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Based on record review and interview, the facility failed to ensure that allied health professionals (nurse practitioners) are approved and privileged for the clinical services they provide to patients. This affects all patients in a census of 31.

Findings included:

1. Review of medical staff bylaws under article IV-Allied Health Professionals stated that advanced practice nurses are in the category of allied health professionals.

2. Article V for application and appointment under section 5.1 states that unless otherwise provided in these bylaws, no person shall exercise clinical privileges in the hospital unless and until he/she applies for and receives medical staff appointment and/or such clinical privileges are granted as set forth in the bylaws. Appointment to medical staff shall confer only those specific clinical privileges that have been granted in accordance with these bylaws.

3. During an interview on 7/14/10 at 11:05 A.M. Staff AA and Staff O stated that the five employed nurse practitioners are not privileged or approved by medical staff. Only the collaborative agreement (between supervising physician and nurse practitioner) details what the nurse practitioner can provide for patient care. There is one additional nurse practitioner that is not an employee of the hospital, they stated this nurse practitioner has gone through the credentialing process for approval of privileges.

4. During an interview on 7/14/10 at 1:15 P.M. Staff E stated that the board approves all nurse practitioners by nature of being employees of the facility. They would be considered as credentialed by going through the employment process. They are not granted privileges by approval of the medical staff and as employees go through the employment process only.

Based on interview and review of the facility quality assurance improvement records, the facility failed to ensure the governing body assessed the services provided under contract for eight of eight contracted services. The facility had a census of 31.

Findings included:

During an interview on 07/15/10 at 10:00 A.M. Staff C said the facility has approximately eight contracted services. Staff C said different facility staff go on-site to observe the contracted services. Staff C said no contracted services quality indicator information is reported to the facility overall quality improvement committee and no quality indicator information from contracted services is used in performance improvement or reported to the governing body.

Review of the list of contracted services utilized by the facility includes agency staffing, psychiatric services, pharmacy services, laboratory, radiology, organ procurement, janitorial and other services.

Review of the recent Performance improvement committee meeting minutes did not contain any review of contracted services.

Based on policy review and interview the facility failed to ensure the grievance committee, delegated by the governing body, reviews and resolves grievances. The facility had a census of 31.

Findings included:

Review of facility policy #RI-317, "Consumer Complaint (Grievance) Procedure," last reviewed 04/09, documents in the procedure section #8: "The Board of Directors has delegated the ultimate responsibility of the Consumer Complaint (Grievance) procedure to the Executive Team."

During an interview on 07/14/10 at 10:30 A.M., the Quality and Patient Safety Administrator, Staff D, said the grievance committee is the executive team and consists of the President/Chief Executive Officer (CEO), The Chief Financial Officer (CFO), the Chief Operating Officer (COO), and the Chief Medical Officer.

Staff D said he/she is not part of the grievance committee, but reviews and investigates any patient related complaints, and another staff member, Staff CC, the Operations Administrator/Compliance Officer, reviews and investigates any staff related complaints or grievances. Staff D said Staff CC is not part of the executive team.

Staff D said not all complaints/grievances go to the executive team (the grievance committee). Staff D said he/she determines which complaints or grievances he/she takes to the CEO, who is part of the executive team. Staff D said he/she investigates the complaints/grievances, and if a response is needed, the executive team documents his/her findings in a letter to the complainant.

Staff D said the person verbalizing a concern/complaint must fill out a grievance form for the complaint to be considered a grievance.

Staff D said the facility received five complaints in the past year, and three of those he/she considered grievances and were taken to the grievance committee for review of his/her findings.

Based on policy review, record review, and interview, the facility failed to ensure the least restrictive restraint for one of one patient (Patient #21) reviewed with behavioral restraints. The facility census was 31.

Findings Included:

Review of facility policy #RI-319, "Restraints" last reviewed 06/09, showed in section VII. "All direct patient care staff must be trained and able to demonstrate competency in applying restraint as well as monitoring, assessing and providing care for a patient in restraints."

Review of the facility policy TX-510, "CPI-Patient in Behavioral Crisis," last reviewed 02/10, showed in the procedure section 1.b. "Page over the VOCERA (a voice controlled paging system), "CPI code team member to (location)" for additional staff help (CPI is crisis prevention institute, a training in the safe management of disruptive and assaultive behavior with a focus on prevention.). Further review of the policy showed in the procedure section #3. If the patient poses an immediate danger that the staff is unable to manage, the security officer or the police should be contacted."

Closed record review showed Patient #21 entered the facility on 03/25/10 for treatment of life-threatening asthma, continuous positive airway pressure (a method of respiratory ventilation used primarily in the treatment of sleep apnea), and obstructive sleep apnea (a sleep disorder in which breathing repeatedly stops and starts during sleep).

Review of patient progress notes dated 04/14/10 at 7:00 P.M. showed a behavioral dispute erupted between the patient and another peer. Peer reportedly spit on Patient #21. Staff documented Patient #21 called his/her parent and received verbal permission to hit the other patient (there is no evidence Patient #21 hit the other patient). The progress notes document, "Maryland Heights Police in house to facilitate de-escalation of dispute. Parents arrived independently at facility and further Maryland Heights Police needed to secure patient and family."

Review of a summary of the situation attached to the incident report showed staff documented event occurred on 04/15/10 but event occurred on 04/14/10. Staff documented patients were outside for a group session and Patient #21 approached another patient and told that patient not to spit on him/her. Patient #21 became agitated and out of control. Patient #21 entered the building and locked self in a bathroom. The summary documents, "Police officer summoned." Patient then exited the building with staff and remained on hospital property. Patient verbally abusive and threatening to staff. The summary documents, "Police officer always behind (within 20 feet)." The summary documents "Staff DD verbalized to police officer if he/she needed to cuff the patient he/she could. Patient verbalized go ahead and cuff me, then placed his/her own hands behind his/her back." Security officer placed handcuffs on the patient. Further review of the summary showed both parents arrived and demanded the handcuffs be removed. The facility discharged the patient to his/her parents against medical advice.

No time is documented as to when the facility security officer placed Patient #21 in handcuffs or what time the handcuffs were removed.

