HospitalInspections.org

Based on review of clinical records, interviews and review of facility policy for two patients (Patient's # 30 and 31) reviewed, the hospital failed to reassess the patient prior to discontinuation of monitoring checks to determine the individual needs of the patient and/or maintain a safe environment. The findings include the following:

a. Review of the clinical record indicated that Patient # 30 was admitted on 6/22/12 with alcohol abuse and depression. The physician's orders dated 6/22/12 directed every fifteen minute checks for twenty four hours. Review of the clinical record failed to reflect that the patient was reassessed when the twenty-four hour time period had elapsed to determine the individualized needs of the patient.

b. Patient #31 was admitted on 6/22/12 with attempted overdose and Bipolar disorder. The orders dated 6/22/12 directed every fifteen-minute checks which were discontinued on 6/24/12, absent of a reassessment to determine the individualized needs of the patient. The treatment plan dated 6/22/12 identified that the patient had active problems that included depression, potential for self injury and suicidal ideation. Interview with the Nursing Director on 6/27/12 at 10:00 AM indicated that if there is not an order for observation frequency, all patients are placed on 30 minute checks.

Review of the facility policy indicated all patients will be assigned the level of observation required for their safety and therapeutic needs. This will be determined by the psychiatrist in conjunction with the charge nurse. Review of the facility policy indicated that special observation (every 15 minutes, close and 1:1) is initiated with an order by a clinician. The RN will ensure that the patients treatment plan reflects the observational status.

Review of a policy and procedure, titled Patient Rights and Responsibilities, identified that each patient has the right to personal safe environment and to receive care in a safe environment.

Based on review of clinical records, review of facility policy, and interview for three of three patient's reviewed for restraints (#26, 28, and 29), the facility failed to ensure that restraints were applied based on a comprehensive physicians order. The finding includes the following:

a. Patient #26 was admitted on 6/14/12 after ingesting multiple non-edible objects. The clinical record indicated that while in the ED the patient was "banging head on the wall" and was placed in restraints on 6/14/12 at 12:03 AM. Review of the ED record failed to identify a physicians order for the restraints, an evaluation by the licensed independent practitioner and/or monitoring of the patient while in restraints.


b. Patient #28 presented to the ED on 6/9/12 after a motor vehicle accident. Review of the clinical record indicated that the patient was placed in four point restraints secondary to hostile behavior and was a danger to self. Review of the physician's orders directed "restraints for four hours" and "locked restraints or soft restraints limbs/chest vest/ mittens. The physicians order failed to identify the specific type of restraints to be utilized.

c. Patient #29 presented to the ED on 5/1/12 after a suicide attempt. Review of the clinical record indicated that the patient was placed in four point restraints secondary to hostile behavior and was a danger to self. Review of the physician's orders directed "restraints for four hours" and "locked restraints or soft restraints limbs/chest vest/ mittens". The physicians order failed to identify the specific type of restraints to be utilized.
Record review and interview with the Director of Quality on 6/27/12 failed to identify specific restraint orders based on the patient's individualized needs.

Review of the facility policy indicated that each episode of restraints will be initiated upon the order of the physician or LIP.

Based on review of clinical records, review of facility policy, and interview, the facility failed to monitor two of three patients restrained (#28 and 29), in accordance with hospital policy. The findings include the following:

a. Patient #28 presented to the ED on 6/9/12 after a motor vehicle accident. Review of the clinical record indicated that the patient was placed in four point restraints secondary to hostile behavior and was a danger to self. Review of the clinical record indicated that the patient was placed in restraints on 6/9/12 at 2:40 AM. The record indicated that the restraints were decreased from 4 point to 2 point at 3:14 AM. The clinical record failed to identify that the patient was monitored every fifteen-minutes in accordance with hospital policy.

b. Patient #29 presented to the ED on 5/1/12 after a suicide attempt. Review of the clinical record indicated that the patient was placed in four point restraints secondary to hostile behavior and was a danger to self. Review of the clinical record indicated that the patient was placed in four point restraints on 5/1/12 at 6:00 PM. The clinical record failed to identify that the patient was monitored every fifteen-minutes.

Record review and interview with the Director of Quality on 6/27/12 stated that the monitoring checks were not present in the clinical record.

Review of the restraint policy indicated monitoring should be completed and documented every fifteen minutes.

Based on review of clinical records, interviews, review of policies, procedures and documentation, the hospital failed to ensure that physician/provider orders for invasive and/or non-invasive ventilation included all elements of a physician's order. Pease refer to A347.
Cross reference A1151, 1160, and 1163.

Based on a review of clinical records, interviews, review of facility policies, procedures, and documentation, the hospital failed to ensure that physician/provider orders for invasive and/or non-invasive ventilation included all elements of a physician's order for four of eight patients (#21, 22, 23, and 19). The findings include:


a. Patient #21 was admitted on 6/22/12 with respiratory failure. Review of a physician's order, dated 6/23/12 at 8:25 A.M. and 3:36 P.M., 6/24/12 at 9:30 A.M. and 6/26/12 at 9:05 A.M., directed staff to place the patient on BiPAP (non-invasive mechanical ventilation) with the following parameters: Inspiratory Positive Airway Pressure (IPAP) of 14 centimeters (cm) of water and Expiratory Positive Airway Pressure (EPAP) of 5 cm of water with supplemental oxygen of 6 Liters (L) per minute. The order failed to specify mode for the BiPAP.

Review of the Respiratory BiPAP Flow sheets, dated 6/23/12 at 9:30 A.M. to 6/26/12 at 11:00 A.M., identified that the respiratory therapist placed the patient in a spontaneous timed mode with the backup respiratory rate of 14 breaths per minute, absent of a physician's order.

