HospitalInspections.org

Based on a review of policy and procedure, medical records, and interview, it was determined the hospital staff initiated restraints without a complete order from the physician which would include the reason for the type of restraint in 2 of 2 records reviewed for restraints. (Patient's #18 and 21)

Failure to obtain a complete physician order has a potential risk for patients being restrained inappropriately.

Findings include:

The policy for Restraints Non-Violent and Non-Behavioral, revealed under procedures the initiation of restraints is based on an order from an LIP (licensed independent provider) who is responsible for rendering the care of the patient. The order of the restraint shall indicate the specific reason for the restraint. The policy required each episode of restraint requires an order - the order covers the duration of each episode and is not bound by clock time once the unsafe situation ends that necessitated the need for restraint; the restraint is discontinued based on the assessment of the LIP and RN (registered nurse).

The Physician Order & Daily Record for Medical Restraints form revealed on the form the following: "An episode of restraint will not exceed 24 hours. A new order must be received for every episode."

Patient # 18

Patient #18's medical record revealed the patient was restrained from 09/09/2015 through 09/13/2015. The attending physician documented an order to initiate restraints on 09/09/2015 at 2:40 P.M. The order included the reason for use, type of restraints and alternatives attempted. The orders subsequent to the initial order revealed the following: 09/10/2015 The order failed to include the type of restraint; the orders on 09/11/2015 09/12/2015, and 09/13/2015 was documented as a telephone order and failed to include the alternatives and were signed by the physician who did not provide the verbal/telephone order. The physician signatures were not dated as to when signed.

Patient # 21

Patient #21's medical record revealed the patient was restrained from 07/07/2015 through 07/09/2015. The physician orders for the restraints on 07/09/2015 revealed the physician failed to document an in-person assessment for the reason for the restraint, the type of restraint to be used and the alternatives attempted to discontinue the restraint.

The Director of the Medical Surgical Nursing unit reviewed the medical record with the surveyor on 11/04/2015, and in an interview on 11/04/2015, the Director confirmed the documentation was not present in the medical records for Patient #18 and #21.

Based on a review of the quality program, meeting minutes, and interview, it was determined the hospital's governing authority failed to document the board actively reviewed the results of the QAPI (Quality Assurance Performance Improvement) activities to include the data collection, analyses, activities for implementation, and projects to demonstrate decisions are made based on such review.

Findings include:

The Performance Improvement and Patient Safety Plan dated 2015 revealed the Board of Trustees of Valley View Medical Center has the overall responsibility for the safety and quality of the care, treatment, and services provided by all providers and employees and maintain ultimate responsibility for the Patient Safety and Clinical Quality Performance Improvement Plan. The Board requires and supports the establishment and maintenance of an effective organizational Patient Safety and Clinical Quality Performance Improvement Plan and recommend organizational and/or activity modifications.

A review of the Board of Trustees meetings from January through October 2015 revealed there was a report on the quality activities of the hospital provided by the hospital staff. There was no documented evidence the board members discussed the reports, analyzed the reports, made recommendations or confirmed the activities of the hospital. The minutes stated under action "Information" after each of the Quality agenda items.

The Director of Quality stated during an interview, conducted on 11/04/2015, the Board Chairman attended the hospital Quality Council meetings and was very active in the discussion at this meeting. The surveyor reviewed with the Director of Quality the attendees for the Quality Council meetings for January through October 2015 and the Board Chairman was only in attendance at the October meeting and not present at any of the other quality council meetings.

