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Based on medical record review, patient interview, staff interview, and review of policies and procedures, the facility failed to ensure adequate discharge planning for 2 of 20 sample patients (#6, #10). The findings were:

1. Medical record review showed patient #6 was admitted to the facility on 12/13/15 with chest pain and discharged on 12/16/15. Review of the 12/15/15 discharges summary showed the following for the hospital course, "95 y/o [gender] caught [himself/herself] from falling by grabbing ahold of bed rail at home. The following day however [gender] had significant CP so was brought to ER where [gender] had normal CXR, troponin and EKG showed no ischemic changes. We hospitalized [gender] because of significant chest wall pain. [Gender] developed constipation in house requiring digital removal of stool and multiple laxatives. By the 3rd day [gender] chest wall pain was controlled with norco and constipation was resolved. [Gender] has multiple care givers in [gender] home so [gender] was d'c'd to their care 12/15/15. [Gender] will continue norco for pain at home. Care should be taken in the home to prevent constipation with stool softeners and adequate hydration as well as laxatives as needed." Interview with the patient on 12/15/15 at 10:45 AM, just before discharge, showed his/her primary issue was constipation, and s/he had this issue other times in the past. The following concerns with discharge planning were identified:
a. The patient stated on 12/15/15 at 10:45 AM that the facility had not provided education on how to address constipation.
b. Review of the entire medical record showed no education or written instructions were provided to the patient or home providers regarding prevention and interventions for constipation.
c. Interview with the CPAI on 12/17/15 at 8:30 AM confirmed the facility failed to ensure education regarding constipation was provided to the patient or his/her caregivers.

2. Medical record review showed patient #10 was admitted to the facility on 7/14/15 with low back pain, Parkinson's Disease, and urinary retention. The patient was discharged on 7/17/15, returned to the facility on 7/18/15, and was admitted at that time with constipation and abdominal pain, and discharged to a long-term care facility on 7/23/15. Review of the 7/23/15 discharge summary showed the patient received a diagnoses of urinary retention on 7/14/15. The discharge summary included the following, "[Gender] is no longer having abdominal pain since we placed [gender] on a good bowel regimen. [Gender] is having soft stools daily and [gender] is urinating. [Gender] has some urine retention if we do not offer toileting every 3-4 hours but [gender] has emptied [gender] bladder not needing straight cath." The following concerns with discharge planning were identified:
a. Review of the entire medical record showed no education or written instructions were provided to the patient, family, or long-term care facility regarding prevention and interventions for urinary retention.
b. Interview with the CPAI on 12/17/15 at 8:30 AM confirmed the facility failed to ensure education regarding urinary retention was provided to the patient, family or long-term care facility.

Review of the facility policy titled, "Patient Discharge Planning" revised 4/17/15 showed the following, "I. Purpose/Expected Outcome: A. Patient's continuing care needs are met...IV. Procedure/Interventions: A. Discharge/Planning-Preparation for moving a patient from one level of care to another within or outside the current health care agency (NIC)...4. Counsel patients and family regarding the post hospital care needs...7. Review plan prior to discharge to assure that plan is appropriate to current patient needs. 8. Provide written instructions of care after discharge."

Based on observation and staff interview, the facility failed to ensure appropriate techniques and work practices were implemented to effectively clean and disinfect 2 of 2 ORs. The facility further failed to ensure randomly observed disinfected laryngoscope handles and blades were packaged to prevent recontamination. The findings were:

1. On 12/16/15 from 2:15 PM to 3:10 PM environmental services associate #1 and #2 were observed performing terminal cleaning of OR #1 and #2. The following concerns were identified:
a. In both ORs the environmental services associates cleaned and disinfected the overhead procedure lights and ceiling after they cleaned and disinfected the horizontal surfaces, trays, carts, equipment, chairs, anesthesia machine, multiple connection cables, position devices, procedure table, and video monitor equipment.
b. The environmental services associates repeatedly returned a used mop head to the same bucket of disinfectant solution when they mopped the floors.
c. The stored supplies (packaged and unpackaged), clusters of devices, and mobile supply carts in OR #2 consumed most of the space in the room. The limited unencumbered space prevented access to all surface areas for effective cleaning and disinfecting. During the observation the CPAI revealed the room was used for storage; and at times, when a second OR room was needed this room was used for surgical procedures.
d. Interview on 12/17/15 at 9:40 AM with the infection preventionist revealed she was not aware of the cleaning and disinfecting problems in the OR.
e. Review of the policy and procedure titled, "Perioperative Services: EVS [environmental] Cleaning the Surgical Procedural Area, effective date 11/14/15, revealed included specific directions for staff, "Do Not re-dip mop head in previously used solution."
f. According to the 2015 Edition of Guidelines for PeriOperative Practice, Association of PeriOperative Registered Nurses: "I.e.3. Used cleaning materials (eg, mop heads, cloths) should not be returned to the cleaning solutions container. Used cleaning materials are considered contaminated and returning them to the cleaning solution container contaminates the solution. VI.b.2. Cleaning should progress from top to bottom areas. During cleaning of top areas, dust, debris, and contaminated cleaning solutions may contaminate bottom areas. If bottom areas are cleaned first, these areas could potentially be recontaminated with debris from the top areas."

