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Based on interview, record reviews, and review of hospital policies and procedures, the hospital failed to ensure that its patients receive the care in a setting appropriate to the patient's needs and supplies those resources to ensure that its intensive care unit is continuously active for any patient who might require those services and failed to ensure that the hospital ensures oversignt and monitoring of all of the hospital's services.

The findings are:

Cross Reference to A 0263: The hospital failed to ensure Continuous Quality Improvement review of completed quality indicators, staff competencies, governing body oversight and properly allocated personnel to ensure adequate resource availability for the program.


Cross Reference to A 0385: The hospital failed to ensure a well organized service with a plan of administrative authority and delineation of responsibilities for patient care in the Intensive Care Unit.

Based on observations, interviews, record reviews, and review of hospital policy and procedures, staff schedules, and staff assignment sheets, the governing body failed to ensure that specific patient care requirements of the Intensive Care Unit were met in the intensive care unit and not on the medical surgical unit.

The findings are:

Cross Reference to A 0385: The hospital failed to ensure a well organized service with a plan of administrative authority and delineation of responsibilities for patient care in the Intensive Care Unit in that the Intensive Care Unit was not an option for 1 of 1 patient due to no registered nurses assigned to staff the unit.

Based on record review and interview, the hospital failed to provide in its institutional plan's budget for capital expenditures for at least a 3 year period.

The findings are:

On May 6, 2015 at 10:15 a.m., review of the hospital's budgetary data revealed the hospital's budget for capital expenditures for 2015 and 2016 only. On May 6, 2015 at 10:25 a.m., the Director of Nursing was asked if the hospital had a budget plan for capital expenditures for three years. The Director of Nurses reported that the budget data for 2015 and 2016 was all that was available.

Based on record review and interview, the hospital failed to ensure that patients were informed of their right to participate in the development and implementation of his or her plan of care for all patients admitted to the hospital.


The findings are:


On May 5, 2015 at 10:00 a.m., review of the hospital's list for the patient bill of rights enclosed in the inpatient's admission packet,"Patient and Family Guide", and review of the hospital's list for the outpatient patient's bill of rights,"Outpatient Patient & Family Guide" revealed there was no documentation in the either the inpatient or outpatient bill of rights related to the patient and/or family's right to participate in the development and implementation of the patient's plan of care.

On May 5, 2015 at 10:15 a.m., during an interview with the Director of Nursing, the Director of Nursing verified the information was not in the patient's bill of rights. On May 5, 2015 at 10:30 a.m., the Director of Nursing brought a copy of the inpatient bill of rights and stated that the hospital had changed the bulleted sentence in the patient's bill of rights that originally read, "The patient has a right to consultation by health care providers at their request and expense." to "The patient has a right to consultation by health care providers at their request and expense, help decide the details of their Plan Care, ask for a second opinion."

Based on observations, interviews, record reviews, review of hospital policy and procedure, staff schedules, and staff assignment sheets, the hospital failed to ensure the patient's right to receive care in a safe setting in that the hospital's Intensive Care Unit was not available to a patient requiring the services of the Intensive Care Unit due to a lack of staff assigned to the Intensive Care Unit.

The findings are:

Cross Reference to A 392: The hospital failed to ensure the services of the hospital's Intensive Care Unit were available for 1 of 1 patient who required the services, and failed to ensure physician orders were provided for tasks performed on 2 of 2 outpatients (Outpatient 1 and Outpatient 2) and 3 of 10 in-patient (In Patient 3, 5, and 7) charts reviewed.

Based on interview, review of the hospital's Continuous Quality Improvement (CQI) minutes and governing body minutes, the hospital failed to ensure Continuous Quality Improvement review of completed quality indicators, staff competencies, governing body oversight, and properly allocated personnel to ensure adequate resource availability for the program.

The findings are:

Cross Reference to A 0273: The hospital failed to identify completed quality indicator activities or projects related to improved health outcomes with sufficient data collection for analysis and comparison and there was insufficient evidence in the hospital's governing body of approved Quality Assessment Performance Improvement program indicators selected and frequency of data collection.

Cross Reference to A 0283: The hospital failed to ensure that data analysis identified demonstrated areas needing improvement with interventions, evaluation of the interventions for success and/or new interventions with continued evaluation as warranted.

Cross Reference to A 0286: The hospital Continuous Quality Improvement program failed to identify and track medication administration errors, adverse drug reactions and drug related incompatibilities and 2 of 2 causal analyses revealed no identification of the underlying causes, identification of other areas of the hospital at potential risk, development and implementation of preventative actions and tracking for reoccurrences of similar events or near misses and no staff auditing of staff competencies for telemetry monitoring and the intensive care unit (ICU).

Cross Reference to A 0297: The hospital failed to provide evidence showing why each performance improvement project was selected.

Cross Reference to A 0309: The hospital governing body failed to define the number of Quality Assessment Performance Improvement (QAPI) projects to be conducted for the year 2015 and actively review the results of the QAPI data collection, analyses, activities, projects and make decisions based on that review.

Cross Reference to A 0315: The hospital failed to ensure adequate personnel for the allocation of the Quality Assessment Performance Improvement program for the hospital.

Based on interview and review of facility Continuous Quality Improvement (CQI) minutes, the hospital failed to identify completed quality indicators activities or projects related to improved health outcomes with sufficient data collection for analysis and comparison and there was insufficient evidence in the hospital's governing body of approved Quality Assessment Performance Improvement program indicators selected and frequency of data collection.

The findings are:

On 05/07/15 at 4:30 p.m., review of hospital Continuous Quality Improvement (CQI) minutes revealed partially collected quality indicator activities or projects related to health outcomes with sufficient data collection for analysis and comparison. Review of information revealed data collection for 3 quarters designated by the hospital with no further information. On 05/07/15 at 5:00 p.m., interview with the chief nursing officer revealed unsure of an additional information.

On 05/07/15 at 4:30 p.m., review of hospital Continuous Quality Improvement minutes revealed no governing body approval for Quality Assessment Performance Improvement program indicators selected and frequency of data collection. Review of the hospital governing body minutes revealed no mention of the hospital Continuous Quality Improvement oversight. On 05/07/15 at 5:00 p.m., interview with the chief nursing officer revealed unsure of an additional information.

Based on interview and review of Quality Continuous Improvement (CQI) minutes, the hospital failed to ensure that data analysis identified demonstrated areas needing improvement with interventions, evaluation of the interventions for success and/or new interventions with continued evaluation as warranted.

The findings are:

On 05/07/15 at 4:30 p.m., review of the hospital Continuous Quality Improvement (CQI) minutes revealed partially collected data for 2014 quality indicators. On 05/07/15 at 5:00 p.m., interview with the Chief Nursing Officer revealed there was no additional information available.

Based on interview and review of facility Continuous Quality Improvement (CQI) minutes, the hospital Continuous Quality Improvement program failed to identify and track medication administration errors, adverse drug reactions and drug related incompatibilities and 2 of 2 causal analyses revealed no identification of the underlying causes, identification of other areas of the hospital at potential risk, development and implementation of preventative actions and tracking for reoccurrences of similar events or near misses and no staff auditing of staff competencies for telemetry monitoring and the intensive care unit (ICU).

The findings are:

On 05/07/15 at 4:30 p.m., review of facility Continuous Quality Improvement minutes revealed no documentation of identification, tracking of medication administration errors, adverse drug reactions and drug related incompatibilities. On 05/07/15 at 5:00 p.m., interview with the Chief Nursing Officer revealed no additional information was available.

On 05/07/15 at 4:30 p.m., review of facility Continuous Quality Improvement (CQI) revealed 2 of 2 causal analyses reviewed revealed no identification of the underlying causes, identification of other areas of the hospital at potential risk, development and implementation of preventative actions and tracking for reoccurrences of similar events or near misses. On 05/07/15 at 5:00 p.m., interview with the Chief Nursing Officer revealed no additional information was available.

On 05/07/15 at 4:30 p.m., review of facility Continuous Quality Improvement (CQI) minutes revealed no auditing of staff competencies for telemetry monitoring and the high risk area, the intensive care unit for the hospital.

Based on interview and review of facility Continuous Quality Improvement (CQI) minutes, the hospital failed to provide evidence showing why each performance improvement project was selected.

The findings are:

On 05/07/15 at 4:30 p.m., review of the Continuous Quality Improvement minutes revealed no evidence of why each performance improvement project was selected. On 05/07/15 at 5:00 p.m., interview with the Chief Nursing Officer revealed no additional information was available.

Based on interview and review of facility Continuous Quality Improvement (CQI) minutes, the hospital governing body failed to define the number of Quality Assessment Performance Improvement (QAPI) projects to be conducted for the year 2015 and actively review the results of the QAPI data collection, analyses, activities, projects and make decisions based on that review.

The findings are:

On 05/07/15 at 4:30 p.m., review of the hospital Continuous Quality Improvement (CQI) minutes revealed no governing body oversight for the number of quality projects to be completed for 2015 as well as review of QAPI data collection, analysis, activities and projects with discussions and/or decisions pertaining to the information. Review of the hospital governing body minutes revealed no information referencing the hospital CQI program.

Based on interview and review of the hospital's Continuous Quality Improvement (CQI) minutes, the hospital failed to ensure adequate personnel for the allocation of the Quality Assessment Performance Improvement program for the hospital.

The findings are:

On 05/07/15 at 4:30 p.m., review of the hospital's Continuous Quality Improvement (CQI) minutes revealed there was no data collection for the following hospital departments from October 2014 to April 2015: Environmental services, surgical services, 2nd Medical, and Pharmacy. There was also no review of adverse events/incident reports, tracking of medication errors, adverse drug reactions, medication incompatibilities, and contract review. On 05/05/15 from 3:25 p.m.- 3:50 p.m., the Director of Continuous Quality Improvement revealed he/she also held the following positions and responsibilities as well as the (CQI) Clinical Performance Coordinator, Director of Risk Management, Director of Quality, and Director of Swing Bed.

Based on observations, review of patient charts, interviews, review of facility policy, review of facility logs, review of personnel records, and staff interviews, the hospital failed to ensure a well organized service with a plan of administrative authority and delineation of responsibilities for patient care in the Intensive Care Unit.

The findings are:

Cross Reference to: A 0386: The hospital failed to ensure adequate registered nurse coverage for all patients, failed to provide individualized care plans for patients, and failed to provide needed nursing staff to care for patients.

