigation and all appropriate documentation concerning the error has been completed, copies will be sent from NSA to the Pharmacist..."

--Per interview of the Manager of Quality Improvement & Risk Management on 10/20/10 at 11:00 a.m., he/she could not recall this medication error and verified that there was no documentation of the incident or an investigation of the medication error (noted in the MR).

--Per interview of Pharmacist #1 on 10/20/10 at 2:20 p.m., he/she did recall the medication error but could not describe or provide documentation of an investigation or corrective actions taken to prevent recurrence.

Based on findings from observation, document review and interview, the hospital did not follow generally accepted infection control (IC) practices. Specifically, the hospital's IC program did not include the Outpatient Primary Care Clinic in general surveillance activities, the Infection Preventionist (IP) did not observe hospital staff for adherence to IC policies, and the Infection Control Committee (ICC) did not identify follow up actions for expected patient care IC interventions discussed at its meetings, in the ICC meeting minutes. Additionally, a staff member was observed not removing gloves and washing hands when indicated.

Findings include:

--Per interview of the IP on 10/20/10 at 2:15 p.m., he/she does not visit the outpatient primary care clinic for observation or evaluation of staff practices and he/she does not periodically observe hospital staff practices for adherence to infection control guidelines and policies.

--Per review of ICC meeting minutes dated 4/29/10, they state, "Discussed the wiping down of equipment between residents/patients. How does staff know if a piece of equipment is clean?....Reviewed importance of handwashing. Discussed disposable wipes for residents before meals and activities." There are no actions listed for follow up with patient care staff regarding the questions posed or the practices expected.

Per review of ICC meeting minutes dated 5/27/10, they state, "The importance of cleaning and tagging reusable equipment was stressed ...Anything that goes from or touches the patient needs to be wiped down." Again, there are no actions listed for follow up with patient care staff.

Per review of ICC meeting minutes dated 7/30/10, they state, "Patient hand hygiene consists of patients washing their hands before meals with washcloth. Residents are given the wipes at the table before meals." Again, there were no follow up actions listed.

--Per interview of the IP on 10/20/10 at 3:00 p.m., there was discussion about these topics at the ICC meetings because they were brought up at a recent conference he/she attended. However, he/she was not able to say if these issues were a problem at this hospital or not, as they were not investigated.

--Additionally, per observations on 10/20/10 at 10:00 a.m., licensed practical nurse (LPN) #1 carried a urine sample into the utility room for testing with gloved hands. He/she removed the lid from the container and dipped a test strip into the urine. Without first removing gloves and performing hand hygiene, he/she then proceeded to do other things (e.g., opened a drawer to get something, reached in her pocket to remove a pen) and then documented on a form.

Based on findings from document review and interview, the hospital does not have a P & P for pressure ulcer prevention and treatment pertaining to acute care (short term) patients, and its P & P pertaining to swing bed (long term) patients was not consistent with generally accepted standards of nursing practice. Specifically, the swing bed P & P lacked description of:
1) a risk assessment tool to use to identify patients at risk for pressure ulcer development,
2) a requirement for nursing to implement preventative measures based on factors contributing to a patient's risk to develop a pressure ulcer,
3) indications for the selection and use of appropriate patient support surfaces,
4) complete/accurate definitions of pressure ulcer stages,
5) the pressure ulcer treatments utilized at this hospital,
6) acceptable frequency for repositioning patients while out of bed in a chair,
7) a requirement for physician notification about a patient's initial pressure ulcer development or change in pressure ulcer status,
8) requirements for medical record documentation regarding daily skin inspection and pressure ulcer preventative interventions.
Also, 9) the hospital lacked a P & P for pressure ulcer prevention and management in acute care patients.

Additionally, 10) in 3 of 8 swing bed MRs reviewed for patients who fell while in the hospital, the followup assessments for injuries were not completed by a registered nurse (RN).

Findings regarding 1) above include:

--Per review of the hospital's swing bed P & P entitled "Protocol for Prevention and Treatment of Pressure Ulcers," not dated, it stated "A Patient will be identified as at risk if they have 1 or more of the following: a. A pressure ulcer, b. Cellulitis, c. Immobility. Additionally, a patient may be deemed at risk if they have 3 or more of these contributing factors: a. Impaired nutritional status, b. Incontinence, c. Diabetes, d. Edema, e. Poor skin turgor, f. Renal disease, g. Immunosuppression, h. Altered circulation, i. Dehydration, j. Obesity."

