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Based on record review and interview, the Hospital failed to ensure for one of two restrained intensive care unit patients (Patient #5),in a toal sample of 37, a renewal order for medical (non-violent) physical restraints was documented on 1/14/17 and 1/15/17, as required.

Findings include:

The Hospital ' s Restraint Policy for the Management of Patient Safety, dated 5/2/13, indicated for non-violent behavior, "Orders shall remain in effect until the patient's behavior no longer meets criteria for restraints. Renewal orders MUST be given each calendar day based on an in-person evaluation by a physician or LIP primarily responsible for the patient's care."

Patient #5's record indicated that Nurse Practitioner #1 wrote an order for Patient #5, dated 1/12/17 at 3:51 P.M., for bilateral soft wrist restraints.

Patient #5's nursing restraint assessments indicated that he/she was in physical restraints on dates which included: 1/12/17, 1/13/17, 1/14/17 and 1/15/17.

Patient #5's record indicated that Physician #1 wrote renewal orders for a physical restraint, dated 1/13/17. Patient #5's record indicated there were no renewal orders for a physical restraint dated either 1/14/17 or 1/15/17.

The Surveyor interviewed Nurse #28 at 2:00 P.M. on 1/19/17. Nurse #28 said that her review of Patient #5's electronic and hand written records indicated there was no documentation of a restraint renewal order dated 1/14/17 or 1/15/17, as required.

Based on record review and interview, the Hospital failed to ensure that for one of two restrained intensive care unit patients (Patient #5) the attending physician (Physician #1) was immediately consulted after the nurse practitioner (Nurse Practitioner #1) wrote an order for Patient #5 to be physically restrained on 1/12/17, in a total sample of 37.

Findings include:

The Hospital's Restraint Policy for the Management of Patient Safety, dated 5/2/13, indicated, "Notification of the Attending Physician: If ordered by a practitioner other than the attending physician, the attending physician will be notified that the restraint was applied as soon as possible after initiation. Documentation of attending physician notification will be entered into the patient record."

Patient #5's record indicated that Nurse Practitioner #1 wrote an order, dated 1/12/17 at 3:51 P.M., for bilateral soft wrist restraints.

Patient #5's record indicated there was no documentation from Nurse Practitioner #1, or any other staff, that a restraint consultation, or notification, involving either the attending physician or a covering physician, occurred.

The Surveyor interviewed Nurse #28 at 2:00 P.M. on 1/19/17. Nurse #28 said that her review of Patient #5's electronic and hand written records indicated there was no documentation of a restraint consultation with the attending physician as required.

Based on review of hospital documentation and interview, hospital staff failed to ensure that all appropriate staff (all staff that participate in the application of restraints) received education, training and certification for cardiopulmonary resuscitation (CPR). Findings include:
During the tour of the Emergency Room with the Director of Emergency Services (DES) on 1/18/17 at 9:45 A.M., the Surveyor observed several Security Guards on duty. The Surveyor asked what role they have in the use of restraints. The DES told the Surveyor that they help nursing staff in the application of restraints for patients that are extremely combative and are a danger to themselves or others.

During interview on 1/19/17 at 2:00 P.M., the DES gave the Surveyor a list of all the Security Guards (23 total) and the dates of CPR certification. The list indicated that of 11 of the 23 security guards, were not yet certified. These 11 security guards were working in the hospital performing the same duties as the 12 CPR certified guards which included assisting in restraint application of combative or agressive patients when needed.

During interview on 1/23/17 at 9:10 A.M., the Director of Security told the Surveyor that all the guards can help medical staff apply restraints, however, there were 11 guards who have not been CPR certified yet, although required.

Based on document review and staff interviews, Hospital staff failed identify opportunities for improvement related to timeliness of referrals for Organ, Tissue and Eye Procurement (OTEP), in order to ensure improvements were made, attained or sustained after implementing actions. Findings include:

During interview with OTEP Nurses #1 and #2 on 1/19/17 at 8:10 A.M., OTEP Nurse #1 said that the Hospital ranked below the National Threshold (greater than 85%) for timeliness of referrals made to the Organ Donation Agency, and provided a "Hospital Performance Summary" indicating the "% Timely Referral Rate" (for Quarter Two, dated from 1/1/16 - 6/30/16) was 78%. OTEP Nurse #1 said that the national Threshold requires the Hospital to be greater than 85%, and that nursing staff were not making referrals, within 1 hour of a patient's death, to the Organ Donation Agency.

Review of the Quality Patient Safety (QPS) Council Meeting Minutes (dated 8/2016) indicated a section entitled "Reporting Agenda" for the Organ Donation Agency, indicated it was essential that all deaths were referred to the Organ Donation Agency in a timely manner, and that timely referrals was an area for improvement. The minutes indicated 76% of Hospital deaths were referred timely (National threshold required greater than 85%), and education would be provided.

Review of the "Hospital Performance Summary" (dated 1/2016 - 9/2016) indicated the total deaths for this time frame was 208, and the timely referral of deaths at the Hospital was 80%.

During interview on 1/23/17 at 2:30 P.M., OTEP Nurse #2 said that she had been newly appointed to take over the organ donation program at the Hospital, but has only been employed at the Hospital for 3 months. OTEP Nurse #2 said she would ensure implementation of an action plan for attaining, sustaining timeliness of referrals to the Organ Bank Agency, to measure performance improvement.

Based on record review and interview, the pediatric nursing staff failed to assess one of two pediatric patients (#10) accurately for type of nutritional intake (breast milk versus formula), in a total sample of 37. Findings include:

1. Record review indicated Patient #10, a newborn, was admitted on 1/14/2017 with a highly infectious respiratory virus and placed on contact and droplet precautions in a private room.

The initial nursing assessment, completed on 1/14/2017, indicated Patient #10, received bottle formula only for intake. Review of the nursing care plan indicated there was no plan for storage of breast milk or alternate feeding of breast and formula feeding.

During an interview with the mother of Patient #10, on 1/18/2017 at 2:00 P.M., the mother stated she had been pumping breast milk and had been feeding breast milk in the room. The mother said she did not have a refrigerator in the room to store pumped breast milk.

During an interview with the Registered Nurse (RN) #16, on 1/19/2017 at 9:00 A.M., RN #16 said that the infant was drinking both breast milk and formula and said that the nursing assessment failed to to address the use of breast milk by the mother. RN #16 also said staff were storing excess breast milk in the lactation refrigerator located in the nutrition kitchen on the pediatric unit.

RN #16 said the staff did not consult the infection control nurse about taking breast milk out of a contact isolation room and had not provided a refrigerator in the room for the mother to store her breast milk in.

Based on record review and interview, the nursing staff failed to develop nursing care plans for identified problems for five patients (#1, #10, #11, #12, #13 ) in a total sample of 37. Findings include:

1. For Pediatric Patient #10, the staff failed to develop a nursing care plan for infection and for breast feeding.

Record review indicated Patient #10, a newborn, was admitted on 1/14/17 with a highly infectious respiratory virus and placed on contact and droplet precautions in a private room.

The initial nursing assessment, completed on 1/14/17, indicated the infant received bottle formula only for intake. Review of the nursing care plan indicated there was no plan for storage of breast milk or alternate feeding of breast and formula feeding. There was no nursing care plan to address the baby's infection or isolation precautions.

During an interview with Registered Nurse(RN)#16, on 1/19/17 at 9:00 A.M., RN #16, said that the baby was drinking both breast milk and formula. RN #16 also said staff were storing excess breast milk in the lactation refrigerator located in the nutrition kitchen.

RN #16 said the staff did not consult the infection control nurse about taking breast milk out of a contact isolation room and had not provided a refrigerator in the room for the mother to store her breast milk in.



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2. For Patient #11, Hospital staff failed to develop nursing care plans with individualized goals and interventions regarding chronic kidney disease (CKD Stage 3) and diabetes mellitus.

Patient #11 was admitted to the Hospital in 1/2017 after a fall at home. Diagnoses include chronic kidney disease (Stage 3), diabetes mellitus, Alzheimer's Disease and increased confusion.

Review of the laboratory report, indicated that Patient #11's Blood Urea Nitrogen (BUN) on admission was 32 (normal ranges 7-20) and the Creatinine was 1.61 (normal ranges 0.44-1.27). BUN and Creatinine if elevated can be indicators of kidney disease and/or dehydration.

Review of the clinical record indicated that facility staff were monitoring the patient's laboratory results while the patient was being treated with intravenous fluids (IVF).

Review of the clinical record indicated the Patient #11 was receiving Humalog Insulin (Lispro) subcutaneously on a sliding scale according to what the finger stick blood sugar reading (FSBS) was three times a day prior to meals.

During clinical record review, there was no evidence that a nursing care plan with measurable goals had been developed with individualized interventions to address the problems of dehydration, kidney failure or diabetes.

During a discussion on 1/19/17 at 11:20 A.M., Nurse #12 (also a Unit Manager), said that the entire medical record is considered the patient's care plan. The Surveyor asked her where in the clinical record specific goals and individualized interventions for CKD were located. Nurse #12 was unable to find individualized goals and interventions in the computerized plan of care or the medical record.

3. For Patient #12, hospital staff failed to develop a nursing plan of care addressing the patient's admitting diagnosis of Cerebrovascular Accident (CVA).

