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Based on the findings of the Sample Validation and complaint survey concluded on 01/25/10, it was determined Condition of Participation: Organizational Structure was not met. The facility failed to demonstrate that the governing body or the individual who assumes responsibility for Critical Access Hospital (CAH) operation was involved in the day-to-day operation of the CAH. Based on findings of a follow-up survey conducted on 02/12/10 it was determined the Condition of Participation: Organizational Structure continued not to be met.

Under Condition of Participation 485.627.
Refer to Standard Tag, C241

Based on interview and record review it was determined the facility failed to ensure the governing body or the individual who assumes responsibility for Critical Access Hospital's (CAH) operation was involved in the day-to-day operation of the CAH to ensure quality health care was provided in a safe environment.

This failure to ensure the CAH provided quality health care in a safe environment on a day to day basis places all patients at risk for serious injury, harm, impairment or death.

Based on observation, interview and record review it was determined that Immediate Jeopardy was identified on 01/25/10 and removed on 02/12/10 at 485.627 Condition of Participation: Organizational Structure.

The findings include:

Review of governing body meeting minutes for November 24, 2009, October 27, 2009 and September 29, 2009 revealed no documented evidence the facility reported or discussed any identified areas in need of improvement or correction, regarding infection control, wound care, clinical records, staff education needs, or medication management to ensure the Critical Access Hospital was providing quality care and treatment.

Interview on 01/25/10 at 4:00pm with the Chief Executive Officer revealed he was unaware of the infection control practice issues, that wound care was not provided as ordered, medications were not labeled or stored appropriately, or the computerized clinical record system was not effective to ensure the medical record was accurate and complete. He stated he had not directed or advised the staff to follow infection control policies. He had not directed staff to follow policy and procedures regarding medications, wound care or medical record management. He stated he considered those items to be common sense and the staff should know what to do. He stated he was ultimately responsible for ensuring the facility provided quality care and treatment.

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Based on the findings of the Sample Validation and complaint survey concluded on 01/25/10, it was determined Condition of Participation: Provision of Services was not met. Findings of a follow-up survey conducted on 023/12/10 revealed the Condition of Participation continued not to be met.


Under Condition of Participation 485.635.
Refer to Standard Tags, C271, C276, C295, C296, and C298

Based on observation, interview and record review it was determined the facility failed to ensure two (2) of twenty (20) sampled patients medical information was kept confidential. (Patient #4 and #15)

The findings include:

1. Observation on 01/20/10 at 1:50pm revealed a bag containing a Flovent Inhaler with Patient #4's name on it was on the crash cart in front of the nursing station. Observation revealed staff, visitors and other patients were passing by the patient labeled medication that was left on the crash cart.

Interview on 01/20/10 at 2:00pm with Respiratory Therapist #2 revealed she had left the medication on the crash cart sometime after 10:00am. She stated she left the unit and went to the emergency room and did not return. She stated the medication should not have been left on the crash cart. She stated her hands were full of supplies and she decided to place the patient labeled medication on the crash cart until she could return and store it appropriately. However, she had gotten busy and forgot to return to retrieve the medication.

Interview on 01/20/10 at 2:10pm with the Director of Nursing (DON) revealed it was a violation of Patient #4's privacy and confidentiality for the patient labeled medication to be left on the crash cart in full view of visitors, patients and staff. She stated the medication should have been properly stored and not left on the crash cart.

2. Observation during a medication pass on 01/20/10 at 9:50 AM revealed Certified Nurse Aide (CNA) #2 entered the room of Patient #21, while two nurses were working with Patient #21's intravenous access. CNA #2 stated to Registered Nurse (RN) #3 that Patient #15 (the patient's last name and the room number were said by CNA #2) was sick, vomiting and needed some medication. Patient #21 had a visitor in the room and both Patient #21 and the visitor were able to hear the patient's name, what room they were in, and the medical symptom the patient had.

Interview on 01/21/10 at 3:30 PM with the DON revealed it was a violation of Patient #15's privacy and confidentiality for staff to reveal private medical information about another patient.

Review of the facility's Administration policy titled "Patient Rights and Responsibilities" revealed "The patient has the right, within the law, to personal privacy and confidentiality of information."





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21585

Based on observation, interview and record review it was determined the facility failed to follow their policy and procedures regarding the appropriate storage, handling, and administration of drugs and biologicals.

This failure of the facility to ensure the staff followed their medication policy and procedures places all patients at risk for serious injury, harm, impairment or death.


The findings include:

Review of the facility policy "Medication Storage" revealed medications and biologicals are stored safely, securely, and properly. Medication rooms, carts and medication supplies are locked or attended by persons with authorized access. Potentially harmful substances (such as household poisons, cleaning supplies, disinfectants etc..) are clearly identified and stored in a locked area separately from medication. Outdated medications are immediately removed from stock, disposed of according to procedures for medication disposal. Medication storage conditions are monitored on a regular basis and corrective action taken if problems are identified. The facility's failure to ensure this policy was implemented allowed medications to be stored and not monitored appropriately.

Review of the facility policy "Medication Administration" revealed medications are administered as prescribed in accordance with good nursing principles and practices. Personnel authorized to administer medications should do so only after they have familiarized themselves with the medications. Prior to administration, the medication and dosage schedule on the patient's medication administration record (MAR) is compared with the medication label. If the label and MAR are different, and verification of correct dose cannot be made the physician's orders will be checked for the correct information. The facility failed to follow their policy when the surveyor observed Registered Nurse #3 administered an unlabeled syringe of medication to Patient #17 on 01/21/10 at 10:05 AM.

