HospitalInspections.org

Based on record review, policy review and staff interview it was determined the facility failed to ensure the hospital provided each inpatient Medicare beneficiary with the standardized notice, "An Important Message from Medicare" (IM), within 2 days of admission for eight (#1, 2, 3, 4, 5, 6, 8, 9 ) of eleven randomly sampled patient records.

Findings Included:

A review of facility policy, Discharge Planning, #H-PC 02-004, States, "An Important Message for Medicare/Champus - This form shall be given to the patient within 2 calendar days of admission and be signed by the patient/representative. A follow-up copy of the form signed at admission shall be given to the patient within 2 calendar days of discharge.

Patient #1, a Medicare beneficiary, admitted to facility on 08/10/2017. A detailed review of the medical record failed to document the important message from Medicare notice was provided to the patient or patient representative within 2 days of admission.

Patient #2, a Medicare beneficiary, admitted to facility on 11/22/2017. A detailed review of the medical record failed to document the important message from Medicare notice was provided to the patient or patient representative within 2 days of admission.

Patient #3, a Medicare beneficiary, admitted to facility on 10/30/2017. A detailed review of the medical record failed to document the important message from Medicare notice was provided to the patient or patient representative within 2 days of admission.

Patient #4, a Medicare beneficiary, admitted to facility on 11/10/2017. A detailed review of the medical record failed to document the important message from Medicare notice was provided to the patient or patient representative within 2 days of admission.

Patient #5, a Medicare beneficiary, admitted to facility on 11/09/2017. A detailed review of the medical record failed to document the important message from Medicare notice was provided to the patient or patient representative within 2 days of admission.

Patient #6, a Medicare beneficiary, admitted to facility on 11/11/2017. A detailed review of the medical record failed to document the important message from Medicare notice was provided to the patient or patient representative within 2 days of admission.

Patient #8, a Medicare beneficiary, admitted to facility on 11/07/2017. A detailed review of the medical record failed to document the important message from Medicare notice was provided to the patient or patient representative within 2 days of admission.

Patient #9, a Medicare beneficiary, admitted to facility on 7/15/2017. A detailed review of the medical record failed to document the important message from Medicare notice was provided to the patient or patient representative within 2 days of admission.

An interview with the Chief Clinical Officer on 12/05/2017 at 3:00 p.m. confirmed the above findings.

Based on facility policy review, record review and staff interview it was determined the facility failed to ensure a consent was in place prior to the initiation of hemodialysis treatments for one (#6) of eleven randomly sampled medical records reviewed .

Findings included:

A review of the facility policy, Informed Consent, #H-PC 08-006, states, "The physician performing, ordering, or supervising the surgical or special procedure, or his/her designee, shall be responsible for obtaining informed consent.
Consent must be obtained at a time when the patient is fully capable of understanding the procedure so that he/she can make an informed decision regarding consent."

A review of Patient #6's medical record to include the physician's hemodialysis orders and hemodialysis treatment flow sheets revealed patient consent forms did not reveal a patient consent for hemodialysis.

On 12/05/2017 at 3:00 PM an interview with the Chief Clinical Officer confirmed the above finding.

Based on record review, policy review and staff interview it was determined the facility failed to ensure hemodialysis prescription was followed as prescribed by the ordering physician for two (#4, 6) of eleven randomly sampled medical records.

Findings included:

Patient #4 was admitted to the facility on 11/10/2017. On 11/11/2017 physician ordered hemodialysis with BFR [blood flow rate] of 400 and DFR [dialysis flow rate] of 700. A review of the dialysis treatment flow sheets for 11/11/2017 revealed:
08:33 AM treatment started with BFR set at 200 and DFR set at 700
09:00 AM - BFR set at 400 and DFR set at 700
09:15 AM - BFR and DFR not documented
09:30 AM - BFR and DFR not documented
09:45 AM - BFR and DFR not documented
10:00 AM - BFR and DFR not documented
10:15 AM - BFR and DFR not documented
10:30 AM - No documentation
10:45 AM - BFR and DFR not documented
11:00 AM - BFR and DFR not documented
11:15 AM - BFR and DFR not documented
11:30 AM - BFR and DFR not documented
11:45 AM - BFR and DFR not documented
12:00 PM - BFR set at 200 and DFR set at 300 Treatment ended
A detailed review of the patient medical record with ICU RN (RN-A) showed no documentation the Blood Flow Rate and Dialysis Flow Rate were monitored during treatment.