Interview with Respiratory Therapist #1, on 6/26/12 at 11:44 A.M., identified that the physician orders did not include the mode of ventilation and/or the backup respiratory rate. Interview with the Respiratory Therapy Supervisor, on 6/26/12 at 1:25 P.M., identified that the physician must order the mode of ventilation for BiPAP.

b. Patient #21 had a physician's order, dated 6/23/12 at 5:30 P.M., that directed respiratory therapy staff to administer Xopenex 1.25 milligrams (mg) via small volume nebulizer every two hours as needed, however, the order failed to specify the indication for this medication. Interview with Respiratory Therapist #1, on 6/26/12 at 11:44 A.M., identified that the order failed to contain the indication for the medication.
Review of the policy titled, Prescribing/Ordering General Practices, identified that orders for "as needed" medications must specify the indication for use.


c. Patient #22 was admitted on 6/24/12 with pneumonia and on 6/26/12 at 8:05 A.M. s/he required intubation for invasive mechanical ventilation. Review of the physician's order, dated 6/26/12 at 8:00 A.M., directed staff to place the patient on the ventilator with the following settings: Tidal Volume: 450 milliliters (ml), respiratory rate of 16 breaths per minute and 100 % oxygen to be administered. the physician's order failed to direct mode of ventilation.

Review of the Respiratory Care Mechanical Flow sheet, dated 6/26/12 from 8:05 A.M. to 12:00 Noon identified that Patient #22 was maintained on the assist control mode of ventilation. Interview with the Respiratory Therapy Supervisor and observation of the ventilator for Patient #22, on 6/26/12 at 1:35 P.M., identified that the mode of ventilation was assist control although there were no physician orders for the mode of ventilation.

d. Patient #23 arrived via ambulance at the Emergency Department (ED) on 6/19/12 at 2:10 P.M. after ingesting an unknown amount of the medication Seroquel with a past medical history that included COPD and sleep apnea. Review of the ED clinical record, reflected that the patient was intubated at 5:15 P.M. with a physician's order, dated 6/19/12 at 6:08 P.M., that directed staff to place the patient on the ventilator with the following settings: Tidal Volume: 650 milliliters (ml), respiratory rate of 14 breaths per minute and 100 % oxygen to be administered. The order failed to direct mode of ventilation ordered.

Respiratory Care Mechanical Flow sheet, dated 6/19/12 at 5:30 P.M., identified that Patient #23 was maintained on the assist control mode of ventilation, absent a physician's order.

A second physician order, dated 6/19/12 at 6:24 P.M., directed staff to adjust the ventilator setting as follows: Tidal Volume: 650 milliliters (ml), respiratory rate of 16 breaths per minute and 60 % oxygen to be administered. The order failed to direct mode of ventilation.

Respiratory Care Mechanical Flow sheet, dated 6/19/12 at 6:15 P.M., identified that Patient #23 was maintained on the assist control mode of ventilation, absent a physician's order.

e. Patient #23 had a physician's order, dated 6/19/12 at 8:30 P.M., that directed staff to carry out the ventilator setting as follows: Tidal Volume: 650 milliliters (ml), respiratory rate of 16 breaths per minute and 60 % oxygen to be administered. The physician's order lacked mode of ventilation.

Review of the Respiratory Care Mechanical Flow sheet, dated 6/19/12 at 7:10 P.M., identified that Patient #23 was maintained on the assist control mode of ventilation with TV of 650, respiratory rate of 16 breaths per minute and 60% oxygen administered.

A physician's order, dated 6/20/12 at 7:35 A.M., directed the following ventilator setting: Tidal Volume: 600 milliliters (ml), respiratory rate of 16 breaths per minute and 50 % oxygen to be administered. The order lacked mode of ventilation.

Review of the Respiratory Care Mechanical Flow sheet, from 6/20/12 at 7:30 A.M. through 6/21/12 at 7:50 A.M., identified that Patient #23 was maintained on assist control mode of ventilation, absent a physician's order.

f. Patient #23 was admitted to the Behavioral health Unit on 6/22/12 at 2:00 P.M. Review of the physician's order, dated 6/22/12 at 4:15 P.M., directed staff to use Continuous Positive Airway Pressure (CPAP) at hour of sleep. The order failed to direct the amount of pressure (at centimeters of water) to be administered. Review of the clinical record, from 6/23/12 at 12:00 Midnight to 6/25/12 at Midnight, identified that Patient #23 was placed on CPAP at hour of sleep with no documentation of the level of pressure that was delivered (in centimeters of water).

g. Patient #19 arrived, via ambulance at the Emergency Department (ED) on 6/16/12 at 3:44 P.M. after ingesting an unknown amount of the medications Klonopin, Latuda and Humulin insulin with a past medical history that included sleep apnea, bipolar disorder, schizoaffective disorder and Insulin Dependent Diabetes Mellitus. The patient was diagnosed with overdose and hyperglycemia and admitted to the Intensive Care Unit (ICU). On 6/18/12 at 5:00 P.M., Patient #19 was transferred to the Behavioral Health Care Unit. Review of the physician's order, dated 6/20/12 at 7:30 A.M., directed the staff to apply BiPAP 13/7. The order failed to direct the time of application, the mode of ventilation and/or the use of supplemental oxygen to be administered.

Review of the facility policy and procedure, titled Incomplete Respiratory Orders, identified that respiratory care and services are provided in accordance with physician orders and if the orders are not complete the physician is contacted.