Based on review of clinical records, review of hospital policies and procedures, and staff interviews, it was determined for five of ten in-patients, the hospital failed to ensure physician ordered medications were administered within the time frames identified in their policies and procedures. (Patients #: 1, 2, 4, 18, and 19)

Findings include:

The hospital's policy on the subject of Time Critical and Non Time Critical Meds, 13-20 included: "...Time critical scheduled medications are those where early or delayed administration of maintenance doses of greater than 30 minutes before or after scheduled administration time may cause harm or result in substantial sub-optimal therapy or pharmacological effect. Non time critical scheduled medications are those where early or delayed administration of maintenance doses within a range of either 1 or 2 hours from scheduled administration time will not cause harm or result in substantial sub-optimal therapy or pharmacological effect...Time critical medications include and must be administered within 30 minutes before or after scheduled administration time...Non time critical medications may be administered within 1 hour before or after the scheduled time, but should be administered as close to the scheduled time as possible...."

Patient #1

Patient #1 was a current inpatient on the medical/surgical unit. The patient had physician orders for intravenous multivitamins, folic acid and thiamine daily. A review of the Medication Administration Records revealed the IV was scheduled to be administered at 9 a.m., however, was not administered until 11:30 a.m., two hours later. The late dose reason was "Medication not Available."

Patient # 2

Patient #2 was a current inpatient on the medical/surgical unit during the survey. A review of the MAR's for the period from 10/31/2015 through 11/02/2015 revealed the following physician ordered medication was administered late because the nurse was "Administering Other Meds."

11/02/2015-Apresoline (antihypertensive) 25 mg scheduled for 3 p.m. was not administered until 4:18 p.m.

Patient # 4

Patient #4 was a current inpatient on the medical/surgical unit during the survey. A review of the MAR's for the period from 10/26/2015 through 11/03/2015 revealed the following medications were administered late. The late dose reason was "Administering other meds."

10/26/2015
Advair Diskus 1 puff was scheduled for 7 a.m. administration but was not administered until 8:44 a.m. No reason was documented.

10/27/2015
Solumedrol 40 mg IV push 12 noon dose was not administered until 1:23 p.m.

10/28/2015
Solumedrol 40 mg IV push scheduled for 12 midnight was not given until 1:30 a.m.
Zosyn (antibiotic) IV scheduled for 10 a.m. was not given until 10:41 a.m.

10/29/2015
The IV Zosyn scheduled for 2 a.m. was not given until 2:55 a.m.
Protonix 40 mg scheduled for 7:30 a.m. was not given until 8:56 a.m.

10/30/2015
Protonix 40 mg by mouth scheduled for 7:30 a.m. was not administered until 9:28 a.m.
Duoneb inhalation and Advair Diskus scheduled for 7 p.m. administration were not administered until 8:03 p.m.

10/31/2015
Protonix 40 mg by mouth scheduled for 7:30 a.m. was not administered until 9:26 a.m.
Proventil nebulizer scheduled for 7 a.m. was not administered until 10:23 a.m.

11/01/2015
Protonix 40 mg by mouth scheduled for 7:30 a.m. was not administered until 8:37 a.m.
Duoneb inhalation and Pulmicort nebulizer scheduled for 7 p.m. were not given until 8:08 p.m.

11/02/2015
Flagyl 500 mg by mouth and Merrem (antibiotic) 1 gram IV scheduled for 2 p.m. were not given until 4:12 p.m.

Patient # 18

Patient #18's medical record for one day, 09/13/2015, revealed 19 of the 30 ordered medications were administered outside of the reported required administration timeframe of 30 minutes prior or 30 minutes from the documented ordered time.

The medications to be administered revealed the following examples of medications administered outside of the stated policy: Lasix; Diflucan; Clinimix E; Multirace; Regular Insulin; potassium Acetate; Magnesium Sulfate; Potassium Phosphate; Accu-check Fingerstick Glucose; and Protonix were all administered 1 hour or later after the documented administration time. The RN documented this was due to "Administering Other Meds."

Patient # 19

Patient #19's medical recored for the date of 10/01/2015 revealed medications were not administered as ordered. The following medications were administered outside of the stated policy. Zosyn was ordered to be administered at 10:00 A. M. and was not administered until 10:58 A.M., one hour from the documented time of administration. Trans DermScop Patch was ordered to be administered at 2 P.M. and was administered at 6 P.M., four hours from the documented administration time. The RN documented the reason for the delay was "Administering Other Meds."