Cross Reference to A 0392: The hospital failed to ensure the services of the hospital's Intensive Care Unit were available for 1 of 1 patient who required the services, and failed to ensure physician orders were provided for task performed on 2 of 2 outpatients (Outpatient 1 and Outpatient 2), and 3 of 10 in-patient (In Patient 3, 5, and 7) charts reviewed.

Cross Reference to A 0409: The hospital failed to ensure that blood transfusions were administered in accordance with the hospital's policies and procedures for 1 of 1 patient chart reviewed who received 2 units of packed cells.

Based on observations, interviews, and record reviews, the hospital failed to ensure adequate registered nurse coverage for all patients, failed to provide individualized care plans for patients, and failed to provide needed nursing staff to care for patients.

The findings are:

On 5/7/2015 at 10:30 am, the Chief Nursing Officer explained that she has no staff positions for the hospital's Intensive Care Unit and she uses an on call system to staff the hospital's intensive care unit as needed. The Chief Nursing Officer stated that she had no schedule for the intensive care unit.

On 5/7/2015 at 9:15 a.m., the nurse covering the hospital's intensive care unit on the day shift on 3/28/2015 stated that she didn't know if someone was assigned to work in the intensive care unit on that date on the night shift. ICU Nurse 1 stated that she might have called the nurse off since she was transferring the patient to the medical surgical unit. Review of the assignment and staffing sheet for 3/28/through 3/30/2015 revealed that there was no nurse scheduled or assigned to the intensive care unit those shifts.

On 5/7/2015 at 11:05 a.m.,Medical Surgical Nurse 10 stated that she worked the medical surgical on 3/29/2015 on the 7 p.m. shift. Medical Surgical Nurse 10 stated that the Supervisor for that shift called out sick so she was the supervisor, the charge nurse, and had 5 patients. Medical Surgical Nurse 10 reported that she had Patient 1 on that shift on 3/29/2015, and he was so critical that the other nurse working with her had to take care of her other 4 patients, and that it was a very trying situation in that the intensive care unit was not available on 3/29/2015 for that shift.

Based on interview, review of patients medical records, and review of the hospital policy and procedures, the hospital failed to ensure the services of the hospital's Intensive Care Unit were available for 1 of 1 patient who required the services, and failed to ensure physician orders were provided for tasks performed on 2 of 2 outpatients (Outpatient 1 and Outpatient 2), and 3 of 10 in-patient (In Patient 3, 5, and 7) charts reviewed.

The findings are

On 05/06/2015 at 1500, review of Patient 1's chart revealed the patient presented to the emergency department on 03/25/2015 at 1148 via a car with a chief complaint of "weakness in the legs for a month that has gotten worse over the last day or so". At 1158, the triage nurse documented the patient's temperature, pulse, blood pressure, respiration rate, and oxygen saturation as: 97.6, 90, 123/68, 20, and 100% (percent) on room air. Review of the patient's history and physical completed by the emergency department physician showed a past medical history of Hypertension and Renal disease. The patient's history and physical showed home medications were Lisinopril - HCTZ 20 -25 and Naproxen 375 milligrams. Documentation showed the patient reported that he had not taken his medications in a few weeks. The history and physical showed the emergency room physician also documented, "The patient is very vague about his alcohol use. He initially states that he quit "quit drinking." This later became he "quit for a while but started back on my birthday."
Emergency Department physician orders in the emergency room consisted of but was not limited to: Complete Blood Count, Comprehensive Metabolic Panel, Thyroid Profile, Urinalysis, Electrocardiagram, Chest AP(Anterior Posterior) only, Sodium Chloride 0.9 %(percent) with 20 meq/L (millequivalent/Liter) at 150 cc(cubic centimeters) per hour, Foley catheter, Culture Urine, Intake and Output, CT Head without Intravenous Contrast, Cortisol, Magnesium, Fluzone, Pneumovax.
Reported laboratory results are significant for Cortisol 29.0 (Reference 2.3 - 19.4 ug/dl), Magnesium 1.4 L (Reference 1.6 - 2.3 mg/dL), Osmolality Serum 1.3 L (Reference 275 - 295), Albumin 2.7 (Reference 3.5 - 5.2 g/dl), Bilirubin, Total 3.3 (Reference 0.3 - 1.2 mg/dl), Calcium Total S 7.1 (Reference 8.5 - 10.3 mg/dl), Chloride, Serum 72.4 L (reference 98 - 108 mmo1/1), Potassium, Serum 1.7L (Normal 3.6-5.1mmol/L), Sodium, Serum 120L (Normal 135-145 mmo1/L), Red Blood Count 2.3 (Normal 4.7-6.1 x10-6/ul, Hematocrit 25.5 (normal 42.0-52.0 %), and Hemoglobin 8.7 (Normal 14.0- 18.0 g/dl). Review of the results of the patient's chest X-Ray results dated 3/25/2015 showed,"No acute chest pathology." Review of the patient's CT(Computerized Tomography) Head report dated 3/25/2015 showed, "No intracanial or osseous pathology. Right maxillary sinusitis. No change in intracanial status from 07/23/2012."
On 03/25/15 at 1451, the nurse recorded, "Pt (Patient) has not been able to void. In/Out Cath Done With Only 25cc(cubic centimeters) Dark Tea Colored Urine Returned. Dr. (emergency room physician) Notified." On 03/25/2015 at 2328, the emergency room nurse documented, "Patient was assisted with the following: toilet. Patient very weak, needed assisted on/off toilet." On 03/25/2015 at 2338, the emergency room nurse wrote, "Neuro Checks Level of Consciousness: Alert; oriented to person: (y); place: (y); time:(n); speech: clear.....". Nursing documentation showed the patient was transferred from the emergency department to the intensive care unit(ICU) on 03/26/2015 at 0004. Review of the patient's care plan problems showed: Weakness, Activity, Diet, Additional Medication Instruction, Other instructions. Care Plan Goal: Weakness in Both Legs. Although the patient's alcohol intake was identified in the emergency room, the patient's care plan never showed a problem for potential delerium tremons for this identified at risk patient and the hospital's Alcohol Detoxification Protocol was not initiated until 3/29/2015. Further, the patient's low urine output was not identified on the emergency room's care plan.

Review of the nurse notes dated 3/26/2015 at 0500 showed:"Blood Pressure: 137/60, Pulse 93, Respirations 18, and O2(oxygen) Sats(saturation level) 100 % on 2 liters Oxygen via nasal cannula." On 3/26/2015 at 0554, the nurse recorded: "PT (Patient) A/O X 3(Alert/Oriented times 3). Denies pain. Denies shortness of breath. Dry cough noted. Lung sounds diminished but no rales heard. O2 sats 99% On 2 LPM (Liters Per Minute)Via NC (nasal cannula). Sinus Rhythmn Continues on Monitor. HR 96 with occasional PAC. .....". NS (Normal Saline) 20 KCL @150ML/HR(Normal Saline with 20 milliequivalent Potassium infused at 150 milliliters/Hour). On 3/26/2015 at 0628, the nurse recorded, "Amount of Urine Obtained: 200 cc dark amber". On 3/26/2015 at 0629, the nurse recorded,"Intake, PO(by mouth); 100, Primary IV (intravenous): 824 cc". This would be a 724 cc fluid balance variance. The nurse recorded the patient had bilateral non pitting edema to bilateral upper extremeties.

On 3/26/2015 on the 7 a.m. to 7 p.m. shift, the nurse recorded the patient was alert and oriented times 4, had bilateral upper extremity edema, had a small slimy green stool that was sent to the lab, intake was 597 cc intravenous and 300 cc by mouth and urine output was 300 cc." This is a variance of 597cc fluid balance. NS with 20 meq was infusing at 100 cc/hr. On 3/26/2015 at 1832, the nurse recorded,".....Eyes are jaundiced and BUE(Bilateral Upper Extremeties) continue to be edematous and tight.....". There was no documentation that the physician was notified of this change of condition.

On 3/26/2015 on the 7 p.m. to 7 a.m. shift on 3/27/2015, the nurse recorded at 2000 that the patient's temperature was 97, pulse as 91, respirations as 20, O2 sats as 100% on room air. Pt(Patient) is alert and oriented x 3, and NS with 20 meq Potassium infusing at 100 cc/hour. Heart Rhythm: normal sinus. Risk level for Falls: Low. Review of the patient's vital signs revealed there were no out of normal limit values. Review of the section labeled ,"Intake and Output" revealed the section was blank for this shift.

On 3/27/2015 at 0450, the nurse recorded, "PT HR(Heart Rate) has been consistently between 90-100. At this time Heart Rate trending down to 60's for approximately 8 minutes then back up to 90's. Called Resp (Respiratory) to bedside. EKG Obtained. Pt A/O X3. ....Called Dr. (emergency room physician) in ED. While giving Pt HX(History), HR went back to 90's." On 3/27/2015 at 0552, the ICU nurse recorded, ".....Dry cough noted. Lung sounds diminished. Wt. obtained. 10 (pound) WT increase noted since admission. 250 ML amber colored urine from Foley." On 2/27/2015 at 0547, the ICU nurse recorded, "Intake,po: 120, Primary IV(intravenous) 1034. Output: 250 cc tea/amber urine." This is a fluid balance variance of 904 cc fluid intake." On 3/27/2015 at 0636, the ICU nurse recorded, "HR dropped to 58. Pt became agitated, trying to get oob(out of bed). Pt alert but unable to describe any symptoms, O2 sat remained 100%. Placed on 2 LPM(liters per minute) via NC(nasal cannula). HR back to 90's. Pt calm and reports he feels better." On 03/27/2015 at 0649, the ICU nurse rcorded, "Therapist called by nurse to ICU to assess Patient. Pt HR 102, RR 34, SAT 100% on 2 LNC. Pt breath sounds were clear and equal throughout. ....Physician notified and ABG drawn. 0605 PT appears to have calmed down and is more comfortable at this time. ...". During this shift, the patient began episodic bradycardia, decreased urine output, a 10 pound weight gain, and mental status changes. On 3/27/2015 at 0741, documentation showed the patient's blood pressure was 135/72, pulse was 96, temperature was 97.5 degrees Faherenheit(FH), respirations were 22, and the patient received 2 liters oxygen via nasal cannula with the oxygn saturation at 100%. Heart Rate was sinus rhythmn at 98. Intravenous was Normal Saline with 20 meq Potassium at 100 cc/hr. , pupil size was not recorded, Edema bilateral upper extremeties, diminished breath sounds right lower lobe, low fall risk, non - productive cough, " On 3/27/2015, the ICU nurse recorded, " ...At approximately 0840, the patient's pulse dropped to 55 BPM (Beats Per Minute). Pt stated he couldn't "Get his breath" and Didn't "feel Right". EKG ordered and PT assisted to side of bed. Episode lasted approximately 8 or 9 minutes, Physician notified of event and cardiac consult ordered." There was no evidence that a cardiac consult was completed on the patient. On 3/27/2015 at 1227, the ICU nurse recorded, "Pt assisted to BSC (Bedside Commode). Pt had a small loose BM(Bowel Movement). Pt reports feeling SOB (shortness of breath) when he has to have a BM. .....". On 3/27/2015 at 1422, the ICU nurse recorded,"Pt c/o (complaint/of) pain abd(abdomen)." On 3/27/2015 at 1506, the ICU nurse recorded, "When Pt assisted to BSC, PT became Bradycardic and C/O(complained of) pain in abdominal area, Pt looked pale and stated that he didn't feel well. Pt pulse then increased to 105 BPM(Beats Per Minute). ....". On 3/27/2015 at 1506, Patient 1's blood pressure was documented as 156/95. On 3/27/2015 at 1546, the ICU nurse recorded,"Pt assisted to BSC. Pt Pulse Again Dropped to 58 Before getting onto the BSC. BP was checked and was 127/60." On 3/27/15 at 1710, the ICU nurse documented, "Pt pulse again dropped to 58. Pt stated that he needs to get on BSC......". On 3/27/2015 at 1822, the ICU nurse documented, "Assisted ER physician with central line placement...". Intake was recorded as 500 by mouth and 1190 by intravenous. Output was recorded as 350 via Foley. This is a variance of 1340 cc fluid balance on the 0700 - 1900 shift on 3/27/2015. On 3/27/2015 at 1800, the patient's temperature was documented as 97.6(F).