The Procedure for Initiation of BiPAP S/T-D pressure Support Ventilation (NPSV) or Positive Pressure Ventilation (PPV), identified that the BiPAP settings, including the mode of ventilation, are in accordance with physician orders.

The policy titled, Mechanical Ventilation Guidelines, identified that the physician order for mechanical ventilation includes the tidal volume, the respiratory rate, oxygen percentage to be administered , positive end expiratory pressure (PEEP) and mode of ventilation.

On 6/26/12, the hospital provided the Department with an immediate action plan that addressed incomplete orders for invasive and non-invasive mechanical ventilation. The plan included review of selected respiratory policies and procedures, staff education and real time and retrospective audits. Review of the accepted action plan on 6/27/12, identified that the hospital carried out the plan as written.

15482

Based on observation, review of clinical records, interviews, review of facility policies, procedures and documentation the facility failed to ensure that fall risk signage was posted for one patient (#13) and/or that one patient (#24) received medications in accordance with the physician's order and/or that components of the cardiac rhythm monitoring strip was documented for four patients (#21, 23, 19, and 31) and/or that IV medication was titrated for one patient (#22) in accordance with orders and/or that a diagnostic test was completed for one patient (#23) in accordance with physician orders and/or that two patients (#19 and 39) were assessed when a change from baseline was identified and/or that vital signs were monitored for one patient (#27) in accordance with physician orders. The findings include:

a. Patient #13 arrived at the Emergency Department (ED) on 6/25/12 at 9:22 P.M. with the chief compliant of wanting to hurt him/herself with a past medical history of hypertension, alcohol and substance abuse and depression. Review of the triage assessment, on 6/25/12 at 9:33 P.M., identified that the patient was at risk to fall due to altered mobility. Review of the clinical record, at 9:41 P.M., reflected that a constant attendant was initiated on 6/25/12 at 9:42 P.M. for Patient #13's safety. The instruction sheet for the constant attendant identified that the patient was at risk to fall.
During a tour of the ED, on 6/26/12 from 9:15 A.M. to 11:07 A.M., no signage was posted on the patient's door that identfied the patient as a fall risk in accordance with hospital policy.
Interview and clinical record review with the ED Nursing Director and Patient Safety Technician #1, on 6/26/12 at 10:17 A.M., identified that Patient #13 was at risk to fall.
Prior to the conclusion of the ED tour, on 6/26/12 at 11:07 A.M., the ED Nursing Director of the ED directed staff to post signage at the doorway of Patient #13's room indicating that s/he was at risk to fall.
Review of the facility policy and procedure, titled Ruby Slipper Prevention Program, identified that for patients in the ED if the patient is at risk to fall, a sign will be affixed to the doorway indicating a fall risk and each patient will be reassessed post procedure and/or a significant change in condition.

b. Patient #24 arrived at the ED on 6/25/12 at 6:38 P.M. with the complaint of opiate dependence and requesting detoxification. Review of the physician orders, dated 6/25/12 at 7:26 P.M., directed the nursing staff to administer Tylenol 650 milligrams (mg) by mouth every four hours as needed for pain/discomfort and Bentyl 20 mg by mouth every four hours as needed for abdominal cramps. Review of the pre-printed Medication Administration Record identified that the nursing staff transcribed the identified orders as Tylenol 975 mg by mouth every four hours as needed for pain and discomfort and Bentyl 10 mg by mouth every four hours as needed for abdominal cramps. In addition, review of the clinical record identified that Patient #24 received three doses of medications that were not in accordance with the physician orders (two doses of Tylenol 975 mg on 6/25/12 at 7:45 P.M. and 6/26/12 at 7:45 A.M. and one dose of the Bentyl 10 mg on 6/25/12 at 7:45 P.M.)
Interview and review of the clinical record with the Nursing Director of the ED, on 6/26/12 at 10:40 A.M., identified that the identified physician orders for the medications Tylenol and Bentyl were not transcribed accurately onto the Medication Administration Record and the three medications administered were not in accordance with the physician orders.
The facility initiated, on 6/26/12, an immediate corrective action plan to address this issue, which included removal of the pre-printed Medication Administration Record for opiate withdrawal and education to the medical and nursing staff of the ED regarding the issue.

c. Patient #21 was admitted on 6/22/12 with respiratory failure with past medical conditions that included hypertension, coronary artery disease, status post cerebral vascular accident and transient ischemic attacks, Insulin Dependent Diabetes Mellitus and renal disease. Review of the clinical record identified that on 6/23/12 the patient was transferred to the Intensive Care unit (ICU) for acute respiratory failure. Review of the ICU cardiac rhythm monitoring strips, dated 6/25/12 and 6/26/12, failed to reflect that the nursing staff measured and/or documented the required components.

d. Patient #23 arrived via ambulance at the Emergency Department (ED) on 6/19/12 at 2:10 P.M. after ingesting an unknown amount of the medication Seroquel with a past medical history that included COPD and sleep apnea. Review of the ED record reflected that the patient was intubated at 5:15 P.M., placed on mechanical ventilation, and admitted to the ICU. Review of the ICU cardiac rhythm monitoring strips, dated 6/21/12 and 6/22/12, failed to reflect that the nursing staff measured and/or documented the required components.

e. Patient #19 arrived, via ambulance at the ED on 6/16/12 at 3:44 P.M. after ingesting an unknown amount of the medications Klonopin, Latuda and Humulin insulin with a past medical history that included sleep apnea, bipolar disorder, schizoaffective disorder and Insulin Dependent Diabetes Mellitus. The patient was diagnosed with overdose and hyperglycemia and admitted to the ICU. Review of the ICU cardiac rhythm monitoring strips, dated 6/16/12, 6/17/12 and 6/18/12, failed to reflect that the nursing staff measured and/or documented the required components.

f. Patient #31 arrived, via ambulance, at the ED on 5/29/12 at 4:09 P.M. after ingesting known amounts of the medications Propranolol and Vistaril with a past medical history that included bipolar disorder and multiple suicide attempts. The patient was diagnosed with overdose, hypotension and cardiac arrhythmia and was admitted to the ICU. Review of the ICU cardiac rhythm monitoring strips, dated 5/30/12 and 5/31/12, failed to reflect that the nursing staff measured and/or documented the required components.