This policy did not describe a generally accepted (validated) pressure ulcer risk assessment tool that nursing staff in this hospital should use.

Findings regarding 2) above include:

--Per review of the hospital's swing bed P & P referenced above, not only does it lack description of a validated risk assessment tool that nurses should use to assess and document a patient's risk for developing pressure ulcers, but it also lacks guidance on how to plan necessary pressure ulcer prevention measures in accordance with the particular risk factors placing an individual at risk for development of pressure ulcers.

Findings regarding 3) above include:

--In 1992, the Agency for Health Care Policy and Research ( AHCPR) in the United States Department of Health and Human Services issued a publication entitled "Clinical Practice Guidelines, #3, Pressure Ulcers in Adults: Prediction and Prevention" (Publication #92-0047). It states "Any individual assessed to be at risk for developing pressure ulcers should be placed when lying in bed on a pressure-reducing device, such as foam, static air, alternating air, gel, or water mattress. For chair bound individuals, the use of a pressure reducing device such as those made of foam, gel, air, or a combination is indicated. Do not use donut -type devices."

--Per review of the hospital's swing bed P & P referenced above, under the equipment section it lists "Pillows, Heel and /or elbow protectors, Egg crate (with cover) for bed and /or chair, special mattress if available.." Then under the section entitled "Standard Care-Protocol for Prevention and Treatment of Pressure Ulcer," it states "Utilize pressure relief mattresses when indicated."

The policy lacks guidance as to when use of this equipment is indicated and does not provide information regarding what bed surface types are available at this hospital.

Findings regarding 4) above include:

--Per review of the National Pressure Ulcer Advisory Panel's (NPUAP) description of pressure ulcer stages, last revised on its website at www.NPUAP.org in 2/07, 2 additional pressure ulcer stages were added to the original pressure ulcer stages 1 through 4. These included deep tissue injury and unstageable pressure ulcers.

--However, per review of the hospital's swing bed P & P referenced above, it lacks any reference to the pressure ulcer stages involving deep tissue injury and unstageable pressure ulcers.

Findings regarding 5) above include:

--In 1994, the Agency for Health Care Policy and Research (AHCPR) in the United States Department of Health and Human Services issued a publication entitled "Clinical Practice Guidelines, #15, Treatment of Pressure Ulcers " (AHCPR Publication #95-0652). It states "the four basic components of effective ulcer care plan include: (1) debridement of necrotic tissue...(2) cleansing of the wound on initial and subsequent assessment (3) prevention, diagnosis and treatment of infection and (4) using a dressing that keeps the ulcer bed continuously moist and the surrounding intact tissue dry..."

However, per review of the hospital swing bed P & P referenced above, it does not contain guidelines for management of pressure ulcers.

Findings regarding 6) above include:

--Per review of the hospital's swing bed P & P referenced above, it states "Change position at least every 2 hours when in a chair..."

--However, per review of AHCPR's 1992 publication entitled "Clinical Practice Guidelines, #3, Pressure Ulcers in Adults: Prediction and Prevention" (Publication #92-0047), it states "Any person at risk for developing a pressure ulcer should avoid uninterrupted sitting in a chair or wheel chair. The individual should be repositioned, shifting the points under pressure at least every hour or be put back to bed if consistent with overall patient management goals. Individuals should be taught to shift weight every 15 minutes."

The hospital's P & P does not require staff to ensure patients are repositioned hourly while out of bed in a chair.

Findings regarding 7) above include:

--The hospital's swing bed P & P referenced above does not require nursing staff to notify the attending physician upon a patient's initial development of a pressure ulcer, or upon changes in wound characteristics thereafter (e.g., color, drainage, odor or pain.) The generally accepted standard of nursing practice is to confer with the patient's responsible practitioner relative to significant changes in the patient's condition.

Findings regarding 8) above include:

--In 1992, the AHCPR issued a publication entitled "Clinical Practice Guidelines #3, Pressure Ulcer in Adults: Prediction and Prevention" (AHCPR Publication #92-0047). It states "Intervention and outcomes should be documented and monitored."

--However, per review of the hospital's swing bed P & P referenced above, it only addresses documentation of skin assessment and wound descriptions at time of patient's admission and discharge.

Findings regarding 9) above include:

--During interview of the Director of Nursing (DON) on 10/21/10 at 12:30 p.m., he/she acknowledged that the hospital only has a written pressure ulcer P & P for its swing bed patient population. He/she also indicated that while the hospital lacks a P & P for pressure ulcer prevention and treatment that applies to acute care patients, it does have some procedures in place for documentation of skin risk assessments and interventions; they just are not organized in a written and complete P & P.

