HospitalInspections.org

Based on review of hospital policies/procedures, Medical Staff Rules and Regulations, Medical Staff Bylaws, review of medical records and interview, it was determined that the hospital failed to require the medical staff obtain documented orders for "Do Not Resuscitate" (DNR) for one (1) of one (1) patient (Patient #19 ) who stopped breathing on 10/06/2014; and CPR was not initiated.

Findings include:

Review of hospital policy titled "Death- Natural Death of a Patient" revealed: "...Patients identified by a Do Not Resuscitate order who have presented with an Advanced Directive or other document that identifies a surrogate health care decision maker...."

Review of hospital policy titled Advanced Directives revealed: "...If the patient/legal representative reports an Advance Directive has been formulated the staff will request a copy of the document be provided for verification purposes and to have available in the medical record...If the Advanced Directive document includes a DNR the following shall occur...The admitting physician will be contacted for a "Do Not Resuscitate" order. The DNR process will be implemented...A DNR sticker placed on the front of the chart...."

Review of hospital policy titled "Code Blue" revealed: " ... CPR will be initiated immediately unless the patient is clearly identified as "Do Not Resuscitate" ("DNR")...."

Review of hospital Rules and Regulations of the Medical Staff revealed: "...Orders...All orders for medication and/ or treatment for patients admitted to the hospital shall be in writing...Orders must be complete, including the name of the Practitioner giving the order and the dated, time, and justification for the order...."

Review of hospital Governing Board Bylaws revealed: "...The Governing Board shall ensure that the Medical Staff remain accountable to the Governing Board for the quality of care provided to Hospital patients. Subject to limitations of these Bylaws, the Medical Staff Bylaws, the rules and Regulations, and any applicable policies of Hospital...."

Review of Pt #19's medical record revealed the advance directives form was in the chart stating that the patient had Advanced Directives. However, there was no documentation of a copy of the Patient's Advanced Directives. The chart did have a "DNR" sticker placed on the first page of the medical record. However, Patient # 19 medical record did not contain any orders for "Do Not Resuscitate" ("DNR"). Patient # 19's medical record further revealed that she stopped breathing on 10/6/14 and CPR was not initiated.

The Director of Risk Management and Quality confirmed in an interview conducted on 7/28/15, that there was no documentation of an order for DNR code status in Patient #19's medical record. She also confirmed that the patient's advance directives were not available in the medical record for review.

Based on review of hospital policy/procedure, hospital documents, medical records and interviews, it was determined that the administrator:

1. failed to ensure that a registered nurse must supervise and evaluate the nursing care for each patient by not requiring the initiation of CPR for one (1) of one (1) patient (Patient #19 ) who stopped breathing on 10/06/2014, and did not have a "Do Not Resuscitate" order in the medical record.

2. failed to ensure that nursing services provided adequate numbers of nursing personnel to meet the patients needs from 07/25/15 through 07/29/15, according to the facility policy related to Acuity and Assignment. Failure to obtain the required nursing staff has the potential to cause the patient harm by not meeting the patient's physical and mental health needs.

Findings include:

1. Cross reference Tag 0049 for information regarding registered nurses not initiating CPR for a patient who stopped breathing.

The Director of Risk and Quality confirmed in an interview conducted on 7/18/15, that there was no documentation in the medical record that an DNR order was obtained.

2. Hospital policy titled Assignment of Nursing Staff requires: "...Patient care assignment is commensurate with the qualifications of each nursing staff member and the identified nursing need of the patient according to acuity. Patient care assignment is based on acuity and equally distributed among staff...Staff who are assigned to a patient who is on 1:1...will not be assigned any other responsibility during the time they are assigned to the 1:1...."

The Acuity and Assignment policy requires: "... Level 1: Line of sight...1:1 ordered... recent suicide... impulsive... agitated...Level 2: Mildly psychotic... needs frequent redirection... moderate assistance...medical problems/symptoms requiring frequent monitoring...Level 3 Independently performs ADL's... routine supervision...minimal staff intervention...."

The acuity scoring revealed the following: DAYS/EVES RN-three level (1), eight level (2), one, Level(sp) (3)...BHT-two level (1), five level (2), three level (3)...NIGHTS...RN-three level (1), ten level (2) one, Level (sp) (3) BHT-three level (1), ten level (2), one level (3)...."