On 3/27/2015 at 1900 (7 pm shift), the patient's temperature was recorded as 93.1 degrees Fahrenheit(F) and the patient was placed on a warming blanket. On 3/27/2015 at 1900, the ICU nurse recorded,"Pt up to BSC with assist for BM, while up, heart decreases from 93 to 66, pt in distress, confused, c/o being hot, pulling at all tubes, pushing nurse, says he needs to leave for work, ask for air, O2 on sats(saturation) dropping from 99% to 83%, nurse got pt to sit on bed, while being fanned after about 5 mins (minutes) of this episode, pt back to his norm, back to....". On 3/27/2015 at 2000, staff recorded the patient's temperature was 93.7 (F) and oxygen was increased to 3 liters. On 3/27/2015 at 2000, the ICU nurse documented, "Alert confused at times. Pt has had a period of symptomatic Bradycardia, He is confused, C/O being hot, Heart rate 66, Resp(respirations) 44. Pt is pulling at all lines. He is combative, trying to get out of bed. This lasted about 5 mins (minutes) and he is back to norm." With the temperature of 93.1(F), the patient was placed on a warming blanket. Review of the documentation of the patient's temperature, there was no temperature recorded for 2100 or 2200. Respirations were recorded as 27 and 31. The ICU nurse documented another episode of bradycardia on 3/27/2015 at 2245. Documentation showed the patient's temperature at 2300 was 95.7 (F). During the shift, the patient's temperature dropped to 93 degrees, mental status and behavioral changes, Oxygen saturation on 3 liters Oxygen decreasing, and patient continued with a positive fluid balance greater than urine output.

Review of Patient 1's chart showed that on 3/28/2015 at 0000, the ICU nurse documented, "Alert confused at times. ..Temp 95 from 93. Tolerating O2 at 2.5 L/M." At 0106, documentation showed the respiration rate was 25 and oxygen was 3 l/m. On 3/28/2015 at 0408, staff documented respirations as 12, temperature as 96.5, pulse as 100. At 0530, staff documented 200 po(by mouth) intake, 973 intravenous intake, and 400 cc urine output for a variance of 773 cc fluid balance.

Review of documentation in Patient 1's chart for 3/28/2015 from 0700 - 0900 showed the patient's temperature was 98.2 tympanic and contiue with warming blanket, respirations were 34, blood pressure was 103/49, oriented x 3 and cooperative, eyes were jaundiced, some disorientation, Heart Rate 102 - 108 sinus tachycardia, diminished breath sounds right lower lobe, abdominal distention, jaundice, Hyperactive and Hypoactive bowel sounds, Foley catheter, NS with 20 meq KCL at 100 cc hr, Potassium level 3.3 and Hemoglobin 7.6 . At 0856, the ICU nurse documented "Pt becoming very determined to go home. ...Pt oriented to person, states year 2014." At 0913, the ICU nurse documented administration of Ativan 0.5 millgrams intravenous. At 0930, the ICU nurse documented "Pt sleeping at present. Appears more calm. VSS(vital signs stable). Respiration rate was 36. At 1000, the patient's respiration rate was documented as 39 on 2 liters oxygen with an oxygen sat reading of 98%. At 1030, the ICU Nurse documented, Primary IV 540, output 50 cc urine." At 1100, the patient's respiration rate was 39, pulse 101, and no temperature was documented. At 1212, the nurse documented, "Pt drowsy, no further agitation." The nurse intiated the patient's blood transfusion on 3/28/2015 at 1430 and ended it at 1730. Vital signs were documented: temperature: 97.4, pulse: 98, respirations: 29, blood pressure: 132/78. The infusion rate was 100 cc(cubic centimeters) per hour and patient sleeping. On 3/28/2015 at 1445, the ICU nurse documented: "temperature: 97.1 (F), pulse: 102, respirations: 29, blood pressure: 136/76, infusion rate increased to 125 cc/hour and patient drowsy. On 3/28/2015 at 1500, the ICU nurse documented: temperature: 97.5(F) , pulse: 100, respirations: 21, blood pressure: 140/87, infusion rate: 125cc/hr, and patient sleeping." On 3/28/2015 at 1600, the ICU nurse documented: "temperature: 97.5, pulse: 101, respirations: 20, blood pressure: 154/76, infusion rate: 125 cc/hr, and patient sleeping." On 3/28/2015 at 1700 , the ICU documented: "temperature: 97.3, pulse: 102, respirations: 30, blood pressure: 142/73, infusion rate 125 cc/hr, and patient sleeping." The blood transfusion was ended at 1730. There were no post procedural vital signs recorded on the transfusion record after 1700. On 05/07/2015 at 0915, ICU Nurse 1 reported that the ending vital signs for the first unit of blood would have been the beginning vital signs for the second unit of blood that was hung but based on documentation on the transfusion record, the second blood transfusion was not initiated until 1800.

Review of the patient's transfusion record dated 3/28/2015 revealed the patient received a blood transfusion from 1800 until 2325. Review of the transfusion record revealed the ICU nurse recorded the patient's pre transfusion vital signs as: temperature: 97.3 Tympanic, pulse: 102, respirations: 20, blood pressure: 152/83, infusion rate at 100 cc/hr, and patient drowsy. At 1815, the ICU nurse documented: "temperature: 97, pulse 114, respirations: 32, blood pressure: 136/79, infusion rate: 125 cc/hr, and patient alert." At 1930, the ICU nurse documented: "temperature: 97.7, pulse 102, respirations: 30, blood pressure: 154/80, infusion rate: 125 cc/hr and patient alert." The patient was transferred to the medical surgical unit and the medical surgical nurse documented at 2030: "temperature: 97.8, pulse 109, respirations: 22, blood pressure: 153/82, infusion rate: 124 cc. hr, and patient is stable." At 2325 the medical surgical nurse documented: temperature: 97.8, pulse, 110, respirations: 20, blood pressure: 154/82, infusion completed, and patient stable." There was no 1 hour vital signs documented per policy post blood transfusion.

On 3/28/2015 at 1839, the ICU nurse documented the patient's urine output was 100 cc for the 7a to 7 p shift. Intake was 810 consisting of NS(Normal Saline) with 20 KCL(Potassium) 400 cc and Blood products as 410 cc that shift. There was no dcoumentation that the nurse notified the physician of the patient's low urinary output. The ICU nurse also documented that the patient was becoming more agitated. At 1850, the ICU nurse documented that she administered Ativan 0.5mg (milligrams) intravenously for anxiety.

On 05/07/2015 at 0915, ICU Nurse 1 verified that she had provided care for the patient on 3/28/2015 and that she had transfused the first unit of blood and started the second unit of blood prior to transferring the patient to the medical surgical unit. ICU Nurse 1 stated that the patient's vital signs during the blood transfusion had not been reported to the physician because the vital signs were base line for the patient.

On 05/07/2015 at 1025, a telephone interview was conducted with RN 2 who was assigned to the medical surgical unit on 3/28/2015 for the 7 PM shift when the patient was transferred from the ICU. RN 2 verified that the date and time recorded on the patient's transfusion record was accurate. RN 2 stated the patient was asleep when received from the ICU, but within a short time after arrival, the patient pulled all of the intravenous lines out. After an intravenous line was inserted, the blood was restarted and completed infusing at 2330 which showed the blood was hanging for 5 and 1/2 hours from the start of the transfusion until the completion of the transfusion. There was no documentation that the physician was notified of the patient's increased pulse rate.