An interview was conducted on 11/05/2015 with the Chief Nursing Officer and one the staff pharmacists. They reported being aware of some medications not being administered following their policies and procedures.

Based on a review of the hospital policy and procedure, medical records, quality audits and interviews, it was determined the hospital failed to ensure blood administration was performed according to the hospital policy and procedure in one of one medical record reviewed for blood transfusion. (Patient #18) as evidenced by:

1. The intensive care staff failed to document two qualified individuals verified the blood unit is the correct unit for the patient;

2. The intensive care staff failed to monitor the patient as frequently as required by the hospital policy; and

3. The system for monitoring the compliance to the policy and procedure completed by the laboratory staff identified the non-compliance with the hospital policy, and there has not been action to improve compliance as of the date of the survey, November 6, 2015.

The failure of not following the hospital policy and procedure by the intensive care staff has the risk of the incorrect blood products being administered and a patient adverse event due to the transfusion not being identified through the failure of not assessing the patient throughout the transfusion.

Findings include:

1. The approved Blood Administration Policy revealed under Identification that verification is to be done by 2 nurses (one RN and one other licensed professional).

Patient #18's medical record revealed the patient received packed red blood cells on 09/14/2014. The patient received a blood transfusion at 0500; 0515; 0530 and 0600.

The transfusion was documented as initiated at 0500 and revealed only one nurse verification completed. There was no documented evidence of a second qualified person verification of the packed red blood cells. The packed red blood cells documented as initiated at 0515 revealed one RN verification and the second nurse documented in the visible medical record revealed the second verification was the same nurse as who documented the first verification. The packed red blood cells documented as initiated at 0530 revealed in the nursing documentation one nurse verification and no second verification. Packed red blood cells documented as initiated at 0600 revealed one RN verification and no second nurse verification.

The Director of Quality and the Director of the Medical Surgical inpatient unit revealed during an interview the computerized system requires multiple sign ins to do the verifications and this can then record the same nurse doing both verifications and/or eliminate the second verification. The Directors could not determine at the time of the survey if this was a failure of not having two staff members verify the units of blood prior to transfusion or if this was a failure in the automation documentation system.

The record was reviewed with a staff RN, and the RN confirmed the above findings related to the verification prior to administration of the blood product and patient verification was not clearly documented as being in compliance with the hospital policy and procedure.

2. The approved hospital policy and procedure revealed under Assessment the vital signs are to be taken prior to initiating the transfusion, after initiating the transfusion, and continued vital signs are to be taken and timed at 15 minutes, 30 minutes and every 30 minutes until completed and PRN (as needed) if patient condition warrants.

Patient #18's record revealed for the packed red blood cells administered at 0515; 0530; and 0600 the only vital signs documented were the pre administration vital signs.

Patient #18 was actively bleeding and required emergency admission to the operating room. There was no documented evidence of vital signs or nursing assessments of the patient's condition during the rapid administration of the blood products to attempt to stabilize the patient.

The documentation in the medical record was reviewed with a staff RN who verified there was no evidence of the nursing assessment of the patient from 0500 through 0600 on 09/14/2015.

The surveyor reviewed the medical record documentation with a hospital staff RN and she confirmed there was no documented vital signs on the blood transfusion form.

3. The Director of the Laboratory and the Blood Bank lead technician revealed in an interview conducted on 11/04/2015, the technician completes an audit on all blood transfusions to ensure compliance with the policy and procedure.

The audits revealed there was a concern identified in July, August, and September 2015 with the compliance of the intensive care unit staff with the policy and procedure for transfusions.

A review of the documented audits revealed in July 2015 there were 12 events of blood product administration in the intensive care unit. Seven of the 12 events revealed there was non-compliance with two registered nurses completing the verification prior to administration of the blood product(s), and 8 of the 12 events with failure to complete the vital signs as required by the policy and procedure.