During an interview on 07/14/10 at 1:10 P.M. registered nurse (R.N.) manager Staff DD said staff did not call any type of security code (a call for help to subdue a patient) and did not attempt to physically restrain the patient in any manner other than the handcuffs because of the patient's size and staff feared for their safety. Staff DD said the patient probably weighed over 300 pounds. [The admitting history and physical shows the patient is 63 ? inches tall and weighs 149 pounds.]

Staff DD said the patient could not re-enter the building because the door to the building was locked and no other patients were in that area at the time staff handcuffed Patient #21.

Staff DD said the facility does not have any behavioral restraints to put on a patient and staff is not trained to put hands on a patient to do a physical hold.

Review of the medical record for Patient #21 showed no evidence of a less restrictive method of restraint.

Based on policy review, record review and interview the facility failed to obtain a physician's order for a restraint for one patient (Patient #21) of four restraint records reviewed. The facility had a census of 31.

Findings included:

Review of the facility policy TX-510, "CPI-Patient in Behavioral Crisis," last reviewed 02/10, documents in part that the purpose is to support a patient through a behavioral crisis situation and prevent harm to him/herself or others. It is the policy to provide each patient with as safe an environment as possible. Further review of the policy showed when a patient becomes behaviorally unmanageable and demonstrates such a threat that non-violent physical intervention is necessary, the staff must respond immediately by doing the following:
"a. Provide for the safety of all concerned, by removing all other patients from the situation to another area in the building.
b. Page over the VOCERA system (a voice controlled paging system), 'CPI code team member to (location)' for additional staff help.
c. Notify the Medical Director or the on call Medical Staff.
d. If the incident occurs during the evening or night shift hours as well as the weekend, Social Service personnel on call should be notified.
e. The Social Service personnel on call should notify the patient's family or guardian.
The Medical Director has the authority to order PRN [as needed] medications for the patient if necessary for the patient's safety as well as for the safety of others. If the patient poses an immediate danger that the staff is unable to manage, the security officer or the police should be contacted."

Closed record review showed Patient #21 entered the facility on 03/25/10 for treatment of life-threatening asthma, continuous positive airway pressure (a method of respiratory ventilation used primarily in the treatment of sleep apnea), and obstructive sleep apnea (a sleep disorder in which breathing repeatedly stops and starts during sleep).

Review of patient progress notes dated 04/14/10 at 7:00 P.M. showed a behavioral dispute erupted between the patient and another peer. Peer reportedly spit on Patient #21. Staff documented Patient #21 called his/her parent and received verbal permission to hit the other patient (there is no evidence Patient #21 hit the other patient). The progress notes document, "Maryland Heights Police in house to facilitate de-escalation of dispute. Parents arrived independently at facility and further Maryland Heights Police needed to secure patient and family."

Review of a summary of the situation attached to the incident report showed staff documented event occurred on 04/15/10 but event occurred on 04/14/10. Staff documented patients were outside for a group session and Patient #21 approached another patient and told that patient not to spit on him/her. Patient #21 became agitated and out of control. Patient #21 entered the building and locked self in a bathroom. The summary documents, "Police officer summoned." Patient then exited the building with staff and remained on hospital property. Patient verbally abusive and threatening to staff. The summary documents, "Police officer always behind (within 20 feet)." The summary documents "Staff DD verbalized to police officer if he/she needed to cuff the patient he/she could. Patient verbalized go ahead and cuff me, then placed his/her own hands behind his/her back." Security officer placed hand cuffs on the patient. Further review of the summary showed both parents arrived and demanded the handcuffs be removed. The facility discharged the patient to his/her parents against medical advice.

During an interview on 07/14/10 at 1:10 P.M., registered nurse (R.N.) manager Staff DD said staff did not call any type of security code (a call for help to subdue a patient) and did not attempt to physically restrain the patient in any way because of the patient's size. Staff DD said the patient probably weighed over 300 pounds. [The admitting history and physical shows the patient is 63 ? inches tall and weighs 149 pounds.]

Staff DD said the facility does not have any behavioral restraints to put on a patient and staff is not trained to put hands on a patient to do a physical hold. Staff DD said the summary of the incident documents in several places a "police officer" handcuffed the patient, but the officer who handcuffed the patient is a facility employee.

Staff DD said that he/she did not attempt to contact the physician for an order to restrain the patient in any way.

Review of the medical record for Patient #21 showed no evidence of an order for a chemical or behavioral restraint.

Based on policy review, record review, observation and interview the facility failed to ensure restraint orders are not written as a PRN (as needed) order for one patient (Patient #8) of four patients reviewed for medical restraints. The facility had a census of 31.

Findings included:

Review of the facility policy RI-319, "Restraints" last reviewed 06/09 showed in section II. Physician Orders: section B. "PRN restraint orders are prohibited" and section C. "Restraint orders may not be reinitiated once discontinued without obtaining a new order from a physician."

Open record review showed Patient #8 entered the facility 07/08/10 due to residual traumatic brain injury. The physician ordered Jevity 1.2 (a high-protein, fiber-fortified formula that provides balanced nutrition) to infuse by PEG tube (percutaneous endoscopic gastrostomy tube placed into a patient's stomach as a means of feeding when the patient is unable to eat) for one hour every four hours.

Review of the physician order dated 07/08/10 at 4:00 P.M. showed the physician ordered, "Side rails x4 plus padding or may use Posey if needed."

Review of the physician order dated 07/12/10 at 11:30 A.M. showed the physician ordered a R (right) hand mitt while feeding infusing to prevent patient from disrupting lines, tubes or other medical devices.

Review of the progress notes showed no evidence of assessment every four hours, at the time of the tube feeding, to determine if the patient continued to need the restraint applied to the right hand. There is no documentation the patient is trying to pull at the feeding tube.

Review of the physician order dated 07/13/10 at 11:30 A.M. showed an order for padded mitts to prevent patient from disrupting lines, tubes or other medical devices.

During an observation on 07/13/10 at 2:00 P.M. the staff had the patient sitting in a wheelchair in a therapy group. Patient #8 was restless and was touching the leg support of the wheelchair with his/her right hand. Staff II took the patient's right hand and put the mitten on the patient's hand.