Review of the facility policy and procedure, titled Telemetry: ICU Responsibilities identified that the ICU nurse measures the PR interval, QRS interval and heart rate and records that information.

g. Patient #22 was admitted on 6/24/12 with pneumonia and on 6/26/12 at 8:00 A.M. he/she required intubation for invasive mechanical ventilation. Review of the physician order, dated 6/25/12 at 8:30 A.M., directed the nursing staff to administer Propofol via infusion at a rate of 20 micrograms per kilogram per minute (mcg/kg/min) and titrate the medication infusion to achieve the Riker sedation-agitation score of 3. Review of the ICU flow sheet, dated 6/26/12, identified that the Propofol was started at 20 mcg/kg/min at 8:28 A.M. and at 9:00 A.M., 10:00 A.M. and 11:00 A.M. the patient's Riker sedation-agitation score was 4. Nursing staff failed to titrate the Propofol in accordance with the physician order. Interview and chart review with RN #4, on 6/26/12 at 12:00 Noon, identified that although Patient #22's Riker score was 4 from 9:00 A.M. to 11:00 A.M. he/she did not titrate the Propofol and/or contact the physician.

Review of the facility policy and procedure, titled Prescribing/Ordering General Practices, identified that medications are administered according to licensed medical independent practitioner orders.

h. Patient #23 arrived via ambulance at the Emergency Department (ED) on 6/19/12 at 2:10 P.M. after ingesting an unknown amount of the medication Seroquel. The patient was intubated at 5:15 P.M., placed on mechanical ventilation, and admitted to the ICU. Review of the physician orders, dated 6/22/12 at 4:15 P.M., directed staff to complete an Electrocardiogram (EKG). Review of the clinical record and interview with the Nurse Director of the Behavioral Health Care Unit, on 6/27/12 at 9:55 A.M., identified that although the Unit Secretary requested that the EKG be completed on 6/23/12 at 12:45 P.M., the record lacked documentation that the test was completed. Interview with Cardiology Technician #1 and tour of the area, on 6/27/12 at 10:46 A.M., identified that there was no EKG completed for Patient #23.

i. Patient #19 arrived, via ambulance at the Emergency Department (ED) on 6/16/12 at 3:44 P.M. after ingesting an unknown amount of the medications Klonopin, Latuda and Humulin insulin with a past medical history that included sleep apnea. The patient was diagnosed with overdose and hyperglycemia and admitted to the Intensive Care Unit (ICU). On 6/18/12 at 5:00 P.M. Patient #19 was transferred to the Behavioral Health Care Unit. Review of the nursing progress notes, dated 6/19/12 at 5:00 A.M., identified that the patient had frequent periods of apnea although the record failed to reflect that the Registered Nurse assessed Patient #19's respiratory status and/or informed the physician/provider of this change in condition. Interview and review of the clinical record with the Nurse Director of the Behavioral Health Care Unit, on 6/27/12 at 10:30 A.M., identified that documentation failed to reflect assessments and/or physician notification of the change in status.

In addition, a physician's order, dated 6/20/12 at 7:30 A.M., that directed staff to apply BiPAP 13/7. The order failed to contain the time of application and/or the mode of ventilation and/or the use of supplemental oxygen to be administered. Nursing failed to contact the physician for clarification of the orders. Review of the respiratory progress note, dated 6/20/12 at 11:00 P.M., identified that the patient refused to wear the BiPAP. Neither the RT or the RN notified the physician of the patient's refusal.

j. Patient #39 underwent a left carpal tunnel and left trigger finger release on 6/26/12. During surgery, the patient received Toradol 30 mg for pain and nasal oxygen at 5 liters/min. Upon release to the PACU at 12:36 PM, the patient's oxygen saturation (O2 sat) was 95% (prior to surgery the patients baseline oxygen sat was 97%). Upon entry to the PACU the patient was scored at a "2" on the modified Aldrete Scale for respiratory status. A score of "2" indicates the patient is breathing room air with an O2 sat at pre-op level or >95%. At 12:44 PM, the patient's O2 sat was 93%; at 12:50 PM the O2 sat was 92%; at 12:55 PM, the O2 sat was 91%; and upon discharge, at 1:03 PM, the patient's O2 sat was 92%. Nursing assessments erroneously identified the patient's Aldrete score to consistently be "2" (O2 sat greater than 95% on room air). Although the patient's O2 saturations decreased, the clinical record failed to reflect that the patient was assessed and/or that the physician was notified of the O2 saturations below baseline prior to discharge. Review of the hospital policy for discharge of ambulatory patients directs that patients who have received anesthesia services must be seen by an MD and score a "2" with no respiratory distress prior to discharge.

k. Patient #27 was admitted on 6/23/12 in labor, and was started on Pitocin at 9:47 PM. Review of the clinical record indicated that the Pitocin was stopped at 9:57 PM and restarted at 10:13 PM. The patient was on Pitocin for the period of 10:13 PM through 2:09 AM on 6/24/12 for a total time of approximately four hours. Review of the clinical record with the Manager indicated that vital signs were obtained at 10:58 PM and 1:03 AM. Review of the policy indicated that vital signs should be completed every thirty minutes to one hour.