The policy requires the maximum acuity score of the RN on the day/evening shift shall be 22 and the maximum acuity score of the BHT on the day/evening shift shall be 21. There is no acuity score assigned for LPN's for any shift.

The policy requires the maximum acuity score of the RN on the night shift shall be 26 and the maximum acuity score of the BHT on the night shift shall be 26. There is no acuity score assigned for LPN's for any shift.

Review of the Assignment sheets revealed the following:

On 07/25/15 day shift, two (2) RN's were scheduled. The first RN's acuity score was documented as 29. The LPN was assigned as medication nurse with no documented acuity score.

On 07/25/15 night shift, two (2) RN's were scheduled. Both RN's acuity scores were documented as 30.

On 07/26/15 night shifts, two (2) RN's were scheduled. The first RN's acuity score was documented as 30, and the second RN's acuity score was documented as 28.

On 07/27/15 evening shift, two (2) RN's were scheduled. The first RN's acuity score was documented as 28, and the second RN's acuity score was as 26.

On 07/28/15 day shift, three (3) RN's were scheduled. The second RN's acuity score was documented as 27, and the third RN's acuity score was documented as 26.

On 07/29/15 day shift, three (3) RN's were scheduled. The second RN's acuity score was documented as 24.

On 07/29/15 night shifts, two (2) RN's were scheduled. The second RN's acuity score was documented as 28.

The Director of Nursing confirmed during an interview conducted on 07/30/15, that on the above dates, the facility failed to follow their Acuity and Assignment policy.

Based on review of hospital policy/procedure, observation and staff interview it was determined the hospital failed to properly store and protect the patient medical records from water damage when no water resistant covering was readily available.

Failure to protect the medical records from potential water damage has the potential risk for loss of pertinent medical information about the patient, when files are destroyed if the sprinkler system is activated.

Findings include:

Hospital policy titled "Confidentiality & Security Of Medical Records" requires: "The medical record is the property of the hospital and is maintained for the benefit of the patient...the record remains the property of the patient...."

Observation of the Medical Records storage area on 07/23/15, revealed a secure location with limited access for authorized personnel only. The room had a sprinkler system to protect the records from fire, however, the records are not protected from water damage if the sprinkler system was activated.

The Health Information and Management Systems Manager confirmed during an interview conducted on 07/23/15, the records are not protected by any water resistant material/covering.

Based on recommendations of Centers for Disease Control and Prevention (CDC), manufacturer's product label directions for use, hospital documents, observations on the patient unit and staff interviews it was determined the Infection Control Officer

1. failed to monitor the contracted cleaning staff for the use of appropriate disinfectant that was effective against Clostridium Difficile (C-diff);

2. failed to monitor the contracted cleaning staff for appropriate usage (contact time) of the disinfectants; and

3. failed to confirm the contracted cleaning staff had appropriate infection control training.

Failure to review appropriate disinfectant indications, usage and infection control training has the potential risk for the spread of infections to patients and staff.

Findings include:

The CDC website http://www.cdc.gov/HAI/organisms/cdiff/Cdiff_faqs_HCP.html, recommends: Routine cleaning should be performed prior to disinfection. EPA-registered disinfectants with a sporicidal claim have been used with success for environmental surface disinfection in those patient-care areas where surveillance and epidemiology indicate ongoing transmission of Clostridium difficile.

Note: EPA-registered disinfectants are recommended for use in patient-care areas. When choosing a disinfectant, check product labels for inactivation claims, indications for use, and instructions.

Review of the current disinfectants "Directions for use" revealed: GS Neutral Disinfectant Cleaner is formulated to kill a broad spectrum of microorganisms; allow surface to remain wet for 10 minutes. Directions for use for Sani Cloth Plus: kills 16 strains of bacteria and viruses with a 2 to 5 minute wet time.

1. There is no documentation on the manufacturer's labels to confirm that GS Neutral Disinfectants and the Sani Cloth Plus are effective against C-diff.

The Pharmacist confirmed during an interview conducted on 07/24/15, that the disinfectants used by the facility are ineffective against C-diff.

2. Observations while on tour of the patient unit on 07/24/15, the contracted cleaning staff was seen mopping the hallway.

The contracted cleaning staff member (employee #22) confirmed during an interview conducted on 07/24/14, that the contracted service uses GS Neutral Disinfectant and Sani Cloth Plus. The contracted staff confirmed she does not know if the disinfectants are effective against C-diff; she hasn't read the manufacturer's label; nor does she know the contact (wet) time of the disinfectants.