Findings regarding 10) above include:

--In 3 of 8 medical records reviewed for patients who fell, each lacked any assessment by an RN. Patient A's assessment was documented by LPN #2, Patient B's assessment was documented by LPN # 3, and Patient C's assessment was documented by LPN #4.

--During interview with the DON and Manager of Quality Improvement and Risk Management at various times throughout the survey, the above findings were acknowledged.

Based on findings from document review and interview in 3 of 10 medical records reviewed, patients' (Patients D, E, and B ) responses to pain medication were not documented, per generally accepted standards of practice and the hospital's policy.

Findings include:

--Per review of the hospital's P & P entitled "Pain Assessment and Management," last revised 4/09, it states, "...Assess and record pain intensity and relief levels at regular intervals. Determine degree of relief after each pain management intervention..." Additionally, per review of the hospital's Nurse's Medication Notes form, the reason for administering, and the result of an as needed (PRN) medication are to be documented following each administration of a pain medication.

--Per review of Patient D's Nurse's Medication Notes, on 8/4/10 at 10:30 a.m., Tylenol 650 mg by mouth (PO) was administered for leg aches; however, there is no documentation of the result/effect of the administered pain medications.

--Per review of Patient E's Nurse's Medication Notes, on 10/1/10 at 8:15 p.m. Endocet one tablet PO was administered for back pain, and on 10/3/10 Endocet one tablet PO was administered for neck and shoulder pain; however, there is no documentation of the results/effects of the administered pain medications.

--Per review of Patient B's Nurse's Medication Notes, on 8/3/10 at 8:00 p.m. Tylenol 650 mg PO was administered for back pain and on 8/7/10 at 5:30 p.m. it was administered for leg pain; however, there is no documentation of the results/effects of the administered pain medications.

--Per interview of the DON on 10/21/10 at 1:30 p.m., it was verified that the patient's response to the administration of a pain medication is to be documented on the Nurse's Medication Notes form.

Based on findings from document review and interview, in 2 of 10 medical records reviewed, transcription (documentation) of patients' (Patients A and F) medications on the Medication Administration Record (MAR) was not consistent with hospital policy or generally accepted standards of nursing practice. For example, medication orders that were to be discontinued were not highlighted (with "discontinue" written over it) per policy. Additionally, during medication pass observations, 4 of 4 patients given medications were not asked to state their name and date of birth; also, their name band was not checked prior to the medication administrations.

Findings include:

--Per review of the hospital's P & P policy entitled "Medication Documentation," last revised 11/2/08, it states "...When discontinuing a current order, the appropriate line on the MAR will be highlighted and "discontinued" will be written in the line also with the nurses initials."

Per medical record review, Patient A's medication dosing orders for Coreg and potassium were changed by a physician on 9/14/10. Nursing staff did not discontinue the order on the MAR in the manner described above in the P & P. Instead they only drew a line over the existing order on the MAR.

During interview of Charge Nurse #1 on 10/19/10 at 2:00 p.m., he/she verified that the above documentation of discontinued medications orders on the MAR was not consistent with the hospital's P & P.

--Per medical record review, Patient F's medication dosing order for Effexor ER was changed on 9/14/10 from 150 mg to 225 mg. On 10/01/10 physician orders were renewed. The renewal included the increased dosage of Effexor ER 225 mg PO daily.

However, per review of the MAR dated 10/1/10, it contained preprinted orders which stated "Effexor XR 150 mg cap Take 1 capsule by mouth once a day." The preprinted order was crossed out and changed . Specifically, 250 mgs was handwritten over the 150 mgs. Then the 250 was crossed out and 150 was written above it. One (1) capsule was written over to say 2, and then the 2 was crossed out and 1 capsule was written above it. This manner of documentation on the MAR was unsafe and not consistent with generally accepted standards of practice.

Per interview of Pharmacist #1 on 10/20/10 at 10:45 a.m., he/she verified that the order should have been discontinued and completely rewritten.

--Per review of the hospital P & P entitled "Medication Administration," last revised 11/2/08, it states "Two identifiers must be used and verified at the bedside when identifying a patient to administer a medication. Any two of the following can be used: a. Patient's name b. Patient's date of birth c. Patient's hospital Number....The two identifiers chosen by the medication nurse must be verified at the bedside by asking the patient... and by using the patient's ID Band...."