Patient #6 was admitted to the facility on 11/11/2017. On 11/12/2017 physician ordered hemodialysis with BFR [blood flow rate] of 400 and DFR [dialysis flow rate] of 700. A review of the dialysis treatment flow sheets for 11/12/2017 revealed:
12:30 PM treatment started with BFR set at 200 and DFR set at 700
1:00 PM - BFR set at 350 and DFR 700. No documentation of reason why BFR set below prescribed rate.
1:30 PM - BFR set at 350 and DFR 700. No documentation of reason why BFR set below prescribed rate.
2:03 PM - BFR set at 350 and DFR 700. No documentation of reason why BFR set below prescribed rate.
2:31 PM - BFR set at 350 and DFR 700. No documentation of reason why BFR set below prescribed rate.
3:01 PM - BFR set at 350 and DFR 700. No documentation of reason why BFR set below prescribed rate.
3:31 PM - BFR set at 350 and DFR 700. No documentation of reason why BFR set below prescribed rate.
4:00 PM - BFR set at 200 and DFR set at 300 Treatment ended
A detailed review of the patient medical record with ICU RN (RN-A) showed no documentation why the Blood Flow Rate was below prescribed rate.

On 11/13/2017 physician ordered hemodialysis with BFR of 450 and DFR of 800. A review of the dialysis treatment flow sheets for 11/13/2017 revealed:
2:00 PM - treatment started with BFR set at 200 and DFR set at 800
2:30 PM - BFR set at 450 and DFR at 800
3:00 PM - BFR and DFR not documented
3:34 PM - BFR and DFR not documented
4:00 PM - BFR and DFR not documented
4:30 PM - BFR and DFR not documented
5:00 PM - BFR and DFR not documented
5:30 PM - BFR and DFR not documented
6:00 PM - BFR and DFR not documented
6:14 PM - BFR and DFR not documented treatment ended.
A detailed review of the patient medical record with ICU RN (RN-A) showed no documentation the Blood Flow Rate and Dialysis Flow Rate were monitored during treatment.

On 11/16/2017 physician ordered hemodialysis with BFR of 450 and DFR of 600. A review of the dialysis treatment flow sheets for 11/17/2017 revealed:
10:55 AM - treatment started with BFR set at 200 and DFR set at 800
11:30 AM - BFR set at 450 and DFR set at 800. No documentation of reason why DFR set above prescribed rate
12:00 PM - BFR set at 450 and DFR set at 800. No documentation of reason why DFR set above prescribed rate
12:30 PM - BFR set at 450 and DFR set at 800. No documentation of reason why DFR set above prescribed rate
12:59 PM - BFR set at 450 and DFR set at 800. No documentation of reason why DFR set above prescribed rate
1:31 PM - BFR set at 450 and DFR set at 800. No documentation of reason why DFR set above prescribed rate
2:02 PM - BFR set at 450 and DFR set at 800. No documentation of reason why DFR set above prescribed rate
2:31 PM - BFR set at 450 and DFR set at 800. No documentation of reason why DFR set above prescribed rate
3:00 PM - BFR set at 450 and DFR set at 800. No documentation of reason why DFR set above prescribed rate
3:15 PM - BFR set at 200 and DFR set at 300 Treatment ended
A detailed review of the patient medical record with ICU RN (RN-A) showed no documentation why the Dialysis Flow Rate [DFR] was set above prescribed rate.

A review of the dialysis treatment flow sheets for 11/20/2017 revealed:
07:45 AM - BFR set at 450 and DFR set at 800. No documentation of reason why DFR set above prescribed rate
08:15 AM - BFR set at 450 and DFR set at 800. No documentation of reason why DFR set above prescribed rate
08:45 AM - BFR set at 450 and DFR set at 800. No documentation of reason why DFR set above prescribed rate
09:17 AM - BFR set at 450 and DFR set at 800. No documentation of reason why DFR set above prescribed rate
09:44 AM - BFR set at 450 and DFR set at 800. No documentation of reason why DFR set above prescribed rate
10:20 AM - BFR set at 450 and DFR set at 800. No documentation of reason why DFR set above prescribed rate
10:47 AM - BFR set at 450 and DFR set at 800. No documentation of reason why DFR set above prescribed rate
11:03 AM - BFR set at 450 and DFR set at 800. No documentation of reason why DFR set above prescribed rate
11:19 AM - BFR set at 450 and DFR set at 800. No documentation of reason why DFR set above prescribed rate
11:44 AM - BFR set at 450 and DFR set at 800. No documentation of reason why DFR set above prescribed rate
12:00 PM - Treatment Ended.
A detailed review of the patient medical record with ICU RN (RN-A) showed no documentation why the Dialysis Flow Rate [DFR] was set above prescribed rate

An interview with the Chief Clinical Officer on 12/05/2017 at 3:00 PM confirmed the above findings.