The Administrative Assistant of the cleaning service (employee #24) confirmed during an interview conducted on 07/28/15, that she was unaware the disinfectant was ineffective against C-diff.

3. The Administrator Assistant of the cleaning service confirmed during the above interview that she and employee #24, had infection control training, however, she had no documentation of the training.

The Director of Risk Management confirmed during an interview that the hospital had five (5) patients admitted into the hospital with C-diff (Patients #'s 35, 36, 37, 38, and 39). The Director confirmed Patient #38 was positive on admission.

The Director of Nursing confirmed during an interview conducted on 07/24/15, that she was aware the hospital has had patients with C-diff infections, and they are placed in contact isolation.

The Director of Nursing confirmed during the same interview that she was not aware the contracted cleaning service was using disinfectants that were not effective against C-diff.

An unannounced onsite complaint investigation was conducted on 07/22/15 through 07/30/15.


Based on review of the medical record of Patient # 5 , interview with hospital staff and review hospital policies and procedures.

Review of the medical record of patient # 5 confirms the patient had an order written on 07/21/14 at 2:42 pm "...Bacitracin ointment daily on left elbow open wound cover w/ non-adhesive dressing...."

A photo was included in the complaint allegation from the complainant that had a handwritten label "left arm" however there is no other identifying marks such as a date, time, or the identification of the person with an arm band identifying whose arm it was supposed to be in that photo.
Employee # 9 Charge Nurse confirmed in an interview that the RN assigned to the patient on the day of discharge 07/22/2014 no longer works at the hospital. Employee # 9 confirmed in a review on the medical record that there was no change in the level of consciousness (LOC) the morning of the transfer.

Review of medical record on 07/22/2014 at 1600 for Patient # 5 revealed in a nursing note: "...oriented to self only, lethargic but responsive to name only. BP 122/55 PR 81, RR 18, O2 sat 97% and T 101.5 medicated with prn Tylenol @1440. Patient # 5 was being treated for a Urinary Tract Infection(UTI). The temperature on discharge was 97.8.

Employee # 9 confirmed in an interview on 07/30/2015 at 1010 there is no documentation present in the medical record of a report being called to the receiving Adult Living facility.

Review of hospital policy - Discharge/Aftercare Plan PolicyStat ID 1663658 revealed:

On page 2 of 4 Include timely and direct communication with and transfer of information to other programs, agencies, or individuals that will be providing continuing care (i.e.: PCP,skilled nursing facility, therapists,etc.)

On Page 4 of 4 - Discharge Process and Responsibilities:
"Nurse to Nurse with receiving facility, if applicable". The facility failed to "hand off" the current patient status prior to transfer to (name of facility).

1-Allegation that the patient had burns on the upper extremity cannot be substantiated. The patient had a wound on her left elbow which was being cared for by the facility. There is no rule violation related to the allegation.

2- Allegation that the patient was transferred in a comatose state without notice to the daughter is substantiated.

Based on review of policies and procedures, facility documents, medical records, and interviews, it was determined that the hospital failed to require the nursing staff notify the Donor services following the death of two (2) of two (2) patients (Patient# 19 and # 20) as per facility policy, which has a potential risk for decreasing the number of potential donors available to the Donor Network.

Findings include:

Review of hospital policy titled Organ, Tissue and Eye Procurement revealed: " ...All families will be presented with the option of organ, tissue and eye donation for transplantation and/or research at or near the time of patients' death...The hospital has an agreement with a donor services...Notification criteria to the donor services (Name of Facility) would include ...Death or Imminent death...The staff nurse caring for the patient notifies donor services within one hour after the patient dies...Notification of the donor services will be documented in the patient's progress note...."

Review of facility's Annual Contract Service Evaluation revealed: "...Service not used in 2014...."

Patient # 19's medical record revealed there was no documentation of notification to the donor services on 10/6/14, after the patient was pronounced deceased.

Patient # 20's medical record revealed there was no documentation of notification to the donor services on 3/2/15, after the patient was pronounced deceased.

The Risk Manager confirmed in an interview conducted on 7/28/15, that there was no documentation in Patient # 19 and 20's medical record about notification to the donor network, as stated in the facility's policies and procedures.