During interview on 1/19/17 at 11:00 A.M., Nurse #12 said that there were no measurable nursing goals and/or interventions for this diagnosis in the clinical record.

4. For Patient #13, hospital staff failed to develop a nursing plan of care addressing end stage renal disease requiring dialysis.

Patient #13 was admitted to the hospital in 1/2017. Admitting diagnoses included pneumonia, end stage renal disease, hypertension and atrial fibrillation. Prior to admission, the patient was receiving peritoneal dialysis, but also had a fistula, so that he/she could receive hemodialysis while in the hospital.

Record review indicated no evidence that a nursing care plan had been developed to address the dialysis with measurable goals and individualized interventions.

During interview on 1/18/17 at 2:30 P.M., Nurse #2 said there should have been a nursing care plan developed to address the patient's nursing care needs related to receiving dialysis.



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5. For Patient #1, Hospital staff failed to ensure an individualized nursing care plan had been developed related to substance abuse, affecting the patient's discharge planning.

Patient #1 was admitted to the Hospital in 1/2017 with diagnoses including crack cocaine abuse, history/of (H/O) Intravenous (IV) Drug Use (IDU), osteomyelitis, gangrene to the right foot, toe amputations, cardiomyopathy from drug use, Myocardial Infarction (MI), Congestive Heart Failure (CHF) and poorly controlled Insulin Dependent Diabetes Mellitus.

According to the Hospital policy, related to patient assessments, an assessment would be conducted consistent with the scope of care, treatment services and the patient's condition.

During interview on 1/18/17 at 9:40 A.M., Nurse #26 said that she was familiar and assigned to care for Patient #1 on 1/18/2017. Nurse #26 said that Patient #1 had a Peripherally Inserted Central Catheter (PICC), and required long term IV antibiotics (with a stop date of 2/8/17) for a foot infection. Nurse #26 said that due to Patient #1's IDU, that Patient #1 could not be discharged home, as this was the Facility's policy. Nurse #26 said that Patient #1 required placement in a Skilled Nursing Facility (SNF) for the remaining course of IV antibiotics.

During record review (on 1/18/17 at 1:30 P.M.), Patient #1 was admitted to the Hospital with purulent drainage from an amputated toe incision, and that Patient #1 used crack cocaine two days prior to being admitted to the Hospital.

A progress note, dated 1/11/17, indicated Patient #1 used injections of crack cocaine about a week or two piror to 1/11/2017.

Record review indicated there was no evidence an individualized care plan had been developed for substance abuse in the clinical record, with goals or specified interventions to assist Patient #1 with the issue of polysubstance abuse disorder.

During interview on 1/19/17 at 11:08 A.M., Nurse #27 said that she was assigned to care for Patient #1 on 1/19/2017. Nurse #27 said that the Hospital was having difficulty placing Patient #1 in a Rehabilitation Facility/SNF due to the Patient's leaving Against Medical Advice (AMA) in the past, and substance abuse.

During interview on 1/19/17 at 11:20 A.M., Nurse #21 who assisted navigation through the Electronic Medical Record (EMR), said there was no evidence nursing staff had developed a nursing care plan related to Patient #1's substance abuse. Nurse #21 said that perhaps the Social Worker had created a care plan or had notes that were not available in either the hard copy of the medical record or the EMR.

During interview on 1/19/17 at 11:30 A.M., the Nurse #13 (Nurse Manager) said that she was very familiar with Patient #1, and that there was no nursing care plan developed for substance abuse, individualized with interventions and goals to treat this condition identified as a problem in the nursing assessment, and throughout the clinical record. Nurse #13 said that the EMR does not allow nursing staff to customize a care plan.

During interview on 1/19/17 at 11:30 A.M., Social Worker #3 said that she meets with Patients on day 1 or 2 of their hospital stay, informally, and offered out patient services and Intensive outpatient program for drug use to Patient #1 and the patient declined. SW #3 said that she did not document this as an intervention, or in the clinical record, but recalled the conversation. She said that the initial plan was for the patient to be discharged home, but due to the intravenous drug use, the patient required discharge to a SNF/Rehabilitation facility.

During the Hospital's Quality Assessment Performance Improvement meeting, attended by several Hospital staff members and the Surveyor on 1/19/17 from 10:05 A.M. - 11:00 A.M., the Quality Director said that the EMR system does not allow "customization" for care plan development.

Based on observation, interview and review of hospital policy and nursing personnel files, the hospital failed to provide evidence that nursing staff with the appropriate education, experience, competence and specialized qualifications were assigned to provide nursing care for 1 of 1 Non-sampled patients ( NS #1) with an Intra-Aortic Balloon Pump (IABP) (a cardiac device utilized for critically ill patients within the intensive care setting). Findings included:

During an observation tour of the Intensive Care Unit (ICU), on 1/18/17 at 8:30 A.M., the Surveyor observed Nurse #25 caring for NS #1. This patient was being treated with an IABP.

Review of the hospital policy, Intra-Aortic Balloon Pump and Catheter, dated 6/15/15, indicated the following:
* To be initially qualified, staff is required to attend an IABP hands on workshop and complete IABP skills competency checklist.
* All RN staff and Cardiac Cath Lab Radiological Technologists must complete an IABP review monthly unless they were involved with the care of a patient on an IABP in the prior month.
* A yearly inservice by viewing the Manufacturers learning module on line is also required.

Monitoring: Yearly competencies are completed and stored in the department of education.


On 1/20/17 at 12:30 P.M., during review of Nurse #25's personnel file, indicated that the last documented time Nurse #25 received competency training in regard to caring for a patient with a IABP was on 12/3/2012. There was no evidence that monthly reviews of IABP compentency were tracked as required.

During interview on 1/20/17 at 12:30 P.M., the Professional Development Director (PDD) gave the surveyor a document which indicated a simulation training program, which included use of the IABP, was scheduled to be conducted on 3/18/15 (22 months ago). She could not show evidence that the simulation was conducted on that day or that any staff (including Nurse #25) attended. She said she could not find the sign in sheet. The PDD also said that the hospital scheduled another simulation for 1/10/17 and 1/11/17 but it was canceled by the vendor. When asked if a simulation lab was conducted in 2016 (per the hospital policy of yearly competencies), the PDD said she could not find anything else in addition to what she brought to the Surveyor already.

Based on observation, record review and interview, the nursing staff failed to administer medication for one of 37 sampled patients in accordance with accepted standards of practice. Findings include:

1. For Patient #30, the physician's orders included an order for Lactaid 2 tablets twice a day. Lactaid is a digestive enzyme that breaks down the kind of sugar found in milk in people who have problems with lactose intolerance. Manufacturer's directions for use state to swallow Lactaid with the first bite or drink of dairy products and if you continue to consume foods containing dairy after 20 to 45 minutes, take another tablet. The medication works by reducing the presence and effects of lactase (milk sugar) in the stomach.

Review of the Medication Administration Record (MAR) for Patient #30 indicated the patient was scheduled to receive Lactaid at 8:00 A.M. and 8:00 P.M.

During an interview on 1/18/17 at approximately 10:00 A.M., the Unit Nurse Manager (UNM) said breakfast is served around 8:30 A.M. and supper is served a 5:00 P.M. or a little earlier. The UNM said the Lactaid medication was not given at appropriate times to be effective in managing lactose intolerant symptoms.

Based on record reviews and interviews, the Hospital failed to use verbal orders infrequently, for three (#19, 20 and #22)of 37 sampled patients. Findings include:

Review of the Hospital policy titled Medication Orders, effective date 1/10/04 indicated that "Verbal/telephone orders will not be accepted for non-urgent/emergent medication orders when the physician is available on the unit."
"The physician who provides the verbal/telephone order must promptly [the policy did not indicated a specific time frame] authenticate the order with signature, date and time. If the ordering physician is not available to authenticate the verbal order with in the required time frame (e.g. the ordering physician placed a verbal order that is written and transcribed, but is then off-duty for the weekend), then it is acceptable for another practitioner who is responsible for the care of the patient to promptly authenticate the verbal/telephone order only if such a practitioner is acting in accordance with state law, including scope-of-practice laws, hospital policies and medical staff bylaws, rules and regulations."

According to Hospital Administration, the patient care records are maintained electronically. Physician orders are entered as a Computer Order Entry System. The two Obstetrical Physician Practices who perform the majority of the deliveries at the hospital have offices where prenatal care is provided within the Hospital. There are multiple computers which any health care provider can utilize to enter information in a patient's medical record. Physicians can enter orders from their office practice.

The Maternal Service Unit Manager [UN] was interviewed on 1/18/17 at 8:45 A.M. and 1/19/17 at 8:45 A.M. The UN said that two Obstetrical Services comprise over 90 % of the deliveries at the Hospital. The UN said that one service includes a medical training component and the other is a private service. The UN said that the private obstetrical service has an office within the hospital, but the physicians consistently give verbal and telephone orders to the Labor and Delivery and Post-Partum Nursing staff and do not come to the unit to evaluate and write orders on patients, nor do they co-sign orders via the computer entry system. The UN said the issue has been identified as a quality improvement topic and medical records monitors and tracks verbal and telephone orders that have not been co-signed in a timely/"prompt" period. The UN said that based on push back from the private obstetrical group, the standing orders have not been entered in the physician computerized order entry system, requiring frequent use of verbal and telephone orders.