Based on review of facility policy, record review, and staff interview it was determined the facility failed to ensure medications were given as prescribed for full therapeutic value on two (#4, 6) of eleven randomly sampled medical records.

Findings included:

An interview with ICU RN [RN-A] revealed every 8 hour medications are given at 6:00 AM, 2:00 PM and 10:00 PM.

A review of the facility policy, Timely Administration of Scheduled Medications, #H-MM 05-005, stated, "Non-time-critical scheduled medications prescribed more frequently than daily, but no more frequently than every 4 hours shall be administered within 1 hour before or after the scheduled time".

A review of Patient #4's medical record documented the patient was admitted to the facility on 11/10/2017. A review of the physician order revealed the following order: Calcium Acetate [Phoslo] per feeding tube tab 667 mg Start 11/13/17 10:00 PM, every 8 hours [6 2 10], stop after 45 days, renewable.

A review of the MAR [medication administration record] revealed the following,
11/13/17 no documentation for this medication.
11/14 17 at 12:34 AM - not done [med not available]
11/14/17 at 05:43 AM - not done [new medication]
11/14/17 at 07:36 AM - verified by pharmacy
11/14/17 at 1:16 PM - given
11/14/17 at 10:33 PM - given
11/15/17 at 5:02 AM - given
11/15/17 at 2:01 PM - given
11/15/17 at 10:11 PM - not done [not available], pharmacy notified]
11/16/17 at 4:05 AM - not done [not available, pharmacy notified]
11/16/17 at 8:16 AM - medication given approximately 1.5 hours early. no documentation why
11/17/17 at 11:53 AM - medication given approximately 2 hours early - no documentation why
11/18/17 at 4:26 PM - medication given approximately 1.5 hours early - no documentation why
11/19/17 at 11:02 PM - medication given approximately 2 minutes late - no documentation why
11/25/17 at 8:22 PM - medication given approximately 1.5 hours early - no documentation why
11/27/17 at 8:20 PM - medication given approximately 1.5 hours early - no documentation why
11/28/17 at 8:18 PM - medication given approximately 1.5 hours early - no documentation why
11/29/17 at 3:15 PM - medication given approximately 18 minutes late- no documentation why
12/02/17 at 8:32 PM - medication given approximately 1.5 hours early - no documentation why

An interview on 12/05/2017 at 3:00 PM with the Chief Clinical Officer confirmed the above findings.


A review of Patient #6 medical record documents patient admitted to the facility on 11/11/2017. Physician order for sevelamer carbonate [Renvela] by mouth tab 2400 mg with meals, Start 11/13/2017 06:00, every eight hours [6 2 10] stop after 45 days, renewable.

Interview with ICU RN [RN-A] every 8 hour medications are given at 6:00 AM, 2:00 PM and 10:00 PM.
Meal trays are delivered to the floors at 7:00 AM, 12:00 PM and 5:00 PM
A review of the MAR [medication administration record] revealed the following,
11/13/2017 medication given at 6:00 AM, 1:01 PM and 10:30 PM . No documentation medication was administered with food for therapeutic effectiveness.
11/14/2017 medication given at 6:17 AM - No documentation medication was administered with food for therapeutic effectiveness.
11/14/2017 medication given early at 12:37 to be with meals - given approximately 2 hours early
11/14/2017 medication give at 8:59 PM - No documentation medication was administered with food for therapeutic effectiveness. - given approximately 2 hours early
11/15/2017 medication given at 6:39 AM - No documentation medication was administered with food for therapeutic effectiveness.
11/15/2017 medication given at 1:52 PM - No documentation medication was administered with food for therapeutic effectiveness.
11/15/2017 medication given at 9:03 PM - [Snack given]
11/16/2017 medication given at 6:07 AM - No documentation medication was administered with food for therapeutic effectiveness.
11/16/2017 medication given at 12:25 PM [ to be given with meal] - given approximately 2 hours early.
11/16/2017 medication given at 9:32 - No documentation medication was administered with food for therapeutic effectiveness.
11/17/2017 medication given at 06:26 AM, 1:44 PM, 9:11 PM - No documentation medication was administered with food for therapeutic effectiveness.
11/18/2017 medication given at 6:01 AM, 1:43 PM, 9:23 PM - No documentation medication was administered with food for therapeutic effectiveness.
11/19/2017 medication only given twice at 2:00 PM and 9:45 PM - No documentation medication was administered with food for therapeutic effectiveness. No documentation why morning dose was omitted.
11/20/2017 through 11/23/2017 documents patient received 3 doses per day , however, No documentation medication was administered with food for therapeutic effectiveness.
11/24/2017 - 08:17 medication not given [in hemodialysis], Medication administered at 2:20 PM and 9:37 PM however, No documentation medication was administered with food for therapeutic effectiveness.