Observation showed Patient #8 was not attempting to disrupt any lines, tubes or medical devices.

During an interview on 07/13/10 at 2:05 P.M. Staff II said that there is an order to use the mitten if needed.

Based on policy review and interview the facility failed to have a policy documenting the training requirements for physicians in the use of restraint or seclusion. The facility had a census of 31.

Findings included:

Review of facility restraint policies showed no policy addressing restraint or seclusion training requirements for physicians.

During an interview on 07/14/10 at 3:40 P.M., the Medical Director, Staff L, said that the facility does not have a policy addressing the training requirements for physicians regarding the use of restraint or seclusion.

Based on policy review, interview, and record review, the facility failed to ensure all staff members who restrain patients receive training in the safe application of restraints for 20 of 20 facility security officers. The facility had a census of 31.
Findings included:

Review of facility policy #RI-319, "Restraints" last reviewed 06/09 showed in section VII. All direct patient care staff must be trained and able to demonstrate competency in applying restraint as well as monitoring, assessing and providing care for a patient in restraints.

Review of facility policy #TX-510, "CPI - Patient in Behavioral Crisis" last reviewed 02/10 showed in the procedure section 1.b. "Page over the VOCERA (a voice controlled paging system) system, 'CPI code team member to (location)' for additional staff help." (CPI is crisis prevention institute, a training in the safe management of disruptive and assaultive behavior with a focus on prevention.) Further review of the policy showed in the procedure section #3. "If the patient poses an immediate danger that the staff is unable to manage, the security officer or the police should be contacted."

During an interview on 07/14/10 at 9:35 A.M., registered nurse (R.N.) manager Staff JJ said that the facility does not apply behavioral restraints and no staff member can do a hands on with a patient unless that staff member is trained in CPI.

During an interview on 07/14/10 at 9:45 A.M., Staff KK said that he/she does the CPI training for staff. Staff KK said security officers do not restrain patients and staff only uses medical restraints. Staff KK said staff does not apply any behavioral restraints and staff does not place patients in seclusion.

Closed record review showed Patient #21 entered the facility on 03/25/10 for treatment of life-threatening asthma, continuous positive airway pressure (a method of respiratory ventilation used primarily in the treatment of sleep apnea), and obstructive sleep apnea (a sleep disorder in which breathing repeatedly stops and starts during sleep).

Review of patient progress notes dated 04/14/10 at 7:00 P.M. showed a behavioral dispute erupted between the patient and another peer. Peer reportedly spit on Patient #21. Staff documented Patient #21 called his/her parent and received verbal permission to hit the other patient (there is no evidence Patient #21 hit the other patient). The progress notes document, "Maryland Heights Police in house to facilitate de-escalation of dispute. Parents arrived independently at facility and further Maryland Heights Police needed to secure patient and family."

Review of a summary of the situation attached to the incident report showed staff documented event occurred on 04/15/10 but event occurred on 04/14/10. Staff documented patients were outside for a group session and Patient #21 approached another patient and told that patient not to spit on him/her. Patient #21 became agitated and out of control. Patient #21 entered the building and locked self in a bathroom. The summary documents, "Police officer summoned." Patient then exited the building with staff and remained on hospital property. Patient verbally abusive and threatening to staff. The summary documents, "Police officer always behind (within 20 feet)." The summary documents "Staff DD verbalized to police officer if he/she needed to cuff the patient he/she could. Patient verbalized go ahead and cuff me, then placed his/her own hands behind his/her back." The facility security officer placed hand cuffs on the patient. Further review of the summary showed both parents arrived and demanded the handcuffs be removed. The facility discharged the patient to his/her parents against medical advice.

No time is documented as to when the facility security officer placed Patient #21 in handcuffs or what time the handcuffs were removed.

During an interview on 07/14/10 at 1:10 P.M. registered nurse (R.N.) manager Staff DD said that it was not the police who handcuffed the patient but the facility security officer. Staff DD said that the security officer is an employee of the facility but also has a job as a Maryland Heights police officer. Staff DD said he/she gave the security officer permission to handcuff Patient #21 because the patient was threatening to staff. Staff DD said staff did not call any type of security code (a call for help to subdue a patient) and did not attempt to physically restrain the patient in any way because of the patient's size. Staff DD said the patient probably weighed over 300 pounds and staff feared for their safety. [The admitting history and physical shows the patient is 63 ? inches tall and weighs 149 pounds.]

During an interview on 07/14/10 at 1:20 P.M., Staff CC, the Operations Administrator/Compliance Officer, said that the facility security officers report to him/her and the security officers do not receive any training in restraint/seclusion. Staff CC said the facility employs 20 security officers.

Based on interview, restraint training review, and personnel file review, the facility failed to ensure staff providing care for patients in restraints received basic first aid training related to restraint use. This failure impacts all patients placed in restraints. The facility had a census of 31.

Findings included:

During an interview on 07/14/10 at 9:45 A.M., Staff KK said he/she does the CPI training for staff (CPI is crisis prevention institute, a training in the safe management of disruptive and assaultive behavior with a focus on prevention.)

Staff KK said staff is not trained in first aid as related to restraint use. Staff KK said staff only uses medical restraints and does not use any type of a behavioral restraint or seclusion for behavioral issues.

Review of the facility restraint training showed no training in the use of first aid as related to restraint use.

Review of five personnel records for registered nurses showed no first aid training related to restraint use.

Based on record review, collaborative agreement review, and interview, the facility failed to ensure the sponsoring physician reviewed and/or evaluated the clinical work of the advanced practice nurses at least every two weeks as required by the collaborative agreement. Four patient records (Patients #5, #6, #7 and #21) were reviewed for physician evaluation. The facility census was 31.

Findings included:

1. Review of the Medical Staff Bylaws, revised 1/25/05, revealed in part: "Article IV-Allied Health Professionals (AHP) Section 4.3 Prerogatives: An AHP shall:
- (a) Provide specifically designated patient care services under the supervisor or direction of a Medical Staff member, if required by licensure."

2. Review of the Collaborative Practice Agreement between the Advanced Practice Nurses (APN) and the Physician revealed in part: "4. Review of Services
- (c) Physician and APN shall discuss each patient, plan of treatment, documentation of APN ' s prescribing practices, and other relevant records of care delivered by APN under this agreement at least every two weeks."