The Chief of Obstetrical Services was interviewed on 1/20/17 at 12: 50 P.M. The Chief of Obstetrical Services said that the clinical policy for verbal and telephone orders was that they were to be signed off within a 24 hour period. The Chief of Obstetrical Services said that in general, they were to be avoided. The Chief of Obstetrical Services said that one physician is on call and rounds every 24 hours on patients cared for in their service. When the Surveyor asked why their particular service was noted to have a high number of verbal and telephone orders, the Chief of Obstetrical Services said that he was not tied to a computer and they had no hospital dedicated computer in their office and/or that the physicians were not always logged on.

The Director of Quality Improvement and Chief Medical Officer [CMO] were interviewed on 1/20/17 at 1:40 P.M. The CMO said that he takes the high frequency of telephone and verbal orders very seriously and it was identified as high priority for improvement in regards to that particular obstetrical group. The CMO said that actions would be taken to reduce the number of telephone and verbal orders issued by the physicians in the group.



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1. For Patient #19, the Hospital failed to follow their policy in regard to receiving physician telephone orders.

Patient #19 was admitted to the Hospital 1/2017 for preterm delivery.

On 1/18/17, review of the clinical record indicated the following physician's order, dated 1/18/17 at 8:00 A.M., to admit the Patient for preterm labor and included multiple standing orders checked off by the nurse and received as a telephone order and transcribed by a nurse. As of 1/20/17 at 8:13 A.M., the order was not co-signed by a physician.

On 1/18/17, review of the clinical record indicated the following physician's order, dated 1/18/17 at 7:24 A.M., to administer Oxytocin induction/augmentation [a medication administered to initiate labor] to the Patient and received as a telephone order and transcribed by a nurse. However, the order was co-signed by an illegible signature the previous day, 1/17/17 at 3:35 P.M.

On 1/18/17, review of the clinical record indicated there were three physician's verbal orders:

* a telephone order, dated 1/18/17 at 8:19 A.M., to administer Tylenol to the Patient received as a telephone order and transcribed by a nurse.
*a telephone order recieved and transcribed by the nurse, dated 1/18/17 at 1:50 P.M., to administer Stadol and Benadryl, both intravenously and intramuscularly, to the Patient for pain relief and received as a telephone order and transcribed by a nurse. As of 1/20/17 at 8:13 A.M., the orders was not co-signed by a physician.
*a telephone order, dated 1/18/17 at 2:40 P.M., that the Patient may have epidural, (which only a physician may initiate), and was received and transcribed by a nurse. As of 1/20/17 at 8:13 A.M., the order was not co-signed by a physician.

2. Patient #20 was admitted to the Hospital in 1/2017 for term delivery.

On 1/18/17, review of the clinical record indicated the following physician's order, dated 1/18/17 at 12:25 A.M., to admit the Patient for term labor and included multiple standing orders checked off by the nurse and received as a telephone order and transcribed by a nurse. As of 1/20/17 at 8:13 A.M., the order was not co-signed by a physician.

On 1/18/17, review of the clinical record indicated the following physician's telephone/verbal orders, dated 1/18/17 at 12:25 A.M., to administer Oxytocin induction/augmentation [a medication administered to initiate labor] to the Patient and received as a telephone order and transcribed by a nurse. As of 1/20/17 at 8:13 A.M., the order was not co-signed by a physician.

On 1/18/17, review of the clinical record indicated there were two telephone/verbal physician's orders:
* one telephone order, dated 1/18/17 at 8:45 A.M., to administer Stadol and Benadryl, both intravenously and intramuscularly, to the Patient for pain relief and received and transcribed by a nurse. As of 1/20/17 at 8:13 A.M., the order was not co-signed by a physician.
*one telephone order, dated 1/18/17 at 10:36 A.M., that the Patient may have epidural, (which only a physician may initiate), administer medications and was received and transcribed by a nurse. As of 1/20/17 at 8:13 A.M., the order was not co-signed by a physician.

3. Patient #22 was admitted to the Hospital in 1/2017 for term delivery.

On 1/18/17, review of the clinical record indicated the following telephone/verbal physician's order, dated 1/14/17 at 3:00 P.M., to admit the Patient for term labor and included multiple orders checked off by the nurse and received as a verbal or telephone order and transcribed by a nurse.
* A verbal order, dated 1/14/17 at 3:00 P.M., for a cook catheter [a medical procedure that is only performed by a physician].
*A telephone order, dated 1/14/17 at 4:20 P.M., for Stadol and Benadryl intramuscularly and intravenously.

As of 1/20/16 at 8:13 A.M., the orders were not co-signed by a physician.

The hospital failed to ensure that all verbal orders were signed and dated and authenticated promptly to include telephone orders for four (#19, #20 #22, #31) patients, in a total sample of 37. Findings include:

During an interview on 1/19/17 at 8:00 A.M., the Director of Quality Management said it is the hospital policy that all verbal/telephone orders be signed and authenticated within 24 hours. The hospital policy is to avoid using verbal orders unless absolutely necessary for patient care.

1. Surveyor reviewed the record of Patient #31 on 1/19/17 and found a verbal order, dated 1/18/17, (no time), for a tube feeding based on an assessment by the Registered Dietitian (RD), on 1/18/17. On the verbal order there was a sticker with a notation, dated 1/19/17, timed 10:15 A.M., written by the unit secretary that indicated "sign here." As of 2:00 P.M. on 1/19/17, the verbal order had not been signed by the licensed independent practitioner (LIP).

On 1/20/17, at 9:55 P.M., the Surveyor checked the verbal order for signature and found that since 2:00 P.M. on 1/19/17, a LIP signed the verbal order and back dated the verbal order to 1/18/17 at 1300.



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2. Review of the medical records documentation for December 2016 of unsigned orders indicated that the same Obstretrician had 50 unsigned orders - the highest number among all the physicians in the analysis.

3. Patient #19 was admitted to the Hospital 1/2017 for preterm delivery.

On 1/18/17, review of the clinical record indicated the following physician's order, dated 1/18/17 at 8:00 A.M., to admit the Patient for preterm labor and included multiple standing orders checked off by the nurse and received as a telephone order and transcribed by a nurse. As of 1/20/17 at 8:13 A.M., the order was not co-signed by a physician.

On 1/18/17, review of the clinical record indicated the following physician's order, dated 1/18/17 at 7:24 A.M., to administer oxytocin induction/augmentation [a medication administered to initiate labor] to the Patient and received as a telephone order and transcribed by a nurse. However, the order was co-signed by a illegible signature the previous day, 1/17/16 day at 3:35 P.M.

On 1/18/17, review of the clinical record indicated there were three physician's orders:
* one dated 1/18/17 at 8:19 A.M., to administer tylenol to the Patient and received as a telephone order and transcribed by a nurse.
*one dated 1/18/17 at 1:50 P.M., to administer stadol and benadryl, both intravenously and intramuscularly, to the Patient for pain relief and received as a telephone order and transcribed by a nurse. As of 1/20/17 at 8:13 A.M., the order was not co-signed by a physician.
*one dated 1/18/17 at 2:40 P.M., that the Patient may have epidural, which only a physician may initiate administer medications and was received as a telephone order and transcribed by a nurse. As of 1/20/17 at 8:13 A.M., the order was not co-signed by a physician.

4. Patient #20 was admitted to the Hospital 1/2017 for term delivery.

On 1/18/17, review of the clinical record indicated the following physician's order, dated 1/18/17 at 12:25 A.M., to admit the Patient for term labor and included multiple standing orders checked off by the nurse and received as a telephone order and transcribed by a nurse. As of 1/20/17 at 8:13 A.M., the order was not co-signed by a physician.

On 1/18/17, review of the clinical record indicated the following physician's order, dated 1/18/17 at 12:25 A.M., to administer oxytocin induction/augmentation [a medication administered to initiate labor] to the Patient and received as a telephone order and transcribed by a nurse. As of 1/20/17 at 8:13 A.M., the order was not co-signed by a physician.

On 1/18/17, review of the clinical record indicated there were two physician's orders:
* one dated 1/18/17 at 8:45 A.M., to administer stadol and benadryl, both intravenously and intramuscularly, to the Patient for pain relief and received as a telephone order and transcribed by a nurse. As of 1/20/17 at 8:13 A.M., the order was not co-signed by a physician.
*one dated 1/18/17 at 10:36 A.M., that the Patient may have epidural, (which only a physician may initiate) administer medications and was received as a telephone order and transcribed by a nurse. As of 1/20/17 at 8:13 A.M., the order was not co-signed by a physician.


5. Patient #22 was admitted to the Hospital 1/2017 for term delivery.

On 1/18/17, review of the clinical record indicated the following physician's order, dated 1/14/16 at 3:00 P.M., to admit the Patient for term labor and included multiple orders checked off by the nurse and received as a verbal or telephone order and transcribed by a nurse.
* A verbal order dated 1/14/17 at 3:00 P.M. for a cook catheter [a medical procedure that is only performed by a physician].
*A telephone order dated 1/14/17 at 4:20 P.M. for stadol and benadryl intramuscularly and intravenously.
As of 1/20/16 at 8:13 A.M., the orders were not co-signed by a physician.