1. Observation of a medication pass on 01/21/10 at 10:05 AM revealed Patient #17 was to get Tussionex Pennkinetic ER (cough medication containing a narcotic). Registered Nurse #3 entered the information required into the electronic medication dispenser. The drawer opened and there were nine syringes with 5 cc of yellow color thick liquid in them. The syringes did not contain a label identifying the medication, the dose, or when it expired. The only instructions on the syringe was "For Oral Use Only."

Interview with RN #3 revealed that usually the syringes were labeled with the name of the drug, the dose, and the expiration date. RN #3 stated she knew what the Tussionex Pennkinetic ER looked like and she was confident that was what was in the syringes. RN #3 went to the Patient #17's room and administered the 5 cc syringe of thick yellow liquid to Patient #17.

Interview with the Pharmacist on 01/22/10 at 9:10 AM revealed it was not their practice to not label a syringe with the name, dose, and expiration date of the drug. He stated he did not know what had happened to cause this. The Pharmacist stated he compared the liquid in the syringes to the bottle of Tussionex Pennkinetic ER and determined it was the same drug. He labeled the syringes and placed them back into the electronic medication dispenser for patient use on 01/21/10.

2. Observations made on 01/20/10 at 11:55am in the Radiology department revealed 14 unlabeled syringes containing a clear liquid.

Interview on 01/20/10 at 11:56 with the Director of Radiology revealed the clear liquid was injectable normal saline. He stated the technicians would draw up the saline to have ready for flushes during a procedure. He stated the syringes should be labeled, and since they were not, staff would not know when they were drawn up or what was in the syringe.

3. Observation made on 01/20/10 at 12:15pm of the Physical Therapy department revealed a cabinet containing Miracle Gro, Bleach, Alcohol, Germicidal Cleaner, and Class Cleaner also contained several vials of medication labeled Dexamethasone. In addition, a bottle of 2% injectable lidocaine with an expiration date of 2005 was found ready and available for use.

Interview on 01/20/10 at 12:20pm with the Physical Therapy Assistant revealed the cabinet was the storage area for patient medication. She stated the cleaning fluids and disinfectants had always been stored in that cabinet. She stated she was unaware that medication was not to be stored with cleaning products. She stated she had not received any training regarding the storage of medication or checking for out dates.

4. Observation on 01/20/10 at 1:50pm revealed a bag containing a Flovent Inhaler with Patient #4's name on it was on the crash cart in front of the nursing station. Observation revealed staff, visitors and other patients were passing by the patient labeled medication that was left on the crash cart.

Interview on 01/20/10 at 2:00pm with Respiratory Therapist #2 revealed she had left the medication on the crash cart sometime after 10:00am. She stated she left the unit and went to the emergency room and did not return. She stated the medication should not have been left on the crash cart. She stated her hands were full of supplies and when she decided to place the patient labeled medication on the crash cart until she could return and store it appropriately. However, she had gotten busy and forgot to return to retrieve the medication.

5. Observation on 01/20/10 at 12:30pm in the Cardiac Rehab Department revealed a filing cabinet contained a box of Tylenol, a Proair inhaler and two bottles of sublingual Nitrolingual spray. The cabinet also contained batteries, blood pressure cuff, stethoscope and office supplies.

Interview on 01/20/10 at 12:30 with Respiratory Therapist #1 and the Cardiac Rehab Technician revealed the medication was for patient use. They stated the filing cabinet was the normal storage area for these medications. They stated they were not aware of the facility's medication storage policy and had not received training on medication storage.

6. Observation on 01/20/10 at 1:45pm of the Medication Room revealed a cabinet containing numerous patient medications also contained 2 bottles of formaldehyde.

Interview on 01/20/10 at 1:52pm with the Director of Nursing revealed she was not aware that formaldehyde was stored with patient medication and should not be.

Continued interview with the Director of Nursing revealed medications in the operating room should be locked or monitored continuously when unlocked. She stated medications should not be stored with cleaning chemicals and out dated medications should be discarded. She stated all medication syringes should be labeled to ensure the appropriate medication and dosage is given to a patient. She stated she was unaware that each department surveyed was not following the facility policies and procedures regarding medication storage and administration and she should have been. She stated she has been busy with the construction of their new hospital wing and has not been as involved in the hospital quality control.

7. Observations made on 01/20/10 at 11:30am of the Operating Room suite revealed an unattended and unlocked anesthesia cart containing a drug box with numerous medications. The medications include: Lasix, Benadryl, Promethazine, Sodium Bicarbonate, Amidate, 5 bottles of Diprivan, Dexamethazone, Nitroglycerin, Solumedrol and epinephrine. Observation also revealed 2 syringes on top of the anesthesia machine labeled Anectine and Norcuron.

Interview on 01/20/10 at 11:32am with the Operating Room Director revealed the Certified Nurse Anesthetist in charge of the medication in the anesthesia cart was in another room doing a surgical case. She stated the Anesthetist was in the Operating Room earlier and had drawn up the medication for the next case.

21585



Based on observation, interview and record review it was determined the facility failed to ensure nursing care was provided in accordance with the patient's needs. The facility's failure to meet the wound care, medication administration, infection control and oxygen needs of the patients prevented patients from being monitored and provided qualtiy care and treatment by competent nursing staff.

This failure of the facility to ensure the nursing staff provided the nursing care in accordance with the patient's needs places all patients at risk for serious injury, harm, impairment or death.