2. Observation on 12/15/15 at 12:15 PM of the crash cart in the emergency room showed one reusable laryngoscope handle and two laryngoscope blades not placed in packaging in one of the drawers. Interview with the medical director at that time showed the facility normally used disposable laryngoscope items. However, the reusable laryngoscope handle and blades were available for use, primarily for one member of the local community who was a challenge to intubate and had a history of respiratory issues. She further stated the reusable equipment should have been sanitized and packaged according to acceptable standards of practice.

According to the Association of Perioperative Registered Nurses 2015 Edition of Guidelines for Perioperative Practice, the standards and recommendations for sterilization and disinfection include the following practice: Laryngoscope blades are semi-critical devices that require at a minimum high-level disinfection and "high-level disinfection devices that cannot be place in appropriate barrier material are prone to recontamination when stored".

Based on staff interview, medical record review, and review of policies and procedures, the facility failed to ensure effective pain management for 1 (#2) of 5 sample patients who required pain management. The findings were:

1. Review of the physician's history and physical for patient #2 showed the patient was admitted on 12/14/15 for epigastric pain. Review of the admission physician's orders revealed orders for pain management included intravenous Morphine 4 milligrams every 4 hours as needed. Review of the 12/13/15 to 12/15/15 patient progress notes, nursing assessments, and medication record revealed the following concerns:
a. Non-pharmacological interventions were not identified or evaluated for effectiveness; nor consistently implemented.
b. On 12/13/15 at 11:49 PM Morphine was administered for pain assessed at level 5 (pain level on a scale of 0 to 10 with 10 being the worst). No additional assessments were completed until 12/14/15 at 1:24 AM. At that time the assessed pain level was zero. Twenty-four minutes later, at 1:48 AM, the pain level was 7, but the patient did not receive Morphine until 2:18 AM when the assessed pain level increased to 10.
c. On 12/14/15 at 5:58 AM the assessed pain level was 10 and Morphine was administered. An additional pain assessment to determine the effectiveness of the pain medication was not done until 4 hours later at 9:57 AM. At that time the assessed pain level was 9 and Morphine was administered again.
d. On 12/14/15 at 8:51 AM the assessed pain level was 6 and Morphine was administered. An additional pain assessment to determine the effectiveness of the medication was not done until more than an hour later at 10 PM.
e. On 12/15/15 at 12:54 AM the assessed pain level was 6 and Morphine was administered. An assessment to determine the effectiveness of the medication was not done.

2. Review of the policy and procedure titled "Pain Management", approved 1/23/14, showed staff were required to complete a pain assessment within 30 minutes of administering intravenous pain medications. Review of the hospital policy on pain management, Procedure #3010-7, effective 2000, showed the following: "All patients will be assessed for presence, absence, and history of pain... "This will include such factors as description, intensity (0 -10 scale), location, aggravating and alleviating factors, signs and symptoms, impact on function ability, pain management in the past and patients goal for pain relief (0 - 10 scale)." ..."Pain intensity and pain relief will be assessed and documented" after pain management intervention once a sufficient time has elapsed for treatment to reach peak effect.

3. Interview on 12/17/15 at 8:30 AM with the CAPI revealed pain assessments were documented in various areas of the medical records and this made it difficult to track the before and after pain assessments.

Based on medical record review, patient interview, staff interview, and facility policies and procedures review, the facility failed to ensure a comprehensive care plan that addressed all patient concerns was developed for 3 of 20 sample patients (#2, #6, #10). The findings were:

1. Medical record review showed patient #6 was admitted to the facility on 12/13/15 with chest pain and discharged on 12/16/15. Review of the 12/15/15 discharge summary showed the following for the hospital course,"... [Gender] developed constipation in house requiring digital removal of stool and multiple laxatives. By the 3rd day [gender] chest wall pain was controlled with norco and constipation was resolved...Care should be taken in the home to prevent constipation with stool softeners and adequate hydration as well as laxatives as needed." Interview with the patient on 12/15/15 at 10:45 AM, just before discharge, showed his/her primary issue was constipation, and s/he had this issue other times in the past. The following concerns were identified:
a. Review of the care plan showed the facility failed to address the patient's issues with constipation.
b. Interview with the CPAI on 12/17/15 at 8:30 AM confirmed the facility failed to address the patient's issues regarding constipation in the plan.