19826

Based on review of clinical records, interviews and review of facility policy, the hospital failed to ensure that three patients (#30, 31 and 27) had a comprehensive careplan to address the individual needs of the patient. The findings include the following:

a. Patient #30 was admitted on 6/22/12 with alcohol abuse and depression. The physician's orders dated 6/22/12 directed every fifteen-minute checks for twenty four hours. Review of the treatment plan dated 6/22/12 identified that the patient had active problems that included depression, alcohol abuse and fall risk. The pre-printed treatment plan failed to be individualized to reflect the actual groups the patient should attend to achieve the desired outcomes and/or observational status.

b. Patient #31 was admitted on 6/22/12 with attempted overdose and Bipolar disorder. The orders dated 6/22/12 directed every fifteen- minute checks. Review of the treatment plan dated 6/22/12 identified that the patient had active problems that included depression, potential for self injury and suicidal ideation. The pre-printed treatment plan failed to be individualized to reflect groups the patient should attend and/or observational status. The plan lacked desired outcomes with specific interventions to achieve these outcomes.
Review of the policy and procedure, titled Individualized Multidisciplinary Treatment Plan, is developed for the members of the health care team to communicate, collaborate and develop a therapeutic plan of care for the patient, including the problem and methods to achieve identified short term and long term goals.

c. Patient #27 was admitted on 6/23/12 in labor. The clinical record indicated that the patient had a stillborn birth via caesarian section. Review of the care plan dated 6/24/12 identified the patients active problems included "Alteration in family/baby bonding" and "Infection". The interventions identified in part, assist patient with initial care of the newborn, monitor parent baby bonding, instruct on perineum care and apply ice and topicals to the perineum care. The facility failed to ensure that an individualized comprehensive care had been completed for Patient #27. Interview with the Manger on 6/26/12 at 12:00 PM indicated that interventions should be based on the needs of the patient.

Based on observation and interview, the hospital failed to ensure that the records for scheduled drugs (specifically Fentanyl) documented the strength of the drug received. The finding includes:

a. During tour of the Ambulatory Surgery Center on 6/27/12, review of the scheduled drug receipt documentation identified that for the drug Fentanyl, the strength (mcg/ml) failed to be identified on the receipt information. During interview at approximately 2:45 AM on 6/26/12, the Manager of Peri-operative Services stated that she had not realized the strength was missing from the documentation.

Based on a tour of the inpatient psychiatric unit with the hospital administrative and engineering staff and review of hospital documentation, the hospital failed to ensure that the physical environment was designed and constructed to maintain the safety of patients with suicidal tendencies and/or tendencies to cause harm to themselves or others. The finding includes:



The hospital had an environmental risk assessment completed in January 2010 and failed to implement immediate safety interventions to correct the environmental safety issues in all rooms. During tour, the following was observed:
a. The inpatient psychiatric unit had electric adjustable beds with cords that were zip tied, however, the cords were not shortened to prevent a hanging.
b. The grab rails, faucet and shower controls, sprinkler heads, door handles, under sink piping, lighting ventilation diffusers, electrical receptacles and door hinges throughout the unit posed a potential hanging hazard and were not designed to a psychiatric/ institutional standard.
c. The psychiatric unit had numerous rooms that lacked institutional hardware. There was no documented risk based assessment or policy for use of these areas.

The facility failed to meet the provisions of the Life Safety Code of the National Fire Protection Association (NFPA 101, 2000 edition) that are applicable to Health Care Occupancies. These findings are based on tour and observation of facility, review of policy procedures and maintenance logs and interview of facility personnel.

Please refer to form CMS-2786R Tags K029, K046, K050, K052, K051, K054, K062, K067, K069, K077, K104, and K130.

Based on tour and interview the facility failed to ensure that the facility was maintained to ensure an acceptable level of safety and quality. The finding includes the following:


a. Tour of the Radiology Department on 6/27/12 at 1:15 PM identified that the floor outside the CT scan was taped. The floor had numerous cracks and was being held in place with the use of "duck" tape. Interview with the Director indicated that they are aware the area needs to be replaced.

Based on observation, interview and review of hospital policy, the hospital failed to ensure that environmental conditions and/or practices were conducive to maintaining infection control standards. The findings include:

a. During tour of the Operating Suite on 6/26/12 with the Manager of Perioperative Services, OR #1 was observed to have tile walls that had been painted and were presently abraded and peeling at the contact points of equipment stored on the perimeter of the room. During interview on 6/26/12 at 10:15 AM, the Manager stated that although all the operating rooms were flaking and peeling, OR #1 was the worst and efforts were made to diminish the use of the room.

b. The substerile room located between OR #1 and OR #2 contained cabinets that were delaminated making disinfecting/cleaning of the area impossible with bare wood exposed.

c. Armboards, armrests on vinyl covered chairs and a hand table located in storage were observed to have cracked vinyl coverings and/or bare wood worn and exposed. During tour the Manager stated that such items would be removed from the OR environment.

d. OR #2's recessed wall area located beneath the wall suction containers was observed to be utilized as storage for supplies from case to case.

e. Observation of total joint replacement surgery in OR #3 at approximately 10:45 AM on 6/26/12 identified that the physician's assistant and surgeon failed to have entire coverage of the hair at the sides and back of the head as they worked over the surgical incision. According to AORN Standards 2010, all hair at the back and sides of the head should be covered in its entirety when in the restricted environment of the OR.