The August 2015 reports revealed 10 events for blood product administration. Six of the 10 events there was no documented evidence of compliance with two RNs verifying the blood products prior to administration. Five of the 10 events revealed vital signs were not documented as required by the hospital policy and procedure.

The September 2015 reports revealed 4 events of blood product administration. Two of the four events did not clearly identify that there were to qualified RNs completing the verification. Two of the four events revealed vital signs were not documented as required.

The Laboratory Director stated the audits are reported to the Pharmacy and Therapeutics Committee related to the blood transfusion. A review of the Pharmacy and Therapeutic Committee meeting minutes revealed the committee meets once each quarter and there had not been a meeting since the July 23, 2015 meeting so the audits of the July, August, and September blood transfusion results had not been presented.

Based on review of clinical records, review of hospital policies and procedures, and staff interviews, it was determined for one of one patient, (Patient #16) the hospital failed to ensure all documentation entered into patient's legal record was accessible and retrievable; which is a potentail health risk for the patient that information needed by all care givers is not readily available if needed.

Findings include:

The hospital's Legal Health Record (LHR) Policy, Policy State ID: 1400740, included: "This LHR defined for disclosure is a hybrid record, created from the paper medical record and the EHR consisting of MedHost, EDIS, Nexgen, Cintricity, Epiphany, Lab Corp, LMC, Redoc and documents, the two serving together to form the entire LHR defined for disclosure. The Legal Health Record at Valley View Medical Center includes the documentation of health care services provided to an individual in all delivery settings by our clinical and professional staff. The LHR consists of individually identifiable data in any medium, collected, processed, stored, displayed, and directly used in documenting health care delivery or health status. The LHR at Valley View Medical Center is a hybrid record utilizing both paper-based and electronic documents, which are captured both manually and via electronic processes...Standardized formats are used for documenting all care, treatment, and services provided to patients. The LHR contains sufficient information to identify the patient, support the diagnosis, justify the treatment and services, documents the course and results of care, and promotes the continuity of care among health providers."

The hospital's Blood Product Administration policy, Policy Stat ID: 1657049, included: "Identification is to be verified at the bedside before blood is administered. All information is to match exactly...Verification is to be done by 2 nurses (one RN and one other licensed professional)...The Transfusion Record is to be signed by both nurses who verify the identification of the patient AT THE BEDSIDE. If not documenting in HMS. When documenting in HMS the verifying nurse must be logged on in as the user and complete the 2nd nurse verification."

Patient #16 was a patient in the Intensive Care Unit during the survey. A review of the clinical record revealed the patient received packed red blood cells on 11/04/2015 following physicians orders.

An interview was conducted with the ICU nursing staff on 11/05/2015 at 9:45 a.m. The Registered Nurse (RN) assigned to Patient #16 was asked to locate the documentation of verification of the blood product and patient by two RN's prior to the administration of the blood on 11/04/2015. The RN who was the verifying nurse located documentation of her verification, however she was not able to locate the documentation by the RN who administered the blood. She reported that the documentation by both RN's was in the computer prior to the blood administration and was witnessed by the Manager of the Medical/Surgical Unit.

The Manager of the Medical/Surgical Unit acknowledged during a later interview that she saw the documentation by both RN's in the clinical record.

The Chief Nursing Officer and the Director of Quality reported during interviews that their current electronic health record system was complex and did not realize that some patient care information entered into the system was not retrievable.

Based on review of hospital Medical Staff Bylaws, medical records and interviews, it was determined that the hospital failed to require a complete history and physical examination of a patient prior to surgery for 4 of 6 patients who underwent surgical procedures (Pt #s 11, 13, 27 and 28).

Failure to provide a complete history and physical as per hospital Medical Staff Bylaws poses a potential health risk for the patient that their current medical condition is not readily available to all care givers involved in their delivery of care.

