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Based on staff and family interview, medical record review, and review of MSDS (Material Safety Data Sheets), the hospital failed to ensure 1 of 3 sample patients (#3) with diagnosis of acute respiratory illness was not unnecessarily exposed to the fumes of potentially hazardous materials. The findings were:

Review of the medical record for patient #3 showed s/he presented to the emergency department (ED) on 4/14/13 with complaints of dyspnea and increasing oxygen requirements. The patient had a progressive three day history of worsening chest tightness, cough and dyspnea. The patient was utilizing 4 liters of oxygen at home which was higher than his/her normal baseline oxygen of 1.5 to 2 liters. Review of the laboratory reports showed the patient had an elevated white blood count of 19.5 (normal is 5 to 10) upon admission. According to Mosby's Manual of Diagnostic and Laboratory Tests, Pagana-Pagana, eleventh edition, 2013, "An increased total WBC [white blood cell} count usually indicates infection, inflammation...". The patient was admitted to the hospital on 4/14/13 at 8:52 PM with diagnoses including obstructive chronic bronchitis with acute exacerbation. The following concerns were identified with the lack of ensuring proper ventilation during utilization of a potentially hazardous outdoor insecticide in the patient's room:
a. Review of the patient progress notes dated 4/16/13 and timed at 10:31 AM showed the patient noticed ants in his/her patient room. Further review of this note showed maintenance was notified. Interview with the director of maintenance on 7/25/13 at 3 PM revealed maintenance staff member #1 stated he had sprayed the interior of the patient's room with "Ortho Home Defense MAX Outdoor Perimeter Insect Killer Ready Spray" to exterminate the ants. Maintenance staff #1 stated, at 3 PM on 7/25/13, that he sprayed the baseboard of the patient's room. He further stated the patient remained in the room but was on the opposite side of where the Ortho was sprayed. Interview with the patient's family on 7/25/13 at 2:20 PM revealed they expressed their concerns about spraying chemicals because the patient was suffering from severe lung problems. The family member further stated the maintenance staff told them it was "perfectly safe" and proceeded to spray the room while the patient lay in bed. Review of the Material Safety Data Sheet (MSDS) sheet provided by the facility showed potential health effects included inhalation "...May cause irritation of respiratory tract....Inhalation may aggravate asthma".
b. According to http://www.healthline.com/health-slideshow/avoiding-copd-triggers" accessed on 8/7/13, "Whether it's indoors or outside, air pollution can irritate the lungs and cause COPD symptoms to suddenly arise....chemicals from cleaning products, paint, or textiles can cause flare-ups indoors".
c. Review of the patient's medical record showed s/he was discharged from the hospital on the following day (4/17/13 at 1:30 PM), approximately 24 hours after the room was sprayed. Interview with a family member on 7/25/13 at 2:20 PM revealed the patient became increasingly sick with severe shortness of breath within 3 or 4 hours after discharge and feared the chemical sprayed had aggravated the patient's condition. Continued interview revealed the patient was so sick s/he was transported from home to the ED of another hospital in a different location at approximately 3 AM on 4/18/13. Review of the ED report from the second hospital showed upon arrival in that ED the patient's oxygen saturation rate was 80% (greater than 88% is normal) even with 5 liters of oxygen via nasal cannula. In addition, the report showed the patient was short of breath, wheezing, coughing and complained of chest tightness. The patient was admitted to the intensive care unit with an acute chronic obstructive pulmonary disease exacerbation and his/her prognosis was guarded. The patient required an additional 7 days of hospitalization with discharge on 4/24/13.

Based on staff interview and medical record review, the facility failed to ensure all necessary assessments, monitoring, and nursing measures were implemented for effective and consistent pain management for 1 of 1 sample patient (#1) who had pain. In addition, the facility failed to clarify the parameters of fluid restriction physician orders for 2 of 2 sample patients (#2, #4). The findings were:

1. Review of the medical record for patient #1 showed s/he was admitted to the hospital on 7/23/13 with a diagnosis of hip pain post fall. Review of the July 2013 physician's orders showed an order for Hydrocodone/Acetaminophen 7.5 mg/325 mg, 1 tablet every 4 hours as needed for pain. The following concerns with pain management were identified:
a. Review of the medical record showed no evidence the hospital had performed a comprehensive pain assessment upon admission to determine the patient's acceptable pain level.
b. Review of the July 2013 MAR showed the patient received pain medication on 7/23/13 at 6:34 PM without evidence the patient's pain was assessed as to severity, location, type of pain, duration, aggravating factors, alleviating factors, and response to medications and treatment directed toward the relief and management of pain.
c. Review of the July 2013 MAR showed the patient received pain medication on 7/23/13 at 6:34 PM. Review of the 7/23/13 progress notes timed at 9 PM, 2 1/2 hours later, showed the patient's pain level was 6 on a scale of 1 to 10 with 10 being the worst (6/10). Review of the progress notes timed at 10:42 PM showed the patient's pain remained at 6/10; 4 hours and 8 minutes after the patient was medicated for pain. Review of the medical record showed no evidence non-pharmacological interventions were attempted to alleviate the patient's pain.
d. Review of the July 2013 MAR showed the patient had pain in both hips on 7/24/13 and was administered a pain pill at 1:05 PM. Further review showed the patient was administered another pain pill at 4:59 PM on that same day. Again, review revealed no evidence a comprehensive pain assessment was performed as to severity, type of pain, duration, and aggravating factors.
e. Review of the 7/25/13 timed at 9:10 AM progress notes showed the patient had a pain intensity of 8/10. At that time, it was too soon for the patient to receive another pain pill but s/he did receive one at 10:15 AM. However, review of the progress notes showed no evidence a re-assessment was performed to determine the effectiveness of the pain medication in relieving the patient's pain level of 8/10 which s/he had complained of since 9:10 AM, 1 hour and 5 minutes earlier.
f. Interview with the DON on 7/26/13 at 3:30 PM verified there was no evidence a comprehensive pain assessment was performed; however one should have been done. She further verified a re-assessment of pain should be performed to determine the effectiveness of interventions but was not done in this case.