Review of the hospital policy for environmental cleaning directed that terminal cleaning of the surgical procedure rooms, scrub/utility rooms, endoscopy rooms and patient pre and post assessment rooms should be terminally cleaned daily.

Based on a review of the clinical record, interview and policy review, the anesthesia record failed to record the dose of medication (specifically propofol and Fentanyl) administered to one patient (#34) during invasive procedures. The finding includes:

a. Patient #34 underwent a laparoscopic cholecystectomy on 6/25/12. Review of the anesthesia record identified that 30 cc of Propofol and 4 cc of Fentanyl were administered during surgery, however, the record lacked the total dosage administered since the strength of the drug was unknown (unrecorded). Review of the anesthesia record format directed the administration of Propofol and Fentanyl to be recorded in "cc" rather than "mg". Review of anesthesia policies failed to reflect a documentation policy for administration of medications. During interview on 6/26/12 at approximately 11:30 AM with a staff anesthesiologist identified that the anesthesia record in the hospital had always recorded the amount of drug rather than the dose of the drug administered.

Based on a review of the clinical record and policy review, for one patient (#34) the clinical record failed to reflect documented evidence that a post anesthesia evaluation was completed before the patient was discharged. The finding includes:

a. Review of the clinical record on 6/26/12 identified that Patient #34 underwent a laparoscopic cholecystectomy on 6/25/12. The anesthesia record identified that the surgery ended at 11:40 AM and the patient was transferred to PACU at 11:46 AM until 12:50 PM when the patient was transferred to phase II. Review of the clinical record failed to reflect that the post anesthesia evaluation was completed prior to the discharge of the patient. Review of anesthesia policy for post anesthesia evaluation reflected that an evaluation should be completed prior to the patient's discharge.

Based on a review of clinical records, observations, interviews, review of policies, procedures, and hospital documentation, the hospital failed to ensure that four patients (#21, 23, 44, and 45) were assessed prior to and/or following a nebulizer treatment, and/or that two patients (#46 and 47) had physician orders for bronchodilator medication during pulmonary testing, and/or that oxygen was administered to one patient (#25) in accordance with provider orders and/or that the physician was notified when one patient (#19) refused treatment and/or four of eight patients (Patients # 21, 22, 23, and 19) had complete orders for invasive and/or non-invasive ventilation and/or that Respiratory Therapy staff contacted the physician for clarification of incomplete orders prior to implementing care.

Please refer to A1160 and 1163.

19826

Based on observation, review of clinical records, interviews, review of facility policies, procedures, and facility documentation, the hospital failed to ensure that four patients (#21, 23, 44, and 45) were assessed prior to and/or following a nebulizer treatment, and/or that two patients (#46 and 47) had physician orders for bronchodilator medication during pulmonary testing, and/or that oxygen was administered for one patient (#25) in accordance with provider orders and/or that the physician was notified when one patient (#19) refused treatment. The findings include:

a. Patient #21 was admitted on 6/22/12 with respiratory failure and on 6/23/12 was transferred to the Intensive Care Unit (ICU). A physician's order, dated 6/23/12 at 9:35 A.M. directed respiratory therapy staff to administer Xopenex 1.25 milligrams (mg) via small volume nebulizer every four hours. Review of the Respiratory Care Flow sheet, from 6/23/12 at 4:45 P.M. to 6/26/12 at 11:00 A.M., identfied that ten of the sixteen entries failed to reflect that an assessment of the patient's condition before and/or after administration of the medication (including pulse rate, results/complications/how handled and/or breath sounds) was documented.

b. Patient #23 arrived via ambulance at the Emergency Department (ED) on 6/19/12 at 2:10 P.M. after ingesting an unknown amount of the medication Seroquel with a past medical history that included COPD and sleep apnea. Review of the ED clinical record, reflected that the patient was intubated and placed on a ventilator. A physician's order, dated 6/21/12 at 7:00 A.M. directed respiratory therapy staff to administer Duoneb every two hours for four doses then every four hours while awake. Review of the Respiratory Care Flow sheet, from 6/21/12 at 8:00 A.M. to 6/22/12 at 8:30 A.M., identfied that five of six entries failed to reflect an assessment of the patient's condition before and/or after administration of the medication.

c. Patient #44 was admitted on 6/25/12 with the diagnoses of pneumonia and COPD. Review of the Respiratory Care Flow sheet, from 6/25/12 at 11:15 P.M. to 6/26/12 at 1:00 P.M., identified that two of three entries failed to reflect an assessment of the patient's condition after administration of medication.

d. Patient #45 was admitted on 6/25/12 with the diagnosis of pneumonia. Review of the Respiratory Care Flow sheet, from 6/26/12 at 11:00 A.M. to 6/27/12 at 11:10 A.M., identified three of six entries failed to reflect documentation of an assessment of the patient's condition before and/or after administration of medication.

Interview with the Respiratory Therapy Supervisor, on 6/27/12 at 1:00P.M., identified that the respiratory therapist completes an assessment of the patient before and after medication administration including pulse rate and/or breath sounds.

Review of the policy and procedure, titled Charting of Respiratory therapy Notes, identified that after administration of a treatment/medication the respiratory therapist documents the patient's pulse rate, breath sounds, and results/complications of the treatment.

e. Patient #46 was admitted on 6/19/12 for a Pulmonary Function Test (PFT). Review of the clinical record directed that a PFT be completed.

f. Patient #47 was admitted on 6/20/12 for a Pulmonary Function Test (PFT). Review of the clinical record directed that a PFT be completed.

During a tour of the Respiratory Department, on 6/27/12 from 1:00 P.M. to 2:30 P.M., with the Respiratory Therapy Supervisor and the Director of Accreditation and Regulatory Affairs it was identified that the Respiratory Therapy Supervisor performs the PFTs and during the testing he/she administers a bronchodilator medication absent of physician/provider order.

