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Based on interviews, document review, and during the course of an investigation it was determined that the facility failed to allow the participation of patients in the development and implementation of the plan of care for one (1) out of ten (10) patients, including the findings of a cardiac catheterization test (Patient #1).

The findings are:

In the afternoon of 02/18/20, Staff Member #2 assisted in the review of the Medication Administration Record (MAR) of Patient #1. Review of catheterization report from Staff Member #30 (cardiologist) electronically signed on 09/23/19 at 9:55 PM reveals Patient #1 had right heart catheterization procedure. Documentation note includes date of procedure, procedure performed, indication, technique, and plan. Provider note, however, does not mention if results were communicated with patient and family. Other clinician notes written on 09/23/19, 09/24/19, and 09/25/19 do not mention any communication of results of the cardiac catheterization procedure to patient or family. Interview conducted on 02/12/20 at 12:50 PM with Staff Member #31 (Director of Cardiovascular Department). Staff Member #31 states it is both the expectation and responsibility of the provider to meet and discuss directly the results of the cardiac procedure, and answer any questions related to the procedure in a timely manner, followed by documentation of the encounter.

A review of the provider notes related to the cardiac catheterization procedure do not notate any communication with the patient or family of the procedural results. Interview with facility staff reveal it is the direct responsibility of the physician or advanced practitioner to give procedural results to patient and family, and to document said communication. The surveyor asked Staff Member #31 if a task is not documented on a medical record, is it assumed not to have been done? Staff Member #31 answered that a task is not considered to have taken place if no documentation of that task is noted in chart.
The above findings were discussed with the management team for a final time on 02/20/20 at 2:00 PM. No further evidence was provided to the survey team.

Based on interviews, document review, and during the course of an investigation it was determined the facility failed to implement restraints in a safe manner, including insufficient restraint order and not being included in the plan of care for one (1) out of ten (10) patients (Patient #3).

The findings are:

In the afternoon of 02/13/20, Staff Member #2 assisted with the review of the restraint documentation of Patient #3. Restraint documentation reveals restraints were ordered on 05/08/19 at 7:35 PM for agitation. Nursing progress note written by Staff Member #33 writes restraint order discontinued at 7:54 PM. Bilateral upper extremities restraint ordered by Staff Member #27 as "late entry" on 05/13/2019, without indication of time order written. Restraint order written five (5) days following restraint use, and four (4) day following inpatient death of Patient #3. Order did not include clinical justification for the restraint use, the duration of use, as well as the behavior base criteria for release, as mandated by facility policy.

A review of the facility policy titled, "Patient Restraint/Seclusion" (with last revision date of 11/2018) reads, "The [restraint] order must specify clinical justification for the restraint or seclusion, the date and time ordered, the duration of use, the type of restraint to be used and the behavior-based criteria for release.

Additionally, documentation of Patient #3's medical record did not include restraints as part of plan of care. Facility "Patient Restraint/Seclusion" policy requires the plan of care for Patient #3 to "clearly reflect a loop of assessment, intervention, and evaluation for restraint..." Staff Member #2 confirms this information is not included in the plan of care of Patient #3 despite having restraints applied on 05/08/19 in the Emergency Department.

The above findings were discussed with the management team for a final time on 02/20/20 at 2:00 PM. No further evidence was provided to the survey team.

Based on interviews and review of hospital documents it was determined hospital staff failed to break down aggregated data for restraints allowing for comparison of units implementing restraints.

The findings are:

On 2/18/20 in order to facilitate a review of restraint use in the hospital, the survey team asked to be provided with the log of patients who had been restrained in the last year. The survey team was provided a list of patient names. The surveyor asked Staff Member (SM) #2 to provide information as to whether the restraint were violent or non-violent. SM #2 stated the only way to do that would be to open each individual restraint episode to look at it. The morning of 2/19/20 the survey team was provided with a list of patient names, the location of the patient and the type of restraint. The surveyor was told this information had been collected manually.

The surveyor asked SM #1 if restraint information was trended. SM #1 told the surveyor that he/she reviewed restraint information each morning and would be aware of trends if they occurred. SM #1 stated he/she was not aware of any trends related to restraints. The surveyor noted the information provided did not include restraints implemented in the Emergency Department. The surveyor was aware of a restraint implemented on an Emergency Department patient through chart review. The surveyor asked SM #1 if the restraint information could be further broken down into subsets i.e. location: emergency department, ICU, med/surg, behavioral health. For behavioral health restraints where did the restraint occur i.e. common area, hallway, nurses station, etc. SM #1 was able to provide evidence that more detailed restraint documentation was occurring but agreed with the surveyor that the information was not trended except in the memory of staff present during the review of restraints each day. Only the number of restraint episodes is trended and presented during quality review.