Based on record review and interview the hospital failed to ensure that informed written consent forms were executed for procedures and treatments, including all types of anesthesia in accordance Department of Anesthesia policy and as per the Hospital Policy for General and Informed Consent, for 8 of 37 sampled Patients (#1, #2, #8, #9, #16, #21, #22 and #29). Findings include:

According to the hospital policy for General and Informed Consent, last revised on 6/2016, the Inpatient/Outpatient Procedures: consent to routine treatment is initiated by admitting staff with the patient who obtains the patient signature during registration process. It applies to all patients admitted as inpatients whether scheduled, unscheduled, or emergency admissions or those who arrive for hospital based outpatient procedures or to the emergency center. The consent to treatment form provides authority for routine diagnostic work-up and routine treatment only.

Continuing treatment, invasive examination as well as invasive procedures, all require specific consent. Informed consent should be obtained for all major therapeutic and diagnostic procedures where disclosure of significant medical information, including major risks involved would assist a patient in making an intelligent informed decision whether to undergo the proposed procedure. Such procedures include: all surgical procedures performed under general/spinal anesthesia and selected procedures under local anesthesia. A separate written consent should be obtained for the use of general, spinal and/or epidural anesthesia by the provider administering and/or responsible for the anesthesia. It is the provider's responsibility to obtain the informed consent. A patient's consent should be documented with sufficient clarity and detail such that so as to satisfy the reader that the patient was given and understood the medical information such as material risks involved (such as death, loss of limb, brain damage, paralysis, hemorrhage, allergic reactions, nerve injury, blood clots etc) with the procedure and recuperation benefits expected, likely results of no treatment, available alternatives and their risks and benefits, irreversibility of procedure and inability to predict results.

1. For Patient #1, admitted on 1/9/17, the hospital staff failed to ensure a consent for hospital admission and treatment was completed and a Patient Consent for Anesthesia was complete.

Clinical record review on 1/19/17 indicated no consent for admission and treatment had been found or provided by hospital staff.
During interview on 1/19/17 at 10:30 A.M. with Registered Nurse (RN) # 21, he said that there was no consent for admission in the electronic medical record.

Further clinical record review indicated Patient #1 had undergone a surgical procedure on 1/11/17. A Patient Consent for Anesthesia form was signed by the patient and Student Registered Nurse Anesthetist (SRNA) and was not co-signed by the responsible anesthesia provider responsible for the patient's care as required. Additionally, the anesthesia-related risks section on the consent form was not completed.



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2. For Patient #8, the hospital failed to ensure that a Patient Consent for Anesthesia was complete and contained all of the required information for a surgical procedure performed on 01/17/17.

The Patient Consent for Anesthesia for, signed 01/17/17, indicated the section for risks was not completed.

Surveyor interviewed Nurse #3 at 11:33 A.M. on 01/18/17. Nurse #3 said she did not know why that area on the consent form was left blank. Nurse #3 said she thought that all areas of the consent forms were to be completed or acknowledged.

3. For Patient #16, the hospital failed to ensure that an informed consent was properly executed prior to planned procedures on 12/13/16 and 01/03/17.

Clinical record review on 01/18/17 indicated that Patient #16's primary language was Cambodian.

The Consent for Inpatient/Outpatient/Emergency Department Services, signed 12/13/16, indicated that consent was provided by Patient #16's daughter/Health Care Proxy (HCP).


The Consent for Inpatient/Outpatient/Emergency Department Services, signed 01/03/17, indicated that consent was provided by Patient #16's daughter/Health Care Proxy (HCP).

The Informed Consent to Surgery, Diagnostic Procedures, or Other Medical Procedures, signed 01/03/17, included an Interpreter Services Statement. The statement had a printed interpreter name, and the signature of the interpreter, but was not dated or timed. The statement also was not complete with regards to whether interpreter services were offered or used, and if used, whether the services were telephonic or via video.

There was no copy of a HCP in Patient #16's clinical record.

Surveyor interviewed Nurse #5 at 1:48 P.M. on 01/18/17. Nurse #5 said Patient #16's clinical record noted that his/her primary language was Cambodian. Nurse #5 said there was no documentation of a HCP in the clinical record, of whether the HCP was invoked, that Patient #16 was incapable of signing his/her own consents, or that Patient #16 requested his/her daughter/HCP sign any forms on his/her behalf. Nurse #5 said that if an interpreter was present, Patient #16 should have signed the consent, not the daughter/HCP.

There was no documentation at the time of survey, for either procedure date, to indicate that Patient #16 lacked the capacity to sign the consent forms, requested that the HCP sign the forms on his/her behalf, or that the HCP had been invoked.



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4. For Patient #21 admitted 1/17, for labor and delivery, the hospital failed to ensure a that a complete Patient Consent for Anesthesia was obtained and contained all the required information for the administration of an anesthetic agent.

Review of the anesthesia consent form dated 1/12/17 at 9:24 A.M. indicated that the type of anesthesia [such as general or epidural] was not recorded, nor was there any information recorded in the section to include anesthesia related risks that may occur in conjunction with the type of anesthesia intended for administration.

5. For Patient #22 admitted 1/17, for a cesarean section delivery, the hospital failed to ensure a that a complete Patient Consent for Anesthesia was obtained and contained all the required information for the administration of an anesthetic agent.

Review of the anesthesia consent form dated 1/14/17 at 10:10 P.M. indicated that the type of anesthesia [such as general or epidural] was not recorded, nor was there any information recorded in the section to include anesthesia related risks that may occur in conjunction with the type of anesthesia intended for administration. The time and date where the Patient signed were blank.




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6. Patient #29 presented to the emergency room on 1/18/2017 at approximately 10:20 A.M. with an ulcerated left foot. Record review indicated that a decision was made at about 5:45 P.M. to take the patient to surgery for a resection of the 4th and 5th metatarsal for a question of osteomyelitis. (infection of the bone).

Review of the pre-anesthesia assessment, signed as completed on 1/18/2017 at 5:50 P.M. indicated there was no anesthesia plan although the anesthesiologist indicated on the pre-anesthesia assessment that the plan was explained to the patient and consent was given. The written informed consent for anesthesia did not specify the plan for anesthesia but indicated the patient consented to "anesthesia" and the risks associated with general anesthesia via an endotracheal or laryngeal managed airway.

Record review indicated Patient #29 received moderate sedation not general anesthesia from the anesthesia provider, which was not discussed in the informed consent, as required.

7. For Patient #9, the Hospital failed to get written consent to continue treatment after the infant was placed in the custody of child protective services.

Patient #9, an infant, was removed from parental custody at 3 days old and placed in custody of the child protective services, on 12/13/2016. Patient #9 was born drug addicted and required a morphine drip for drug withdrawal.

Record review on 1/18/2017, indicated there were no signed consents from the mother of Patient #9 in the record for any treatment since birth and no consents from the legal guardian since 12/13/2016, for continued treatment of Patient #9 after custody was awarded by the Court. Record review indicated Patient #9 has been on titration doses of morphine intravenously without any written informed consent of the Legal Guardian for any treatments rendered by the hospital.

After Surveyor inquiry and two days later, the hospital staff found a birthing center consent for treatment, signed by the birth mother, dated 12/9/2016, that allowed immunization and testing of the Patient #9. There was no consent after the Court awarded custody of Patient #9 to the named Legal Guardians.

During an interview on 1/19/2017 at 10:00 A.M., the unit Social Worker said there was no written informed consent from the court appointed legal guardians for treatment of Patient #9.




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8. For Patient #2, admitted to the Hospital on 1/15/17 with hematuria and a Urinary Tract Infection, Hospital staff failed to ensure there was a signed consent authorizing care, treatment, and admission to the Hospital, as required.

Record review on 1/18/17 at 11:14 A.M. indicated a "Consent for Inpatient/Outpatient Emergency Department Services", signed by Patient #1's appointed Health Care Representative (dated 1/14/17). The consent indicated: "I understand that this authorization will automatically expire and is only valid for this date of service."

During interview with Nurse #21 who navigated the Electronic Medical Record (EMR), he said that the "Consent for Inpatient/Outpatient Emergency Department Services" was for the release of specifically protected or privileged health information to the primary care provider (PCP), and was a consent authorizing the ED to disclose information about the patient's condition to the PCP. Nurse #21 said that there was no consent for treatment, services or for admission to the Hospital in either the hard copy of the Medical Record or scanned into the EMR system, authorizing medical treatment, procedures, or authorization for admission to the Hospital on 1/15/17, as required for Patient #2.



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9. For Patient #35 the hospital failed to ensure a that a complete Patient Consent for Anesthesia was obtained and contained all the required information for the administration of an anesthetic agent.

Patient #35 was admitted to the hospital 1/18/17 with diagnoses which included a right acetabulum fracture which required surgical repair.

Review of the anesthesia consent form dated 1/18/17 at 5:47 P.M., indicated that the type of anesthesia [such as general or epidural] was not recorded, nor was there any information recorded in the section to include anesthesia related risks that may occur in conjunction with the type of anesthesia intended for administration.