An interview on 12/05/2017 at 3:00 PM with the Chief Clinical Officer confirmed the above findings and no additional information was provided.

Based on record review, facility documents review, and staff interview it was determined the facility failed to have a policy in place regarding use of verbal orders and a timeframe for the verbal order to be authenticated/countersigned by the physician for three (#1, 2, 6) of eleven randomly sampled medical records.

Findings included:

A review of the Medical Staff Rules & Regulations (August 2013) page 8 stated, "General Conduct of Care - Verbal orders may be authenticated by other Licensed Independent Practitioner(s) (LIP) care for the patient only if the ordering practitioner is unavailable to sign and there are no cross coverage physicians in that practitioner's practice. Orders shall be communicated verbally only when it is not practical for the orders to be given in writing/entered into the electronic medical record by the practitioner. In states that do not define a time frame, the countersignature for drug and biological orders must be obtained in accordance with hospital policy."

An interview with chief clinical officer on 12/05/2017 at 3:00 PM a request for any and all policies related to verbal orders was requested, no policy was received, and informed no policy was found and referred to medical staff rules and bylaws."

A review of Patient #1's medical record shows patient was admitted to the facility on 08/10/2017 and remains in-house. A review of the physician orders show section titled, "Unsigned Verbal/Telephone Orders". On 11/02/2017 a discontinue order for Ensure Enlive 240 ml [milliliter] feeding by mouth with meals. and on 11/25/2017 a discontinue order for Jevity 1.2 feeding per nasogastric tube rate 45 ml/hr. A review of the entire record with the ICU Nurse (RN - A) confirmed the findings.

A review of Patient #2's medical record shows patient was admitted to the facility on 11/22/2017 and remains in-house. A review of the physician orders show section titled, "Unsigned Verbal/Telephone Orders". On 11/23/2017 a discontinue order for Insulin human regular subcutaneous injection sliding scale. and on 11/23/2017 an order for Hydrocodone 5 mg/acetaminophen 325 mg (NORCO) by mouth , 1 tab every 6 hours as needed moderate pain. A review of the entire record with ICU Nurse (RN - A) confirmed the findings.

A review of Patient #6's medical record shows patient was admitted to the facility on 11/11/2017 and discharged on 11/30/2017. A review of the physician orders show section titled, "Unsigned Verbal/Telephone Orders". On 11/29/2017 a discontinue order for digoxin 0.25 mg intravenous push times 1; on 11/30/2017 an order for digoxin 0.25 mg by mouth times 1; and on 11/30/2017 an order for metoprolol tartrate 25 mg by mouth. A review of the entire record with ICU Nurse (RN - A) confirmed the findings.

On 12/05/2017 at 3:00 PM an interview with the Chief Clinical Officer confirmed the above findings.

Based on observation, review of facility policy and procedures and staff interview it was determined the infection control officer failed to ensure staff complied with the facility policy for donning of Personal Protective Equipment (PPE) and cleaning and disinfection of shared patient medical equipment.

Findings included:

On 12/4/2017 at approximately 12:20 pm observation was made of Staff RN (Registered Nurse) # T donning and doffing of PPE and cleaning and disinfection of shared patient medical equipment. Staff RN # T donned a disposable gown and gloves, just inside of a patient room located on the 2 North Unit, that required contact transmission-based precautions, in preparation of providing patient care and blood glucose point of care testing. The RN did not secure the gown, with the attached ties, to prevent potential contamination of staff clothing while performing patient care (oral suctioning) and blood glucose point of care testing.

Following completion of patient care and point of care testing the RN proceeded to clean and disinfect the point of care glucometer (shared patient equipment). Observation of the RN's process revealed the RN did not change her gloves or perform hand hygiene following completion of patient care and prior to performing the cleaning and disinfection of the glucometer. At the time of the observation the Director of Quality Management (DQM) was present. During interview with the DQM on 12/4/2017 at 3:30 pm she confirmed the identified concerns.

Review of the facility policy, "Cleaning of Shared Patient Medical Equipment", states all shared patient care equipment is cleaned after each patient use. The RN failed to perform proper cleaning of the glucometer by failing to change her gloves following completion of patient care and contact.