Review of the facility policy and procedure, titled Pulmonary Function Test, failed to reflect any protocol that medication may be administered during this testing.

Review of the facility policy and procedure, titled Incomplete Respiratory Orders, identified that respiratory care and services are provided in accordance with physician orders and if the orders are not complete the physician is contacted.

g. Patient #25 was admitted to the facility on 6/23/12 with right lower pnuemonia. The physicians order dated 6/23/12 directed Oxygen 2 liters while sleeping. The order dated 6/26/12 directed to titrate the Oxygen to a saturation (O2 sat) greater than 94%. Review of flow sheets dated 6/25/12 identified that the patent had a O2 sat of 95% on room air. The flow sheet dated 6/26/12 identified that the patient had a O2 sat of 96% on 4 liters at 7:45 AM, then 95% at 3:50 PM, absent of an assessment that determined the patient required 4 liters of oxygen and/or a physician's order.

Review of the policy indicated that the Oxygen flow rate should be titrated up or down at one liter increments and that if 4 liters is reached humidification should be added. The policy also indicated that after each adjustment is made a saturation should be rechecked after thirty minutes.

h. Patient #19 arrived, via ambulance at the Emergency Department (ED) on 6/16/12 at 3:44 P.M. after ingesting an unknown amount of the medications Klonopin, Latuda and Humulin insulin with a past medical history that included sleep apnea, bipolar disorder, schizoaffective disorder and Insulin Dependent Diabetes Mellitus. The patient was diagnosed with overdose and hyperglycemia and admitted to the Intensive Care Unit (ICU). On 6/18/12 at 5:00 P.M. Patient #19 was transferred to the Behavioral Health Care Unit. Review of the physician orders, dated 6/20/12 at 7:30 A.M., directed the staff to apply BiPAP 13/7. The order failed to direct the time of application, the mode of ventilation and/or the use of supplemental oxygen to be administered.
In addition, review of the respiratory progress note, dated 6/20/12 at 11:00 P.M., identified that the patient refused to wear the BiPAP. The record failed to reflect that the respiratory therapist notified the physician of the patient's refusal for treatment.

Interview with the Respiratory Therapy Supervisor, on 6/26/12 at 1:25 P.M., identified that the physician must order the mode of ventilation for BiPAP.

Review of the facility policy and procedure, titled Incomplete Respiratory Orders, identified that respiratory care and services are provided in accordance with physician orders and if the orders are not complete the physician is contacted.

The Procedure for Initiation of BiPAP S/T-D pressure Support Ventilation (NPSV) or Positive Pressure Ventilation (PPV), identified that the BiPAP settings, including the mode of ventilation, are in accordance with physician orders.

The policy titled, CPAP/BiPAP Patient Use, identified that the physician may order the pressure to be delivered and/or order the default settings (10 centimeters of water).

Review of the job description for a Respiratory Therapist, identified that the therapist provides respiratory care and services as specified by the physician.

Based on observation, review of clinical records, interviews, review of facility policies, procedures, and facility documentation for four of eight patients that required respiratory care and services (Patients # 21, 22, 23, and 19) the hospital failed to ensure that physician/provider orders for invasive and/or non-invasive ventilation included all elements of a physician's order and/or that Respiratory Therapy staff contacted the physician for clarification of incomplete orders prior to implementing care. The findings include the following:

a. Patient #21 was admitted on 6/22/12 with respiratory failure and on 6/23/12 was transferred to the Intensive Care Unit (ICU). Review of the physician orders, dated 6/23/12 at 8:25 A.M. and 3:36 P.M., 6/24/12 at 9:30 A.M. and 6/26/12 at 9:05 A.M., directed staff to place the patient on BiPAP (non-invasive mechanical ventilation) with the following parameters: Inspiratory Positive Airway Pressure (IPAP) of 14 centimeters (cm) of water and Expiratory Positive Airway Pressure (EPAP) of 5 cm of water with supplemental oxygen of 6 Liters (L) per minute. The order failed to specify mode for the BiPAP.

Review of the Respiratory BiPAP Flow sheets, dated from 6/23/12 at 9:30 A.M. to 6/26/12 at 11:00 A.M., identified that the respiratory therapist placed the patient in a spontaneous timed mode with the backup respiratory rate of 14 breaths per minute, absent of a physician's order.

Interview with Respiratory Therapist #1, on 6/26/12 at 11:44 A.M., identified that the physician orders did not include the mode of ventilation and/or the backup respiratory rate. Interview with the Respiratory Therapy Supervisor, on 6/26/12 at 1:25 P.M., identified that the physician must order the mode of ventilation for BiPAP.

b. Patient #21 had a physician order, dated 6/23/12 at 5:30 P.M., that directed respiratory therapy staff to administer Xopenex 1.25 milligrams (mg) via small volume nebulizer every two hours as needed, however, the order failed to specify the indication for this medication. Interview with Respiratory Therapist #1, on 6/26/12 at 11:44 A.M., identified that the order failed to contain the indication for the medication.

Review of the policy titled, Prescribing/Ordering General Practices, identified that orders for as needed medications must specify the indication for use.


c. Patient #22 was admitted on 6/24/12 with pneumonia and on 6/26/12 at 8:05 A.M. s/he required intubation for invasive mechanical ventilation. Review of the physician order, dated 6/26/12 at 8:00 A.M., directed staff to place the patient on the ventilator with the following settings: Tidal Volume: 450 milliliters (ml), respiratory rate of 16 breaths per minute and 100 % oxygen to be administered. the physician's order failed to direct mode of ventilation.