Findings include:

Review of the hospital Medical Staff Bylaws revealed: "...A medical history and physical examination must be completed and documented for each patient no more than thirty (30) days before or twenty-four (24) hours after admission or registration, but prior to surgery and prior to procedures requiring anesthesia services, regardless of whether care is being provided on an inpatient or outpatient basis...."

Pt # 11

Review of Pt # 11's medical record revealed that she underwent a total laparoscopic hysterectomy with bilateral salpingo-oophorectomy on 9/8/15. Review of the form titled History & Physical Record revealed a physician's illegible handwriting in the space designated for Chief Complaint and Indications for Procedure. Spaces designated for Medical History and Family History contained handwritten zeros. The space for Social History was blank. Spaces for Past Hospitalizations and Prior Operations contained a single short handwritten straight line. Spaces for Present Medications and Allergies and "NKA" (No Known Allergies) were all blank. Hand writing in the spaces for Diagnosis/Impression and Plan of Care was illegible. The space for date was blank. Spaces for Vital signs were blank. Categories listed under Physical Examination contained spaces for "WNL" (Within Normal Limits) and "Other" and lines to record descriptive remarks. Hand written lines were drawn at diagonal angles in the spaces for "WNL", including the space for "Rectal/Pelvic".

The medical record contained documentation recorded by a cardiologist, that the patient had a history of coronary artery disease and a family history of cardiovascular disease. This information was not included or referenced in the History and Physical Examination.

Pt # 13

Review of Pt # 13's medical record revealed that he underwent surgery for a Right Total Knee Replacement, on 9/22/15, "utilizing minimally invasive surgical technique, non muscle cutting approach" and "computer assisted navigation right knee replacement surgery." The medical record contained documentation that Pt # 13 had diabetes, hypertension, history of "heart attack", and "GERD" (Gastroesophogeal Reflux Disease). Physician's Assistant (PA-C) # 6 utilized the form titled History & Physical Record to document the History and Physical Examination required prior to surgery. The Physical Examination did not contain documentation of vital signs. Categories listed under Physical Examination contained X marks in the spaces for "WNL", including Heart and Chest/Lungs, with no description of the findings of the examination documented.

Pt # 27

Review of Pt # 27's medical record revealed that she underwent a Hysteroscopy for removal of an Essure coil, on 10/20/15. MD # 8 documented the History and Physical Examination on a revised form for that purpose. Review of the form revealed illegible writing in the space designated for Chief Complaint. Spaces designated for Past Medical History, Allergies, including "NKDA" (No Known Drug Allergies) and Known Allergies were blank. Under Review of Systems, spaces for Renal, "GU" (Genitourinary), Hematology, Musc/Skeletal, Skin and Immunizations were all blank. The space for Date/Time contained a horizontal line drawn across the space. The space designated for Impression and proposed Plan of Care contain illegible handwriting.

Pt # 28

Review of Pt # 28's medical record revealed that she underwent a "Mesh,Vaginal Removal or Revision", on 10/10/15. MD # 8 documented the History and Physical Examination on a revised form for that purpose. Review of the form revealed illegible writing in the space designated for Chief Complaint. Spaces designated for Past Medical History, Allergies, including NKDA and Known Allergies were blank. Under Review of Systems, spaces for Renal, GU, Hematology, Musc/Skeletal, Skin and Immunizations were all blank. The space for Date/Time contained an illegible date.

The Director of Surgery and the Director of Med/Surg confirmed, during interviews conducted on 11/4/15, that the Histories and Physical Examinations documented for Pt #s 11 and 13 were incomplete.

Physician # 4, a surgeon, confirmed, during interview conducted on 11/5/15, that the Histories and Physical Examinations documented for Pt #s 11, 13, 27 and 28 were incomplete and that MD # 8's handwriting was illegible in his documentation of the Histories and Physical Examinations of Pt #s 11, 27 and 28.