The patient's chart revealed a verbal physician order obtained by the intensive care unit nurse on 3/28/2015 to transfer the patient to the medical surgical unit due to the patient's condition improving. The patient arrived to the medical surgical unit at 2012. Documentation showed the nurse was called to the room by the certified nursing assistant at 2032 and found the patient sitting in the recliner, alert, and stating he needed to go to the bathroom. The patient had pulled all of his intravenous lines out including the right jugular. On 5/7/2015 at 1055 a.m., RN 2 stated during the interview that he/she had notified the physician that the patient had pulled the right jugular line out and the physician had asked if the tip was intact and it was so the physician did not order a chest x-ray. On 3/28/2015 at 2153, RN 2 docmented, "Continued the infusion of the PRBS's (Packed Red Blood Cells)." At 2325, RN 2 documented that the blood had infused and was discontiued. Five and 1/2 hours had elapsed between when the blood was hung and when the blood was discontinued. On 3/29/2015 at 0128, four point restraints were ordered and placed on the patient who was found on the floor. At 0200, the nurse documented the patient was lethargic. At 0400, the nurse documented the patient was lethargic, pupils 4, intake was 125 cc blood, no intravenous fluids charted, and urinary output was documented as 700 cc. On 3/29/2015 at 0740, the nurse documented, "Pt alert to person only and hard to make sense of what he is saying. Pt. does not follow simple commands. IV right arm looks infiltrated. Edema to right FA and elbow." At 0757, respirations were documented as 36 and pulse 112. At 0901, the nurse documented that the physician was in to see patient. At 1200, documentation showed the pulse was 114, blood pressure was160/101, respirations were 23. There was no documentation that the physician was notified of the patient's blood pressure. At 1446, the nurse documented, "....Pt. not following any commands. Does not respond to asking his name. Pt. does not answer. We have moved patient to room 213, 10 feet from nursing station.... "At 1915, the nurse documented, ".....ordered chest x-ray for Pt. Cont. (continues) to decline." At 1930, pulse was 112, respirations were 48, blood pressure was 174/102. There was no po intake or IV intake recorded and urinary output was 500 cc. for the 7a shift on 3/29/2015. The nurse documented the patient's respirations were labored. with rales. At 1930, the oncoming shift nurse documented,"...Pt transferred out of ICU yesterday. Patient confused, gurgling. Rales noted to all lung fields. Doctor notified." Review of the nurse note dated 03/29/2015 at 2000 revealed "Therapist was told there are no ICU nurses for Pt(patient) to unit." At 2040, the nurse documented, ".... Dr.(Doctor) at bedside. Does not think Pt. needs intubation at this time. At 2055, the respiratory therapist wrote, "
Review of the documentation on 3/29/2015 on the 7 p.m. shift showed at 0000 revealed the patient's temperature was 96.3, blood pressure was 163/93, respirations were 40, pulse was 111, 2 LPM via nasal cannula. The documentation showed the EKG revealed tachycardia. The patient's pupils were documented as 4 instead of the 3 that had been previously documented. At 0038, the nurse documented the patient's speech was garbled and the patient was agitated.






30011

On 05/05/15 from 2:45 p.m. to 2:49 p.m., random observations on the medical surgical floor revealed a patient on telemetry. Observations revealed there was no staff monitoring the telemetry screen. On 05/05/15 at 2:49 p.m., Unit Secretary 1 revealed, "the secretary and nurse will monitor the screen. The Cardiopulmonary Director did a class and checked us off on it almost a year ago. I can read sinus rhythm but nothing else".

On 05/06/15 from 10:20 a.m.- 10:30 a.m., random observations on the medical surgical floor revealed one patient on the telemetry monitor. Observation revealed no staff monitored the telemetry screen because the secretary was not at the monitor, but assisting the physician. Registered Nurse 5 was located at the opposite end of the desk and not visualizing the telemetry screen. Licensed Practical Nurse 1 was in a patient's room.

On 05/07/15 from 1:00 p.m.-2:00 p.m., review of personnel files for nursing education revealed there was no documented telemetry monitoring training for the staff in their files. Review of information presented to surveyor revealed there were 4 staff members who completed an upgraded electrocardiogram strip test March 2015. On 05/07/15 from 2:00 p.m.- 2:10 p.m., Administrative Assistant 1 revealed, "the prior respiratory therapist completed some training last year, but a copy of the training was not given to the administrative assistant".

Hospital policy, titled, "Telemetry monitoring", reads, ".... nurses may interpret rhythm strips after completion of competency exam in EKG (electrocardiogram) monitoring....".

On 05/06/15 at 10:35 a.m., review of Patient 3's chart revealed the patient was admitted to the medical surgical unit on 05/01/15. Review of the patient's chart revealed a nursing entry on 05/04/15 at 5:31 p.m. stating per physician "discontinue cardiac monitor" recorded by Registered Nurse 5. Review of the patient's physician orders revealed there was no verbal order or written order by the physician to discontinue cardiac monitoring. Further review of the patient's chart revealed the telemetry was discontinued on 05/04/15 at 8:37 a.m. prior to the nursing note documented on 05/04/15 at 5:31 p.m. to discontinue the documentation. On 05/06/15 at 12:00 p.m., the findings were verified by Registered Nurse 7.

On 05/06/15 at 10:35 a.m., review of Patient 3's chart revealed the patient was admitted to the medical surgical floor on 05/01/15 at 5:15 a.m.. Review of physician orders dated 05/01/15 at 3:02 a.m. revealed "cardiac -monitoring, interpret strip with the first noted telemetry to the medical surgical floor documented at 5:27 a.m.".

Hospital policy, titled, "Telemetry Monitoring", reads, "....Telemetry strips will be recorded: Upon initiation of telemetry, 2. Every 4 hours while on telemetry, 3. With any change in patient's rhythm or condition. Strips are placed in graphic part of chart....". Further review of the electrocardiogram strips report revealed a strip recorded on 05/01/15 at 5:27 a.m. and at 8:04 p.m. with 4 hour strip documentation missing between these times. On 05/02/15 between 3:53 p.m. and 8:11 p.m., greater than 4 hour documentation. On 05/03/15 between 8:19 a.m. and 8:15 p.m.. 4 hour strips documentation missing between these times. On 05/06/15 at 12:15 p.m., the findings were verified by Registered Nurse 7.

On 05/06/15 at 10:35 a.m., review of Patient 3's chart revealed a patient admitted to the medical surgical floor on 05/01/15 at 5:15 a.m. and diagnosed with syncope and collapse, cerebral infarction, hypertension and diabetes mellitus. Review of physician orders dated 05/01/15 at 3:02 a.m. revealed neurological checks to be performed every four hours. Review of nursing neurological assessment documentation revealed missing neuro assessments on 05/01/15 at 11 a.m. and 3 p.m., on 05/04/15 at 8 a.m., 12 p.m., 4 p.m., and on 05/05/15 at 12 p.m. and 4 p.m.. On 05/06/15 at 11:50 a.m., the findings were verified by Registered Nurse 7.

On 05/06/15 at 10:35 a.m., review of Patient 3's chart revealed a patient was admitted to the medical surgical unit from the hospital's emergency room on 05/01/15. Review of the patient's chart revealed on 05/01/15 at 5:15 a.m. revealed the patient was admitted to the medical surgical unit on 05/01/15 at 5:15 a.m. with a number 20 Jelco to the left forearm saline locked. On 05/05/15 at 5:00 a.m., a number 20 Jelco to the right hand was placed by the night shift nurse.

Review of hospital policy, titled, "Care of Peripheral and Central Vascular Access", reads, "....3. All IV (intravenous) sites will be routinely changed every 72 to 96 hours. If for any reason the IV site is to remain beyond 72 hours, an order must be received from the physician to keep current IV site. Documentation of reasons IV not changed will be required by nursing....". On 05/05/15 at 5:59 a.m., nursing documentation revealed, "IV plug outdated and needed to be changed. # (number) 20 Jelco inserted in right hand without problem".

On 05/06/15 at 10:35 a.m., review of Patient 3's chart revealed a patient admitted to the medical surgical unit on 05/01/15. Review of the patient's chart revealed the patient was diagnosed with syncope and collapse, cerebral infarction, hypertension and diabetes mellitus. Review of medications ordered for the patient included (1) Cardiem 180 milligrams (mg) by mouth daily, Plavix 75 mg 1 tablet daily, Aspirin 81 mg 1 tablet daily, Norvasc 10 mg 1 tablet everyday, Lopressor 50 mg, Vasotec 20 mg, Lovenox 40 mg, Humalog 3 milliter (ml), Zofran 4 mg/2 ml and Acetaminophen 325 mg.
Further review of the patient's chart revealed all of the patient's blood pressures were outside normal ranges for blood pressures. Review of the nurse notes revealed there were no interventions by the nursing staff or notification to the doctor concerning the patient's blood pressure readings which ranged from 153/94 to 201/171. On 05/06/15 at 12:15 p.m., the findings were verified by Registered Nurse 7.





31395

On 05/05/15 at 10:50 a.m., review of Patient 7's chart revealed the patient was in the hospital's emergency department from 8:06 a.m. until 10:28 a.m. Further review of the patient's chart revealed Patient 7 had orders for intravenous (IV) fluids of "Sodium Chloride 0.9% 1,000 ml (milliliters) IV soln(solution) IV/Q1H (every 1 hour)". There was no physician order for the placement of a intravenous catheter needle for the infusion. On 05/05/15 at 11:00 a.m., Registered Nurse (RN) 1 revealed, "there is no order for IV placement and there should be. We asked them to couple the orders because the physicians will order the solution but not the IV placement. But there is an order in the computer for IV placement".

On 05/06/15 at 3:30 p.m., review of Outpatient 1's chart revealed the patient had a left shoulder arthroscopy performed on 05/06/15. Further review of the patient's chart revealed the patient received "IV Lactated Ringers KVO(Keep Vein Open)" as well as "Ancef 1 gm (gram) IVPB (intravenous piggyback)" from the time of arrival to discharge. There was no physician order for placement of an intravenous catheter.

On 05/06/15 at 4:00 p.m., review of Outpatient 2's chart revealed the patient had a right shoulder arthroplasty performed on 05/06/15. Further review of the patient's chart revealed the patient received "IV Lactated Ringers(LR) KVO" as well as "Ancef 1 gm (gram) IVPB (intravenous piggyback)" from the time of arrival to discharge. There was no physician for placement of an intravenous catheter. On 05/07/15 at 1:10 p.m., RN 12 revealed, "I suppose since they checked for IV LR at KVO, you can't run the LR IV unless an IV was started. I don't know".

Facility policy and procedure, titled, "Care of the Peripheral and Central Vascular Access", reads, "....A peripheral cannula shall be placed for therapeutic and/or diagnostic indication according to a physician's order....".

Based on record review and interview, the hospital failed to ensure that the intensive care unit provided 24 hour - nursing services furnished or supervised by a registered nurse, and had a licensed nurse on duty at all times.

The findings are:

On 05/06/2015 at 1500, review of Patient 's chart revealed the patient presented to the emergency department on 03/25/2015 at 1148 via a car with a chief complaint of weakness in legs for a month that has gotten worse over the last day or so. Review of laboratory results were significant for Cortisol 29.0 (Reference 2.3 - 19.4 ug/dl), Magnesium 1.4 L (Reference 1.6 - 2.3 mg/dL), Osmolality Serum 1.3 L (Reference 275 - 295), Albumin 2.7 (Reference 3.5 - 5.2 g/dl), Bilirubin, Total 3.3 (Reference 0.3 - 1.2 mg/dl), Calcium Total S 7.1 (Reference 8.5 - 10.3 mg/dl), Chloride, Serum 72.4 L (reference 98 - 108 mmo1/1), Potassium, Serum 1.7L (Normal 3.6-5.1mmol/L), Sodium, Serum 120L (Normal 135-145 mmo1/L), Red Blood Count 2.3 (Normal 4.7-6.1 x10-6/ul, Hematocrit 25.5 (normal 42.0-52.0 %), and Hemoglobin 8.7 (Normal 14.0- 18.0 g/dl). The patient was admitted to the hospital's intensive care unit for close monitoring of the patient's electrolyte imbalance. The patient was in the hospital's intensive care unit from March 25, 2015 through the 7 am shift of March 28, 2015 when the patient was transferred to the general medical surgical unit on the 7 pm shift.

