HospitalInspections.org

Based on interviews and record review the facility failed to ensure patients who were transferred to another facility had the correct transfer paperwork in the medical record in 2 of 5 transferred patients (Patients #10 and #26).

Findings include:

Policy:

Transfer of Patients to Other Acute Care Facilities read, an interfacility transfer sheet must be filled out for transfers. The original goes with the patient, one copy stays with the medical record and one copy is available for the discharge planner.

1. The facility failed to ensure all patients who were transferred to another acute care hospital for a higher level of care had a interfacility transfer sheet completed and in the medical record.

a. Review of medical records for Patient #10, admitted 4/2/18, and Patient #26, admitted 5/6/18, revealed no documentation of an interfacility transfer sheet in the completed medical record.

b. Chief Executive Officer (CEO) # 5 was interviewed on 5/8/18 at 1:22 p.m. CEO #5 reported the facility was aware of the missing interfacility transfer sheet for Patient #10. CEO #5 said all copies of the form had been sent with the patient to the facility where the patient was transferred to. The facility requested a copy of the interfacility transfer sheet, from the receiving hospital. The facility was unable to provide a copy of the interfacility transfer sheet by the exit of the survey.

c. Director #2 (Director of IT and Safety) was interviewed on 5/8/18 at 2:05 p.m. Director #2 stated he would get the missing interfacility transfer sheet for Patient #26. Director #2 said he was not sure why it was missing but would look into finding the missing transfer form. The facility failed to provide Patient #26's interfacility transfer sheet by the exit of the survey.

Based on observations and interviews the facility failed to ensure point of care testing materials were dated when opened.

Findings include:

Reference:

Accu-Chek inform II manufacturer's instructions 2016 Roche Diabetes Care read, note: Write the date the bottle was opened on the bottle label. The control solution is stable for 3 months from that date or until the Use By date on the bottle label, whichever comes first.

Acceava Strep A manufacturer's instruction read, once the canister is opened, the remaining test strips are stable for 12 months. Do not use beyond the expiration date.

1. The facility failed to date Accu-Chek control solutions (solutions used to test a machine for accuracy when measuring a patients' blood sugar level) when the bottles were opened pursuant to manufacturer's instructions.

Additionally, the Acceava Strep A strip (a strip that is used to test a patient for Strep throat) container was opened and failed to have a date placed on the container to identify when the strips were opened and when they were no longer stable for use.

a. On 5/7/18 a tour was conducted at the facility from 11:45 a.m. to 2:15 p.m. At 1:42 p.m. an observation of two Accu-Chek Inform II control solutions were noted in the family medicine clinic with no evidence of a date on either bottle. During the same observation time a container of Acceava Strep A point of care testing strips was observed with no evidence of an open date on the container.

b. Medical Assistant (MA) # 12 was interviewed on 5/7/18 at 1:42 p.m. She verified the Accu-Chek control solutions did not have a date on the bottles. MA #13 stated the laboratory unit of the hospital opened the Accu-Chek control solutions. She reported the control solutions were used until the bottles were emptied. MA #13 said if the solution had expired, using the solutions could give a false test result.

MA #13 also verified the Acceava Strep A testing strip container had been opened and not dated. MA #13 reviewed the manufacturer instructions and verified the bottle was to be dated after it was opened. MA #13 said she did not know when the bottle had been opened. MA #13 said without a date on the bottle expired strips could be used on a patient which could result in an inaccurate test result.

c. On 5/7/18 a tour of the facility was conducted from 11:45 a.m. to 2:15 p.m. At 12:12 p.m. two Accu-Chek Inform II control solutions were discovered in the Emergency Room with no evidence of a date on either bottle.

d. Registered Nurse (RN) #7 was interviewed on 5/7/18 at 12:12 p.m. RN #7 verified each bottle of Accu-Chek control solutions did not have a date open written on the bottle. RN #7 said there was no way of knowing if the control solutions were accurate because they were not dated. RN #7 reported because she could not be sure the control solutions were accurate, she could also not be sure accurate test results were obtained when testing a patient.

e. RN #6 was interviewed on 5/7/18 at 12:12 p.m. RN #6 confirmed the Accu-Chek control solutions needed to have a date opened on each bottle. RN #6 said the date was important so the staff would know when the solutions expired. RN #6 reported if inaccurate control solution were used then staff could not be sure if the test was accurate.

f. Chief Executive Officer (CEO) #5 was interviewed on 5/9/18 at 4:38 p.m. CEO #5 stated over time point of care testing strips and control solutions degrade in quality. Because the testing strips and control solutions were not maintained properly inaccurate testing could have resulted, as well as inaccurate control readings.