Based on observation, interview and record review it was determined that Immediate Jeopardy was identified on 01/25/10 and removed on 02/12/10 at 485.635 Condition of Participation: Provision of Services

The findings include:

1. Observation of a dressing change on Patient #22 on 01/21/10 at 4:00 PM was conducted. Registered Nurse (RN) #5 removed the old dressing from the coccyx of Patient #22 which had a moderate amount of yellow drainage on it. There was a stage 2 pressure sore on the coccyx that measured 3 cm by 4 cm (staged and measured by RN #5). There were multiple superficial areas surrounding the coccyx pressure sore. RN # 5 stated she had not seen the pressure sore of Patient #22 for several days and felt the area surrounding the coccyx was getting worse. Licensed Practical Nurse (LPN) #1 was present to assist RN #5 with the dressing change. RN #5 cleansed the buttocks area and began measuring the areas. RN #5 removed her gloves. She placed a card to write on and an ink pen on Patient #22's bed on the incontinent pad where the patient had been lying. She would measure each area and pick up the ink pen and write the measurements on the card. The procedure was done ungloved and was repeated four times. While RN #5 was measuring the pressure sores RN #7 entered the room. The three nurses began discussing what type of dressing would be appropriate for the types of wounds Patient #22 had. They determined that a "wet to dry saline dressing" with a special tape to preserve the skin would be the most beneficial for Patient #22. RN #5 left the room for 3 to 5 minutes and returned with dressing supplies. A zinc oxide based latex free adhesive waterproof tape was cut into 3 large pieces and 2 smaller pieces and applied around the coccyx area. RN #5 (ungloved) smoothed the tape out to remove all of the wrinkles. As RN #5 was cutting each piece of tape she would lay her scissors on the bed on the patient's dirty incontinent pad. RN #5 washed her hands, put her gloves on, and applied a saline wet to dry dressing to the coccyx area. RN #5 removed her gloves and applied a thick dry gauze dressing over the wet dressing and secured it with tape. RN #5 trimmed and smoothed the tape out around the rectum area with her ungloved hands. RN #5 was leaning over to reach Patient #22 and her left arm was lying across the bed and her upper body was lying on the dirty incontinent pad with her uniform touching the bed and incontinent pad. RN #5 (ungloved) and LPN #1 removed the dirty incontinent pad and placed a clean one under Patient #22. While they were positioning Patient #22 the patient was pulling at RN #5's stethoscope which was hanging around her neck. RN #5 removed the stethoscope and placed it on the patient's bed. At 4:40 PM RN #5 placed the ink pen and scissors in her pocket, placed the stethoscope around her neck, and took the card she wrote the measurements on out of the room. She stated she needed to write an order for the dressing change.

Review of the medical record of Patient #22 revealed documentation on a Progress Note by the Physician on 01/17/10 and results of a sputum culture showing Patient #22 to be positive for Methicillin Resistant Staphylococcus Aureus (MRSA). There was no physician's order documented for the dressing (saline wet to dry) which was applied to Patient #22.

Interview with RN #5 and LPN #1 on 01/21/10 at 4:50 PM revealed they did not think Patient #22 had MRSA. RN #5 reviewed Patient #22's medical record. She stated that after reviewing the chart it was determined Patient #22 had MRSA. They stated they should have been wearing a mask, gloves and a gown when performing the dressing change. An additional interview with RN #5 on 01/25/10 at 11:30 AM revealed Patient #22 should have been in isolation but they were not aware of Patient #22 having MRSA until the surveyor asked on 01/21/10. She stated she had not cleaned her stethoscope, scissors, or ink pen since being exposed to MRSA. She revealed she had continued to use the equipment on other patients without cleaning it. RN #5 revealed the facility did not have a ostomy/wound care nurse and no staff had received special training in wound care. Staff had received training from the vendors of the dressing supplies on how to use their products. She could not remember the last inservice provided by the facility on skin care. Additionally, RN #5 stated she changed the dressing that was applied to Patient #22 without a Physician's order. She stated staff were required to obtain Physician's orders for all medications and treatments prior to performing the care.

Interview with the Infection Control Nurse on 01/22/10 at 10:20 AM revealed she was not aware of Patient #22 having MRSA. Patient #22 should have been in contact isolation. She stated she monitored diagnoses, patients with elevated temperatures, and cultures of patients in order to identify patients requiring isolation and enable the facility to track infections. She had been reviewing Patient #22's laboratory results, temperatures, and the Physician's progress notes online. She stated she did not know why she did not notice the laboratory culture results being positive for MRSA or the Physician progress notes in which he documented that Patient #22 had MRSA. She was aware Patient #22 had an elevated temperature above 102 degrees Farenheit but failed to follow through with a thorough review of Patient #22. Additionally, she stated the dressing change on Patient #22, which was observed by the surveyor, was not conducted in an acceptable manner. The Infection Control Nurse was not aware of any problems with the technique of the nurses providing care. She did not include observations of nursing staff performing care in her infection control plan.

2. Observation of a medication pass on 01/20/10 at 3:00 PM revealed Patient #2 was to receive Digoxin 0.25 mg intravenous (IV). RN #5 and RN #6 calculated the dose and drew it up. Both nurses verified the amount of Digoxin in the syringe. RN #6 went to Patient #2's room and identified the patient by the armband. RN #6 monitored the radial (wrist) pulse for 30 seconds prior to the administration of the Digoxin. The Digoxin was administered over five minutes through the IV access.

Interview with RN #6 on 01/20/10 at 3:15 PM revealed the facility required a second nurse to verify a dose of Digoxin IV prior to administering. RN #6 stated she monitored the radial pulse for 30 seconds and multiplied by 2 to get the heart rate per minute. She stated Patient #6's heart rate was very irregular and could run from 80 to 115.