Review of the nurse note dated 03/29/2015 at 2000 revealed "Therapist was told there ae no ICU nurses for Pt(patient) to unit." Review of the assignment sheet for the intensive care unit showed there were no nurses assigned to the unit after the 7am shift on 3/28/2015. Review of the hospital's nursing schedule dated March 2015 - April 2015 revealed only staffing for the medical surgical unit, the emergency department, supervisors, and prn (as needed) staff. There was no staffing schedule for nurses for the intensive care unit.

On 05/07/2015 at 0915, during an interview with ICU Nurse 1, ICU Nurse 1 revealed " the hospital was in need of an ICU nurse. I work as the hospital's IT nurse through the week and sometimes prn (as needed) in the hospital's intensive care unit. I found out on the previous Thursday or Friday that I was supposed to come in the Saturday (3/28/2015). I don't know if someone was scheduled to come in after me. I don't know when someone is scheduled on call. I think ....was scheduled to follow me if needed and I called her to tell her that the patient was being transferred out. I got verbal orders for transfer of the patient out of the intensive care unit to the floor at 1952.

Review of the intensive care unit assignment dated 3/28/2015 revealed that only the 7 am shift has a nurse assigned. There was no nurse identified as scheduled to come in for the 7 pm shift.

On 5/07 2015 at 1315, the Director of Nurses stated that the hospital has no staffing for nurses in its intensive care unit. The Director stated that if there is a patient in the intensive care unit that he/she pulls staff from other areas of the hospital to work in the intensive care unit. The Director of Nurses reported that the staff assigned to the intensive care unit is based on how long the staff member has been with the hospital and if they emergency room experience and advanced cardiad life support(ACLS), BLS (Basic Life Support), or PALS(Pediatric Advanced Life Support). The Director reported that the hospital staff have had no critical course that she is aware of.

Based on interview, record review, and review of hospital policy and procedure, the hospital failed to ensure the changing of the patient's intravenous sites for 1 of 12 inpatient charts reviewed. (Patient 3)

The findings are:

On 05/06/15 at 10:35 a.m., record review for Patient 3 revealed a patient admitted to the medical surgical unit from the emergency room. Review of chart revealed on 05/01/15 at 5:15 a.m. that the patient was admitted to the medical surgical unit with a number 20 Jelco to the left forearm saline locked. On 05/05/15 at 5:00 a.m., a number 20 Jelco to the right hand was placed by the night shift nurse. Review of hospital policy, titled, "Care of Peripheral and Central Vascular Access", reads, "....3. All IV (intravenous) sites will be routinely changed every 72 to 96 hours. If for any reason the IV site is to remain beyond 72 hours, an order must be received from the physician to keep current IV site. Documentation of reasons IV not changed will be required by nursing....". On 05/05/15 at 5:59 a.m., review of the nursing documentation revealed, "IV plug outdated and needed to be changed. Number (#) 20 Jelco inserted in right hand without problem".

Based on record review and interview, the facility failed to ensure the nursing care plan was individualized for 6 of 18 patients. (Inpatient 1, 3, 12) (Closed Patient 1, 2, 3 )

The findings are:

On 05/06/2015 at 1500, review of Patient 1's chart revealed the patient presented to the emergency department on 03/25/2015 at 1148 via a car with a chief complaint of weakness in legs for a month that has gotten worse over the last day or so. The history and physical showed the emergency room physician also documented, "The patient is very vague about his alcohol use. He initially states that he quit "quit drinking." This later became he "quit for a while but started back on my birthday." On 03/25/15 at 1451, the nurse recorded, "Pt (Patient) has not been able to void. In/Out Cath Done With Only 25cc(cubic centimeters) Dark Tea Colored Urine Returned. Dr. (emergency room physician) Notified. Although the patient's alcohol intake was identified in the emergency room, the patient's care plan never showed a problem for potential delerium tremons for this identified at risk patient and the hopital's Alcohol Detoxification Protocol was not initiated until 3/29/2015. Further the patient's low urine output was not identified on the emergency room's care plan.






25877

On 05/06/2015 at 1:33 p.m., review of Patient 12's clinical record on the medical/surgical unit revealed the patient was admitted with redness to the buttocks and Desitin Cream was being applied. Further review of the patient's nursing care plan showed the plan did not include a plan of care for potential skin breakdown. The finding was verified with Registered Nurse (RN 5) on 05/06/2015 at 2:00 p.m.

Review of the closed clinical record of Patient 2 on 05/06/2015 at 3:05 p.m. revealed the patient's primary diagnosis and complaint on admission as well as discharge was Urinary Tract Infection and Dehydration. The patient's nursing care plan included a plan for general pulmonary, but there was no plan of care related to Urinary Tract Infection or Dehydration. The finding was verified with the Medical Record's Clerk on 05/06/2015 at 4:00 p.m. and the Chief Nursing Officer on 05/07/2015 at 4:15 p.m.

Review of the closed record for Patient 3 on 05/07/2015 at 3:55 p.m. showed the patient was admitted with a diagnosis of Sepsis. Further review of the patient's chart revealed the patient had 2 pressure ulcers: a stage 4 and and un-stageable pressure ulcer on admission. Review of the patient's care plan revealed there was no plan of care for prevention of further skin breakdown. The finding was verified with the Medical Record Clerk on 05/07/2015 and the Chief Nursing Officer on 05/07/2015 on 05/07/2015 at 4:15 p.m.



30011

On 05/06/15 at 10:35 a.m., review of Patient 3's chart revealed a patient admitted to the medical surgical unit on 05/01/15. Review of the patient's chart revealed the patient was diagnosed with syncope and collapse, cerebral infarction, hypertension and diabetes mellitus. Review of medications ordered for the patient included (1) Cardiem 180 milligrams (mg) by mouth daily, Plavix 75 mg 1 tablet daily, Aspirin 81 mg 1 tablet daily, Norvasc 10 mg 1 tablet everyday, Lopressor 50 mg, Vasotec 20 mg, Lovenox 40 mg, Humalog 3 milliter (ml), Zofran 4 mg/2 ml and Acetaminophen 325 mg. Further review of the patient's chart revealed all of the patient's blood pressures were outside normal ranges for blood pressures. Review of the nurse notes revealed there were no interventions by the nursing staff or notification to the doctor concerning the patient's blood pressure readings which ranged from 153/94 to 201/171. On 05/06/15 at 12:15 p.m., the findings were verified by Registered Nurse 7.
Review of the patient's care plan problem list revealed that the patient's care plan had not been individualized and the patient's elevated blood pressures had not been addressed.

Based on interview, record review and review of hospital policy and procedure, the hospital failed to ensure administration of insulin as ordered by the physician for 1 of 12 inpatient records reviewed. (Patients 3)

The findings are:

On 05/06/15 at 10:35 a.m., record review of patient 3 revealed a patient admitted to the medical surgical floor on 05/01/15. Review of physician orders dated 05/01/15 at 3:02 a.m. revealed, "Humalog 3 ml (milliliters) vial 100 unit/1 ml vial with option 1 and option 2 sliding scale administration". Dosage instructions noted for Option 1 sliding scales as followed:
Less than 140-------Give 0 units
141-200--------------Give 2 units
201-250--------------Give 4 units
251-300--------------Give 6 units
301-350--------------Give 8 units
351-400--------------Give 10 units
Greater than 400---Give 12 units and notify MD (medical doctor).
Review of blood glucose and insulin administration record on 05/01/15 at 12:00 p.m. revealed the patient's blood glucose was 144 and there was no insulin administered. On 05/02/15 at 9:16 p.m., the patient's blood glucose was 154 with no insulin administration. On 05/06/15 at 11:35 a.m., the findings were verified by Registered Nurse 7.


On 05/05/15 at 9:20 a.m.- 10:45 a.m., record review of patient 5 revealed a verbal physician's order dated 04/30/15 for Humalog 3 ml (milliliter) vial 100 unit/ml vial with option 1 and option 2 information for sliding scale insulin. Dose instructions revealed option 1 for sliding scale insulin with the following instructions for administration:
Less than 140-------Give 0 units
141-200--------------Give 2 units
201-250--------------Give 4 units
251-300--------------Give 6 units
301-350--------------Give 8 units
351-400--------------Give 10 units
Greater than 400---Give 12 units and notify MD (medical doctor). Review of patient blood glucose levels on 04/30/15 at 11:50 p.m. revealed a level of 149 with no administered insulin of 2 units with a reason documented for non administration as within normal range by the registered nurse. On 05/02/15 at 5:25 p.m., the patient's blood glucose level was 155 with no administered insulin of 2 units with a reason documented for non administration as within normal range by the registered nurse. On 05/04/15 at 7:29 a.m., the patients blood glucose level was 167 with no administered insulin of 2 units with a reason documented for non administration as within normal range. On 05/04/15 at 5:08 p.m., the patient's blood glucose level was 153 with no administered insulin of 2 units with a reason documented for non administration of normal range by the registered nurse. On 05/05/15 at 7:30 a.m., the patient's blood glucose level was 188 with no administered insulin of 2 units with a reason documented for non administration as other. On 05/05/15 at 11:25 a.m., interview with registered nurse 6 revealed "I didn't want to bottom the patient out". On 05/05/15 at 10:30 a.m., findings verified by the Clinical Performance Coordinator/Director of Discharge Planning.







31395

On 05/05/15 at 10:15 a.m., observations of RN 2 revealed the registered nurse opened a new pre-filled Hydromorphine 2 milligram (mg) carpuject syringe and withdrew the medication into a new syringe, but RN 2 failed to disinfect the medication vial's septum prior to withdrawing the medication.
On 05/05/15 at 10:45 a.m., RN 2 stated, "I never wipe the top of the vial because I didn't touch it. If I had touched it or it was a multidose vial, then I would have wiped it off. The top suppose to be sterile underneath the top".