3. Current record review on 7/13/10 revealed Patient #5 entered the facility on 6/4/10. Review of Patient #5's progress notes revealed the physician entered a progress note for the patient every two weeks. However the note did not include documentation he/she was in agreement with the APN's clinical care of the patient.

4. Current record review on 7/13/10 revealed Patient #6 entered the facility on 6/19/10. Review of Patient #6's progress notes revealed the physician entered a progress note for the patient every two weeks. However the note did not include documentation he/she was in agreement with the APN's clinical care of the patient.

5. Current record review showed Patient #7 entered the facility on 03/11/10. Review of Patient #7's orders showed orders written by an APN. Review of progress notes showed the physician entered a progress note for the patient every two weeks. However the note did not include documentation he/she was in agreement with the APN's clinical care of the patient.

6. Closed record review showed Patient #21 entered the facility on 03/25/10 for treatment of life-threatening asthma and continuous positive airway pressure (a method of respiratory ventilation used primarily in the treatment of sleep apnea) and obstructive sleep apnea (a sleep disorder in which breathing repeatedly stops and starts during sleep). Review of Patient #21's progress notes showed entries written by an APN. Review of progress notes showed the physician entered a progress notes for the patient however the notes did not include documentation he/she was in agreement with the APN's clinical care of the patient.

In an interview on 7/13/10 at 9:15 A.M. Staff L, Medical Director said the physicians had been communicating with the APNs on an ongoing basis during team conference. Staff L said they physician completed a progress note every two weeks for patients. Staff L said the physicians had not been co-signing the APN's notes and had not been documenting their agreement with the APN's clinical care. Staff L said the facility was in the process of changing their current practice to indicate physician agreement with the APN's clinical care.



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Based on record review, collaborative agreement review and interview the facility failed to ensure the sponsoring physician cosigned the History and Physical within one week as required by the collaborative agreement for two patients (Patients #5 and #6) of 27 sampled records. The facility census was 31.

Findings included:

1. Review of the facility's Collaborative Practice Agreements between the physician and advanced practice nurse revealed in part: 4. Review of Services:
- "Physician will review the work, records and practice of the healthcare provided by the Advanced Practice Nurse (APN) as evidenced by the following:
- (b) Physician shall review and co-sign all initial history and physical examinations performed upon patient admission and discharge summaries prepared by the APN within one week of completion."

2. Current record review on 7/13/10 revealed Patient #5 entered the facility on 6/4/10. The Readmission Note (history and physical) completed on 6/4/10 by the Certified Pediatric Nurse Practitioner had no physician signature.

3. Current record review on 7/13/10 revealed Patient #6 entered the facility on 6/19/10. The Readmission Note (history and physical) completed on 6/19/10 by the Certified Pediatric Nurse Practitioner had no physician signature.

In an interview on 7/13/10 at 9:15 AM Staff L, Medical Director, stated the physicians are to co-sign behind the advanced practice nurses as per the collaborative agreement.

Based on facility policy review, observation, record review, and interview, the facility failed to ensure medications were administered as ordered by the physician for three (Patients #2, #12, and #9) of eight patients observed during medication administration. The facility census was 31.

Findings included:

1. Review of the facility policy titled, "Medication Administration," last reviewed 5/10, showed the following (in part):
- "All medications will be administering (administered) within 30 minutes of scheduled administration time. The criteria for Standard Administration Times may be found in policy PHARM 401."
- "Medications will be charted immediately following the administration by the person administering the drugs. The date, time administered, and dosage must be entered on the Medication Administration Record (M.A.R.) and signed by the person entering the data."

2. Review of the facility document utilized for nurse orientation titled, "The Six Rights of Medication Administration in Children," showed the following (in part):
- "Check the M.A. R. and note the time that you have medication due. Take time at the beginning of your shift to carefully note the time that your medications are due for all of your patients. Note how they correlate with other procedures for the child such as dressing changes or feedings so you can plan appropriately."
- "When drugs are omitted, include the reason for the omission in your charting. There are sometimes reasons why a particular drug dose may not be given on time. For example, your patient was vomiting and the physician allowed the dose to be held. Or your patient has I.V. (intravenous) medication and the P.I.V. (peripheral I.V.) infiltrates. Please notify the physician or P.N.P. (Pediatric Nurse Practitioner) if a med is not give(n) within one hours of its scheduled time."
- "Late medications. Medications should be given within 30 minutes of scheduled time.

3. Observation on 07/13/10 at 8:20 A.M. showed Registered Nurse (R.N.) Staff S preparing to administer medications to Patient #2. Upon entering the patient's room, R.N. Staff S noticed that the patient's T.P.N. and Lipids had completely infused and stated the line needed to be flushed. R.N. Staff S obtained a prefilled syringe with Heparin (an anticoagulant) and flushed the syringe. When this process was completed, R.N. Staff S gave the patient a wet washcloth to wash his/her face before administering Benzoyl Peroxide (used to treat acne) 5% Gel.

Review of the M.A.R. on 07/13/10 at 1:00 P.M. for current Patient #2 showed the medication was scheduled to be given at 8:00 A.M. The medication was initialed as though it was given at 8:00 A.M. rather than the time it was actually administered, 8:40 A.M.. The Heparin flush was not documented as being given at all.

Review of the nursing documentation showed the initial notation by R.N. Staff S on 07/13/10 was entered at 9:30 A.M. The notation showed, "Pt. (patient) sitting up in bed, assessment per flow sheet. No c/o (complaint of) pain or discomfort. Pt. cooperative with care. Will continue to monitor." There was no documentation of the reason why the medication was administered late, nor was there an indication that the patient's physician was notified of late medication administration.

