HospitalInspections.org

18559

Based on credential file review, governing board bylaw review, and interview, the provider failed to ensure physicians' credentials and privileges had been reviewed and approved every two years for two of two telemedicine physicians' (D and E) staff reappointments. Findings include:

1. Review of physicians D and E's credentialing files revealed:
*Both physicians were telemedicine emergency physicians.
*They had been appointed to the medical staff on 7/19/16.
*Neither physician had been reappointed to the medical staff.

Review of the provider's 1/27/09 governing board bylaws revealed all appointments to the medical staff would have been for a two year period and needed to be renewed every two years.

Interview on 7/31/19 at 2:30 p.m. with director of health information C revealed:
*She was responsible for credentialing.
*All physicians should have been reappointed every two years.
*Physicians D and E had not been placed on her list to be reappointed.
*Physicians D and E should have been reappointed in July 2018.

Interview on 7/31/19 at 2:50 p.m. with administrator A revealed she was not sure how often the physicians should have been reappointed.

A. Based on quality assurance record review, and interview, the governing board failed to ensure a comprehensive quality assurance program had been established. Findings include:

1. Review of the provider's quality assurance program revealed:
*Department quality information had not been shared with the hospital wide quality assurance program.
*Quality indicators and benchmarks had not been established.
*Department information review, interventions, and follow-up had not been documented.

Refer to C330, findings 1 and 2.

B. Based on credential file review, governing board bylaw review, and interview, the governing board failed to ensure physicians' credentials and privileges had been reviewed and approved every two years for two of two telemedicine physicians' (D and E) staff reappointments. Findings include:

1. Review of physicians D and E's credentialing files revealed:
*Both physicians were telemedicine emergency physicians.
*They had been appointed to the medical staff on 7/19/16.
*Neither physician had been reappointed to the medical staff.

Review of the provider's 1/27/09 governing board bylaws revealed all appointments to the medical staff would have been for a two year period and needed to be renewed every two years.

Interview on 7/31/19 at 2:30 p.m. with director of health information C revealed:
*She was responsible for credentialing.
*All physicians should have been reappointed every two years.
*Physicians D and E had not been placed on her list to be reappointed.
*Physicians D and E should have been reappointed in July 2018.

Interview on 7/31/19 at 2:50 p.m. with administrator A revealed she was not sure how often the physicians should have been reappointed.

Based on record review, interview, and policy review, the provider failed to ensure:
*Physician's orders were clarified prior to the delivery of ordered care for one of one sampled patient (10) who required thickened liquids.
*The registered dietician had been notified to review one of one sampled patient (10) who required a therapeutic diet.
*Speech therapy had been involved and reviewed one of one sampled patient (10) who had swallowing difficulties and required thickened liquids.
*The care plan had identified all areas of concern for one of one sampled patient (10) to ensure proper care and services had occurred for him.
Findings include:

1. Review of patient 10's medical record and care plan revealed:
*He had been admitted on 7/5/19 to acute care.
*On 7/20/19 he was discharged from acute care and admitted to their swingbed program.
*His admitting diagnoses included: dehydration, transient ischemic attack (TIA), and dementia - vascular.
*On 7/18/19 he was diagnosed with right lower lobe pneumonia.
*He had swallowing difficulties, and on 7/20/19 the physician had ordered him to have thickened liquids.
-Those orders had not supported the consistency/thickness of the liquids the patient required for his safety.
*There was no documentation to support the nursing staff had:
-Clarified the physician's orders to ensure the patient received the right consistency and thickness of those liquids.
-Referred the patient to the registered dietician to ensure a proper nutritional assessment had been completed on him.
-Referred or recommended the speech therapy department to assess him for the appropriate thickness of those liquids for his continued safety and overall well-being.

Review of patient 10's 7/20/19 nutritional assessment revealed:
*The assessment:
-Had been completed by a registered nurse.
-Supported he had swallowing problems and required thickened liquids.
*There was no documentation to support:
-The consistency and thickness level of those liquids the patient had required for his safety.
-The registered dietician had reviewed the patient for the appropriateness of his diet and thickness of liquids.

Review of patient 10's 7/17/19 care plan revealed:
*He had two focus areas identified on his care plan.
*Those areas of concern had been:
-"Alteration in thought processes related to factors associated with aging and TIAs."
-"Alteration in comfort: pain related to immobility/improper positioning and falls."
*There was no documentation to support the care plan had been updated to ensure the following focus areas had been identified as a concern for him for his overall health and well-being:
-Alteration in ineffective airway related to his diagnosis of pneumonia.
-Alteration in swallowing capabilities related to his need for thickened liquids and the risk for aspiration pneumonia.