On 05/05/15 at 11:45 a.m., random observations of the seven (7) surgical bays revealed pre-filled, pre-package 10 milliliter normal saline syringes located in each bay: bay A=2 prefilled syringes; bay B=3 prefilled syringes; bay C=1 prefilled syringe; D=6 prefilled syringes; E=7 prefilled syringes; bay F=8 prefilled syringes; and bay G=6 prefilled syringes. The surgical staff failed to keep syringes secure in the patient treatment area.

On 05/05/15 at 2:53 p.m., observations of RN 3 revealed the registered nurse administered "Levothyroxine (Synthroid) 100 micrograms (mcg) by mouth (PO) at 3:00 p.m. to Patient 1. RN 3 failed to follow medication administration orders for administering Synthroid. On 05/05/05 at 2:54 p.m., review of Patient 1's medication profile revealed, "Levothyroxine Sodium 100 mcg PO(by mouth) 0700; *TAKE ON EMPTY STOMACH, PRIOR TO BREAKFAST". On 05/05/15 at 2:57 p.m., RN 3 stated, "I don't know why the patient (Patient 1) didn't receive the medication earlier. I guess due to circumstances on the hall or maybe when the medication was ordered".

On 05/06/15 at 10:55 a.m., observations of CRNA 1 revealed the CRNA opened four (4) new vials of different medications and withdrew the medication from the vials, but CRNA 1 failed to disinfect the medication vial septum prior to withdrawing the medication. On 05/06/15 at 10:57 a.m., CRNA 1 revealed, "No I didn't wipe the top of the medication vials because it's sterile underneath the caps".

On 05/06/15 at 11:15 a.m., observations of CRNA 1 revealed the CRNA attached a syringe to the patient's intravenous (IV) injection port and administered the medication, but CRNA 1 failed to disinfect the IV injection port prior to administration of medication.

Facility policy and procedures, titled, "Dating of Open Containers and Use Of Needles, Medication Vials, and Solutions", reads, "....All rubber septum on medication vials are to be disinfected with alcohol prior to piercing....".

Facility policy and procedures, titled, "Drug Administration Times and Automatic Stop Orders", reads, "....A physician may now and always order a medication to be administered when he deems appropriate, but when the above abbreviations are written, the times specified will be used. If a dose is needed upon admission that is not yet due, the physician must write, "first dose now" in the orders....".

Based on record review and interview, the hospital failed to ensure that blood transfusions were administered in accordance with the hospital's policies and procedures for 1 of 1 patient chart reviewed who received 2 units of packed cells.

The findings are:

On 05/06/2015 at 1500, review of Patient 1's chart revealed the patient presented to the emergency department on 03/25/2015 at 1148 via a car with a chief complaint of weakness in legs for a month that has gotten worse over the last day or so. Emergency Department physician orders in the emergency room consisted of but were not limited to: Complete Blood Count which resulted at Red Blood Count 2.3 (Normal 4.7-6.1 x 10-6/ul(unit/liter), Hematocrit 25.5 (normal 42.0-52.0 %(percent), and Hemoglobin 8.7 (Normal 14.0- 18.0 g/dl (grams/deciliter)). Documentation in Patient 1's chart for 3/28/2015 from 0700 - 0900 showed staff did not document the patient's temperature, but respirations were 34, blood pressure was 103/49, oriented x 3 and cooperative, eyes jaundiced, some disorientation, heart rate 102 - 108 sinus tach(tachycardia), diminished breath sounds right lower lobe, abdominal distention, jaundice, hyperactive and hypoactive bowel sounds, Foley catheter, NS with 20 meq KCL at 100 cc hr. The Intensive Care Unit (ICU) nurse documented that the physician was notified that the patient's Potassium level was 3.3 and the patient's Hemoglobin level was 7.6 and physician order received for 2 units red blood cells to be transfused.

Review of the patient's vital signs on 3/28/2015 at 1259 revealed, "Temperature: 98.0 (F), Pulse: 98, Blood Pressure: 134/70, Respirations: 23. O2 saturation: 100% on 3 liters minute.

Review of the patient's transfusion record dated 3/28/2015 showed the patient's blood transfusion was started at 1430 and ended at 1730. Vital signs were documented: temperature: 97.4, pulse: 98, respirations: 29, blood pressure: 132/78. The infusion rate was 100 cc(cubic centimeters) per hour and patient sleeping. On 3/28/2015 at 1445, the ICU nurse documented: temperature: 97.1 (F), pulse: 102, respirations: 29, blood pressure: 136/76, infusion rate increased to 125 cc/hour and patient drowsy. On 3/28/2015 at 1500, the ICU nurse documented: temperature: 97.5(F) , pulse: 100, respirations: 21, blood pressure: 140/87, infusion rate: 125cc/hr, and patient sleeping. On 3/28/2015 at 1600, the ICU nurse documented: temperature: 97.5, pulse: 101, respirations: 20, blood pressure: 154/76, infusion rate: 125 cc/hr, and patient sleeping. On 3/28/2015 at 1700 , the ICU documented: temperature: 97.3, pulse: 102, respirations: 30, blood pressure: 142/73, infusion rate 125 cc/hr, and patient sleeping. The blood transfusion was ended at 1730. There were no post procedural vital signs recorded on the transfusion record after 1700. On 05/07/2015 at 0915, ICU Nurse 1 reported that the ending vital signs for the first unit of blood would have been the beginning vital signs for the second unit of blood that was hung but based on documentation on the transfusion record, the second blood transfusion was not initiated until 1800.

Review of the patient's transfusion record dated 3/28/2015 revealed the patient received a blood transfusion from 1800 until 2325. Review of the transfusion record revealed the ICU nurse recorded the patient's pre transfusion vital signs as: temperature: 97.3 Tympanic, pulse: 102, respirations: 20, blood pressure: 152/83, infusion rate at 100 cc/hr, and patient drowsy. at 1815, the ICU nurse documented: temperature: 97, pulse 114, respirations: 32, blood pressure: 136/79, infusion rate: 125 cc/hr, and patient alert. At 1930, the ICU nurse documented: temperature: 97.7, pulse 102, respirations: 30, blood pressure: 154/80, infusion rate: 125 cc/hr and patient alert. The patient was transferred to the medical surgical unit and the medical surgical nurse documented at 2030: temperature: 97.8, pulse 109, respirations: 22, blood pressure: 153/82, infusion rate: 124 cc. hr, and patient is stable. At 2325 the medical surgical nurse documented: temperature: 97.8, pulse, 110, respirations: 20, blood pressure: 154/82, infusion completed, and patient stable. There was no 1 hour vital signs documented per policy post blood transfusion.

On 3/28/2015 at 1839, the ICU nurse documented the patient's urin output was 100 cc for the 7a to 7 p shift. Intake was 810 consisting of NS(Normal Saline) with 20 KCL(Potassium) 400 cc and Blood products as 410 cc that shift. There was no dcoumentation that the nurse notified the physician of the patient's low urinary output. The ICU nurse also documented that the patient was becoming more agitated. At 1850, the ICU nurse documented that she administered Ativan 0.5mg (milligrams) intravenously for anxiety.

On 05/07/2015 at 0915, ICU Nurse 1 verified that she had provided care for the patient on 3/28/2015 and that she had transfused the first unit of blood and started the second unit of blood prior to transferring the patient to the medical surgical unit. ICU Nurse 1 stated that the patient's vital signs during the blood transfusion had not been reported to the physician because the vital signs were base line for the patient.

On 05/07/2015 at 1025, a telephone interview was conducted with RN 2 who was assigned to the medical surgical unit on 3/28/2015 for the 7 PM shift when the patient was transferred from the ICU. RN 2 verified that the date and time recorded on the patient's transfusion record was accurate. RN 2 stated the patient was asleep when received from the ICU but within a short time after arrival, the patient pulled all of the intravenous lines out. After an intravenous line was inserted, the blood was restarted and completed infusing at 2330 which shows the blood was hanging for 5 and 1/5 hours from the start of the transfusion until the completion of the transfusion. There was no documentation that the physician was notified of the patient's increased pulse rate.

On 05/07 2015 at 1:15 p.m., during an interview with the Director of Nursing, the Director stated, "We don't perform any blood audits. The lab doesn't take any blood back that has been out over 30 minutes. I have been considering starting audits of blood transfusions."

Hospital policy, titled, "Blood Component Transfusion", written 04/2006 and reviewed October 2011, reads. "Purpose: To provide institutional guidelines for the safe and effective administration of Blood Components issued through the Blood Bank, which include Packed Red Blood Cells, Fresh Frozen Plasma, and Platelet Concentrate.
14. Time for infusions are as follows: PRBC ----2 - 4 hours(never more than 4)
20. Vital signs are to be assessed as follows:
- Just prior to initiation of transfusion
- 15 minutes after starting transfusion
- Hourly during transfusion
- When the transfusion is complete
- One hour post transfusion
21. Patient is to be observed throughout the transfusion for reaction: volume overload, headache, flushing, tachycardia, hives, chest pain, fever greater than 2 degrees above baseline, anaphylaxis, any feeling of doom, or bronchospasm. If reaction occurs, immediately stop the transfusion and notify the physician. Reactions may occur up to 6 hours after infusion. "

Based on interview and record review, the hospital failed to ensure a history and physical was signed within 24 hours of the patient's admission for 1 of 11 inpatient records reviewed. (Patient 3).

The findings are:

On 05/06/15 at 10:35 a.m., review of Patient 3's chart revealed the patient was admitted on 05/01/15 to the medical surgical floor,but the patient's admission history and physical was not electronically signed until 05/05/15 at 5:05 p.m. by the physician.

Based on observation, interview, and review of the
hospital policy and procedure, the hospital staff failed to remove/discard expired supplies from current patient stock and date, time, and initial opened controls.

The findings are:

On 05/04/15 at 4:00 p.m., random observations in the laboratory revealed the "Rapid Mono Test" controls and the "Strep A Dipstick" controls had no date, time, or initials of the staff who opened the control.

On 05/04/15 at 4:05 p.m., random observations in the laboratory revealed an opened bottle of "Status DS" positive and negative controls dated 10/03/14. On 05/04/15 at 4:07 p.m., Medical Lab Technician (MLT) 1 revealed controls are good until the manufacturer's expiration date. Manufacturer's Guideline for "Status DS Control Set", reads, "... After opening A. the controls are stable for six months or until the expiration date, whichever comes first when stored at -10 to -20 C. (Controls can be aliquoted and frozen). B.