2. Medical record review showed patient #10 was admitted to the facility on 7/14/15 with low back pain, Parkinson's Disease, and urinary retention. The patient was discharged on 7/17/15, returned to the facility on 7/18/15, and was admitted at that time with constipation and abdominal pain, and discharged to a long-term care facility on 7/23/15. Review of the 7/23/15 discharge summary showed the patient received a diagnoses of urinary retention on 7/14/15. The discharge summary included the following, "...[Gender] is having soft stools daily and [gender] is urinating. [Gender] has some urine retention if we do not offer toileting every 3-4 hours but [gender] has emptied [gender] bladder not needing straight cath." The following concerns were identified:
a. Review of the care plan showed no plan to address urinary retention.
b. Interview with the CPAI on 12/17/15 at 8:30 AM confirmed the facility failed to address the patient's urinary retention in the care plan.

3. Review of the physician's history and physical for patient #2 showed the patient was admitted on 12/14/15 for epigastric pain. Review of the admission physician's orders revealed orders for pain management included intravenous Morphine 4 milligrams every 4 hours as needed. Review of the December 2015 medication administration records showed the patient requested and received Morphine. However, review of the care plan showed pain had not been included in the patient's identified problems and interventions related to pain were lacking in the care plan.

4. Review of the policy and procedure titled, "Adult Patient Standards of Care" last revised on 11/6/15 showed the following, "The plan of care...1. Planning for care, treatment, and services is individualized to meet the patient's unique needs. Initiation and creating the plan of care is begun on admission. 2. To continue meeting the patient's unique needs, the plan is maintained and revised based on the patient's response at a minimum once daily. The plan may be modified or terminated based on reassessment, the patient's need for further care, treatment, and services, or the patient's achievement of goals. 3. The patient's goals and needs guide the consultation and collaboration relative to planning an implementing care, formulating the patient's plan of care."

Based on medical record review, staff interview, and policy and procedure review, the facility failed to ensure informed consents were completed for 3 of 9 sample patients (#17, #18, #24) who required informed consents. The findings were:

1. Review of the medical record for patient #17 revealed the patient received anesthesia during an endoscopic procedure on 12/16/15. Review of the informed consent form for the procedure and an additional one for anesthesia revealed both forms were incomplete. The sections for the date and time the patient signed the forms were blank.

2. Review of the medical record for patient #18 showed an anesthesia consent form, dated 12/15/15, was incomplete. The date and time the patient signed the form were lacking.

3. Review of the medical record for patient #24 revealed the patient was transferred to another facility on 1/16/15. Review of the informed/consent to transfer form showed the section for the physician's signature, date, and time was blank.

4. Review of the "Consent Guidelines" Policy and Procedure #7391, approved 11/4/14, showed purpose/expected outcome ..."to ensure that written informed consent contains all required elements and is obtained as required by law and prior to Surgical Services except in an emergency."

5. During an interview on 12/17/15 at 10:15 AM the CPAI stated it is the expectation that all informed consent forms be completed.

Based on review of employee files, staff interviews, and review of policies and procedures, the facility failed to ensure the nurse aide registry was checked prior to hire for 5 of 5 certified nurse aides (CNA) reviewed (#1 through #5). The findings were:

CNAs #1 through #5 employee files were reviewed on 12/16/15 at 3:45 PM. Of the 5 files reviewed, all lacked evidence to show the facility had checked the nurse aide registry prior to hiring the individuals. Review of policies and procedures revealed none had been developed that address pre-hire nurse aide registry checks. Interview with the Chief Human Resources Officer during review of the files revealed the nurse aide registry check had not been done for any of the CNAs currently employed and the facility did not have a policy and procedure that addressed this process. Interview with the Regulatory Consultant on 12/16/15 at 4:15 PM revealed the nurse aide registry had not been checked for 5 of 5 currently employed CNAs because staff did not know this was a regulatory requirement for swing-bed facilities.

Based on staff list review and staff interview, the facility failed to provide a qualified activity director for swing bed patients. The findings were:

Review of the facility provided staff list showed there was no staff member listed for activities. Interview with the CNO on 12/17/15 at 10:50 AM confirmed the facility did not have a qualified activity director for swing bed patients, and confirmed there were no swing bed patients currently at the facility.

Based on staff list review and staff interview, the facility failed to ensure a dental agreement to provide routine and emergency dental care for swing bed patients. The findings were:

Review of the facility provided staff list showed there was no dentist listed. Interview with the CNO on 12/17/15 at 10:50 AM confirmed the facility did not have an agreement with a dentist to provide routine or emergency dental care, and confirmed there were no swing bed patients currently at the facility.