Based on observation, records reviewed and interviews, the hospital staff failed to ensure physician orders were complete for wound care treatment and/or as needed medications for 2 patients (Patient #4 and #30) in a total sample of 37 patients. Findings Include:

1. Record review indicated Patient #4 was admitted for treatment of a right leg cellulitis (a bacterial infection involving the inner layers of the skin).

Record review indicated Patient #4 had a Physician's Order, dated 1/10/17, that read:: Wound Care Nurse Consult, frequency once, large right mid tibia wound - eval and recommendations and treatment.

Record review indicated a Wound Care Nurse Note, dated 1/10/17, indicated the Clinical Wound Care Nurse (CWCN) recommended applying: Drawtex (a non-adherent dressing), Optifoam (a highly absorbent wound dressing), Kerlix and Ace wrap to Patient #4's wound twice a day or once per day. There was no Physician's Order for the wound care recommendation.

Record review indicated Patient #4 had a Physician's Order, dated 1/11/17, for: Dressing Change, frequency once, please follow wound nurse wound care except d/c (discontinue) Ace bandage as Patient #4 developed a large blister, keep RLE (right lower extremity) up on 2 pillows.

Record review indicated the CWCN assessed and treated Patient #4's wound on 1/10/17 and 1/16/17. The Nurse Progress Notes from 1/10/17 through 1/16/17 indicated nursing staff documented wound care treatment was provided at least daily by nursing staff and there were no Physician Orders for wound care treatment.

Record review indicated a Wound Care Nurse Progress Note, dated 1/16/17 and written by the CWCN, indicated she evaluated Patient #4's wound and applied: Adaptic (A clear non-adhering wound dressing), 4 abd pads (a sterile, highly absorbent dressing) secure with Kerlix and 6 inch Ace Wrap (bandage). There was no Physician Order for the recommended wound care treatment.

The Surveyor observed The CWCN and Nurse #24 provide Patient #4 with wound care treatment at 10:52 A.M. on 1/18/2017. During the observation the Surveyor heard Patient #4 ask the CWCN not to apply an Ace wrap (bandage) because it was bothersome to his/her leg. The Surveyor observed The CWCN apply Adaptic, abd pads and Kerlix to Patient #4's right leg wound. Patient #4 did not have Physician Orders for the wound care treatment (Adaptic, abd pads and Kerlix) applied to his/her right leg during the observation on 1/18/2017.

The Surveyor interviewed the CWCN at 10:52 A.M. on 1/18/17 and throughout the survey. The CWCN said she did not know the Physician had ordered, on 1/11/17, no Ace Wrap (bandage) for Patient #4 and said she had applied an Ace Wrap (bandage) to Patient #4 on 1/16/17.

The CWCN said it was her practice to evaluate patients as ordered by a Physician and report her recommendations for wound care treatment to the patient's primary care nurse. The CWCN said wound care treatments required a Physician's Order and it was the primary care nurse's responsibility to obtain a Physician's Order for the wound care treatment. The CWCN confirmed Patient #4 did not have Physician Orders for the wound care treatment recommendations she made on 1/10/17 and 1/16/17. The CWCN said Patient #4 did not have a Physician's Order for the wound care treatment observed by the Surveyor on 1/18/17 at the time she applied the wound care treatment.

The Surveyor interviewed Nurse #3 and Nurse #22 at 12:01 P.M. on 1/20/17. Nurse #3 and Nurse #22 said a Physician's Order is required for wound care treatments and said Patient #4's wound care treatments did not have a Physician's Order.



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2. For Patient #29, the Hospital staff failed to ensure physician orders for as needed (PRN) medications were complete, to include when they were to be given and that this information was translated to the Medication Administration Record (MAR) where nurses were able to see when they could administer the PRN medication. Findings include:

1. Patient #29 had diagnosis that included insulin dependent diabetes for which he/she took the long acting Lantus insulin daily. Review of the physician orders, dated 1/18/17 indicated the patient was on sliding scale insulin coverage every six hours (low) using a set protocol which included fingerstick blood sugars and hypoglycemia treatment protocol.

The physician orders also included (as part of the hypoglycemia protocol) the following orders:
1. give for severe hypoglycemia if IV access present as needed: Dextrose 50% syringe 50 ml IV (intravenous)- severe hypoglycemia no defined no parameters given
2. Glucagon 1 mg (milligram) IM (intramuscular) prn - no parameters given
3. Glucose 4 g (grams) 3 chew tabs oral as needed or 4 oz orange/apple juice - no parameters given

Review of the MAR indicated the entry read only as the orders stated above with no parameters as per the protocol. Although there are written protocols that have all the parameters, they are not available to the nurse through the MAR.

During an interview on 1/19/17 at 10:00 A.M., the H2 unit manager said the nurse would have to access the protocols via a computer and in an emergency she would not have time to get them. The UM said they do use agency staff on occasion so even though staff may know the protocols, it should be on the MAR.

Based on observation, documentation review and staff interview, the hospital failed to ensure that the condition of the physical plant was maintained in a manner to ensure the safety and well being of patients. Findings include:

Observations on 1/18/17 and 1/19/17 in the Food and Dietetic Services Department indicated in 2 of 3 observed walk-in refrigerators, the ceilings of the milk walk-in and the meat walk-in had areas of peeling paint. The peeling paint could fall onto one of the food storage shelves and possibly cause a physical contamination problem.

During an interview on 1/18/17 at 10:40 A.M., the Food Service Director (FSD) said that a work order had been submitted for repair of the peeling paint in the milk walk-in and he was still waiting for Facilities Department to repair the ceiling's peeling paint.

On 1/19/17, review of the Board of Health Report dated 8/4/16 indicated that the milk walk-in had "ceiling paint peeling" and indicated that the "violation was discussed for immediate correction".

On 1/19/17 at 10:50 A.M., the Facilities Department provided a copy of a work order dated 12/15/16 indicating that the ceiling in the milk walk-in is "chipped and cracked" and indicated that the area would be scraped and painted.

On 1/19/17 at 11:00 A.M., the FSD said that a work order would be submitted "today" for repair of the meat walk-in refrigerator ceiling.

Based on observation, documentation review and interview, the hospital failed to ensure that the quantity of emergency water was readily available as per the hospital's policy and procedure for the loss/reduction of water. Findings include:

Review of the hospital's "Loss/Reduction of Water" policy in the Emergency Management Manual indicated that a par level of 200 five gallon containers of purified water is kept on hand and should be used wherever potable water is required.

On 1/19/17 at 11:30 A.M., observation of the location where the emergency water is stored indicated that the emergency water was not in stock.

On 1/19/17 at 1:00 P.M., the hospital provided documentation that the water was ordered and would be delivered the following day: 1/20/17.

Based on observations, records reviewed and interviews the Hospital failed to consistently adhere to infection prevention standards for three sampled patients (#10, #18 and #34), in a total sample of 37 and one nonsampled patient (NS #2). Findings include:


1. The Hospital failed to consistently adhere to infection prevention standards related to Contracted Hospital nursing staff (Nurse #1), who failed to ensure adequate infection control practices had been provided on the Dialysis Unit for one patient (#18), related to:

- (A) improper hand hygiene;
- (B) wearing of personal protective equipment;
- (C) risk of cross-contamination when touching contaminated dialysis equipment, patients, telephone and cabinetry;
- (D) not ensuring adequate disinfection of the central venous catheter (CVC) limbs and endcap/hubs, prior to initiation of dialysis;
- (E) aseptic technique when preparing and administering Intravenous (IV) Heparin medication (blood thinner).

Review of the Contracted Agency Policies and the Hospital Policy for infection control practices related to CVC access devices (revised 3/2016) indicated the following:

- Perform hand hygiene;
- Put on Personal Protective Equipment (PPE);
- Scrub CVC limbs with 4 large alcohol pads large enough to cover the circumference of the catheter limb for 60 seconds; Place a sterile gauze pad under the limbs while removing the alcohol prep pad;
- Administer Heparin Loading dose via the venous limb. Do not initiate dialysis for 5 minutes after Heparin administration to allow Heparin to circulate systemically.

During observation on 1/18/17 at 1:25 P.M., Nurse #1 did not perform hand hygiene, donned gloves, walked to the windowsill (Stored on the windowsill were yellow protective gowns that were identified as being non-fluid resistant, 3 unwrapped syringes filled with Normal Saline, face shields, face masks, clamps, and miscellaneous equipment.), picked up and donned a yellow gown that he did not fasten appropriately, therefore, his uniform was exposed at the sides and at the neck. Nurse #1 reinforced a dressing over a small blood stained dressing on an unidentified patient's right arm access area, post hemodialysis, removed the gown, then gloves, pressed them into an open trash receptacle, and with contaminated hands, picked up an answered a telephone that was on the Nursing Desk.