Interview with the DON on 01/20/10 at 4:35 PM revealed the expectation when administering Digoxin was to monitor the apical (chest with a stethoscope) for a full minute to ensure an accurate count is obtained. If the heart rate was 60 or less the Digoxin should be withheld. The DON stated the facility did not have a policy or protocol in place for the administration of Digoxin. The facility used a specific nursing procedure manual for their authority on nursing procedures.

The DON provide the nursing procedure manual for review. The manual detailed that when administering the medication Digoxin the nurse should "take an apical-radial pulse for a full minute" prior to administering.

3. Observation of a medication pass on 01/21/10 at 10:05 AM revealed Patient #17 was to receive Tussionex Pennkinetic ER (cough medication containing a narcotic). Registered Nurse #3 entered the information required into the electronic medication dispenser. The drawer opened and there were nine syringes with 5 cc of thick yellow color liquid in them. The syringes did not contain a label identifying the medication, the dose, or when it expired. The only instructions on the syringe was "For Oral Use Only."

Interview with RN #3 revealed that usually the syringes were labeled with the name of the drug, the dose, and the expiration date. RN #3 stated she knew what the Tussionex Pennkinetic ER looked like and she was confident that was what was in the syringes. RN #3 went to Patient #17's room and administered the 5 cc syringe of thick yellow liquid to Patient #17.

Review of the facility policy "Medication Administration" revealed medications are administered as prescribed in accordance with good nursing principles and practices. Personnel authorized to administer medications should do so only after they have familiarized themselves with the medications. Prior to administration, the medication and dosage schedule on the patient's medication administration record (MAR) is compared with the medication label. If the label and MAR are different, and verification of correct dose cannot be made the physician's orders will be checked for the correct information. The facility failed to follow their policy when the surveyor observed Registered Nurse #3 administer an unlabeled syringe of medication to Patient #17 on 01/21/10 at 10:05 AM.

An interview with the Director of Nursing (DON) on 01/21/10 at 10:20 AM revealed RN #3 did not follow facility policy by administering a medication without a label. The facility policy required the nurse to compare the medication label with the patient's MAR prior to administering. All medications without a label should not be administered to patients and be sent back to the pharmacy for appropriate packaging.

4. Review of Patient #11 ' s medical record revealed the patient was admitted on 01/12/10 with Metastatic Pancreatic Cancer. Nursing documented on admission the skin assessment score was a 15 which indicated a high risk for skin breakdown. Nursing documentation on 01/12/10 at 9:00pm stated the patient had a 1cm open area on the left buttock with a Tegaderm dressing in place. Continued nursing documentation stated the patient also had a reddened excoriated area on the right buttock.

Review of physician orders revealed an order was written on 01/14/10 at 6:07pm that stated the physician wanted the decubitus checked daily and a foam Tegaderm to be placed on the 1cm open area on the left buttock.

Further review of the nursing documentation revealed no documented evidence that Patient #11 ' s wounds on the buttocks had been assessed or the dressing changed from 01/13/10 through 01/19/10 (total of 7 days). Nursing documentation revealed the next time the wound was looked at was on 01/19/10 at 9:35pm when nursing documented " dressing on decubitus in place at this time " . The nursing documentation did not indicate a wound or skin assessment had been performed. There was no documented evidence of what the decubitus looked like or if it was infected, had improved or worsened.

Review of the facilities wound care protocols revealed the primary physician must be notified for wounds that show no improvement within 14 days, are deteriorating, or show signs of infection.

Review of the facility policy regarding " Shift Assessment and Documentation " revealed a shift assessment is required to perform on each patient, once per shift, by the primary nurse. This is done in addition to the nurse ' s notes, and other documentation. A skin assessment is included in the shift assessment. This includes any new findings since the previous shift assessment. The care plan is also reviewed each shift, with changes made as indicated. The facility failed to ensure the nursing staff followed and implemented the wound care protocols and shift assessment and documentation policy to ensure quality care and treatment was provided to all patients.

Review of the nursing shift assessments revealed nursing failed to document a nursing shift assessment for Patient #11 on 01/13/10. Interview on 01/21/10 at 11:20am with the Medical Surgical Director revealed the nursing staff was required to perform an assessment on each patient on each shift and document their findings in the medical record. She stated she did not perform chart audits to determine if nursing was performing their required shift assessments. She stated she was unaware nursing was not performing the required nursing assessments each shift.

Observation on 01/21/10 at 11:55am of Patient #11 ' s dressing change and wound assessment revealed the Tegaderm was on the right buttock and not on the left buttock as ordered. The patient had a circular reddened area on the left buttock and the patient stated the left buttock area of skin breakdown hurt when touched by the nurse. There was also a reddened area of skin breakdown noted at the top in the crease of the buttocks. The nurse stated the top layer of skin was gone in these areas. She measured the right buttock wound to be 1cm round and the left buttock wound to be ? cm round. She did not measure the area at the top in the crease of the buttocks. She cleansed the skin with a wash cloth containing soap and water and then applied one new Tegaderm that covered the center and right buttock wounds, leaving the left wound uncovered. While she performed this dressing change the nurse leaned on the bed linens, rested her arms on the patient ' s pillows which allowed her uniform and skin to touch areas the wound and the patients buttocks had been in contact with.