Based on interview and document review, the facility failed to ensure patients who were placed in restraints were monitored, per facility policy in 1 of 1 restraint records reviewed (Patients #13).

Findings include:

Policy:

Restraint or Seclusion: Behavioral dated 4/20/17 read, assessment, observation and documentation requirements for behavioral restraint. Ongoing assessment and observation included every 2 hour requirements for vital signs, nutrition, hydration, personal hygiene, elimination.

1. The facility failed to provide evidence which showed how nursing staff monitored the patient's in restraints per facility policy.

a. Review of Patient #13's medical record showed the patient was admitted to the facility on 9/11/17. Patient #13 was in soft limb behavioral restraints from 9/11/17 at 2:45 p.m. through 9/12/17 at 8:00 a.m. Patient #13's History and Physical dated 9/11/17, showed the patient was admitted to the facility for alcohol intoxication and aggression.

Review of the Patient #13's 15 minute check form, implemented on 9/11/17 at 3:44 p.m., showed the patient was not offered nutrition and fluids and did not have his personal hygiene and elimination needs assessed every two hours while restrained, as required.

On 9/11/17 from 3:44 p.m. until 8:45 p.m. (a total of 5 hours) there was no evidence the restraints had been removed. During the same 5 hours there was no documentation the patient was offered nutrition and hydration, or that his personal hygiene and elimination needs were assessed. Further, there was no documentation range of motion was provided to the restrained patient during this time. The patient continued to be in restraints. On 9/12/17 at 4:45 a.m. the patient's needs were assessed. There was no documentation the patient was offered nutrition and hydration or had his personal hygiene and elimination needs assessed subsequently until 7:45 a.m. (3 hours later).

b. Chief Executive Officer (CEO) #5 was interviewed on 5/9/18 at 4:38 p.m. He stated the staff were required to document about restraint patients according to facility policy.

c. Registered Nurse (RN) #14 was interviewed on 5/9/18 at 2:45 p.m. RN #14 reported restraints had to be documented in the chart. RN #14 reported the patient had to be monitored and the patient had to have one on one supervision when behavioral restraints were used.

Based on the manner and degree of standard level deficiencies referenced to the Condition, it was determined the Condition of Participation, §485.645 Special Requirements for CAH Providers of Long-Term Care Services (Swing-Beds) was out of compliance.

C-0361 Resident Rights- The facility has the duty to fully inform the resident of their rights verbally and in writing and to ensure the rights of the resident are upheld. The facility failed to provide swing bed (skilled nursing) patients with notification of their rights in 4 of 4 swing bed medical records reviewed (Patients #22, #23, #24 and #29) .

C-0381 Restraints-The resident has the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms. The facility failed to ensure patients admitted to swing bed status (skilled nursing care) had orders and documentation to support the reason for restraint use for 1 of 1 swing bed restraint records reviewed (Patient #29).

C-0385 Patient Activities- The facility must provide for an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental, and psychosocial well-being of each resident. The facility failed to provide activities, other than routine activities of daily living (ADLs), to patients admitted for skilled nursing care (swing bed). Four of four medical records reviewed showed no evidence program activities, which enhanced the physical, cognitive and emotional health of the patient, were provided (Patients #22, #23, #24 and #29) .

Based on interviews and record review the facility failed to provide swing bed (skilled nursing) patients with notification of their rights in 4 of 4 swing bed medical records reviewed (Patients #22, #23, #24 and #29) .

Findings include:

1. The facility did not provide verbal or written notification of rights to swing bed patients.

a. A review of 4 swing bed patient medical records was performed. Patients #22, #23, #24 and #29 were each admitted to swing bed status between August 2017 and May 2018. None of the patient records contained documentation to show the patients had been advised of their rights as required by federal regulation.

b. During an interview with Lead Provider (LP) #4 on 5/8/18 at 5:07 p.m., she confirmed she was aware swing bed patients had different rights which were supposed to be presented with their consent. LP #4 was unable to provide evidence any swing bed patient had been notified of their rights under swing bed status.

c. Chief Executive Officer (CEO) #5 was interviewed on 5/9/18 at 4:35 p.m. CEO #5 stated he was not aware swing bed patients had different rights than those admitted for inpatient care. He stated the facility was in the process of creating a new rights document for swing bed patients

Based on interviews and record review the facility failed to ensure patients admitted to swing bed status (skilled nursing care) had orders and documentation to support the reason for restraint use for 1 of 1 swing bed restraint records reviewed (Patient #29).

Findings include:

Policy:

The Restraint: Non-Behavioral policy read, the purpose was to support the patient's right to be free from restraint or seclusion as a means of convenience and used as a last resort for the shortest time possible. Each episode of restraint required an order by the provider responsible for the patient's care. The use of restraint would not be used as an alternative to staffing or monitoring of the patient. Each patient placed in restraints would have documentation of the type and location of restraint; behaviors which warrant continuation of the restraint and the education of the patient/family of the criteria for release of the restraint. The plan of care should be modified to reflect the patient had been placed in restraints.