Medical record review and interview on 7/31/19 at 3:05 p.m. with the director of nursing regarding patient 10 revealed:
*She confirmed the above medical record review.
*She agreed the nursing staff should have:
-Clarified the physician's orders of thickened liquids to support the level of thickness the patient required for his safety from aspiration.
-Referred him to the registered dietician and speech therapy department for review due to his swallowing difficulties and requirement of thickened liquids.
*She agreed the care plan should have:
-Supported an individualized focus area for each of those areas of concern.
-Supported interventions for those focus areas to ensure a successful and safe recovery process had occurred for him.

Review of the provider's September 2014 Nursing Plan of Care policy revealed: "The patient's plan of care is based on the Nursing Process and is utilized to communicate actual or potential patient health problems identified by the nurse which require nursing interventions."

Review of the provider's July 2007 Documentation policy revealed:
*Purpose:
-"To analyze, synthesize, and collate the extensive collection of patient data from flowsheets into a summary statement which highlights the caregiver's clinical decision making."
-"To highlight the major focus of patient concern, caregiver intervention, and patient outcome to that intervention."
-"In summary, to communicate essential information to help the entire health care team provide continuity of care and quality of care."

Based on record review, interview, and interview, the provider failed to ensure one of nine sampled acute care patients (18) had a comprehensive care plan. Findings include:

1. Review of patient 18's medical record revealed:
*She had been admitted on 5/26/19.
*The diagnosis for her hospitalization was for acute left sciatica pain.
*The results of her CT scan revealed she had osteoarthritis with joint space narrowing and moderate colonic bowel burden.
*Her admission nursing assessment revealed she:
-Had diarrhea but no vomiting or nausea.
-Was ambulatory with assistance and used a walker.
-Was dependent on staff to assist with her activities of daily living (ADL).
-Had denied discomfort or pain at 7:15 p.m.
*A 5/26/19 admission assessment note of her history of present illness revealed "C/O [complains of] pain (L) [left] hip area down to ankle on admission. States pain started during the night and increased today. No pain @ present."
*The admission nursing diagnosis/goal was for comfort: pain.

Review of patient 18's nursing notes revealed:
*5/26/19 at 6:20 p.m. "Pt [patient] admitted OBS [observation] status from ER [emergency room]. Pt moved on ER stretcher. Changed into gown. States has no pain @ present because she is laying down. To CT per cart for CT scan. Moved to table by 2 lifting. Back to cart per 3 lifting. Back to room with stretcher. pt able to stand with walker & standby assist X [times] 2 to transfer to bed. "
*5/26/19 at 9:30 p.m. "Up to BR [bathroom] with walker & assist of 1. States pain started in (L) hip down to ankle about an hour ago. Pain is "6" on 1-10 scale. Large loose stool & voided. Requests pain med. [medication]. Hydrocodone APAP [acetaminophen] 10/325 one given po [by mouth] for pain with other hs [hour of sleep] meds. Assisted with hs cares."
*5/26/19 at 11:30 p.m. "Incontinent of large stool in brief. Unable to clean self- assisted with cleaning. Small open area on coccyx. Back to bed. States pain pill eased pain some but has numbness in leg. Requests aide to sleep. Diazepam 2 mg [milligram] give po."
*5/27/19 at 3:58 a.m. "States has to go to BR. Inc [incontinent] of stool in brief. Assisted to BR."
*5/27/19 at 4:00 a.m. "States pain increase in (L) leg unable to get off stool. States unable to stand on leg. Assisted to stand with walker and assist of 2. Put on commode and wheeled to bedside and assist of 2 to bed. Unable to lift legs in. Small emesis in BR - bile colored liquid. States pain is 10 on 1-10 scale when standing. Will hold pain med due to emesis."
-Her physician had not been notified of her emesis.
*5/27/19 at 6:45 a.m. "States slept some. States pain is centered around (L) knee right now. "Feels like its going to explode." Hydrocodone 10/325 given po for pain."
*5/27/19 at 8:00 a.m. "Up in bed. Slurring speech. Faint breath sounds, regular rate/rhythm radial pulse. muffled bowel sounds. C/O (L) knee "7" on 1-10 scale for pain Pedal edema +1-2. Rec'd [received] hydrocodone 10/325 @ 0645 [6:45 a.m.]."
*5/27/19 at 10:30 a.m. "Reddened area under abdominal fold and peri-groin area noted after showered by CNA [certified nursing assistant]. Calmozine applied. Up in recliner."
*5/27/19 at 1:00 p.m. "Up to BR with moderate assist to BR several times (x5) this shift - some med [medium] and others small -diarrhea. 30cc [cubic centimeter] MOM [milk of magnesia] given for CT results "moderate stool burden", not evidence of obstruction."
*5/27/19 at 6:30 p.m. " No BM [bowel movement] since MOM administered. No C/O abdominal discomfort. Sluggish bowel sounds."
*5/27/19 at 7:30 p.m. "No stools since MOM given."
-That was documented five and one-half hours after the MOM had been given.
*There was no further documentation regarding the result from the MOM administration, open area on her coccyx, or reddened area under her abdominal fold and peri-groin area.
*She was discharged on 5/28/19 at 1:00 p.m.