2. Review of the emergency room physician notes for patient #2 showed s/he was brought to the emergency department (ED) on 6/28/13 by ambulance with the feeling of nausea, intermittent vomiting and a feeling of dysphoria. The patient stated s/he had not been feeling well for several days. While in the ED the patient was intermittently confused. The ED physician determined the patient had acute renal insufficiency of an unknown etiology and admitted him/her to the hospital. The physician's plan was to further evaluate the patient's condition, restrict his/her fluids, hold his/her medication and monitor the blood pressure to see if the renal function returned to normal. Review of the physician's orders and the entire medical record showed no parameters were established for the fluid restriction. Interview with the DON on 7/26/13 at 3:30 PM verified no parameters of fluid restriction were established and nursing should have requested clarification from the physician.

3. Review of the emergency room physician notes for patient #4 showed s/he was brought to the hospital ED via ambulance because s/he was lethargic, somewhat confused, and "unresponsive". The patient was admitted to the hospital for observation. Review of the admission history and physical showed the patient would receive a small amount of normal saline and have his/her fluids restricted in hopes of correcting his/her hypo-natremia (low sodium). However, review of the physician's orders and the entire medical record showed no parameters for the fluid restriction. Interview with the DON on 7/26/13 at 3:30 PM verified no parameters of fluid restriction were established and nursing should have requested clarification from the physician.

Based on staff interview and medical record review, the facility failed to ensure individualized comprehensive care plans were developed in a variety of areas for 5 of 5 sample patients (#1, #2, #3, #4, #5). The findings were:

1. Review of the medical record for patient #1 showed s/he was admitted to the hospital on 7/23/13 with a diagnosis of hip pain post fall. Review of the patient's problem list showed pain, skin integrity with potential impairment, falls and discharge planning were identified as care planning issues. Continued review showed goals were established in regard to these identified problems. However, review of the medical record showed no evidence a comprehensive care plan to include interventions and approaches was developed or implemented. Interview with the director of nursing on 7/26/13 at 3:30 PM verified she was unable to locate interventions and approaches for staff to follow to address the identified problems in order to meet the patient's goals.

2. Review of the emergency room physician notes for patient #2 showed s/he was brought to the ED on 6/28/13 by ambulance with the feeling of nausea, intermittent vomiting and a feeling of dysphoria. The patient stated s/he had not been feeling well for several days. While in the ED the patient was intermittently confused. The ED physician determined the patient had acute renal insufficiency of an unknown etiology and admitted him/her to the hospital. The physician's plan was to further evaluate the patient's condition, restrict his/her fluids, hold his/her medication and monitor the blood pressure to see if the renal function returned to normal. Review of the patient's problem list showed body temperature, and impaired gas exchange were identified as care planning issues. Continued review showed goals were established in regard to these identified problems. However, review of the medical record showed no evidence a comprehensive care plan to include interventions and approaches was developed or implemented. Interview with the director of nursing on 7/26/13 at 3:30 PM verified she was unable to locate interventions and approaches for staff to follow to address the identified problems in order to meet the patient's goals.

3. Review of the medical record for patient #3 showed s/he presented to the emergency department (ED) on 4/14/13 with complaints of dyspnea and increasing oxygen requirements. The patient had a progressive three day history of worsening chest tightness, cough and dyspnea. The patient was utilizing 4 liters of oxygen at home which was higher than his/her normal baseline oxygen of 1.5 to 2 liters. Review of the laboratory reports showed the patient had an elevated white blood count of 19.5 (normal is 5 to 10) upon admission. According to Mosby's Manual of Diagnostic and laboratory Tests, Pagana-Pagana, eleventh edition, 2013, "An increased total WBC [white blood cell} count usually indicates infection, inflammation...". The patient was admitted to the hospital on 4/14/13 at 8:52 PM with diagnoses including obstructive chronic bronchitis with acute exacerbation. The following concerns were identified:
a. Review of the medical record showed 3 problems were identified including impaired gas exchange, activity intolerance, and anxiety. Further review of the medical record showed goals were established in regard to these identified problems. However, review of the medical record showed no evidence a comprehensive care plan to include interventions and approaches was developed or implemented. Further, review of the patient summary plan of care showed "No plan of care items. No plan of care procedures."
b. Interview with the director of nursing on 7/26/13 at 3:30 PM verified she was unable to locate interventions and approaches for staff to follow to address the identified problems in order to meet the patient's goals.

4. Review of the emergency room physician notes for patient #4 showed s/he was brought to the hospital ED via ambulance because s/he was lethargic, somewhat confused, and "unresponsive". The patient was admitted to the hospital for observation. Review of the patient's problem list showed weakness and depression were identified as care planning issues. Continued review showed goals were established in regard to these identified problems. However, review of the medical record showed no evidence a comprehensive care plan to include interventions and approaches was developed or implemented. Interview with the director of nursing on 7/26/13 at 3:30 PM verified she was unable to locate interventions and approaches for staff to follow to address the identified problems in order to meet the patient's goals.

5. Review of the history and physician dated 7/4/13 for patient #5 showed s/he presented to the ED with progressive shortness of breath associated with dyspnea on exertion. The patient had a long history of COPD, pneumonia, and renal insufficiency. The patient was admitted to the hospital with oxygen, broncho-dilators, cortico-steroids, and antibiotics ordered. Review of the entire medical record, verified by the medical records person, showed no problem list or care plan of any kind was developed.