Restraints, as defined by the facility, would involve "all manual, physical, mechanical, and material devices used to involuntarily limit freedom of movement, immobilize or reduce the ability of a patient to move his/her arms, legs, body or head freely." The use of side rails to prevent a patient from voluntarily getting out of bed would be considered a restraint.

1. The facility failed to ensure supporting orders and documentation were present in the medical record.

a. An interview was conducted with the chief nursing officer (CNO #5) on 5/9/18 at 9:16 a.m. According to CNO #5, the facility did not use restraints. He confirmed the use of four bed side rails to contain a patient was considered a restraint. Care for the patient in restraints should follow the facility policy. CNO #5 stated, the restraint policy provided applied to all units within the facility.

b. Registered Nurse (RN) #14 was interviewed on 5/9/18 at 2;44 p.m. and confirmed nursing staff worked in the emergency room and the inpatient unit depending on the needs of the facility. He stated examples of restraints were physical (limb), chemical and bed rails. RN #14 stated the use of all four side rails on the bed of a patient that was used to prevent him from climbing out of the bed was considered a restraint. RN #14 reported he would expect there to be an order from the provider for the use of restraints. He also confirmed there should be documentation to show the patient was monitored for safety while the restraints were in use.

c. Patient #29 was admitted to swing bed status on 9/8/17 for physical therapy services after hospitalization for a urinary tract infection. According to the history and physical in the medical record, Patient #29 had a history of falls and dementia (a decline in thinking skills). The nursing assessment documented by Registered Nurse (RN) #16 on 9/8/17 at 8:30 a.m. revealed the patient was unable to stand, was combative at times, and forgot his limitations which placed him at a high risk for falls.

d. On 9/22/17 at 3:15 a.m. RN #18 documented in the Bedside Rounding Log of Patient #29. According to RN #18, the bed's four side rails were up because the patient tried to get out of bed. There was no order for restraints, no Restraint Observation Flowsheet and no modified plan of care in the medical record as required by facility policy.

e. The clinical coordinator (CC #6) was interviewed on 5/9/18 at 10:19 a.m. CC #6 stated he coordinated the training and supervised nurses in the emergency room and on the inpatient units. During the interview CC #6 reviewed the Bedside Rounding Log (log) for Patient #29. According to CC #6, the log was completed by the RN every two hours during their shift and was used to document all safety interventions in place for the patient. CC #6 confirmed on 9/22/17, the RN had documented "side rails up x 4" in the log and stated that meant the patient was in his bed with all four side rails in the up position. According to CC #6, the use of four side rails was considered a restraint.

The medical record of Patient #29 showed four bed side rails were up on 7 of 23 days during his admission. There were no orders or restraint monitoring documentation present in the medical record.

Based on interviews and record review the facility failed to provide activities, other than routine activities of daily living (ADLs), to patients admitted for skilled nursing care (swing bed). Four of four medical records reviewed showed no evidence program activities, which enhanced the physical, cognitive and emotional health of the patient, were provided (Patients #22, #23, #24 and #29) .

Findings include:

Policy:

Swing Bed Admits read, the hospital would remain compliant with state and federal regulations for swing bed admissions.

1. The facility failed to provide a program of activities for its skilled nursing residents designed to enhance their psychosocial, mental and physical well-being.

a. Review of the medical records of four swing bed patients revealed none had been provided programmed activities during their admission.

Patient #22 was admitted to swing bed status on 5/1/18 for ongoing behavioral issues, generalized weakness and deconditioning. He required full assistance to walk and would be provided physical therapy during his stay. On 5/3/18 he was transferred to a long-term care facility. There was no documentation in the medical record to show Patient #22 had been offered any additional activities to enhance his cognitive and physical needs.

Patient #23 was admitted to the facility for swing bed services from 8/5/17 to 8/7/17. According to the medical record, Patient #23 had become weak and required physical therapy to improve overall muscle strength with the goal of returning home. During her admission there was no documentation to show Patient #23 had been provided with activities of interest.

On 8/26/17, Patient #24 was admitted for swing bed care to improve the management of his shortness of breath while walking. According to the medical record Patient #24 was able to walk independently and spent time in his room watching television. On 8/27/17 at 2:52 p.m. the nurse documented Patient #24 was standing in the doorway of his room. At 4:07 p.m. on the same day, a nurse's note described the patient was irritable when speaking with the nurse. There was no documentation within the medical record to show Patient #24 had been offered recreational activities during his stay.