4. Observation on 07/13/10 at 8:45 A.M. showed R.N. Staff S preparing to administer medications to Patient #12. R.N. Staff S said Patient #12 was "off the unit" for breakfast but should be back by the time medication set up was completed. Patient #12 returned as predicted and the following medications were administered by R.N. Staff S:
- Desipramine (antidepressant) 25 mg (milligrams)
- Docusate Sodium (used to treat constipation) 100 mg
- Guanfacine (used to treat hyperactivity) 4 mg
- Multivitamin
- Carbamazepine (used to control seizures) 600 mg
- Miralax (used to treat constipation) 17 gm in apple juice
- Diazepam (used to relieve anxiety) 1 mg

Review of the M.A.R. on 07/13/10 at 1:05 P.M. for current Patient #12 showed these medications were scheduled to be given at 8:00 A.M.. The medications were initialed as being given at 8:00 A.M. rather than the time they were actually administered, 9:00 A.M.

Review of the nursing documentation showed the initial notation by R.N. Staff S on 07/13/10 was entered at 9:55 A.M. The notation showed, "Pt. (patient) up in WC (wheelchair) out of clinical services area with staff. Assessment per flow sheet. No c/o (complaint of) pain. Will continue to monitor." There was no documentation of the reason why the medications were administered late, nor was there an indication that the patient's physician was notified of late medication administration.

5. Observation on 07/13/10 at 9:00 A.M. showed R.N. Staff S administered Miralax (used to treat constipation) 17 gm in milk to Patient #9.

Review of the M.A.R. on 07/13/10 at 1:10 P.M. for Patient #9 showed this medication was scheduled to be given at 8:00 A.M. The medication was initialed as being given at 8:00 A.M. rather than the time it was actually administered, 9:05 A.M.

Review of the nursing documentation showed the initial documentation by R.N. Staff S on 07/13/10 was entered at 9:45 A.M. The notation showed, "Pt. (patient) up in clinical area playing video games with peers. Assessment per flow sheet. No c/o (complaint of) pain. Will continue to monitor." There was no documentation of the reason why the medication was administered late, nor was there an indication that the patient's physician was notified of late medication administration.

During an interview on 07/14/10 at 2:00 P.M., Chief Nursing Officer Staff F said that if medications were administered more than 30 minutes past the scheduled time, the procedure was to notify the physician and ask whether or not to proceed with giving the medication. Chief Nursing Officer Staff F further said that the time should be charted as the time the medication was actually given.

Based on policy review, record review and interview, the facility failed to obtain physician's orders that contained all necessary information to administer medication for three patients (Patients #5, #6 and #7); and the facility failed to ensure renewal orders for medications are properly written for two patients (Patients #5, #7, and #2) of eight medication orders reviewed. The facility census was 31.

Findings Included:

Review of the facility's rules and regulations of the medical staff showed in the Standards of Care section 1.5, "The physician's/nurse practitioner's orders shall be written clearly, legibly and completely. Orders which are illegible or improperly written will not be carried out until rewritten or understood by those carrying out the order. It will not be sufficient to refer to an order previously written when such an order is to be renewed. It will be necessary to restate the order completely."

Review of facility policy titled, "Medication Order Information," last reviewed 4/09, showed the following (in part):
- "Prescribers shall legibly, clearly and completely record all medications to be administered during the patient's treatment at Ranken Jordan."
- "Orders are written in the medical record and must include the following information:
- Date and hour written
- Name of medication (preferably by generic name)
- Drug strength and dosage units (if dose ordered in ml's then include concentration)
- Route of administration
- Frequency or interval of administration
- Indication
- Prescriber's signature"
- "Orders to 'resume previous orders' are prohibited."

1. Current record review of showed Patient #7 entered the facility 03/11/10. Review of the physician's orders showed the following orders:

An order dated 03/22/10 at 3:40 P.M. to please decrease feeds to 240 ml (milliliter, a measure of volume) QID (four times a day). The order does not contain the name of the nutritional product to be given to the patient by the staff or the route of administration.

An order dated 05/27/10 at 10:55 A.M. to renew Chlorothiazide (a diuretic, which increases urine output), Docusate (a laxative), Flovent (a medication used to decrease inflammation in the lungs), Lansoprazole (prevents the stomach from producing gastric acid), Singulair (used to prevent and treat the symptoms of asthma), Acetaminophen (a pain reliever) and Albuterol (medication, which helps open up the airways in the lungs to make it easier to breathe.
The order does not contain the dosage, frequency or route of administration of the medications.

An order dated 06/30/10 at 12:00 P.M. to renew MVI (multivitamin) and glycerin suppository (used to treat constipation).
The order does not contain the dosage, frequency or route of administration.


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2. Current record review revealed Patient #5 entered the facility on 6/4/10. Review of the physician's orders revealed the following orders:
- An order dated 7/9/10 at 10:40 A.M. to change Prednisone (steroid medication) to 9 mg (milligrams) today and tomorrow, then go back to 4.2 mg on Sunday. The order did not contain the route of administration.
- An order dated 7/9/10 at 1:34 P.M. to please change Ibuprofen (used to reduce inflammation and pain) to every 6 hours for fever/pain. The order did not contain the route of administration.
- An order dated 6/6/10 to please repeat Augmentin (antibiotic), Chlorothiazide (medication for high blood pressure and excessive fluid) and Cetirizine (allergy medication). The order was not timed and did not contain the dosage, frequency or route of administration.

3. Current record review revealed Patient #6 entered the facility on 6/19/10. Review of the physician's orders revealed the following orders:
- An order dated 6/22/10 at 12:01 P.M. to change Desonide (steroid medication) to every other day on even days. The order did not contain the dosage, frequency or route of administration.



