HospitalInspections.org

Based on medical record review, interview and observation, it was determined that the hospital failed to accurately record a patient's code status directives for 1 of 30 inpatients reviewed. (Patient identifier is #18.)

Findings include:

Review on 4/17/19 of Patient #18's code status listed in the demographics of the hospital's electronic medical records revealed a code status of "Full Code."

Review on 4/17/19 of Patient #18's Pre-Admission Assessment dated 4/8/19 revealed that under the section patient identification information, the advanced directives were recorded as "DNR" [Do not resuscitate].

Review on 4/17/19 of Resident #18's history and physical dated 4/9/19 revealed the provider noted Patient #18's code status as full code.

Review on 4/17/19 of Resident #18's Case Management Admission Assessment, dated 4/10/19, revealed that under section Patient Identification information, the advanced directives were recorded as "DNR".

Interview on 4/17/19 at approximately 12:15 p.m. with Staff A (Case Manager) revealed that Patient #18 had wished to have a DNR code status.

Interview on 4/17/19 at approximately 12:20 p.m. with Staff B (Unit Manager) revealed that the facility would follow the physician's order for code status and Patient #18 did not have an order for a DNR code status. Staff B also revealed that a patient wearing a purple bracelet would indicate a code status of DNR.

Interview with Patient #18 and observation on 4/17/19 at approximately 12:25 p.m. revealed that Patient #18 did not want to be resuscitated and Patient #18 was not wearing a purple bracelet to indicate a code status of DNR.

Based on record review and interview, it was determined that the hospital failed to follow physicians orders for the use of pain medications for 1 of 30 patients for pain management prior to and after therapy treatment. (Patient identifier is #29.)

Findings include:

Review on 4/16/19 of Patient #29's physician's orders revealed the following order dated 4/3/19: "Oxycodone 2.5 mg PO [by mouth] Q[daily] 0700 & Q 1300 M[Monday]-Sat[Saturday] for 10 total treatment days".

Review on 4/16/19 of Patient #29 physician's orders revealed the following order dated 4/6/19: "1) D/C [discontinue] Oxycodone, 2) Tramadol 25mg [milligrams] PO Q [every] 8 [hours] PRN [as needed] mod [moderate] pain, 50 mg [milligrams] PO Q 8 [hours] PRN [as needed] severe pain..."

Review of the facility's "Pain Assessment Interventions" sheet categorizes a level of 8 as severe or horrible pain.

Review on 4/16/19 of Patient #29's "PRN Pain Medication Record" for April revealed that on 4/10/19 at 8:10 a.m., 25 mg of Tramadol was given to Patient #29 for a initial pain level of 8 out of 10 with a reassessment pain level at 9:10 a.m. of a 5 out of 10. The facility failed to follow physicians order by only giving 25 mg of Tramadol when 50 mg of Tramadol was prescribed.

Review on 4/16/19 of Patient #29's "PRN Pain Medication Record" revealed that on 4/11/19 at 8:25 a.m., 25 mg of Tramadol was given to Patient #29 for a initial pain level of 8 out of 10 with a reassessment pain level at 9:25 a.m. of a 3 out of 10. The facility failed to follow physicians order by only giving 25 mg of Tramadol when 50 mg of Tramadol was prescribed.

Review on 4/16/19 of Patient #29's "PRN Pain Medication Record" revealed that on 4/11/19 at 10:00 p.m., 25 mg of Tramadol was given to Patient #29 for an initial pain level of 8 out of 10 with a reassessment pain level at 10:30 p.m. of a 3 out of 10. The facility failed to follow physician's order by only giving 25 mg of Tramadol when 50 mg of Tramadol were prescribed.

Review on 4/16/19 of Resident #29's Medication Administration Record (MAR) for April revealed that since 4/6/19 when Patient #29's medication orders where changed, Patient #29 failed to receive pre-therapy pain management to prevent Resident #29 from reaching pain levels of 8/10 thus being unable to maximize therapy treatment. Patient #29's MAR showed that on 4/7/19, 4/8/19, 4/10/19, 4/12/19, 4/13/19, and 4/15/19 Patient #29 failed to receive pre-therapy medication treatment to maintain levels as ordered in the medical record.

Interview on 4/16/19 at approximately 2:00 p.m. with Staff C (Unit Manager) confirmed the above findings, and that the facility failed to follow physician's orders as written.

Based on record review and interview it was determined that the Hospital failed to ensure that the medical record was complete at a satellite hospital for 2 of 16 patients in a survey sample of 30 patients. (Patient identifiers are #22 and #23.)

Findings include:

Review on 4/17/19 at approximately 10:00 a.m. of the medical records for Patient #22 and #23 revealed that the preprinted forms confirmed by Staff H (Registered Nurse) as the Hospital form used for discharging patients was signed by the physician and the section below for the physician printed name was filled in with the physician name. All other sections of these discharge forms for Patients #22 and #23 were not filled in with the required individual patient discharge information.

Interview on 4/17/19 at approximately 11:30 a.m. with Staff H confirmed that the discharge forms for Patient #22 and #23 were pre-signed by the physician without any individual discharge information filled in for Patient #22 and #23.