Patient #29 was admitted to swing bed status on 9/8/17 for physical therapy for overall improvement in balance and strength due to a history of falls. According to the history and physical in the medical record, Patient #29 also had a history of dementia (a decline in thinking skills). There was no documentation within the medical record to show Patient #29 was offered recreational activities to enhance his cognitive abilities.

b. An interview was conducted with Chief Nursing Officer (CNO) #5 on 5/19/18 at 4:35 p.m. CNO #5 confirmed all policies related to swing bed patients had been provided. He stated he was not aware the facility was required to offer activities to its swing bed patients in addition to routine nursing and rehabilitative care already provided.

Based on interview and document review, the facility failed to develop a means to track patients and on-duty staff in the facility during an emergency event.

Findings include:

1. The facility failed to provide evidence of their ability to track patients and on-duty staff during an emergency.

a) On 5/8/18 at 12:43 p.m., an interview was conducted with the Director of Ambulance Service (Director #1). Director #1 confirmed he was the internal incident commander during an emergency event. According to Director #1, the EMTALA (Emergency Medical Treatment and Labor Act) form would be used if patients were transferred to other medical facilities. Director #1 was unable to provide the means by which on-duty staff would be tracked if they were required to report to a different facility.

The Director of IT and Safety (Director #2) was present during the same interview and confirmed he was the workplace emergency coordinator. Director #2 stated he was not aware of a means to track patients and on-duty staff during an emergency event upon evacuation or relocation.

Chief Executive Officer (CEO) #5 was also present during the interview and stated, the facility had not developed a tracking log for the emergency preparedness plan.

Based on interviews and document review the facility failed to develop a policy and procedure for sheltering staff and patients in place when evacuations during a disaster were not feasible.

Findings include:

1. The facility was unable to provide policies or procedures for sheltering in place.

a) An interview was conducted with the the Director of IT and Safety (Director #2) on 5/8/18 at 12:43 p.m. Director #2 confirmed he was the workplace emergency coordinator. According to Director #2, all policies related to the Emergency Preparedness Program had been provided.

b) During an interview with Clinical Coordinator (CC) #6 on 5/9/18 at 10:19 a.m., he stated he was responsible for coordinating the training of nursing care staff. CC #6 stated he had not been provided training on where to take patients within the facility in the event an evacuation was not possible during a disaster to ensure their safety.

There were no policies included within the facilities Emergency Preparedness Program which addressed the criteria for patients who would not be evacuated, where the patients would be sheltered and how the staff would continue to care for those patients.

Based on interviews and document review the facility failed to ensure all staff were trained in their respective roles during a disaster.

Findings include:

Policy:

The Emergency Preparedness Program read, all employers were required to have an Emergency Action Plan (EAP) which must be in writing if there were 10 or more employees and must be available in the facility for all employees to review. Additionally, procedures must be established and employees trained on when and how to sound an alarm and notify emergency personnel. The EAP must be reviewed with each employee "when the plan is first developed and when an employee is assigned initially to a job in the workplace covered by a plan; when an employee's responsibilities under a plan change; and when a plan itself is changed."

Reference:

According to the county's Multi-Year Training and Exercise Plan (updated March 2018), "high quality realistic training is the foundation of high performance organizations and teams." The Office of Emergency Management (EOM) "will provide the resources and exercise framework (scenario and injects) to test the EOC (Emergency Operation Center staff) functionality and county response and recovery capabilities. Implicit in this approach is the understanding that all departments, agencies and organizations conduct sustainment training on a regular basis and test their individual plans and standard operating procedures.

1. The facility failed to train all personnel on their responsibilities during emergency disaster operations.

a) An interview was conducted with the the Director of IT and Safety (Director #2) on 5/8/18 at 12:43 p.m. Director #2 confirmed he was the workplace emergency coordinator. According to Director #2 all emergency medical service (EMS) staff, directors and safety committee members had completed FEMA (Federal Emergency Management Agency) independent study courses but there had been no training of the front line clinical or general staff regarding emergency preparedness.

b) Registered Nurse (RN) #7 was interviewed on 5/7/18 at 11:57 a.m. RN #7 stated she was a travel nurse who was not familiar with the emergency preparedness plan for the facility and would rely on the clinical coordinator or unit manager for guidance in the event of a disaster.

c) On 5/9/18 at 10:19 a.m., Clinical Coordinator (CC) #6 was interviewed. He stated, there had been no specific training provided on the emergency preparedness plan, only fire drills had been conducted. If there were a disaster, the management team would step in to provide guidance at that time.

d) The Chief Executive Officer (CEO #5) was present during the interview on 5/8/18 at 12:43 p.m. CEO #5 stated emergency preparedness had been discussed at meetings but the training had not filtered down to frontline staff.