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Based on medical record review, staff interview and review of the facility's policy and procedures it was determined the facility failed to provide the standardized notice "An Important Message from Medicare" (IM) within 2 days of admission and/or within 2 days of discharge for four (#7, #11, #22, #23) of thirty eight patient's sampled. This does not ensure patients and/or their representatives have the information necessary to exercise their rights.

Findings include:

1. Review of the medical record for patient #7 revealed the patient was admitted on 3/08/2012 and was a medicare beneficiary. Review of the record revealed no indication the IM was provided to the patient within 2 days of admission.

An interview with the case manager on 3/20/2012 at 11:45 a.m. confirmed there was no evidence an IM was provided to the patient within 2 days of admission.

2. Review of the medical record for patient #11 revealed the Case Manager's initial note dated 03/13/12 documenting the patient's Mental Status/Cognition as "alert/oriented" and the Discharge Plan "Discussed with Patient". The Case Manager's note dated 03/20/12 indicated "Patient refusing everything per nurse. Asked secretary to mail IM (Important Message) to patient's son who is POA (Power of Attorney)". Further review of the notes did not reveal a discussion of the content of the POA document or why the Case Manager was having the IM letter sent to the son rather than discussing it with the patient, who had been identified as "alert and oriented" and having had signed the "choice letter".

Interview with the Director of Case Management on 03/22/12 beginning at 9:15 a.m. revealed when IM letters are mailed to responsible parties a green postal card was attached requiring signature on receipt that the hospital received back. She confirmed the hospital did not ask the responsible party to return a signed copy of the IM letter to the hospital.

3. Review of the medical record for patient #22 revealed the patient was admitted on 2/24/2012 and was a medicare beneficiary. Review of the record revealed upon admission the patient was incapacitated and the patient's representative was identified. Review of the record revealed an IM was signed by the patient's representative but there was no date or time on the form. Review of the case management documentation on 3/06/2012 at 11:55 a.m. stated the IM letter left at bedside for the patient's representative to sign. Review of the record revealed the patient was discharged on 3/07/2012. There was one IM signed by the patient's representative with no date or time. It could not be determined if the IM was signed within 2 days of admission or discharge.

Interview with the Director of Case Management on 3/21/2012 at 4:00 p.m. confirmed there was only one IM form signed by the patient's representative that had no date or time on it.

4. Review of the medical record for patient #23 revealed the patient was admitted to the facility on 3/08/2012 and was a medicare beneficiary. Nursing documentation revealed the patient was alert and oriented. Review of the record revealed no evidence of an IM form that was presented and signed by the patient within 2 days of admission. Review of the record revealed the patient was discharged on 3/12/2012. There was no evidence the IM was presented or signed by the patient.

Interview with the Director of Case Management on 3/21/2012 at 4:00 p.m. confirmed the findings.

Review of the facility's policy "Important Message" last revised 01/2012 stated all Medicare beneficiaries will be provided the Important Message no more than two (2) days prior to discharge to assist with CMS compliance guidelines.

Based on clinical record review and staff interview it was determined the facility failed to measure, analyze, and track an adverse patient event for one (#38) of thirty eight sampled records. This could result in missed opportunities to improve patient safety and processes of care.

Findings include:

Patient #38 presented to the Emergency Department on 12/12/2012 and was triaged at 3:07 p.m. Documentation revealed the patient had an allergy to Penicillin. Review of the medication administration record on 12/12/2012 at 6:31 p.m. revealed the patient was administered Zosyn. The medication Zosyn contains a combination of piperacillin and tazobactam. Piperacillin is a penicillin antibiotic. Review of facility documentation revealed the Pharmacy Clinical Manager would investigate the event.

On 3/23/2012 at 8:35 a.m. the risk manager was interviewed. She stated she had no documentation in her file related to the Pharmacy Clinical Manager's investigation.

The Director of Quality Management and Risk Manager confirmed there had been no tracking completed to analyze the occurrence of nursing staff overriding medication allergy alarms put in place for patient safety.

Based on record review, staff interview and review of the facility's policy and procedures it was determined the facility failed to use the data collected to monitor for the safety of service and quality of care for patients in the emergency department following an adverse event for one (#38) of thirty eight sampled records. This does not ensure patient safety is maintained and facility processes are adhered to.

Findings include:

Patient #38 presented to the Emergency Department on 12/12/2012. Documentation revealed the patient had an allergy to Penicillin. Review of the medication administration record on 12/12/2012 at 6:31 p.m. revealed the patient was administered Zosyn. The medication Zosyn contains a combination of piperacillin and tazobactam. Piperacillin is a penicillin antibiotic. Review of facility documentation revealed the Pharmacy Clinical Manager would investigate the event.