Interview on 01/21/10 at 12:10pm with Registered Nurse #8 revealed she worked and was assigned to Patient #11 on 01/20/10, but did not change the dressing or document a wound assessment. She stated the wound protocol for a Tegaderm was for it to be changed every 72 hours. She stated skin assessments were to be documented every shift. She was not aware of the physician ' s order to check the decubitus everyday and that the Tegaderm was to be on the left buttock and not on the right. She stated she should have reviewed the orders and clarified with the physician what was expected. She stated the wound had worsened and she was not aware of the 2 new areas of skin breakdown prior to performing the dressing change and skin assessment.

Interview on 01/21/10 at 12:00pm with the Medical Surgical Director revealed the nursing staff should have verified the physician ' s order and performed wound assessments every shift. She stated the dressing should have been on the left buttock per the physician ' s order. The physician should have been contacted about the condition of the wound as the facility ' s protocol indicated. She stated she did not monitor the staff for competency regarding dressing changes, nursing assessments or following physician orders.

Interview on 01/25/10 at 10:52am with the Director of Nursing revealed the facility had no documented evidence of training provided to the nursing staff regarding wound assessments, dressing changes or skin breakdown. She stated she did not monitor the staff for competency regarding these nursing services. She stated nursing should perform skin assessments daily and document their findings per hospital policy. She stated the physician should be contacted if the patient ' s skin condition deteriorates per the hospital protocol. She stated she had been busy with the new hospital ' s construction and was not aware the nursing staff was not performing and documenting assessments.

Interview with the Chief Operating Officer on 01/25/10 at 4:00pm revealed he was not aware that the nursing staff had not received training on wound care, the required wound care documentation or that the nursing staff was not performing nursing assessments. He stated he was ultimately responsible for the day to day operation of the facility but had just taken the position 24 days ago.

5. Review of Patient #3 ' s clinical record revealed the patient was admitted on 11/26/09 for Pyelonephritis and was discharged on 11/30/09. The patient was a Diabetic and had Spina bifida which resulted in paralysis of the lower extremities. Nursing documented on admission the patient had decubitus on the lateral right foot and coccyx area. Review of physician orders revealed no orders for dressing changes. However, review of history and physical revealed the physician was aware of the wounds. The physician documented assessment revealed " dressing on pressure ulcers on the patient back which home health takes care of. We have to get instructions from them before we can start changing these."

Review of nursing documentation revealed no assessment of patient #3 ' s wounds upon admission. Registered nurse #2 documented on 11/26/09 at 8:30am that she called the home health agency and the patient ' s wound care doctor regarding wound care instructions. However, due to the holiday weekend no one was available so she left a message for them to return her call. Registered Nurse #2 documented again at 11:15am that the family was present and informed her that they had changed the dressing before and will instruct the staff that evening on how to perform the dressing change. Registered Nurse #2 documented on 11/26/09 at 3:37 that a parent was at the bedside and she assisted the parent in changing the dressing.

Continued review of physician orders and progress notes did not revealed any orders regarding wound care or dressing changes. Continued review of nursing documentation revealed no wound assessments or documentation concerning the description, size or staging of the wounds to the coccyx or foot. The nursing staff only documented that the dressing was dry and intact.

Interview on 01/21/10 at 2:30 with Registered Nurse #2 revealed she did not remember much about patient #3. However, she did remember she had trouble getting in touch with the home health agency about Patient #3's dressing changes. She stated the mother told her she knew how to change the dressings so she assisted the mother in changing the dressings later on that evening. She stated she did not follow up with the physician or the home health agency to obtain an order for dressing changes since the mother knew what to do. She stated she thought there was an order for dressing changes and thought they were to be performed as needed but was not for sure. She stated she should have documented the wound assessment which would include the size, color, and temperature of the wound. However, the computer program where they documented this information has been down for some time.

Interview on 01/21/10 at 3:00pm with the Director of Nursing and Medical Surgical Director revealed the facility's new computer program had an area for the documentation of wound assessments with an anatomical person to use. They both stated this program had been broken for three months. They stated the company has been notified of the problem but has yet to fix it. They stated the nursing staff still could document the wound assessments in the nursing notes section of the computerized medical record and they were unaware the staff was not doing so.

6. Review of Patient #2's clinical record revealed the patient was admitted on 01/19/10 due to Hypoxia (a condition in which a person is deprived of adequate oxygen supply). The physician ordered the patient to receive oxygen at 2 liters per nasal cannula. The physician also ordered the patient's oxygen saturation (O2 sat) to be maintained above 93%.

Observation of Patient #2 on 01/20/10 at 2:30pm revealed the patient did not have the nasal cannula in the nares.

Interview on 01/20/10 at 2:35pm with Registered Nurse #4 revealed the patient's O2 sat was 88%. She stated she was not sure why the patient was not wearing the nasal cannula as ordered. She stated the physician ordered the patient to receive O2 continuously at 2 liters due to the diagnosis of hypoxia. She stated no other interventions were implemented to ensure the patient kept the cannula in the nares for the continuous delivery of oxygen as ordered by the physician.

Interview with the Director of Nursing on 01/20/10 at 01/20/10 revealed the nursing staff should ensure Patient #2 received the physician ordered oxygen therapy and was not aware the patient was not receiving oxygen at 2 liters per minute as ordered.

Based on interview and record review it was determined the facility failed to ensure a registered nurse supervised and evaluated the nursing care for one (1) of twenty two (22) sampled patients's. (Patient #22)

The findings include:

Review of the clinical record of Patient #22 revealed the patient was admitted on 01/13/10 with the diagnosis of pneumonia. Licensed Practical Nurse (LPN) #1 had completed the admission nursing assessment. The nursing assessment revealed Patient #22 was confined to the bed, completely immobile, had poor oral intake, and was a high potential for skin breakdown. Additionally, Patient #22 was admitted to the facility with skin breakdown present on the coccyx area. LPN #1 formulated the nursing care plan.