Based on record review and interview, it was determined that the hospital failed to implement physicians orders as written for 1 of 30 inpatients reviewed. (Patient identifier is #4).

Findings include:

Review on 4/16/19 of Patient #4's physician orders revealed the following order dated 4/14/19: "Fluid restrictions 1.5 liter/day".

Review of Patient #4's care plan and also the nurses card ex which is over Patients #4's bed fails to show that this order was completed.

Interview on 4/16/19 with Staff D (Nurse Manager) confirmed that the facility failed to implement fluid restriction for Patient #4 as written by the physician on 4/14/19.

Based on observations and interview, it was revealed that the hospital failed to properly maintain water temperatures at an acceptable level of safety to prevent the possibility of scalding patents in their rooms.

Findings include:

Review of the "Guidelines for Design and Construction of Hospitals" reveals The facility Guidelines Institute 2018 Edition. Under section 2.1 "Common Elements for Hospitals" pg 135 Table 2.1-4 "Hot Water Use -General Hospital" 105-120 degrees Fahrenheit for clinical areas, the range represents the minimum and maximum allowable temperatures.

Observation on 4/16/19 at 10 a.m. revealed that the hot water in the public bathroom was hot to the touch. Based on this, Staff E (Director of Facilities) was asked if they had a thermometer to take water temperatures in patient's rooms. On 4/16/19 at 10:00 a.m. Staff E tested patient's rooms sink temperature which read 124 degree's. Staff E was then asked if the facility keeps temperature logs on patient room water temperatures. Staff E provided logs since the first of the year starting in January 2019. On review of the water temperatures logs titled "Water Temperature Check-Weekly...Test and record the temperature of 6 random samplings of hot water per week. 4 samples are to come from patient rooms and 2 from public areas" Then in April new logs were started titled "NRHN Engineering log (Daily/Weekly rounds". Based on both logs neither log showed the allowable temperatures to be maintained in order to protect patients from potential scalding or burning.

On review of the logs from January till time survey the water temperatures obtained from the logs ranged from 120 degrees up to 130 degrees as documented by facility. Interview with Staff E on 4/18/19 Staff E stated Staff E was unaware of the standards for water temperatures at patient faucets.

Based on observation and interview, it was determined the hospital failed to properly store dry food products, and properly load and unload dishes in the dish room to prevent cross contamination, and properly dating supplements by following manufactures instruction in 2 of 3 kitchens.

Findings include:

Observation on 4/16/19 during the initial tour of the kitchens located in Salem and in Nashua revealed that at both locations dish room personal, while washing the dishes, cross contaminated the dirty to clean and failed to wash their hands and change gloves when going from dirty to clean and back again. At both locations Staff F (Director of Food Service) was present and concurred with the findings. At time of survey Staff F had staff rerun the dishes that had been cross-contaminated.

Observation on 4/16/19 at 10 a.m. revealed that the Salem location had multiple food products such as white rice, bread crumbs, etc which had soup bowls located in the products to scoop material out of the containers.

Interview on 4/16/2019 with Staff F (Director of Food Services confirmed that the bowls should not be in the products as observed.

Observation on 4/16/19 at 10:05 a.m. while at the Salem location revealed that bulk product such as flower, sugar, and other items were left in the original shipping bags and then the shipping bags were placed in the containers and the product was not poured from the shipping bags into the holding containers. These shipping bags could be contaminated and unsanitary. By failing to transfer products from their original shipping bags into the holding containers could contaminate the food product already in the container.

Also while touring the kitchen at the Salem location there were multiple "Mighty shakes" located in the refrigerator. These dietary supplement shakes failed to have dates on them showing when they were defrosted. This product is only good for 14 days after being thawed. The facility failed to have a system in place for dating product once thawed so that they would know the use by date for the product.

Based on record review and interview, it was determined that the hospital failed to ensure that education on donation issues was inclusive of all patient care staff.

Findings include:

Review on 4/16/19-4/25/19 and of the facility's Memorandum of Understanding with their designated Organ Procurement Organization (OPO), which was entered into as of 4/29/15, reveals that a list of Duties are spelled out for the facility (Donor Hospital) and a list of Duties are spelled out for the OPO. Two of the Duties of the Donor Hospital are to "Designate a staff member who will collaborate with ... [OPO] to facilitate the development and implementation of an effective organ and tissue donation program." and to "Train the members of its medical staff with the current medical standards with respect to brain death criteria and with all relevant Donor Hospital policies and procedures." One of the Duties of the OPO is to "Conduct periodic in-service education programs on organ, tissue and eye donation."

Review on 4/16/19-4/25/19 of the training documentation provided by the facility revealed that the only documented training were those listed on the "CLINICAL STAFF CLASS ORIENTATION AGENDA DAY 1" which has a bullet listing for: Care of the Terminal Ill Patient Policy (Code Status, Advanced Directives, Organ bank, Pronouncement).

Interview on 4/16/19 p.m. with Staff G (Nurse Educator) established that this orientation is for nurses and nurse aides. When Staff G was asked about training of the medical staff with the current standards with respect to brain death criteria and all relevant facility policies and procedures, Staff G was not aware of that training having been done in the years that Staff G has been at the facility.