Interview with the Assistant Director of Emergency Services and Director of Quality Management was conducted on 3/23/2012 at 11:20 a.m. The Director stated she spoke with the Registered Nurse (RN) who administered the medication. She stated the RN removed the Zosyn from the automated medication dispenser that triggered an alarm warning the RN of an allergy alert. The RN was able to override the alarm and removed the medication. Upon scanning the patient's arm band and the medication, a second alarm warning the RN of an allergy alert was present. The RN overrode the second alarm and administered the medication. The Assistant Director of Emergency Services stated she counseled the RN. No documentation could be provided to confirm the counseling. The Director of Quality Management and the Risk Manager confirmed there had been no tracking completed to analyze the occurrence of nursing staff overriding medication allergy alarms put in place for patient safety.

Based on record review and staff interview it was determined the facility failed to identify an opportunity for improvement and failed to make changes related to an adverse event for one (#38) of thirty eight records reviewed. This does not ensure the facility identified an opportunity that could lead to improvement in patient safety and facility processes.

Findings include:

Patient #38 presented to the Emergency Department on 12/12/2012. Documentation revealed the patient had an allergy to Penicillin. Review of the medication administration record on 12/12/2012 at 6:31 p.m. revealed the patient was administered Zosyn. The medication Zosyn contains a combination of piperacillin and tazobactam. Piperacillin is a penicillin antibiotic. Review of facility documentation revealed the Pharmacy Clinical Manager would investigate the event.

Interview with the Assistant Director of Emergency Services and Director of Quality Management was conducted on 3/23/2012 at 11:20 a.m. The Director stated she spoke with the Registered Nurse (RN) who administered the medication. She stated the RN removed the Zosyn from the automated medication dispenser that triggered an alarm warning the RN of an allergy alert. The RN was able to override the alarm and removed the medication. Upon scanning the patient's arm band and the medication, a second alarm warning the RN of an allergy alert was present. The RN overrode the second alarm and administered the medication. The Director of Quality Management and the Risk Manager confirmed there had been no performance improvement or changes made due to the occurrence of nursing staff overriding medication allergy alarms put in place for patient safety.

Based on record review, staff interview and review of policy and procedures it was determined the Registered Nurse (RN) failed to reassess the effectiveness of pain medication according to the facility's policy for one (#37) of thirty eight patients sampled. The RN failed to
ensure nursing documented a patient event for one (#31) of thirty eight patients sampled. This practice does not ensure needed information to develop or change the plan of care is available.

Findings include:

1. Patient #37 was admitted on 3/01/2012. Review of the nursing assessments revealed the patient complained of pain to both knees. Documentation revealed the pain was chronic. Review of physician orders revealed on 3/21/2012 at 11:00 a.m. an order for Morphine 30 mg (milligrams) by mouth every 4 hours as needed for pain.

Review of the MAR (Medication Administration) revealed the patient received Morphine on 3/21/2012 at 8:22 p.m. for a pain score of 8 on a scale from 1 to 10 with 10 being the worst pain. Review of the nursing documentation did not reveal evidence the nurse reassessed the patient's pain to determine if the medication was effective.

Review of the facility's policy, "Pain Management", last revised 10/2011, stated a reassessment of the patient's pain will be completed within one hour after intervention to determine the effectiveness of the intervention.

Review of the record revealed the patient received Morphine on 3/22/2012 at 12:30 a.m. and 10:03 a.m. Review of the nursing documentation revealed no evidence the patient's pain was reassessed for effectiveness.

On 3/23/2012 at 11:00 a.m. an interview with the patient's RN and the Nurse Manager confirmed the above findings.

2. Patient #31 was found on the floor in the patient's room on 11/26/2011 at 4:30 p.m. Review of the record revealed no documentation by the nursing staff that the patient was found on the floor. There was no documented evidence of an injury assessment or any treatment or intervention. There was no indication the patient's representative was notified. Documentation revealed the patient was confused upon admission and prior to the fall.

Review of the facility's policy, "Occurrence Reporting", last revised 6/2011, stated patient events will be documented in the medical record and will include the type of event or injury, injury assessment, any treatment intervention, notification of the physician, follow up plan of care and follow up assessments and interventions.

Interview with the Director of Quality on 3/22/2012 at 3:15 p.m. confirmed there was no documentation in the patient's record to indicate the patient was found on the floor, injury assessment, intervention, or family notification.