On 05/04/15 at 4:10 p.m., random observations in the laboratory revealed a gastrocult developer with a manufacturer's expiration date of 04/2015. On 05/04/15 at 4:25 p.m., random observations in the laboratory revealed 93 expired serum blood collection (red top) tubes. On 05/04/15 at 4:26 p.m., MLT 1 revealed "tubes are expired but we only use them to collect and perform wet preps for the Emergency Department."

Manufacturer's Guideline for "Status DS Control Set", reads, "... After opening A. the controls are stable for six months or until the expiration date, whichever comes first when stored at -10 to -20 C. (Controls can be aliquoted and frozen). B. The controls are stabled 31 days or until the expiration date, whichever comes first when stored tightly capped at 2-8 C....".

Facility policy and procedures, titled, "Out of Date Supplies", reads, "....Expiration dates of medical supplies kept in the Central Supply area shall be monitored monthly....Medical supplies stocked in various departments shall be monitored monthly by the Materials Management Department....Items will be pulled from the shelves at time of expiration....".







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On 05/06/15 at 10:20 a.m., observations of the pediatric airway box and the adult airway box on the medical surgical floor revealed the following expired supplies:
(1) Portex nasopharyngeal airway expired 09/14
(2) Uncuffed tracheal tube Murphy eye, oral/nasal tube 2.0 mm(millimeter) expired 06/09
(2) Uncuffed endotracheal oral/nasal tube 5.5 mm expired 04/09
(2) Uncuffed Endotracheal oral/nasal tube 2.5 mm expired 06/09
(1) Uncuffed Endotracheal oral/nasal tube 3.5 mm expired 06/07
(2) Uncuffed tracheal tube, Murphy eye, oral/nasal tube expired 04/09
(2) Duracell batteries expired 03/10
(6) Sodium Chloride inhalation solution tubes expired 09/09
(8) Sodium Chloride inhalation solution tubes expired 11/06

On 05/06/15 at 10:40 a.m., Unit Secretary 1 revealed, "the nurses and respiratory (therapy) are responsible for the supplies on the crash cart.

Hospital policy, titled, "Emergency Crash Carts,....2. All adult and pediatric intubation equipment will be kept in the labeled boxes in the clean utility room or on the cart. Cardiopulmonary is responsible for restocking all respiratory equipment and supplies....5. Cardiopulmonary therapy will check for any respiratory supplies that are expired....".

Based on observation and interview, the hospital failed to ensure the appropriate food temperatures for a test tray delivered to the floor.

The findings are:

On 05/05/15 at 12:47 p.m., observations of a test tray delivered to the patient floor revealed a hamburger patty delivered to the patient floor with a temperature of 115 degrees which was 45 degrees lower than the allowable temperature of 160 degrees Fahrenheit. On 05/05/15 at 12:47 p.m., Dietary Aide 1 verified the finding.

Based on observation and interview, the hospital failed to ensure there was a supply of emergency food and/or water on site.

The findings are:

On 05/04/15 at 4:35 p.m., observations of the dietary food storage area revealed there was no extra supply of reserved food and/or water for an emergency. On 05/04/15 at 4:35 p.m., Dietary Manager 1 revealed the canned goods on hand would be used for emergency food for 5 days and any water needed will be obtained by the local national guard in the event that the hospital needs it.

Based on observation and interview, the hospital dietary staff failed to ensure food substitutes for patients for dietary meal plans.

The findings are:

On 05/05/15 at 2:25 p.m., review of weekly diet menu for the patients revealed a meal plan with one food choice with variations based on regular/no added salt, 2 gram sodium, cardiac, no concentrated sweets, and mechanical altered/soft diets. On 05/05/15 at 12:20 p.m., the Dietary Director revealed, "the diet menu is the same from one week to the next week".

ased on observation and interview the facility failed to ensure the environment was safe for patients related to an unclean emergency waiting room, the preventative maintenance had not been completed on the blanket warmer in the ICU, improperly working temperature gauge in the dietary department and an accumulation of dust located in the motor area of one of the hot warmer/freezer units.

The findings include:

On 05/04/15 at 4:15 p.m., random observation of the hospital kitchen revealed the warmer unit located across from the grill had a temperature gauge which displayed the temperature as 2 degrees Farenheit. The units door was opened and inside was noted to be warm. On 05/04/15 at 4:15 p.m., interview with dietary director 1 revealed the gauge on the warmer was incorrect.

On 05/04/15 at 4:35 p.m., random observation of the hospital kitchen revealed dust accumulation noted in the top of the motor area of the hot warmer/freezer unit adjacent from the gas stove. On 05/04/15 at 4:35 p.m., interview with dietary director 1 revealed that the top of the warmer did have an accumulation of dust on the top of the unit.

On 05/05/2015 at 9:15 a.m. a tour of the physical environment was conducted. During the tour of the emergency waiting room, moderate amounts of dust/dirt was observed behind the chair next to the baseboard all around the room. The Plant Operations Director verified the findings on 05/05/2015 at10:30 a.m.

A tour of the physical environment was conducted on 05/05/2015 at 9:15 a.m. The ICU (intensive care unit) was surveyed and during the tour the blanket warmer in the ICU had a preventative maintenance sticker dated 01/2014 as the expiration date. The plant operations director stated stickers were used as expired preventative maintenance dates for the blanket warmers. The plant operations director verified the finding on 05/05/2015 at 9:45 a.m.






Based on observations and interview, the hospital failed to ensure the environment was safe for patients related to an unclean emergency waiting room and the blanket warmer in the Intensive Care Unit.

The findings include:

On 05/04/15 at 4:40 p.m., random observations in the Respiratory Department revealed the preventive maintenance for the pulse oximetry machine was last checked on 09/22/14 with a "next due date" of 3/15.

On 05/05/2015 at 9:15 a.m., observations of the hospital's emergency department waiting room showed moderate amounts of dust/dirt behind the chairs next to the baseboard all around the room. The Plant Operations Director verified the findings on 05/05/2015 at10:30 a.m.

On 05/05/2015 at 9:15 a.m., observations of the intensive care unit revealed the blanket warmer located in the hospital's ICU had a preventative maintenance sticker dated 01/2014 as the expiration date. The plant Operations Director stated stickers were used as expired preventative maintenance dates for the blanket warmers. The plant Operations Director verified the finding on 05/05/2015 at 9:45 a.m.

Based on observation and interview, the hospital dietary staff failed to document sanitizer and temperature readings for the dish machine, temperature readings for the salad refrigerator, refrigerator and freezer located by the gas stove, walk-in refrigerator and freezer, grab and go refrigerator, and the prep refrigerator.

The findings are:

On 05/04/15 at 4:55 p.m., review of the dish machine log revealed missing sanitizer times, ppms, and wash and rinse temperatures for the following days:
02/01/15---breakfast, lunch and dinner
02/03/15--dinner
02/15/15--dinner
02/16/15--breakfast
02/19/15--breakfast
02/22/15--breakfast, lunch and dinner
02/24/15--dinner
02/26/15--dinner
02/28/15--dinner
03/02/15--dinner
03/05/15--lunch
03/14/15-dinner
03/15/15-breakfast, lunch and dinner
03/19/15-dinner
03/22/15-breakfast, lunch and dinner
03/26/15-breakfast
03/29/15-breakfast, lunch and dinner
04/17/15- lunch and dinner
04/23/15-lunch and dinner

Review of the salad reach-in refrigerator logs revealed missing temperatures for the following dates: 02/01/15, 02/19/15, 03/19/15 and 03/29/15.
Review of the refrigerator logs by the stove revealed missing temperatures for the following days: 02/02/15, 02/05/15, 03/18/15, 03/19/15 and 03/29/15.
Review of the walk-in refrigerator logs by the back door of the kitchen revealed missing temperatures for the following dates: 02/02/15, 02/05/15, 02/10/15, 03/12/15, 03/19/15 and 04/05/15.
Review of the refrigerator grab and go refrigerator revealed missing temperatures for the following dates: 02/15/15, 02/22/15, 02/24/15, 03/04/15, 03/22/15 and 03/27/15.
Review of the preparation reach-in cooler revealed missing temperatures for the following dates: 02/01/15, 02/22/15, 03/26/15 and 03/30/15.
On 05/04/15 at 5:15 p.m., the findings were verified by the Dietary Director.

Based on interview and review of personnel records, the hospital's governing body failed to designate in writing the appointment of the hospital's infection control officer.

The findings are:

On 05/05/15 at 3:25 p.m., review of the Infection Control Officer's personnel file revealed there was no evidence that the governing body had appointed the staff member as the hospital's Infection Control Officer . Further review of the staff member's personnel file showed the staff member had no documentation of infection control training or ongoing infection control training. On 05/05/15 at 3:40 p.m., Human Resource (HR) Personnel 1 stated, "I don't have anything as far as someone being designated to a specific position. I just don't have that".

On 05/06/15 at 2:10 p.m., the Infection Control Officer revealed, "I have been in this position for a while. I left the hospital and then came back". The Infection Control Officer stated, "It's not actually training. I am registered with APIC and receive all the latest updates and changes. I have not taken any classes or training because of financial reasons. We were not able to attend any training in the latter part of 2014".

Based on observation, interview, review of the hospital policy and procedures, 1 of 11 Registered Nurses (RN 2), 1 of 1 Dietary Aids (Dietary Aid 1), 1 of 1 Medical Director (MD 1)failed to disinfect patient equipment for 1 of 1 Medical Technicians (Med Tech 1), 1 of 1 Phlebotomist (Phlebotomist 1), and 1 of 11 Registered Nurses (RN 1) observed in the treatment area.

The findings are:

On 05/05/15 at 9:15 a.m., random observations in the laboratory revealed a patient was called to the lab draw room and seated in a chair for venipuncture for blood draw performed by Phlebotomist 1. Observations showed Phlebotomist 1 placed a dressing on the puncture site and the patient exited the room. Phlebotomist 1 touched the buttons on the computer wearing the gloves for the venipuncture procedure. Phlebotomist 1 removed the soiled gloves and performed hand hygiene. At 9:20 a.m., Phlebotomist 1 called another patient to the lab draw room, seated the patient in the chair, performed the venipuncture, dressed the site, and the patient exited the lab draw room, but Phlebotomist 1 failed to disinfect the patient equipment used between the two patients. On 05/05/15 at 9:25 a.m., Phlebotomist 1 stated, "I usually wipe the chair down during the morning time and usually if someone is real filthy. House keeping comes in everyday and do a deep cleaning".