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4. Review of the medical record on 07/13/10 at 3:15 P.M. for current Patient #2 showed the following:
- A form titled "Parenteral Nutrition Order Sheet" dated 07/06/10 at 12:00 P.M. The order included the patient's allergies, weight, route and indication, as well as the following (in part):
- "Dextrose: 227.5 grams/day; 4.2 grams/kg (kilogram)/day; final Concentration 10%"
- "Amino Acid: Travasol (a solution of amino acids) 43 grams/day; 0.8 grams/kg/day; Final Concentration 1.9%"
- "Pharmacy additives-electrolytes:
- Calcium Gluconate (used to treat calcium deficiencies) 4.2 mEq (milliequivalents)/day; 0.08 mEq/kg/day
- Magnesium Sulfate (used to treat magnesium deficiencies) 5.3 mEq/day; 0.1 mEq/kg/day
- Potassium Acetate (mineral) 16.7 mEq/day; 0.3 mEq/kg/day
- Potassium Chloride (mineral) 16.7 mEq/day; 0.3 mEq/kg/day
- Total Potassium (mineral): 33.4 mEq/day; 0.6 mEq/kg/day
- Sodium Acetate (mineral) 62 mEq/day; 1.1 mEq/kg/day
- Sodium Chloride (mineral) 120 mEq/day; 2.2 mEq/kg/day
- Sodium Phosphate (mineral) 9.9 mEq/day; 0.18 mEq/kg/day
- Total Sodium (mineral): 195 mEq/day; 3.6 mEq/kg/day"
- "Pharmacy additives-trace elements: MTE-5C (Concentrated trace elements) one ml (milliliters)/day"
- "Other Pharmacy Additives: Zinc (an essential mineral) 10mg/day"
- "Additional additives at Ranken Jordan:
- Adult multivitamin 10 mL (milliliters)/day if over 12 years
- Famotidine (blocks acid production in the stomach) 20 mg (milligrams)/day"
- "Infusion Schedule:
- T.P.N. (Total Parenteral Nutrition - an intravenous solution that supplies all daily nutritional requirements): Rate 175 ml (milliliters)/hr (hour) X (times) 14 hrs = 2275 ml/day = Total mL/day with one hour ramp up and down."
- "Cycle parenteral nutrition on/off: "Yes" - On 6:00 P.M.; Off 8:00 A.M.; Taper up one hr.; taper down one hr."
- Lipids (a solution of essential fatty acids) 20%:
- 33.6 grams/day; 0.6 grams/kg/day
- Rate: 12 ml/hr X 14 hrs = 16.8 ml/day
- For 5 days/week on (circle days to infuse) M T W Th F"
- A Nurse Practitioner order dated 07/07/10 at 5:00 P.M. states, "Please renew T.P.N./I.L. (Intravenous Lipids) from 07/06/10." The order did not provide specific information regarding the solution, additives, etc.
- A physician order dated 07/08/10 states, "Please renew T.P.N./I.L. from 07/06/10." The order did not provide specific information regarding the solution, additives, etc., and is not timed.
- A physician order dated 07/09/10 states, "Please renew T.P.N./I.L. from 07/06/10." The order did not provide specific information regarding the solution, additives, etc., and is not timed.
- A Nurse Practitioner order dated 07/10/10 at 9:17 A.M. states, "Please renew T.P.N./I.L. from 07/06/10." The order did not provide specific information regarding the solution, additives, etc.
- A Nurse Practitioner order dated 07/11/10 at 9:00 A.M. states, "Please renew T.P.N./I.L. from 07/06/10." The order did not provide specific information regarding the solution, additives, etc.
- A physician order dated 07/12/10 at 7:45 A.M. states, "Please renew T.P.N./I.L. from 07/06/10." The order did not provide specific information regarding the solution, additives, etc.

Based on policy review and record review, the facility failed to ensure verbal orders were dated, timed, and authenticated within 48 hours for four patients (Patients #12,# 5, #7 and #8) of 27 medical records reviewed. The facility census was 31.

Findings included:

1. Review of the facility policy titled: "Verbal/telephone Physician Orders," last reviewed on 5/09, revealed in part:
"Procedure: 3. Telephone orders must be counter-signed by the physician or Facility Medical Director or his physician/nurse practitioner within 48 hours of receiving the telephone order."

2. Review of the medical record for current Patient #12 on 07/13/10 at 2:25 P.M. showed the following (in part):
- A verbal order dated 06/29/10 at 6:15 P.M. stating "OK to give Hydrocodone (narcotic analgesic) 5 mg (milligrams)/Acetaminophen (non-narcotic analgesic) 325 mg two tabs po (by mouth) now. May give next dose at 10:30 P.M." There was no physician signature to authenticate the order.
- A verbal order dated 06/30/10 at 2:10 P.M. stating "Change Lortab (narcotic analgesic) 1 tab 5/325 mg po Q (every) six hours. Increase Senna (stimulant laxative) two tablets po Q HS (hour of sleep - bedtime)." There was no physician signature to authenticate the order.



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3. Review of Patient #5's medical record on 7/13/10 revealed:
- A verbal physician's order dated 6/7/10 at 3:50 A.M. to offer patient Pedialyte (fluid with electrolytes) now and give Pedialyte for 6:00 A.M. feeding. The physician's signature did not include the date and time to ensure the order was signed with-in 48 hours.
-A verbal physician's order dated 6/7/10 at 6:40 A.M. to place nasogastric tube (tube inserted thru the nose into the stomach) and give 6:00 A.M. feeding with Pedialyte. The physician's signature did not include the date and time to ensure the order was signed with-in 48 hours.
-A verbal physician's order dated 7/10/10 at 7:30 P.M. to attempt oral Pedialyte at this time. If patient's oral intake well, offer formula at 12:00 A.M. as scheduled. If patient refuses keep offering every one hour. There was no physician signature to authenticate the order.



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4. Open record review showed Patient #8 entered the facility 07/08/10 due to residual traumatic brain injury.
- Review of the physician orders showed an untimed verbal order dated 07/10/10 for an enclosure bed restraint. The physician's signature is timed at 9:00 A.M., but the signature lacks a date.

5. Open record review showed Patient #7 entered the facility 03/11/10 due to chronic respiratory failure.
Review of the physician orders showed the following restraint orders:
- A verbal order dated 03/14/10 at 1:00 P.M. for side rails x4. There is no physician signature on the verbal order.
- A verbal order dated 03/27/10 at 8:30 A.M. for side rails x4. There is no physician signature on the verbal order.
- A verbal order dated 03/28/10 at 10:00 A.M. for side rails x4. There is no physician signature on the verbal order.
- A verbal order dated 07/09/10 at 11:00 A.M. for side rails x4. There is no physician signature on the verbal order.
- An untimed verbal order dated 03/15/10 for side rails x4. The physician signed the order at 9:00 A.M. but there is no date of the physician's signature.
- An untimed verbal order dated 06/09/10 for side rails x4. The physician signed the order at 10:00 A.M. but there is not date of the physician's signature.
- An untimed verbal order dated 06/15/10 for side rails x4. The physician signed the order at 10:00 A.M. but there is not date of the physician's signature.
- An untimed verbal order dated 07/01/10 for side rails x4. The physician signed the order at 11:00 A.M. but there is not date of the physician's signature
- An untimed verbal order dated 07/10/10 for side rails x4. The physician signed the order at 9:30 A.M. but there is not date of the physician's signature.