However, per observations on 10/20/10 at 8:30 a.m., when LPN #5 passed medications to 4 swing bed patients, he/she stated their names first but did not use a second identifier to verify the patients' identities prior to medication administrations.

Per interview of LPN #5 after completion of the medication passes, he/she stated because they were swing bed patients, he/she knew them. Also, he/she did state their first name prior to administering the medication.

Based on findings from document review and interview, the hospital's quality assurance (QA) program did not develop corrective action responses to all data collected that indicated non-compliance with expected patient care activities, did not followup on all corrective actions that were developed, and did not require the Pharmacy Department to implement its department-specific QA plan.

Findings include:

--Per review of the hospital's Integrated Facility Improvement Plan (IFIP), last revised/retyped 6/10, it stated "Department Staff Responsibilities: Each department manager...is responsible for identifying quality indicators, collecting and analyzing data and implementing changes to improve service delivery and monitoring to assure that improvement is made and sustained ...Taking actions to correct identified problems and improve overall quality of care. Where Department Manager and/or the Integrated Facility Improvement Committee (IFIC) determines the need for corrective action, an action plan will be formulated that includes: A statement of the problem ...specific action steps to be taken; criteria for determining sufficient correction of deficiencies; time frame for completion ...desired results ...The plan for continued monitoring for effectiveness of corrective actions taken ..."

--Per review of IFIC meeting minutes dated 8/31/10, information in the results of an outpatient clinic quality monitoring form were discussed. Per review of the quality monitoring form, it indicates the objective of the monitor was to review clinical records for documentation of established diabetic care criteria, and that the goal was 90% of diabetic patients' records would meet criteria. This form indicates the following results of monitoring for the second quarter of 2010: History and Physical Criteria was 69% compliance. Laboratory Testing was 74% compliance. Tobacco use documented was 100%. Amount of Tobacco use documented was 71% compliance. Assistance to quit documented was 71% compliance. The 90% goal was clearly not met. However, the minutes lack description of a plan for improvement.

--Per review of a hospital document entitled "Dashboard - Patient ID Band Compliance," not dated, it lists patient ID band compliance measures for Lab, Radiology and Nursing. The legend indicates that 70 - 90% compliance is a concern. Per review of year to date compliance data (1st and 2nd quarters of 2010), it shows the Lab at 77% (ER patients) and 83% (inpatients). This meant that only 77% of outpatients presented to the Lab with ID bands on and 83% of inpatients presented to the Lab with ID bands on. Also, per review of year to date compliance data for Nursing, it indicates 85% of ER patients presented with ID bands on when checked. (The other measures were greater than 90% which met target.) Although IFIC meeting minutes dated 6/29/10 and 7/27/10 indicate that a new ID band system would be in place by 5/28/10 (1 and 2 months previous to the dates of these meetings), there is no indication it was put in place and no follow up thereafter of the non-compliance described above.

--Per review of the hospital's Pharmacy Department "Quality Assurance Plan," last revised 8/10, it states:

" ...To determine what issues should be monitored for quality assurance in the Pharmacy Department ...30 acute care records will be reviewed each quarter and every skilled nursing chart will be reviewed each month by the pharmacist. A combination of failed screen, medication orders, adverse drug reaction, P & T (pharmacy and therapeutics) concerns, multidisciplinary review and random selections.

The pharmacist will inspect all drug areas each quarter, checking for outdates and problems in the areas.

The pharmacist will review Pyxis reports every day (including) Override Report, CDC Report and Pharmacy Key Report.

Focused studies will be conducted periodically as deemed necessary by the Pharmacy Director and/or the P & T committee.

Communication of this information will be written reports of conclusions, recommendations, actions taken and results of actions taken to be maintained and reported to the P & T committee, Medical Staff and Quality Assurance quarterly."

--Further, per review of the Pharmacy P & P entitled "Committee," last revised 8/10, it states "...Meetings are held quarterly. The Committee will also review adverse drug reactions, medication errors, reportable incidents and QA screen pertaining to Pharmacy."

--However, per review of all documents provided during the survey, there was no information indicating that the above QA activities had been documented or reported quarterly.

--During interview of Pharmacist #1 on 10/21/10 at 9:00 a.m., he/she verified that the above QA activities have not been completed, documented or reported quarterly.

-- All of the above findings were acknowledged during the survey exit conference held on 10/21/10 at 3:45 p.m.