On 05/05/15 at 10:18 a.m., observations of Registered Nurse (RN) 2 revealed RN 2 knocked on the patient's door, entered the room, identified the patient, assessed the patient's pain level and allergies, explained the purpose and action of the medication, donned clean gloves, administered the medication, but RN 2 failed to perform hand hygiene prior to donning clean gloves.

On 05/05/15 at 10:23 a.m., random observations in the triage room revealed RN 1 retrieved a patient from the waiting area, obtained the patient's weight, allergies, and chief complaint, placed the blood pressure cuff and pulse oximetry probe onto the patient, and used the oral thermometer to obtain the patient's temperature. RN 1 removed the blood pressure cuff and pulse oximetry probe and then placed the blood pressure cuff back into the common container with the 2 other blood pressure cuffs. RN 1 placed the oral thermometer in the common container with another oral thermometer. RN 1 failed to disinfect patient equipment after patient use.
On 05/05/15 at 10:33 a.m., RN 1 revealed, "We clean the equipment after each patient, but we don't clean the whole thermometer because only the probe is used on the patient so we just clean the probe".

On 05/05/15 at 10: 45 a.m., RN 2 revealed, "You made me nervous and I forgot to wash my hands before I put on my gloves".

On 05/06/15 at 11:55 a.m., observations of Medical Technician 1 revealed the Medical technician took the glucose monitor into patient room 214, exited room 214, took the glucose monitor into patient room 217, exited room 217, disinfected the glucose monitor, and placed the monitor in the holder. Medical Technician 1 failed to disinfect the glucose monitor between patient use. On 05/06/15 at 12:07 p.m., Medical Technician 1 revealed, "I suppose to clean it before use and after each use".

Facility policy and procedures, titled, "Hand Hygiene And Staff Accountability Policy", reads, ".... A. a. Decontaminate hands before having direct contact with patients or their environment, whether or not gloves are worn.... D. Glove Use a. Decontaminate hands prior to putting on gloves....e. Decontaminate hands after removing gloves....".

Facility policy and procedures, titled, "Cleaning Of Equipment", reads, "1. All reusable equipment will be cleaned between patient usage and when visibly soiled using the manufactures recommended cleaning techniques....".




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On 05/05/15 at 9:25 a.m., random observations on the medical surgical floor revealed the physician exited patient room 217 without hand sanitizing.

On 05/05/15 at 11:00 a.m., random observations on the medical surgical floor revealed Dietary Aide 1 exited patient room 217 without performing hand hygiene.

On 05/05/15 at 11:03 a.m., random observations on the medical surgical floor revealed Dietary Aide 1 entered patient room 219 which was designated as an isolation room. Dietary Aide 1 donned no personal protective equipment (PPE) and performed no hand hygiene post exit. On 05/05/15 at 12:50 p.m., Dietary Aide 1 revealed the nurses are asked prior to entering the isolation rooms if its okay. So we go in and discuss the menu with the patient and come back out. We don't have to put on PPE when we go into the rooms as long as we don't touch anything. We just sanitize when we come out".

Hospital policy, titled, "Isolation Precautions,....Contact Precautions", reads, "In addition to standard precautions, use contact precautions for specified patients known or suspected to be infected or colonized with epidemiological important microorganisms that can be transmitted by direct contact with the patient (hand or skin-to skin contact that occurs when performing patient care activities that require touching the patient's dry skin) or indirect contact (touching) with environmental surfaces or patient care items in the patient's environment. 1. Patient Placement: Place the patient in a private room. 2. Gloves and Handwashing: In addition to wearing gloves as outlined in standard precautions, wear gloves (clean, non-sterile are adequate) when entering the room. During the course of providing care for the patient, change gloves after having contact with infective material that may contain high concentrations of microorganisms (fecal material and wound drainage). Remove gloves before leaving the room and wash hands immediately with an antimicrobial agent or waterless antiseptic agent....".

Based on personnel record review and interview, the hospital failed to ensure its staff received annual updated education related to the organ procurement organization, tissue bank, and eye bank.

The findings include:

On 04/02/2015 at 2:10 p.m., during an interview with the Director of Staff development, the Director revealed patient care staff received education related to the organ procurement organization (OPO) only at the employee's orientation at hire. The Director stated that the OPO conducts periodic updates only for the Intensive Care Unit staff and Emergency Department staff and it is not through staff development. The Director of Staff development verified the findings on 04/02/2015 at 2:20 p.m.

Based on chart review, interview, and review of the facility policy and procedures, the facility failed to ensure the patient's history and physical (H&P) was completed within thirty (30) days prior to the date of surgery for 2 of 2 surgical patient charts reviewed. ( Patient 1 and 2 )

The findings are:

On 05/06/15 at 3:30 p.m., review of Outpatient 1's chart revealed the patient had a left shoulder arthroscopy performed on 05/06/15 and the patient's H&P was dated 03/10/15 which is greater than 30 days prior to the surgery date.

On 05/06/15 at 4:00 p.m., review of Outpatient 2's chart revealed the patient had a right shoulder arthroplasty performed on 05/06/15 and the patient's H&P was performed on 03/05/15 which was greater than 30 days prior to the surgery date. On 05/07/15 at 1:00 p.m., Registered Nurse 4 revealed, "the physicians usually signed the H&P on the day of surgery stating if there were any changes. Is that not what they are suppose to do"?

Facility policy and procedures, titled, "Administrative Manual of Policies and Procedures", reads, "....C. History and Physical: If a complete history and physical has been obtained, within 30 days prior to admission, it can be used for the current H&P if appropriate....".

Based on interview and record review, the hospital failed to ensure nursing documentation for wound measurements and administration of the patient's insulin for 1 of 1 swing bed patients. (Patient 5)

The findings are:

On 05/05/15 from 9:20 a.m.-10:45 a.m., review of Patient 5's chart revealed a patient admitted to the hospital's swing bed on 04/30/15. Review of physician orders dated 04/30/15 revealed an order for skin assessment on admission and every 3 days and wound orders: skin assessment on admit and every 3 days, heel protectors at all times, air mattress at all times and hand rolls to contractures at all times. Review of wound assessment/care and documentation revealed stage 4 pressure ulcers to the left hip, right hip, and sacrum, a stage 2 pressure ulcer right heel, a pressure ulcer with eschar to the left ankle, a skin tear to the right shoulder, and blisters to the abdomen on 05/01/15 at 7:00 p.m.. Review of nurse documentation revealed there were no wound measurements on 05/01/15 at 7:00 p.m. by the registered nurse. Wound assessment/care and documentation on 05/04/15 at 7:00 a.m. and 7:55 p.m. revealed there was no wound measurement documentation at either time respectively. On 05/05/15 at 10:00 a.m., the findings were verified by Clinical Performance Coordinator/Director Discharge Planning.


On 05/05/15 from 9:20 a.m.- 10:45 a.m., review of Patient 5's chart revealed a verbal physician's order dated 04/30/15 for Humalog 3 ml (milliliter) vial 100 unit/ml vial with option 1 and option 2 information for sliding scale insulin. Dose instructions revealed option 1 for sliding scale insulin with the following instructions for administration:
Less than 140-------Give 0 units
141-200--------------Give 2 units
201-250--------------Give 4 units
251-300--------------Give 6 units
301-350--------------Give 8 units
351-400--------------Give 10 units
Greater than 400---Give 12 units and notify MD (medical doctor).

Review of the patient blood glucose levels on 04/30/15 at 11:50 p.m. revealed a blood glucose level of 149 with no insulin administered with a reason documented for non administration as within normal range by the registered nurse. On 05/02/15 at 5:25 p.m., the patient's blood glucose level was 155 with no insulin administered with a reason documented for non administration as within normal range by the registered nurse. On 05/04/15 at 7:29 a.m., the patient's blood glucose level was 167 with no administered insulin of 2 units with a reason documented for non administration as within normal range. On 05/04/15 at 5:08 p.m., the patient's blood glucose level was 153 with no insulin administered with a reason documented for non administration of normal range by the registered nurse. On 05/05/15 at 7:30 a.m., the patient's blood glucose level was 188 with no insulin administered with a reason documented for non administration as other. On 05/05/15 at 11:25 a.m., Registered Nurse 6 revealed, "I didn't want to bottom the patient out". On 05/05/15 at 10:30 a.m., the findings were verified by the Clinical Performance Coordinator/Director of Discharge Planning.

Based on interview and record review, the hospital swing bed failed to ensure a history and physical was completed by the admitting physician for 1 of 1 swing bed patients. (Patient 5).

The findings:

On 05/05/15 at 9:20 a.m., review of swing bed Patient 5's chart revealed the patient was discharged from acute hospital and admitted to a swing bed on 04/30/15. Review of the patient's chart revealed there was no history and physical for the swing bed admission. On 05/05/15 at 9:20 a.m., the Clinical Performance Coordinator/Discharge Planner revealed, "the patient's hospital discharge summary is used as the history and physical for admission to the swing bed unit".

Based on interview, record review, review of patient activity schedule, and the swing bed policy and procedure, the hospital swing bed program failed to have an activity program directed by a qualified therapeutic specialist, activity professional, or an occupational therapist.

The findings are:

On 05/05/15 at 9:20 a.m., review of Patient 5's chart revealed the patient was admitted to swing bed on 04/30/15. Review of patient activity sheet revealed a schedule for the month of April 2015 and May 2015. On 05/05/15 at 9:30 a.m., the Clinical Performance Coordinator/Director of Discharge Planning revealed, "there is no actual activity director. I put together the calendar and the occupational therapist signs off on the calendar. We don't actually employ an actual activity director". Review of job descriptions for the swing bed revealed there was no description for an activity director. Review of the Swing Bed policy and procedure revealed, "Activities Director: The activities program shall be carried out by the swing bed coordinator under the supervision and direction of the occupational therapist....".

Based on interview, record review, and review of facility job descriptions, the hospital failed to ensure a physical therapy and occupational therapy evaluation was performed on 1 of 1 patient in the swing bed unit.

The findings are:

On 05/05/15 at 9:30 a.m., review of Patient 5's chart revealed the patient was admitted to the swing bed unit on 04/30/15. Review of patient's chart revealed a physician's order dated 04/30/15 for activity per physical therapy and occupational therapy. There was no physical therapy or occupational therapy evaluation for the patient after the patient's admission to the swing bed unit. On 05/05/15 at 9:50 a.m., the Clinical Performance Coordinator/Discharge Planner revealed the physical therapist and the occupational therapist used their evaluations from the period when the patient was an acute patient.