Based on record review and staff interview it was determined the facility failed to ensure one patient (#12) of 38 sampled patients received a medication according to the physician order. This practice does not ensure safe and effective medication therapy.

Findings include:

Patient #12's physician medication orders dated 03/20/12 revealed an order for Flovent inhalation at 8:00 a.m. and 8:00 p.m. Review of the electronic medication administration record (MAR) revealed that the 8:00 a.m. and 8:00 p.m. doses on 03/20/12 had not been given.

Further review of the medical record did not reveal the physician had been notified of the missed doses on 03/20/12.

This was confirmed by record review with the nurse unit manager on 03/21/12 at 2:30 p.m.

Based on review of the electronic medical record and staff interview it was determined the facility failed to ensure that a verbal order for one (#11) of 38 sampled patients was signed by the physician within 48 hours. This practice does not provide for patient safety.

Findings include:

Patient #11 verbal physician order dated 03/15/12 at 2:50 p.m. revealed the nutrition supplement Enlive was to be administered 3 times a day. The order was noted and determined to have been taken by a Registered Dietitian. Review of the computer screen illustrating signed orders did not reveal that the physician had signed the verbal order by the time the patient had been discharged on 03/22/12.

Interview with the Director of Clinical Applications on 03/22/12 at 3:50 p.m. confirmed the policy required that the physicians are to sign (authenticate) verbal orders within 48 hours. She confirmed during the interview that it had been more than 48 hours from the time of the verbal order.

Based on observation in the main kitchen and interview with dietary staff it was determined the facility failed to ensure that the main kitchen and procedures related to maintaining holding temperatures of a potentially hazardous food, was maintained in sanitary order to prevent transmission of food borne illness, and physical contamination.

Findings include:

During the comprehensive tour of the main kitchen on 03/21/12 beginning at 9:30 a.m. the following concerns related to food borne illness were noted:
1. In the dish machine room, on the ceiling in the two corners across from the entrance to the room, the ceiling was noted to be spotted with a black substance.
2. In the walk in freezer four boxes, and the inside plastic bags, of frozen foods were noted to be open to the air.
3. In the walk in refrigerator, a box of health shakes, containing approximately half of the shakes was noted to have expired in January 2012.
4. During the lunch tray line, on 03/21/12 beginning at 11:50 a.m., a slice of meat loaf was plated for service to a patient. The meatloaf had been taken from a container (later identified as containing beef broth) on the steam table. The temperature of the meat loaf was taken by the Production Manager (with the facility's digital thermometer) and read 104 degrees Fahrenheit (F). The temperature of the beef broth that the meat loaf had been taken from was 143 degrees F.
(Foods that are held for hot service must be maintained above 140 degrees F. The steam table was not to be used to bring foods to appropriate temperatures, only to hold the food at the appropriate temperature once that temperature was reached. )
The Production Manager was questioned, at that time, about the low temperature and he reported that the meat loaf slices had been taken from the production chiller and placed into the beef broth to come to temperature.
The Patient Services Manager reported, at that time, that the procedure was to remove cold meat items from the chiller and place them on the 'flat top' (grill surface) until they came to the appropriate temperature and then to place them in the beef broth to maintain the temperature until service. The Production Manager confirmed that the process of using the flat top to bring foods to temperature had been used in the past. The flat top was small and not able to accommodate all protein foods needing to be cooked or warmed, he had been omitting the step of warming on the flat top and was placing the items directly into the steam table pans to hold for service, assuming the foods would come to the appropriate temperature.

Based on record review and staff interview it was determined that the facility failed to ensure the Pre-Admission Screening and Resident Review (PASSR) was completed prior to discharge for one (#22) of thirty eight sampled patients This does not ensure appropriate post hospital placement was provided.

Findings include:

Review of the record for patient #22 revealed the patient was admitted to the facility on 2/24/2012 for altered mental status and seizures. Documentation revealed the patient would be transferred to a Skilled Nursing Facility (SNF). On 3/07/12 the patient was transferred. Review of the record revealed no evidence of a completed PASSR (Pre-Admission Screening and Resident Review).


42 CFR 483.100 requires that the facility transferring a patient to a Skilled Nursing Facility (SNF) ensures that a Pre-Admission Screening and Resident Review (PASSR) be completed prior to the patient being transferred to the SNF to ensure appropriate placement.


During interview with the Director of Case Management on 3/21/12 at approximately 4:00 p.m. the Director confirmed there was no PASSR completed for the patient prior to discharge and transfer to the SNF.