Interviews with Registered Nurse #1 on 01/25/10 at 10:45 AM and with RN #5 on 01/25/10 at 11:35 AM revealed they both functioned as Charge Nurses. The assignment of being in charge was rotated among the RNs. They stated there were usually three licensed staff (two RNs and 1 LPN) on duty from 7:00 AM to 7:00 PM. The patients were divided into three teams and each licensed nurse was assigned a team of patients. The licensed nurse was responsible for the total care of their assigned patients. There duties included medication administration, treatments, assessments, documentation, and care planning. Additionally, a Certified Nurse Aide would be assigned the personal care of the patients. RNs #1 and #5 revealed if they were in charge they would try to see every patient on the floor sometime during the shift. They did not perform assessments of the LPN's team of patients or review the work of the LPN. The LPN could do the initial nursing assessment on a new admission and plan the care of the patient. They stated they were available if the LPN had any questions but they did not routinely supervise the LPN.

Interview on 01/25/10 at 3:00pm with the Director of Nursing revealed that the facility was allowing the Licensed Practical Nurses (LPN) to work independently. She stated the LPN's were not supervised by the Registered Nurses and that each LPN was given an independent case load of patients and the Registered Nurses did not oversee their nursing duties or documentation. She stated she did not fully understand that the Registered Nurse was responsible for evaluating and supervising the nursing care delivered by LPN's.

Based on interview and record review it was determined the facility failed to ensure the nursing care plan for seven (7) of twenty two (22) sampled patients were developed, implemented and kept current for each inpatient. (Patients #2, #10, #11, #13, #17, #18, and #22).

This failure of the facility to ensure nursing care plans were developed and kept current places all patients at risk for serious injury, harm, impairment or death.

Based on observation, interview and record review it was determined that Immediate Jeopardy was identified on 01/25/10 and removed on 2/12/10 at 485.635 Condition of Participation: Provision of Services


The findings include:

1. Review of Patient #2's clinical record revealed the patient was admitted on 01/19/10 due to Hypoxia. The patient also had diagnoses of: Diabetes, Stroke and Hypertension. The patient had a feeding tube and a urinary catheter. Nursing documentation revealed the patient was non-ambulatory and required total care. Review of the care plan revealed the patient's tube feeding and urinary catheter was not addressed as care needs. The care plan did not address the patient's Diabetes and total care needs either.

The physician ordered the patient's oxygen saturation (O2 sat) to be maintained above 93% on 01/19/10 at 8:30pm. Review of Patient #2's care plan revealed it did not reflect this physician order. The care plan stated to keep the patients O2 sat above 90%.

Observation of Patient #2 on 01/20/10 at 2:30pm revealed the patient did not have the nasal cannula in the nares.

Interview on 01/20/10 at 2:30pm with Registered Nurse #4 revealed the patient's O2 sat was 88%. She stated she was not sure why the patient was not wearing the nasal cannula as ordered. She stated the physician ordered the patient to receive the O2 at 2 liters continuous due to the diagnosis of hypoxia. She stated this information should be on the care plan, however, she was not sure if it was.


2. Review of Patient #11's medical record revealed the patient was admitted on 01/12/10 with Metastatic Pancreatic Cancer. Nursing documented on admission the skin assessment score was a 15 which indicated a high risk for skin breakdown. Nursing documentation on 01/12/10 at 9:00pm stated the patient had a 1cm open area on the left buttock with a Tegaderm dressing in place. Continued nursing documentation stated the patient also had a reddened excoriated area on the right buttock.

Review of physician orders revealed an order was written on 01/14/10 at 6:07pm that stated the physician wanted the decubitus checked daily and a foam Tegaderm to be placed on the 1cm open area on the left buttock.

Review of the facility policy regarding "Shift Assessment and Documentation" revealed a shift assessment is required to perform on each patient, once per shift, by the primary nurse. This is done in addition to the nurse ' s notes, and other documentation. A skin assessment is included in the shift assessment. This includes any new findings since the previous shift assessment. The care plan is also reviewed each shift, with changes made as indicated. The facility failed to ensure the nursing staff followed and implemented the wound care protocols and shift assessment and documentation policy to ensure quality care and treatment was provided to all patients.

Review of Patient #11's care plan revealed nursing was to change the dressing as ordered and assess skin for breakdown. However, review of nursing documentation revealed no documented evidence that Patient #11's wounds on the buttocks had been assessed or the dressing changed from 01/13/10 through 01/19/10 (total of 7 days). Nursing documentation revealed the next time the wound was looked at was on 01/19/10 at 9:35pm when nursing documented "dressing on decubitus in place at this time". There was no documented evidence of what the decubitus looked like or if it was infected, had improved or worsened.

Observation on 01/21/10 at 11:55am of Patient #11's dressing change and wound assessment revealed the Tegaderm was on the right buttock and not on the left buttock as ordered. The patient had a circular reddened area on the left buttock and the patient stated the left buttock area of skin breakdown hurt when touched by the nurse. There was also a reddened area of skin breakdown noted at the top in the crease of the buttocks. The nurse stated the top layer of skin was gone in these areas. She measured the right buttock wound to be 1cm round and the left buttock wound to be ? cm round. She did not measure the area at the top in the crease of the buttocks.