Based upon interview and record review, the physician signatures failed to have date and time of signature for the Discharge Summary Reports for five (Patients# 17, #18, #19, #23, and #24) of seven reviewed for this concern. The current facility census was 31.

Finding included:

1. During interview on 07/14/10 at 2:20 P.M., the Director of Medical Records, Staff O, stated that the Medical Staff Bylaws and Discharge Summary Policy expect the physicians to sign the Discharge Summary reports within 14 days of discharge. Staff O stated that the physicians have been discussing the issue of dating and timing the signatures in their meetings, but have not enacted the practice yet.

2. Record review for the following patients, reviewed by closed record review, showed the discharge summaries to have physician signatures, but no date or time of the signature is recorded:
-Patient #17, admitted 05/03-26/10 had a Discharge Summary dictated by the Nurse Practitioner on 05/31/10. However neither the signature of the Nurse Practitioner or the Admitting Physician had date or times for their signatures.
- Patient #18, admitted 04/26-05/21/10 had a Discharge Summary dictated by the Nurse Practitioner. However neither the signature of the Nurse Practitioner or the Admitting Physician had date or times for their signatures.
- Patient #19, admitted 05/08-20/10 had a Discharge Summary dictated by the Nurse Practitioner. However neither the signature of the Nurse Practitioner or the Admitting Physician had date or times for their signatures.
-Patient #23, admitted 05/28/10 had a Discharge Summary dictated by the Nurse Practitioner on 06/11/10. However neither the signature of the Nurse Practitioner or the Admitting Physician had date or times for their signatures.
- Patient #24, admitted 04/06-06/06/10 had a Discharge Summary on 06/04/10. However the Admitting Physician had no date or time for the signature. It is not possible to determine if the signature was within the required timeframe.

Based on observation and interview, the facility failed to ensure medications are kept in a locked, secured area to prevent access by unauthorized persons. This had the potential to affect all patients and staff in the facility. The facility census was 31.

Findings included:

1. Review of the facility policy titled, "Medication Storage Areas and Access," initiated 4/10, revealed in part:
"Medication Storage Areas outside Pharmacy
- 5. Medication storage areas are accessible to authorized personnel (Pharmacy, RN, NP and RT) and locked when not directly supervised by a nurse.
- 6. Medication storage areas in the nurseries must be locked when not under the direct supervision of nursing staff.
- 8. Pharmacy will inspect medication storage areas outside the Pharmacy for compliance with these policies at least monthly."

2. Observation on 07/12/10 at 2:00 P.M. showed patient rooms within the patient care area were arranged so that eight patients shared two adjoining rooms. The exterior wall between the rooms contained a large closet-like structure which functioned as the medication cabinet for each of these two room "units." There were a total of four "units," with 15 patients in residence at the time of the survey.

3. Observation on 07/13/10 at 8:30 A.M. showed Registered Nurse (R.N.) Staff S opened the medication cabinet between rooms five and six and prepared to dispense medications for patients in these rooms. The medication cabinet contained a variety of "stock" medications, as well as medications specific to the patients in rooms five and six. The medications for each patient were enclosed in plastic bins which were labeled with the name of the patient. The cabinet also contained the Medication Administration Records (M.A.R.s) for each of the patients in rooms five and six. The medication closet was not locked before or after medications were dispensed.

4. Observation on 07/13/10 at 1:00 P.M. showed this surveyor was able to open the medication cabinets and review the M.A.R.s for each of the patients in rooms five and six. A group of patients were clustered around a video game within ten feet of the unlocked medication cabinet. Several of these patients were ambulatory and would have been able to open the cabinet without difficulty. A Volunteer who was interacting with these patients was also present.


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5. Observation on 7/13/10 at 8:15 A.M. showed Staff K, Registered Nurse, removed medications from an unlocked refrigerator located in Nursery A. The refrigerator had no locking mechanism.

In an interview on 7/13/10 at 2:25 P.M. Staff K said the medication refrigerator had never had a lock. Staff K said there were always staff in the nursery, but the staff were not always registered nurses.

In an interview on 7/14/10 at 3:15 P.M. Staff I, Director of Pharmacy said the refrigerators in the nursery did not lock. Staff I said she thought nursing staff were in the nursery area at all times.

During an interview on 07/13/10 at 2:30 P.M., Administrator of Quality and Safety Staff D said discussions had taken place at the facility concerning the need to lock the medication cabinets. The decision was made to leave the cabinets unlocked for ease of access.

Based on facility policy review, observation, record review, and interview, the facility failed to follow their internal policy in regard to reporting medication errors for three (Patients #2, # 12, and #9) of eight patients observed during medication administration. The facility census was 31.

Findings included:

1. Review of the facility policy titled, "Medication Administration," last reviewed 5/10, showed the following (in part):
- "All medications will be administering (administered) within 30 minutes of scheduled administration time. The criteria for Standard Administration Times may be found in policy PHARM 401."
- "Report medication errors immediately to Medical Staff, Pharmacy and Nursing Management."

2. Review of the facility policy titled, "Medication Errors," last reviewed 04/09, showed the following (in part):
- "Ranken Jordan will track all types of medication errors, including those that do not cause harm, those that do cause injury and potential errors ('near misses')."
- "The staff member who identified the medication error will immediately complete an Occurrence Report to monitor errors and/or trends."

3. Review of the facility document utilized for nurse orientation titled, "The Six Rights of Medication Administration in Children," showed the following (in part):
- "Late medications. Medications should be given within 30 minutes of scheduled time. If a medication is given outside this timeframe, please complete an occurrence report and give to one of the Nursing Managers. Occurrence reports present an opportunity to evaluate our practice and identify areas to improve. Please remember to not document on the patient's medical record that an occurrence report was completed."