The surveyor and SM #1 discussed the importance of being able to breakdown into subsets the information related to restraint implementation. The surveyor discussed the risk involved with the implementation of restraints and the need to examine restraint episodes carefully even though restraint use is infrequent in this hospital.

The above information was shared with SM #1 and SM #2 during the course of the survey and with the management team prior to exit. No further evidence was provided to the survey team.

Based on interviews and hospital document review, it was determined the hospital's Governing Body failed to determine the number of quality improvement projects and failed to approve of revisions to the quality plan on an annual basis.

The findings include:

Surveyor review of the hospital's quality program was conducted 2/19 - 2/20/2020 with the assistance of Staff Member (SM) #1, the Vice President of Quality. During the review, the surveyor requested evidence of the Governing Body's approval of the quality plan. SM #1 informed the surveyor that prior to his/her involvement in the quality program in September 2019 there was no consistency to meetings of the Patient Safety Committee and other committees that make up the quality program. SM #1 stated he/she could not provide evidence the quality program was presented to the governing body for approval prior to 2019.

Surveyor review of policy "Quality Assessment and Performance Improvement Program" Last revised: 10/2019, Expiration : 10/2022 found the following information in part: Under the heading "ANNUAL PROGRAM EVALUATION The objectives, scope, organization and effectiveness of the Quality Assessment & Performance Improvement Program will be evaluated at least annually and revised as necessary" and "Any changes in the program will be effective upon approval of the Governing Body."

The above information was shared with SM #1 during the quality review and with the management team prior to exit. No further evidence was provided to the survey team.

Based on interviews, document review, and during the course of an investigation it was determined the facility failed to administer medications in accordance with the orders of a practitioner and the accepted standards of practice. Medications not administered as ordered, include Furosemide/Lasix and Humulin R insulin on seven (7) occasions for one (1) out of ten (10) patients (Patient #1).

The findings are:

In the afternoon of 02/18/20, Staff Member #2 assisted in the review of the medication administration record of Patient #1. Medication record confirms Staff Member #20 administered Furosemide/Lasix medication intravenously (IV) to Patient #1 on 09/20/19 at 6:23 AM after medication was discontinued on 09/19/19 at 6:00 PM. Staff Member #2 confirms there was no active order for Lasix medication when administered by Staff Member #20.

Staff Member #28 ordered regular insulin (Humulin R) subcutaneously on a sliding scale for blood sugars one hundred fifty (150) and greater. Insulin ordered on 09/18/19 at 4:30 PM through date of discharge for Patient #1. Medication administration record reveals patient did not get ordered sliding scale insulin on seven (7) occasions for point of care blood sugar of one hundred fifty (150) and greater. Staff member #2 confirms there was no documented reason for medication not to be administered.

The above findings were discussed with the management team for a final time on 02/20/20 at 2:00 PM. No further evidence was provided to the survey team.

Based on interviews, document review, and during the course of an investigation it was determined the facility failed to administer blood products in accordance with facility policy and procedures by not maintaining vital signs monitoring for one (1) out of ten (10) patients (Patient #2).

The findings are:

In the morning of 02/12/20, Staff Member #2 assisted in the review of six blood transfusions for Patient #2. Blood transfusion records of Patient #2 reveal vital signs were not taken in accordance with facility guidelines for six (6) of six (6) blood transfusions.

One of six blood transfusions for Patient #2 initiate it on 01/23/20 at 1:17 PM did not include thirty (30) minutes vital signs. Two (2) of six (6) blood transfusion initiated on 01/25/20 at 6:58 AM did not include any vital signs after the initiation of the blood transfusion. Three (3) of six (6) blood transfusion initiated on 01/25/ 20 at 3:13 PM and only including initiation vital signs, and fifteen (15) minutes following transfusion start. Four (4) of six (6) vital signs initiated on 01/25/20 at 8:02 PM did not include any vital signs with the exception of the start of the transfusion, as well as 15 minutes following. Blood transfusion five (5) of six (6) initiated on 01/28/20 at 5:38 PM did not include either fifteen (15) minute vital signs, or the thirty-(30)-minute following set. Blood transfusion initiated on 01/30/ 20 at 5:58 AM did not include the fifteen (15) minute vital signs nor the thirty-(30)-minute vital signs. Six (6) of six (6) blood transfusions administered to Patient #2 unsafely without proper close vital signs monitoring, as written by facility policy and procedures.

Facility policy titled, "Blood/Blood Product Ordering in Administration" (with last revision date of one 2019) states vital signs to include blood pressure, temperature, pulse, respirations, and pulse oximetry to be initiated at the start of the transfusion, every fifteen (15) minutes for two occasions, again thirty (30) minutes following, and hourly until the completion of the transfusion.