Review of the Respiratory Care Mechanical Flow sheet, dated 6/26/12 from 8:05 A.M. to 12:00 Noon identified that Patient #22 was maintained on the assist control mode of ventilation. Interview with the Respiratory Therapy Supervisor and observation of the ventilator for Patient #22, on 6/26/12 at 1:35 P.M., identified that the mode of ventilation was assist control although there were no physician orders for the mode of ventilation.

d. Patient #23 arrived via ambulance at the Emergency Department (ED) on 6/19/12 at 2:10 P.M. after ingesting an unknown amount of the medication Seroquel with a past medical history that included COPD and sleep apnea. Review of the ED clinical record, reflected that the patient was intubated at 5:15 P.M. with a physician's order, dated 6/19/12 at 6:08 P.M., that directed staff to place the patient on the ventilator with the following settings: Tidal Volume: 650 milliliters (ml), respiratory rate of 14 breaths per minute and 100 % oxygen to be administered. The order failed to direct mode of ventilation ordered.

Respiratory Care Mechanical Flow sheet, dated 6/19/12 at 5:30 P.M., identified that Patient #23 was maintained on the assist control mode of ventilation, absent a physician's order.

A second physician order, dated 6/19/12 at 6:24 P.M., directed staff to adjust the ventilator setting as follows: Tidal Volume: 650 milliliters (ml), respiratory rate of 16 breaths per minute and 60 % oxygen to be administered. The order failed to direct mode of ventilation.

Respiratory Care Mechanical Flow sheet, dated 6/19/12 at 6:15 P.M., identified that Patient #23 was maintained on the assist control mode of ventilation, absent a physician's order.

e. Patient #23 had a physician's order, dated 6/19/12 at 8:30 P.M., that directed staff to carry out the ventilator setting as follows: Tidal Volume: 650 milliliters (ml), respiratory rate of 16 breaths per minute and 60 % oxygen to be administered. The physician's order lacked mode of ventilation.

Review of the Respiratory Care Mechanical Flow sheet, dated 6/19/12 at 7:10 P.M., identified that Patient #23 was maintained on the assist control mode of ventilation with TV of 650, respiratory rate of 16 breaths per minute and 60% oxygen administered.

A physician order, dated 6/20/12 at 7:35 A.M., directed the following ventilator setting: Tidal Volume: 600 milliliters (ml), respiratory rate of 16 breaths per minute and 50 % oxygen to be administered. The order lacked mode of ventilation.

Review of the Respiratory Care Mechanical Flow sheet, from 6/20/12 at 7:30 A.M. through 6/21/12 at 7:50 A.M., identified that Patient #23 was maintained on assist control mode of ventilation, absent a physician's order.

f. Patient #23 was admitted to the Behavioral health Unit on 6/22/12 at 2:00 P.M. Review of the physician orders, dated 6/22/12 at 4:15 P.M., directed the staff to use Continuous Positive Airway Pressure (CPAP) at hour of sleep. The order failed to direct the amount of pressure (at centimeters of water) to be administered. Review of the clinical record, from 6/23/12 at 12:00 Midnight to 6/25/12 at Midnight, identified that Patient #23 was placed on CPAP at hour of sleep with no documentation of the level of pressure that was delivered (in centimeters of water).

g. Patient #19 arrived, via ambulance at the Emergency Department (ED) on 6/16/12 at 3:44 P.M. after ingesting an unknown amount of the medications Klonopin, Latuda and Humulin insulin with a past medical history that included sleep apnea, bipolar disorder, schizoaffective disorder and Insulin Dependent Diabetes Mellitus. The patient was diagnosed with overdose and hyperglycemia and admitted to the Intensive Care Unit (ICU). On 6/18/12 at 5:00 P.M. Patient #19 was transferred to the Behavioral Health Care Unit. Review of the physician orders, dated 6/20/12 at 7:30 A.M., directed the staff to apply BiPAP 13/7. The order failed to direct the time of application, the mode of ventilation and/or the use of supplemental oxygen to be administered.
In addition, review of the respiratory progress note, dated 6/20/12 at 11:00 P.M., identified that the patient refused to wear the BiPAP and documentation failed to reflect that the respiratory therapist notified that physician.

Interview with the Respiratory Therapy Supervisor, on 6/26/12 at 1:25 P.M., identified that the physician must order the mode of ventilation for BiPAP.

Review of the facility policy and procedure, titled Incomplete Respiratory Orders, identified that respiratory care and services are provided in accordance with physician orders and if the orders are not complete the physician is contacted.

The Procedure for Initiation of BiPAP S/T-D pressure Support Ventilation (NPSV) or Positive Pressure Ventilation (PPV), identified that the BiPAP settings, including the mode of ventilation, are in accordance with physician orders.

The policy titled, Mechanical Ventilation Guidelines, identified that the physician order for mechanical ventilation includes the tidal volume, the respiratory rate, oxygen percentage to be administered , positive end expiratory pressure (PEEP) and mode of ventilation.

The policy titled, CPAP/BiPAP Patient Use, identified that the physician may order the pressure to be delivered and/or order the default settings (10 centimeters of water).

Review of the job description for a Respiratory Therapist, identified that the therapist provides respiratory care and services as specified by the physician.

On 6/26/12, the hospital provided the Department with an immediate action plan that addressed incomplete orders for invasive and non-invasive mechanical ventilation. The plan included review of selected respiratory policies and procedures, staff education and real time and retrospective audits. Review of the accepted action plan on 6/27/12, identified that the hospital carried out the plan as written.