During observation and care for Patient #18 on 1/18/17 from 2:40 P.M. - 3:20 P.M., Nurse #1 did not perform hand hygiene, then donned gloves. Nurse #1 walked to the windowsill picked up a gown and donned it, tied it around waist, walked over to a clean supply cart adjacent to the Nursing Desk. Nurse #1 reached into the clean supply cart with contaminated gloved hands, obtained 2 alcohol prep pads, placed them on a bedside table which held sterile and clean supplies and the patient's medical record, picked up a folded blue towel and placed it under the limbs to the CVC. Nurse #1 then opened two alcohol prep pads and placed them over both endcaps/hubs to the CVC, wiped briefly for approximately 8 seconds (did not soak ports/limbs for 60 seconds in accordance to the Facility's policy), removed the pads and discarded them. Nurse #1 did not place a sterile gauze under the limbs/endcaps in accordance with the facility CVC policy, removed his gloves, did not perform hand hygiene, walked to the windowsill, picked up a face shield and face mask, donned them with contaminated hands, walked to a medication supply closet, opened it, removed a package of sterile gloves, and syringes filled with Normal Saline, Nurse #1 then donned the sterile gloves onto contaminated hands, touched the dialysis machine with the sterile gloved hand to check data, removed the cap from an empty syringe, attached it to the red port of the CVC, aspirated blood, removed the syringe, connected the Normal Saline filled syringe, and flushed this port. Nurse #1 did the same with the blue port. He placed contaminated syringes next to sterile supplies, reached up, obtained the hemodialysis tubing that was on the dialysis machine, connected the tubing to the red and blue ports to the CVC then initiated hemodialysis.

Nurse #1 removed the contaminated gloves and gown (non-fluid resistant, therefore blood and infectious fluids could penetrate to Nurse #1's uniform) pressed them into the open trash receptacle, performed hand hygiene, reached into his pocket, retrieved a pen, documented on the clinical record, then donned gloves, without performing hand hygiene after touching his clothing and environmental surfaces, picked up and discarded the blood filled and contaminated syringes.

Nurse #1 removed gloves, did not perform hand hygiene, walked to the medication supply closet, opened it, removed empty syringes, 3 small vials of Heparin and obtained an alcohol prep pad, walked back to the bedside table, and placed all supplies onto the contaminated table.

Nurse #1 did not perform hand hygiene or ensure the bedside table was disinfected prior to preparing IV medications.

Nurse #1 donned clean gloves onto contaminated hands, walked to the windowsill, picked up and donned a yellow gown, walked back to the bedside table, and with contaminated gloves, picked up and opened an alcohol prep pad, placed the wet alcohol pad on the contaminated table, flipped the caps of the three Heparin vials, inverted the first vial's rubber septum onto the contaminated alcohol prep pad, swiped it over the pad, then inserted the needle, and aspirated 1000 units of Heparin. Nurse #1 picked up the second vial, inverted it, swiped it over the same contaminated alcohol pad, inserted the same needle and aspirated 1000 Units of the Heparin, picked up the third vial, inverted it and swiped the rubber septum over the same contaminated alcohol pad, inserted the same needle into the vial, aspirated 1000 units of Heparin for a total dose of 3000 units. Nurse #1 walked to the dialysis machine, removed the protective cap from a port to the IV Normal Saline line that was connected to the running dialysis circuit and instilled the Heparin (Facility/Contracted Agency policy indicated to inject the Heparin into the venous port of the CVC, not into the dialysis circuit during hemodialysis).

During interview on 1/19/17 at 11:30 A.M., the Nurse Manager overseeing the Dialysis Unit said that infection control practices had not been followed, and that she also observed Nurse #1 did not perform hand hygiene and contaminated supplies.

2. For NS #2, Nurse #14 cross contaminated clean supplies while inserting a intravenous needle, considered an aseptic procedure.

During observation on 1/19/17 at 9:20 A.M., the Surveyors observed Nurse #14 insert a peripheral intravenous (IV) line for NS #2.

Nurse #14 wheeled a cart into NS #2's room. The cart contained unwrapped, openly stored filled Normal Saline syringes (plunger side out) and several other IV supplies (tourniquets, angio needles/catheters, gauze pads, tape etc.) stored openly. (IV start cart with clean supplies used from patient to patient thorughout the hospital).

Nurse #14 performed hand hygiene and donned gloves. Nurse #14 then set up and opened several supplies on the windowsill. Nurse #14 walked to the patient, touched the patient, and asked for details to verify patient identification. Nurse #14 walked back to the cart, reached in with contaminated gloved hands and obtained a tourniquet and alcohol prep pad, then walked to NS #2. Nurse #14 applied the tourniquet, touched and palpated the anterior left hand at the wrist area, opened an alcohol pad and rubbed the anterior wrist area. Nurse #14 set the contaminated alcohol on the bed, walked away to the cart, and with contaminated gloved hands, reached in, removed an angio (needle/catheter), walked back to NS #2, opened the angio, and inserted the needle into the dorsal vein. Nurse #14 established placement into the blood vessel, removed the tourniquet, applied a clear transparent dressing over the angio, walked back to the cart, reached in and retrieved a Normal Saline syringe, with the same contaminated gloves, walked back to the patient, flushed the IV device, and secured the tubing to the patient's arm. Nurse #14 then wheeled the IV cart over toward the sink using contaminated gloved hands, removed the gloves and performed hand hygiene.

During interview on 1/19/17 at 9:44 A.M., Nurse #14 said that she was a member of the IV support team, and that she has been performing these duties for years. She said that she should have changed gloves and performed hand hygiene after touching environmental surfaces, and after she touched the patient, before insertion of a needle to gain access into the patient's vascular system, and before touching clean/sterile supplies stored in the portable IV supply cart, that would be used for other patients requiring IV lines.




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3.) The hospital failed to follow infection control practices while one patient (#10) was on transmission based precautions.

Record review indicated Patient #10, a newborn, was admitted on 1/14/2017 with a highly infectious respiratory virus and placed on contact and droplet precautions in a private room.

During an interview with the RN #16, on 1/19/2017 at 9:00 A.M., RN #16, said that the baby was drinking both breast milk and formula. RN #16 also said staff were storing excess breast milk in the lactation refrigerator located in the nutrition kitchen of the pediatric unit.


RN #16 said the staff did not consult the infection control nurse about taking breast milk out of a contact isolation room and had not provided a dedicated refrigerator in the room for breast milk storage.


The Surveyor interviewed the Director of Infection Prevention at 11:30 A.M. on 1/23/17. The Director of Infection Prevention said she had not been consulted about storage of breast milk coming from an Isolation room. The Director of Infection Prevention said provisions would have been made to ensure safe storage if the Infection Prevention team had been consulted.


4.) The Hospital failed to provide a safe, clean and sanitary environment for patients, staff and visitors in the ICU and the Emergency room.

A. The Surveyor toured the Intensive Care Unit (ICU) at 10:00 A.M. on 1/18/17. The Surveyor observed a ceiling panel with a drain fed into the wall dialysis drainage system in ICU #12.

The Surveyor interviewed one of the Registered Nurses (RN) caring for Patient #3 who occupied ICU #12 at 1:30 P.M. on 1/18/17. RN #19 said that ICU Room #12 leaked 1-2 weeks ago and that Maintenance Personnel had installed the diverter panel and had it drain into the dialysis drain.

The Surveyor interviewed the ICU Nurse Manager at 2:45 P.M. on 1/18/17. The ICU Nurse Manager said she was aware that ICU Room #12 had leaked and the room had been vacated until the patient census increased and ICU Room #12 was placed back into service.
The Surveyor interviewed the Director of Infection Prevention at 11:30 A.M. on 1/23/17. The Director of Infection Prevention said she was aware that ICU Room #12 had leaked and that the roof had been repaired. The Director of Infection Prevention said she did not realize that the drainage diverter had been left in place by Engineering in anticipation of an upcoming rain storm to test the repair. The Director of Infection Prevention said was not aware that ICU #12 was now occupied by a patient. The Director of Infection Prevention said she now has the ability to use an on-line program that will allow her to close a hospital room electronically to prevent any admission into an area until the Infection Prevention Team is in agreement that the room can be used.

B. The environment of the Emergency room was not maintained in a clean and sanitary manner.

During the tour of the Emergency Room on 1/18/17 at 10:35 A.M., the Director of Emergency Services (DES) showed the surveyor the CT (Computed Tomography) Scan Room. The floor of the room had dirty floors and scattered on the floor were numerous used alcohol prep pads, bits of paper, intravenous caps. The biohazard waste container and clean supply cart were heavily coated with white dried on contrast dye. The floor in that area also had a heavy buildup of contrast dye (per Supervisor of CT Scans). On the floor next to the table where patients lie, there was a splash of dried blood. The handwashing sink in the room was dirty and stained with a brown and orange substance. On the floor beneath the sink, there was a build-up of dirt and dust.

During observation of the Electrocardiogram (EKG) Overflow area on 1/18/17 at 11:00 A.M., the Surveyor and DES observed that there was a cart that had visble dust and dirt. On the shelf of the cart, clean johnnies were being stored for use. There was a glove on top of the stack of johnnies, which the DES promptly discarded. The floor in the area was dirty and dusty with bits of paper strewn about.



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5. The Hospital failed to follow aseptic technique when preparing medications for Intravenous injections.

For Patient #34, the facility staff failed to disinfect the septum of the intravenous(IV) medication vial (to prevent the introduction of bacteria) prior to drawing up the medication with a syringe.

On 1/19/17 at 8:30 A.M., the Surveyor observed Nurse #20 preparing the IV medication Phenobarbital (sedative) for Patient #34. Nurse #20 entered the patient's room with several medications including the vial of Phenobarbital. Nurse #20 performed hand hygiene and then took the cover off of the needle/ syringe and without disinfecting the rubber septum of the medication vial, proceeded to draw up the medication with the syringe and administered the medication intravenously to Patient #34.