Review of the nursing shift assessments for patient 18 revealed on:
*5/27/19, 7:00 a.m. through 7:00 p.m. she had:
-Been marked as a high risk for falls.
-Been assessed as having no skin problems.
-Normal bowel sounds.
-A bowel movement on 5/26/19.
*5/27/19, 7:00 p.m. through 7:00 a.m. she had:
-Been marked as a high risk for falls.
-Been assessed as having no skin problems.
-Normal bowel sounds.
-A bowel movement on 5/27/19.
*5/28/19, 7:00 a.m. through 7:00 p.m. she had:
-Been marked as a high risk for falls.
-Been assessed as having no skin problems.
-Marked other for her bowel sounds.
-A bowel movement on 5/27/19.

Review of a 5/27/19 at 1:30 p.m. physician's progress note for patient 18 revealed:
*The CT scan results had indicated a moderate colonic stool burden.
*She had been having frequent loose stools since last night.
*No further physician documentation of her bowel status.

Review of patient 18's 5/28/19 physician's discharge summary revealed:
*"Among all the findings of the CT of the pelvis, she was positive for moderate colonic stool burden for which she was given milk of magnesia to help her have a good bowel movement."
*"Patient is to continue all her previous home meds as before plus 2 new ones which are Flexeril 10 mg [milligram] 1 tablet 1 to 3 times a day p.r.n. [as needed] for muscle pain and 2, MiraLax 1 packet mixed with water at bedtime."

Review of patient 18's 5/26/19 nursing care plan revealed the only focus area had been alteration in comfort/pain.

Interview on 7/31/19 at 3:00 p.m. with the director of nursing confirmed the above findings. She agreed the care plan had not addressed patient 18's moderate colonic stool burden, her high fall risk, her need for assistance with her ADLs, and her skin.

Review of the provider's September 2014 Nursing Plan of Care policy revealed: "The patient's plan of care is based on the Nursing Process and is utilized to communicate actual or potential patient health problems identified by the nurse which require nursing interventions."

Review of the provider's July 2007 Documentation policy revealed:
*Purpose:
-"To analyze, synthesize, and collate the extensive collection of patient data from flowsheets into a summary statement which highlights the caregiver's clinical decision making."
-"To highlight the major focus of patient concern, caregiver intervention, and patient outcome to that intervention."
-"In summary, to communicate essential information to help the entire health care team provide continuity of care and quality of care."

Based on interview and record review, the provider failed to ensure a comprehensive facility wide quality assurance performance improvement (QAPI) program to include all departments or patient care departments/services had been developed and implemented a system/process improvement plan. Findings include:

1. Interview on 7/31/19 at 3:10 p.m. with the director of nursing revealed:
*She was responsible for QAPI.
*There had been no formal meetings conducted since August 2018.
*She had taken handwritten notes on what each department was currently working on during their daily department head lineup meetings.
*There had been no meetings planned and conducted to ensure compliance was maintained by all departments to ensure quality of care was delivered to all patients.
*She stated:
-"There are no formal reports for any committee to review."
-"Each department reviews their own concerns within their department."
-"There are no benchmarks/goals or interventions discussed and put in place for them to follow."
-"No, QA [quality assurance] is not a part of the medical staff and there are no formal reports for anyone to review."
*She:
-Confirmed all components of the hospital should have been incorporated into a committee and reviewed at a minimum of quarterly to ensure compliance for the patients' safety and well-being.
-Agreed with a breakdown of that committee and regular meetings they had created the potential for poor quality of care to have occurred.

Interview on 7/31/19 at 3:35 p.m. with the administrator revealed she:
*Confirmed there had not been a formal meeting or QAPI committee established since August 2018.
*Agreed:
-There should have been to ensure all components and concerns of the hospital and departments had been reviewed on a regular basis.
-That was an important committee and should have continued on a regular basis to ensure compliance was maintained.

2. Review of the provider's QA program revealed:
*Quality indicators, benchmarks, and goals had not been established for each department.
*Department information review, interventions, and follow-up had not been documented.
*There were no guidelines or policies to review for a QA program.