4. Observation on 07/13/10 at 8:20 A.M. showed Registered Nurse (R.N.) Staff S preparing to administer medications to Patient #2. Upon entering the patient's room, R.N. Staff S noticed that the patient's T.P.N. (Total Parenteral Nutrition - an intravenous solution that supplies all daily nutritional requirements) and Lipids (a solution of essential fatty acids) had completely infused and stated the line needed to be flushed. R.N. Staff S obtained a prefilled syringe with Heparin (an anticoagulant) and flushed the syringe. When this process was completed, R.N. Staff S gave the patient a wet washcloth to wash his/her face before administering Benzoyl Peroxide (used to treat acne) 5% Gel.

Review of the M.A.R. on 07/13/10 at 1:00 P.M. for current Patient #2 showed the medication was scheduled to be given at 8:00 A.M. The medication was initialed as being given at 8:00 A.M. rather than the time it was actually administered, 8:40 A.M. The Heparin flush was not documented as being given at all.

5. Observation on 07/13/10 at 8:45 A.M. showed R.N. Staff S preparing to administer medications to Patient #12. R.N. Staff S said Patient #12 was "off the unit" for breakfast but should be back by the time medication set up was completed. Patient #12 returned as predicted and the following medications were administered by R.N. Staff S.
- Desipramine (antidepressant) 25 mg (milligrams)
- Docusate Sodium (used to treat constipation) 100 mg
- Guanfacine (used to treat hyperactivity) 4 mg
- Multivitamin
- Carbamazepine (used to control seizures) 600 mg
- Miralax (used to treat constipation) 17 gm in apple juice
- Diazepam (used to relieve anxiety) 1 mg

Review of the M.A.R. on 07/13/10 at 1:05 P.M. for current Patient #12 showed these medications were scheduled to be given at 8:00 A.M. The medications were initialed as being given at 8:00 A.M. rather than the time they were actually administered, 9:00 A.M.

6. Observation on 07/13/10 at 9:00 A.M. showed R.N. Staff S administered Miralax (used to treat constipation) 17 gm in milk to Patient #9.

Review of the M.A.R. on 07/13/10 at 1:10 P.M. for Patient #9 showed this medication was scheduled to be given at 8:00 A.M. The medication was initialed as being given at 8:00 A.M. rather than the time it was actually administered, 9:05 A.M.

7. During an interview on 07/14/10 at 2:00 P.M., Chief Nursing Officer Staff F said that if medications were administered more than 30 minutes past the scheduled time, the procedure was to notify the physician and ask whether or not to proceed with giving the medication. Chief Nursing Officer Staff F further said that the time should be charted as the time it was actually given and an occurrence report should be completed. Chief Nursing Officer Staff F stated no occurrence reports were received for Patients #2, #12, or #9 dated 07/13/10.

Based on facility document review, observation, and interview, the facility failed to ensure staff followed their policies to prevent the risk of transmission of organisms for one patient (Patient #13) out of two patients observed during wound care procedures. The facility census was 31.

Findings included:

1. Review of an orientation training document titled, "Standard Precautions" showed the following (in part):
- "Standard Precautions provide protection to all residents and staff from the potential exposure to ANY AND ALL infectious agents."
- "HANDWASHING: Hands are to be washed at the following time:
- Before and after touching wounds and any/all invasive devices.
- After situations in which hands or gloves get soiled, i.e., mucous membrane contact of any contact with secretions/excretions."
- "GLOVES: Use gloves for contact with any blood or body fluids. Hands (should) be washed before and after removal of gloves. They are to be changed between resident contact and frequently during contact with the same resident."

2. Observation on 07/13/10 at 12:30 P.M. during a dressing change on Patient #13 showed the following:
- Patient #13 received negative pressure therapy via wound vacuum to assist with wound healing. Dressing changes for this technology are considered "clean" rather than "sterile."
- While wearing nonsterile gloves, Nurse Practitioner Staff U measured the wound using a tape measure along the peripheral borders and measured the depth using Q tips. During this process Nurse Practitioner Staff U's fingers were in contact with skin in the scrotal and rectal areas as well as wound secretions.
- Without changing gloves, Nurse Practitioner Staff U picked up a packet of adhesive skin prep from the bedside table, touching the table with his/her gloved hand. There was no protective barrier on the bedside table.
- Without changing gloves, Nurse Practitioner Staff U applied skin prep to the borders of the wound, then picked up scissors from the foot of the bed and began cutting pieces of the barrier dressing into strips and applying them to the periphery of the wound. There was a disposable paper protective barrier at the foot of the bed, however the scissors used for cutting the dressing was sometimes placed on the bed linens rather than the barrier between cutting and placement of the protective barrier strips.
- Without changing gloves or cleansing the scissors, Nurse Practitioner Staff U cut the appropriately sized foam dressing for placement into the wound as well as cutting an appropriately sized segment of petroleum based gauze to wrap around the foam.
- Nurse Practitioner Staff U inserted the combined dressing into the wound, then removed it and repeatedly made adjustments to the combined dressing utilizing the same scissors until it fit correctly into the wound.
- Nurse Practitioner Staff U then removed and reapplied gloves without performing hand hygiene. He/she then completed the dressing application, using the same scissors.
- Without removing gloves, Nurse Practitioner Staff U picked up unused adhesive packets from the bed linens and instructed staff assisting with the procedure to return them to the bedside table for future use, contaminating the contents of the bedside drawer.

3. During an interview on 07/13/10 at 12:55 P.M., Registered Nurse (RN) Staff M said that the decision to place a barrier on the bedside table is up to whoever does the dressing changes, adding that sometimes supplies are placed on the bed.

4. During an interview on 07/13/10 at approximately 2:00 P.M., Administrator of Quality and Safety Staff D said the facility did not have a "Hand Hygiene" policy, but said that staff were trained on appropriate technique during Orientation, and that instructions on "Standard Precautions" were part of the Infection Control plan.

5. During an interview on 07/13/10 at 2:45 P.M. the infection control nurse, staff GG said staff is expected to wash their hands after they remove gloves. Staff GG said if a staff person takes off a pair of gloves and puts on another pair of clean gloves they are to wash their hands between the glove change.





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