During interview on 1/19/17 at 8:45 A.M., Nurse #34 said that the hospital policy is to disinfect the septum of the medication vial prior to inserting a needle. She said she forgot to do it while preparing medications for Patient #34.

Based on record review and interview, the Hospital failed to notify the OPO (Organ Procurement Organization) in a timely manner, as per the agreement, of the death of one of 5 recent deaths reviewed. Findings include:

1. Five recent deaths were reviewed from 8/2016 through 1/21/2017 were reviewed on 1/23/2017.

2. In Death record #5, who expired on 1/21/2017 at 3:30 A.M., there was no evidence of notification of the OPO of the death at all. The record was reviewed on 1/23/2017 at 1:00 P.M. There was no death record form as required by hospital policy.

3. Review of 3 of 4 death records indicated that the reports of death forms used by the hospital, were not signed by the person completing the form. Although there was a notation the organ bank was called, there was no indication on the form or in the clinical record as to who called the organ bank. In all three records, there was no nursing note or physician progress note indicating who notified the organ bank. The death record form only required a signature of the person completing the death record form which was missing on 3 of 4 forms.

Based on record review and interview the hospital failed to ensure that, prior to a surgical procedure, a properly informed consent was executed and in the patients chart for four of six sampled surgical patients (#1, #16, #30, #37). Findings include:

According to the hospital policy for General and Informed Consent, last revised on 6/2016, informed consent should be obtained for all major therapeutic and diagnostic procedures where disclosure of significant medical information, including major risks involved would assist a patient in making an intelligent informed decision whether to undergo the proposed procedure. It is theresponsiblility of the provider performing the procedure to obtain the infomred consent and ensure the patient's understanding of the discussion related to the procedure. A patient's consent should be documented with sufficient clarity and detail such that so as to satisfy the reader that the patient was given and understood the medical information such as material risks involved (such as death, loss of limb, brain damage, paralysis, hemorrhage, allergic reactions, nerve injury, blood clots etc) with the procedure and recuperation, benefits expected, likely results of no treatment, available alternatives and there risks and benefits, irreversibility of procedure and inability to predict results.

1. For Patient #30, the surgical consent was obtained by a provider who was not the provider who performed the surgery and was not a provider credentialed to obtain informed consents for surgical procedures.

Record review indicated Patient #30 required an incision and drainage of an infected right hand wound. Review of the record indicated that on 1/13/2017, a surgical consent for the procedure was obtained by a certified nurse practitioner (CNP) for an orthopedic surgeon who performed the surgery. The CNP did not time of the consent and signed as the provider.

Review of the CNP credentialing record, reappointment date effective 11/20/2015, indicated she was not credentialed to obtain surgical consents and was only credentialed to hold retractors and cut sutures during surgery. The credentialing file was reviewed with Interim Medical Staff Director on 1/19/2017 at 12:30 P.M. who confirmed that the CNP was not credentialed to obtained surgical consents.

2. For Patient #37, the surgical consent procedure was not legible to the Surveyor, the unit nurse manager, the Nurse Director of Obstetrics or a physician on the unit.

Patient #37 presented to the emergency room at approximately 10:20 A.M. with an incarcerated inguinal hernia and was evaluated for surgery.The patient signed a consent for surgery which was dated as "1/18" with no year and no time. On 1/20/2017, at approximately 9:00 A.M., review of the surgical consent indicated the procedure was not fully legible. The procedure read "inguinal hernia possible.. " followed by three words that were not legible. The Surveyor asked the nurse manager of the unit, the Nurse Director of Obstetrics and a physician sitting in the area, all who said they could not read the entire procedure on the consent.

This consent failed to meet the policy requirments for "A patient's consent should be documented with sufficient clarity."



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3. For Patient #1 the hospital failed to ensure a surgical consent was completed and in the Patients chart prior to completing a surgical procedure on 1/11/17.

Record review on 1/19/17 indicated the Patient had a surgical procedure completed on 1/11/17. There was an Informed Consent to Surgery, Diagnostic Procedures, or Other Medical Procedures form in the medical record signed by the Patient and Provider. However, the consent form was incomplete and the following sections were blank: Risks, Benefits and Other Options.



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4. For Patient #16, the hospital failed to ensure that an informed consent was properly executed prior to planned procedures on 12/13/16 and 01/03/17.

Clinical record review on 01/18/17 indicated that Patient #16's primary language was Cambodian.


The Consent for Inpatient/Outpatient/Emergency Department Services, signed 12/13/16, indicated that consent was provided by Patient #16's daughter/Health Care Proxy (HCP).


The Consent for Inpatient/Outpatient/Emergency Department Services, signed 01/03/17, indicated that consent was provided by Patient #16's daughter/Health Care Proxy (HCP).

The Informed Consent to Surgery, Diagnostic Procedures, or Other Medical Procedures, signed 01/03/17, included an Interpreter Services Statement. The statement had a printed interpreter name, and the signature of the interpreter, but was not dated or timed. The statement also was not complete with regards to whether interpreter services were offered or used, and if used, whether the services were telephonic or via video.

There was no copy of a HCP in Patient #16's clinical record.

Surveyor interviewed Nurse #5 at 1:48 P.M. on 01/18/17. Nurse #5 said Patient #16's clinical record noted that his/her primary language was Cambodian. Nurse #5 said there was no documentation of a HCP in the clinical record, of whether the HCP was invoked, that Patient #16 was incapable of signing his/her own consents, or that Patient #16 requested his/her daughter/HCP sign any forms on his/her behalf. Nurse #5 said that if an interpreter was present, Patient #16 should have signed the consent, not the daughter/HCP.

There was no documentation at the time of survey, for either procedure date, to indicate that Patient #16 lacked the capacity to sign the consent forms, requested that the HCP sign the forms on his/her behalf, or that the HCP had been invoked.

Based on record review, the hospital's anesthesia service failed to have complete and accurate pre- anesthesia assessments that included anesthesia plans and /or accurate ASA (American Society of Anesthesiologists) classifications, for two patients ( #29 and #30 ) of 6 surgical records reviewed. Findings include:

The ASA physical status classification system is a system for assessing the fitness of patients before surgery. The ASA adopted the five-category physical status classification system (ASA classification). The higher the score, the more risk.

1. For Patient #29, review of the pre-anesthesia assessment, dated 1/18/2017, timed 1750, indicated there was no anesthesia plan indicated as required.

Patient #29 presented to the emergency room on 1/18/2017 at approximately 10:20 A.M. with an ulcerated left foot. Record review indicated that a decision was made at about 5:45 P.M. to take the patient to surgery for a resection of the 4th and 5th metatarsal for a question of osteomyelitis (infection of the bone).

Review of the pre-anesthesia assessment, signed as completed on 1/18/2017 at 5:50 P.M. indicated there was no anesthesia plan although the completing anesthesiologist indicated that the plan was explained to the patient and consent was given. The consent for anesthesia did not specify the plan for anesthesia but indicated the patient consented to "anesthesia" and the risks associated with general anesthesia via a endotracheal or laryngeal airway.

Review of the intraoperative record indicated Patient #29 received intravenous moderate sedation and local anesthesia not general anesthesia and was awake during the procedure.

2. For Patient #30, the pre-anesthesia assessment failed to accurately assess the ASA classification.

On 1/13/2017, Patient #30 presented to the emergency room with a right hand infection and was assessed as requiring incision and drainage (I & D) of the infected hand. Review of Patient #30's assessed ASA classification on the pre-anesthesia assessment, dated as 1/13/2017, but not timed and done by a Certified Nurse Anesthetist (CRNA) indicated that the ASA classification was circled as a 1, 2, 3 (all were circled.) When done correctly, a patient gets one score.

Based on record review and interview, the Hospital anesthesia service failed to ensure that the intra-operative anesthesia record for two (#29, #37) of 6 surgical records reviewed, the intraoperative anesthesia failed to include the dosage of anesthesia agents administered and/or any complications or problems that occurred during anesthesia, including time and description of symptoms, treatments rendered and patient's response to treatment consistent with anesthesia department policy and procedures. Findings include:

The Anesthesia Record policy, dated 2/2011, indicated that all patients, attended to by the Department of Anesthesia, regardless of the type of anesthesia administered, will have a completed Anesthesia Record, to include a preoperative anesthetic evaluation and assignment of an ASA classification, a complete intraoperative course record with detail to include but not limited, to vital signs every five minutes, oxygen saturation, ETCO2 (end tidal carbon dioxide), FIO2 (fraction of inspired oxygen), temperature, time and amount of anesthetics and drugs administered and any events or problems that arise during the anesthetic period should be indicated in detail.


1. For Patient #37, the Intra-Operative Anesthesia record did not contain a time and description of an event requiring the dosing of Diprivan 100 mg (a sedative drug most often given at the start of anesthesia), administered at the end of the surgery, prior to movement of the patient to the post anesthesia unit or PACU).

Record review indicated Patient #37 had a open repair of an incarcerated inguinal hernia under general endotracheal anesthesia with a liver biopsy. The patient's anesthesia was delivered and maintained by CRNA #1 under the supervision of Anesthesiologist #1.