Interview on 01/21/10 at 12:10pm with Registered Nurse #8 revealed she worked and was assigned to Patient #11 on 01/20/10, but did not change the dressing or document a wound assessment. She stated the wound protocol for a Tegaderm was for it to be changed every 72 hours. She stated skin assessments were to be documented every shift. She was not aware of the physician ' s order to check the decubitus everyday and that the Tegaderm was to be on the left buttock and not on the right. She stated she should have reviewed the orders and clarified with the physician what was expected. She stated the wound had worsened and she was not aware of the 2 new areas of skin breakdown prior to performing the dressing change and skin assessment.

Interview on 01/21/10 at 12:00pm with the Medical Surgical Director revealed the nursing staff should have verified the physician ' s order and performed wound assessments every shift. She stated the dressing should have been on the left buttock per the physician's order. The physician should have been contacted about the condition of the wound as the facility's protocol indicated. She stated she did not monitor the staff for competency regarding dressing changes, nursing assessments or following physician orders.


3. Review of Patient #10's clinical record revealed the patient was admitted on 01/19/10 for cellulitis of the right lower extremities (RLE). Review of physician orders dated 01/19/10 revealed the patient was to receive daily wound care to the RLE. The physician ordered the wound to be cleansed with saline, covered with Telfa and wrapped with a Kling bandage. Review of the nursing care plan revealed the plan did not reflect a nursing diagnosis for wound care or interventions regarding dressing changes.

Observation of Patient #10 on 01/21/10 at 11:00am revealed the patient was in bed receiving physical therapy to the lower extremities. Patient #10 had a dry intact dressing to the right lower calf.

Interview on 01/22/10 at 2:45pm with the Director of Nursing and the Medical Surgical Director revealed Patient #10's nursing care plan should reflect the wound care ordered.


4. Review of Patient #13's clinical record revealed the patient was admitted on 01/21/10 with chronic anemia and history of gastrointestinal bleeding. The patient was ordered to receive 2 units of blood due to a hemoglobin of 7.7 (normal 14-17) and a hematocrit of 25.7 (normal 41-51). Review of laboratory documentation revealed one unit of packed red blood cells was released to Registered Nurse #1 at 2:05pm. Review of patient #13's care plan revealed no nursing care plan for the administration of blood products, blood loss or anemia. The care plan had nursing goals for Activities of Daily Living and Increased Isotonic Fluid Retention.

Interview on 01/21/10 at 4;20pm with Registered Nurse #1 revealed the new computer program used to develop the care plans did not have a care plan for blood transfusion or anemia due to blood loss.

Interview on 01/21/10 at 4:25pm with the Director of Nursing revealed she was unaware that the new computer program for the nursing care plans did not allow nursing to create an individualized care plan.

Interview on 01/20/10 at 2:45pm with the Medical Surgical Director revealed the new computer system would not let you change the preinstalled interventions in or to make an individualized nursing care plan or to reflect specific physician orders.

5. Review of Patient #17's clinical record revealed the patient was admitted on 01/20/10 for Pneumonia. Review of physician orders revealed the patient was to receive oxygen at 2 liter per minute as needed for shortness of breathe and to keep oxygen levels above 92%. The patient was also prescribed a smoking cessation medication patch.

Review of Patient #17's nursing care plan revealed the plan only had goals for Activities of Daily Living and Increased Risk for Pathogenic Organisms. The care plan did not indicate intervention for oxygen therapy or interventions for smoking cessation.

Interview on 01/25/10 at 9:00am with the Medical Surgical Director revealed Patient #17's care plan should address the patient's diagnosis of Pneumonia and the medication for smoking cessation. She stated their new computer program did not have a care plan for smoking cessation and they would have to build one.

6. Review of Patient #18's clinical record revealed the patient was admitted on 01/24/10 for chest pain the patient also had a diagnosis of Diabetes. The physician ordered a cardiac monitor for the patient, oxygen if needed when experiencing chest pain, and blood sugar monitoring along with sliding scale insulin.

Review of the nursing care plan for Patient #18 revealed no nursing interventions regarding cardiac monitoring, blood sugar monitoring or the administration of insulin. The nursing care plan goals listed were for Activities of Daily Living and Acute Chest Pain. However, the Acute Chest Pain nursing intervention listed only one intervention and that was for the staff to administer pain medication as indicated.

Interview on 01/25/10 at 9:05am with the Director of Nursing revealed Patient #18's care plan should reflect the cardiac monitoring and diabetes intervention ordered by the physician. Again she stated the new computer program was not allowing the nursing staff to develop specific or individualized care plans.



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7. Review of Patient #22's clinical record revealed the patient was admitted on 01/13/10 with pneumonia. A nursing assessment was conducted on 01/13/10 and revealed Patient #22 was a "High Risk" for skin breakdown. The nursing assessment revealed Patient #22 was confined to the bed, completely immobile, and had poor oral intake. Additionally Patient #22 was admitted to the facility with skin breakdown present to the coccyx area. A review of the care plan revealed there was no documented evidence of a care plan being formulated related to skin integrity.

An interview with RN #5 on 01/25/10 at 11:35 AM revealed Patient #22 should have had a skin integrity care plan initiated upon admission.

Based on the findings of the Validation and complaint survey concluded on 01/25/10, it was determined the Condition of Participation for Clinical Records was not met. The facility failed to ensure a member of the professional staff maintained the clinical records system in accordance with written policies and procedures ensuring that they were complete, accurate and systematically organized. Findings of a follow-up survey conducted on 02/12/10 revealed the Condition of Participation for Clinical Records continued not to be met.


Under Condition of Participation 485.637.
Refer to Standard Tags, C301

Based on interview and record review it was determined the facility failed to ensure the clinical records were maintain in accordance with written policies and procedures ensuring that they were complete, accurately documented and systematically organized.