Based on record review and interview, the provider failed to perform a yearly review for the surgical, infection control, nursing service, and swing bed policy and procedure manuals. Findings include:

1. Review of the following manuals revealed they had not been reviewed by the medical director on a yearly basis. The last time the policy and procedure manuals had been reviewed and/or revised had been:
*Surgical policy and procedure manual on 4/24/17.
*Infection control policy and procedure manual in August 2017.
*Nursing service policy and procedure manual on 8/15/17.
*Swing bed policy and procedure manual

Interview on 7/31/19 at 3:00 p.m. with the director of nursing revealed:
*She was aware the above policy and procedure manuals had not been reviewed or revised for at least two years.
*Two to three policy and procedure manuals used to be reviewed at the medical staff meetings.
*The provider did not have a current plan to review or revise the policy and procedure manuals.

Based on record review, interview, and policy review, the provider failed to ensure appropriate and timely Medicare Non-coverage notices had been provided for two of nine samples patients (7 and 9) who had been discharged from their skilled services and swingbed program. Findings include:

1. Review of patient 7's medical record revealed:
*Her skilled services under the swingbed program had started on 5/2/19 and ended on 5/7/19.
*She had:
-Covered days remaining and had been discharged from the facility.
-Not received the Notice of Medicare Non-Coverage notice (NOMNC) form two days prior to her discharge.
*She was not provided the necessary information for her to contact the Quality Improvement Organization (QIO) should she have considered an appeal on that decision prior to being discharged.

2. Review of patient 9's medical record revealed:
*Her skilled services under the swingbed program had started on 5/30/19 and ended on 6/3/19.
*She had:
-Covered days remaining and had been discharged from the facility.
-Not received the NOMNC form two days prior to her discharge.
*She was not provided the necessary information for her to contact the Quality Improvement Organization (QIO) should she have considered an appeal on that decision prior to being discharged.

3. Interview on 7/31/19 at 3:00 p.m. with the director of patient care regarding the above patients revealed:
*She:
-Confirmed the medical record reviews above.
-Had not been aware the NOMNC form should have been completed and signed two days prior to the patient's services ending.
*Neither resident had been given the NOMNC form and the opportunity to appeal their decision.
*She agreed their rights to appeal that decision had not been honored.

Review of the provider's 4/11/17 Level of Care Skilled Criteria policy revealed:
*"In cases where a physician determines that skilled level of care is inappropriate, then a notice will be explained and given to the patient and/or his representative.
-There was no documentation to support what the timeliness of that required notification was.

Based on record review, interview, and policy review, the provider failed to ensure the care plan had identified all areas of concern for 1 of 15 sampled patients (10) to ensure proper care and services had occurred for him. Findings include:

1. Review of patient 10's medical record and care plan revealed:
*He had been admitted on 7/5/19 to acute care.
*On 7/20/19 he was discharged from acute care and admitted to their swingbed program.
*His admitting diagnoses included: dehydration, transient ischemic attack (TIA), and dementia - vascular.
*On 7/18/19 he was diagnosed right lower lobe pneumonia.
*He had swallowing difficulties, and on 7/20/19 the physician had ordered him to have thickened liquids.

Review of patient 10's 7/17/19 care plan revealed:
*He had two focus areas identified on his care plan.
*Those areas of concern had been:
-"Alteration in thought processes related to factors associated with aging and TIAs."
-"Alteration in comfort: pain related to immobility/improper positioning and falls."
*There was no documentation to support the following focus areas had been identified as a concern for him to ensure his overall health and well-being had occurred:
-Alteration in ineffective airway related to his diagnosis of pneumonia.
-Alteration in swallowing capabilities related to his need for thickened liquids and the risk for aspiration pneumonia.

Medical record review and interview on 7/31/19 at 3:05 p.m. with the director of nursing regarding patient 10 revealed:
*She confirmed the above medical record review and care plan.
*She agreed the care plan should have:
-Supported an individualized focus area for each of those areas of concern.
-Supported interventions for those focus areas to ensure a successful and safe recovery process had occurred for him.

Review of the provider's September 2014 Nursing Plan of Care policy revealed:
*"The patient's plan of care is based on the Nursing Process and is utilized to communicate actual or potential patient health problems identified by the nurse which require nursing interventions."
*"The plan identifies goals which are mutually established with the patient/family/significant other and also includes nursing measures that will facilitate the medical care prescribed and that will restore, maintain or promote the patient's well-being."
*Purpose:
-"To promote effective individualized nursing care for the patient based on the nursing process.
-To promote accurate communication between all team members involved in the care of the patients."