Review of the intraoperative anesthesia record indicated Anesthesiologist #2 signed into the case as anesthesia relief at 4:30 P.M. Record review indicated that the surgery ended at 5:28 P.M. and anesthesia ended at 5:28 P.M.. According to the anesthesia intraoperative record, at approximately 5:30 P.M., anesthesia administered 100 mg of Diprivan, a sedative. The anesthesia record was not clear as to who from anesthesia adminstered the dose of Diprivan at approxiamtely 5:30 P.M.

There was no indication documented on the anesthesia intraoperative record as to why the patient required a sedative at the end of the surgery when the patient was being awakened from general anesthesia. The record indicated that all inhaled anesthetic gases were turned off at 5:05 P.M. The last note documented by CRNA#1 indicated the patient was awake, extubated without incident and taken to the PACU where a report was given to the nurse. at 5:40 P.M.

During an interview, on 1/19/2017 at approximately 9:00 A.M., Anesthesiologist #2 said he gave Patient #37 Diprivan at the end of surgery "because the patient was agitated and was trying to get off the operating room table." The Surveyor asked why nothing was noted on the intraoperative anesthesia record about this event and Anesthesiologist #1 said he thought that the PACU nurses documented the administration. The Surveyor asked if he gave the medication shouldn't he document the event and intervention? Anesthesiologist #2 said he should have. Anesthesiologist #2 was interviewed because he signed in as relief in the case at 4:30 P.M. on the anesthesia record and did not sign out.

Review of the PACU nursing admission notes, dated and timed 1/18/2017 at 6:00 P.M. indicated the patient was restless but alert but did not mention any medications administered.


2. For Patient #29, the Intra-operative anesthesia record did not contain the doses of Diprivan administered only the total dose administered.

Review of the intraoperative anesthesia record, dated 1/18/2017, indicated that Patient #29, received a total dose of 140 milligrams (mgs) of Diprivan ( a sedative). There was no indication on how much Patietn #29 received at the start of surgery or if the patient received any incremental doses. The anesthesia record only had x's in the column for Diprivan dosing for the first 30 minutes of the surgery.

Based on record review and interview, the Hospital Anesthesia Department failed to ensure that for one of 6 surgical records reviewed (#30), a post anesthesia evaluation was completed and documented by an individual qualified to administer anesthesia, completed and documented by an individual qualified to administer anesthesia, no later than 48 hours after surgery or a procedure requiring anesthesia services and consistent with Department of Anesthesia policies. Findings include:


The Anesthesia Record policy, dated 2/2011, indicated that all patients, attended to by the Department of Anesthesia, regardless of the type of anesthesia administered, were to have in their medical records, a post-operative note when the patient is in the post anesthesia care unit that documents the patient's mental status, and vital signs and that documents any anesthetic related problems identified.

1. For Patient #30, who had surgery under general anesthesia on 1/13/2017, record review on 1/18/2017 indicated there was no post anesthesia evaluation completed.

During an interview, on 1/18/2019 at approximately 2:00 P.M., Registered Nurse (RN) #22 said there was no post anesthesia evaluation in the clinical record.

Based on records reviewed and interviews the hospital failed to ensure outpatient rehabilitation treatment orders were signed by a licensed practitioner for 3 of 7 outpatient records reviewed (outpatient #1, outpatient #4 and outpatient #5), in a total sample of 37. Findings include:

1. Record Review indicated Outpatient #1 was receiving Outpatient Physical Therapy Treatment and there were no signed licensed practitioner orders for Outpatient Physical Therapy services or treatment.

Record Review indicated Outpatient #1 had a Therapy Prescription Order, dated 11/16/2016, to receive rehabilitation treatment for Hand Therapy 2 times per week for 6 weeks. The Therapy Prescription Order had the name of the licensed practitioner printed on the order and was not signed by the ordering licensed practitioner.

A Therapy Prescription Order, dated 12/28/2016, indicated Outpatient #1 was to receive rehabilitation treatment for Hand Therapy 2 times per week for 6 weeks. The Therapy Prescription Order had the name of the licensed practitioner printed on the order and was not signed by the ordering licensed practitioner.

2. Record Review indicated Outpatient #4 was receiving Outpatient Physical Therapy Treatment and there were no signed licensed practitioner orders for Outpatient Physical Therapy services or treatment.

Record Review indicated Outpatient #4 had a Referral Form, dated 12/27/2016, to receive physical therapy treatment for pelvic floor instability. The Referral Form had the name of the licensed practitioner printed on the form, the form was not signed by the ordering licensed practitioner and there were no signed licensed practitioner orders for Outpatient #4 to receive Outpatient Physical Therapy services or treatment.

3. Record Review indicated Outpatient #5 was receiving Outpatient Physical Therapy Treatment and there were no signed licensed practitioner orders for Outpatient Physical Therapy services or treatment.

Record Review indicated Outpatient #5 had a Referral Form, dated 11/4/2016, to receive physical therapy treatment for hemiparesis (weakness of the entire left or right side of the body). The Referral Form had the name of the licensed practitioner printed on the form, the form was not signed by the ordering licensed practitioner and there were no signed licensed practitioner orders for Outpatient #5 to receive Outpatient Physical Therapy services or treatment.

The Surveyor interviewed the Manager of Ambulatory Care Services at 10:45 A.M. and throughout the day on 1/19/2017. The Manager of Ambulatory Care Services said she was responsible for the hospital's outpatient care services. The Manager of Ambulatory Care Services said it was the practice of the hospital's outpatient services department to accept a licensed practitioner's printed name as an electronic signature. The Manager of Ambulatory Care Services said the hospital's outpatient services did not have a policy for electronic signatures for orders by licensed practitioners.

Based on observation, records reviewed and interviews the hospital failed to ensure treatment orders for rehabilitation services were obtained for 3 patients (#4, #17 and #33) sampled patients receiving rehabilitation services, in a total sample of 37. Findings include:

1. Record Review indicated Patient #4 was receiving Physical Therapy Treatment and there were no Physician Orders for treatment.

Record Review indicated Patient #4 had a Physician's Order, dated 1/9/2017, for a Physical Therapy Consult, frequency once. There were no Physician Orders for Physical Therapy Treatment for Patient #4.

A Physical Therapy Evaluation for Patient #4, dated 1/9/2017, indicated a Physical Therapist evaluated Patient #4 and Physical Therapy Treatment 5 times per week for 1 week was recommended. There were no Physician Orders for Patient #4 to receive Physical Therapy Treatment.

Record Review indicated Patient #4 had a Physician's Order, dated 1/16/2017, for a Physical Therapy Consult, frequency once. There were no Physician Orders for Physical Therapy Treatment for Patient #4.

The Surveyor interviewed the Rehabilitation Director on 1/20/2017 at 9:05 A.M. The Rehabilitation Director said Patient #4 was receiving Physical Therapy Treatment and was on her caseload to receive treatment on 1/20/2017. There were no Physician Orders for Physical Therapy Treatment for Patient #4.


2. Record Review indicated Patient #17 was receiving Physical Therapy Treatment and there were no Physician Orders for treatment.

Record Review indicated Patient #17 had a Physician's Order, dated 1/18/2017, for a Physical Therapy Consult, frequency once. There were no Physician Orders for Patient #17 to receive Physical Therapy Treatment.

Record Review indicated a Physical Therapist completed Physical Therapy Evaluation, dated 1/18/2017 at 11:15 A.M., for Patient #17 and the Physical Therapist recommened physical therapy treatment 5 times per week for 1 week. There were no Physician Orders for Patient #17 to receive Physical Therapy Treatment.

Record Review indicated a Physical Therapy Note, dated 1/18/2017 at 12 P.M., indicated Patient #17 was being seen for his/her second Physical Therapy Treatment and there were no Physician Orders for Physical Therapy Treatment.

The Surveyor interviewed Patient #17 at 3:15 P.M. on 1/18/2017. Patient #17 said he/she had worked with Physical Therapy on 1/18/2017.


3. Record Review indicated Patient #33 was receiving Physical Therapy Treatment and there were no Physician Orders for treatment.

Record Review indicated Patient #33 had a Physician's Order, dated 1/19/2017, for a Physical Therapy Consult, frequency once. There were no Physician Orders for Patient #33 to receive Physical Therapy Treatment.

The Surveyor observed Physical Therapist (PT) #3 treat Patient #33 at 10:42 A.M. on 1/20/2017. PT #3 said this was the second time she had treated Patient #33.

The Surveyor interviewed the Rehabilitation Director at 2:20 P.M. on 1/18/2017 and throughout the survey. The Rehabilitation Director said it was hospital procedure to obtain a Physician's Order for Rehabilitation (physical therapy, occupational therapy or speech language pathology) Consults. The Rehabilitation Director said it was the hospital's practice that the Physician's Consult Order permitted the rehabilitation staff to provide treatment to patients at the therapist's discretion based on the therapist's evaluation. The Rehabilitation Director said it was not the hospital's practice to obtain Physician Orders for rehabilitation treatment, duration or frequency. The Rehabilitation Director said the hospital did not have a written policy or procedure for obtaining rehabilitation treatment orders from physicians or to permit therapists to provide rehabilitation treatment without a physician's order.