The findings include:

Review of the facility policy "Medical Records" revealed the facility must ensure that each patient's medical record was an accurate reflection of care provided and contained all medical documents used in the delivery of care. The facility failure to ensure the medical record was accurate and complete and systematically organized prevents medical personnel from having an accurate picture of care and services provided by the facility.

Review of Patient #3's clinical record revealed the patient was admitted on 11/26/09 for Pyelonephritis and was discharged on 11/30/09. Review of the printed computerized medical recorded revealed even though the patient was discharged on 11/30/09, nursing documentation with a date of 12/01/09 was written 82 times. The nursing documentation revealed Patient #3 was receiving care as if the patient was still hospitalized.

Interview on 01/21/10 at 2:00pm with the Director of Nursing revealed there was a problem with the computer system. She stated the nursing documentation made in Patient #2's medical record after the patient was discharged was made by nurses that were not even in the building at the time it was documented. She stated the medical records department was aware of a similar problem with another patient's medical record but they thought the problem had been fixed. She stated the facility did not perform medical record audits after the first incident happened in December to ensure no other records had been affected.

Review of Patient #14's medical record revealed the patient was admitted to an acute care bed on 01/20/10 for pneumonia and discharged on 01/22/10. However the computerized medical record indicated the patient was in a swing bed.

Interview on 12/25/10 at 12:15pm with the Director of Nursing revealed the computerized medical record defaulted to the swing bed category on its own. She stated the facility was in the process of fixing the mistake after surveyor intervention.

Interview on 1/22/10 at 9:50am with Director of Medical Records revealed the medical record was not complete or accurate if the computer system was making erroneous entries and defaulting to a swing bed status even though a patient was in an acute care bed. She stated the facility was aware of an issue with another patient's medical record back in December. She stated they reported it to the company and was told by the company the problem was fixed. She stated the facility had not performed medical record audits to determined if any other records were affected but should have.

Review of medical records #1-#22 revealed the computerized skin assessment module with the anatomical man was not operational for staff use. Review of the printed copies of the assessment for each patient revealed the anatomical man page stated the patients was skin assessed and no abnormalities found even if this was not correct. Review of Patient #2, #10, #11 and #22 had medical records and nursing documentation revealed the patients had wounds.

Interview on 01/21/10 at 3:00pm with the Director of Nursing and Medical Surgical Director revealed the facility's new computer program had an area for the documentation of wound assessments with an anatomical person to use. They both stated this program had been broken for three months. They stated the company has been notified of the problem but has yet to fix it.

Based on the findings of the Validation and complaint survey concluded on 01/25/10, it was determined the Condition of Participation: Periodic Evaluation and Quality Assurance Review
was not met. The facility failed to demonstrate an effective quality assurance program that monitored and evaluated medication storage, medication labeling, wound care, infection control practices and medical records for completeness and accuracy. Findings of a follow-up survey conducted on 02/12/10 determined the Condition of Participation: Periodic Evaluation and Quality Assurance Review continued not to be met.


Under Condition of Participation 485.641.
Refer to Standard Tags, C336

Based on observation, interview and record review it was determined the facility failed to ensure an effective quality assurance program was in place to identify areas in need of process improvement or a corrective action plan.

The failure of the facility to monitor, identify and evaluate medication storage, medication labeling, wound care, infection control practices and medical records for completeness and accuracy places all patients at risk for serious injury, harm, impairment or death.

Based on observation, interview and record review it was determined that Immediate Jeopardy was identified on 01/25/10 and removed on 02/12/10 at 485.641 Condition of Participation: Periodic Evaluation and Quality Assurance Review


The findings include:

Review of the facility policy "Performance Improvement" revealed the purpose of the policy was to identify the current process, the process for analysis, revise the process under scrutiny, and to identify opportunities of improvement within the organization, through aggregation and analyzing of collected data. Special emphasis will be placed on care processes such as medication events and patient identification. The facility's failure to place emphasis on care processes prevented the facility from identifying areas of patient care in need of improvement and a corrective action plan.

Interview on 01/22/10 at 3:30pm with the Quality Assurance (QA) nurse revealed she did not perform Quality Assurance rounds. She stated each department performed their own performance improvement rounds, but she did not know what they were looking at or for. She stated each department made their own decision on what they were going to monitor each quarter. She stated each department would pick one thing and monitor it for the quarter. She stated last quarter the infection control nurse monitored vaccines only and that the practice of each department was to monitor one issue they thought was in need of performance improvement. She stated the departments reported their findings to her and she put their findings in the QA binder and analyzed the information for the yearly evaluation. She stated she did not do anything specific with the departments other than gather their data. She stated she did not direct the staff on what to look for or what improvements were needed. She stated she would not know what their problems were because she did not perform surveillance in each of the facility's departments. She did not monitor medication storage, infection control practices, wound care or medical records for completeness or accuracy. She stated she also performed the facility's Utilization review and that consumed about five hours of each day. She stated she tried in the past to decide if the departments' identified the appropriate problems that needed attention each quarter but was told to let the staff make their own decisions.

Interview on 01/25/10 at 4:00pm with the Chief Operating Officer revealed he was not aware the Quality Assurance (QA) nurse was not actively performing performance improvement rounds to determine areas of deficient practice. He was not aware that the QA nurse only compiled the data provided to her by each department. He stated he had not directed the QA nurse to perform QA surveillance of each department to ensure the appropriate and the highest priority patient care issues were assessed and evaluated for quality of care issues. He stated he had only been in this position for 24 days. However, he was ultimately responsible for the day to day operations of the Critical Access Hospital and quality care and services was his highest priority.