HospitalInspections.org

Based on document review and interview, the governing body failed to identify which categories of practitioners that are eligible for appointment to the medical staff resulting in the potential for patients care to be provided by practitioners without the approval of the governing body. Findings include;

The governing body failed to develop or approve bylaws for the facility therefore the categories of practitioners eligible for appointments was not identified in any documentation.
Interview with Staff D on 02/23/2011 at 1430 revealed there was no further documentation available regarding the corporations BY-LAWS and eligible medical staff.

Based on record review and interview the facility failed to provide the Important Message from Medicare (IMM) to 4 of 7 patients ( #1, #6, #8, #14) to patients per medicare requirements that such notice must be provided within 48 hours of admission and again within 48 hours of discharge, resulting in patients not being informed of their rights under Medicare. Findings include:

During record review for patient #6 on 02/23/2011, it revealed that the patient was admitted on 01/21/2011 the only IMM in the patient 's record was dated 02/01/11 (time of discharge). Patient #8 admitted on 11/18/2010 did not have an IMM in the record within 48 hours of admission. The only signed copy on the record was dated 11/29/201 (time of discharge). Unable to locate a signed IMM for patient #14, upon admission 11/03/2010 or discharge 11/17/2010.
Records were reviewed with staff U on 02/24/2011 at 1415 who was also unable to locate the IMM documentation.



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During record review for patient #1 on 02/24/2011, it was revealed that the patient was admitted on 01/18/2011 and died at the facility on 1/28/11. The "Important Message from Medicare" found in patient #1's clinical record was not signed or dated. These findings were confirmed by staff B on 02/24/2011 at 1400.

Based on interview and record review, the facility failed to ensure that 1 of 1 sampled patients (#2) who alleged abuse by staff was free of possible abuse by failing to respond to patient #2's allegation of staff abuse and investigate promptly, per policy, resulting in the possibility of on-going patient abuse. Findings include:

Policy Review:

The facility's Staff Nurse Job Description, policy HR-6.22, 4/10, states that the Nurse: "Provides a safe, therapeutic environment that protects patient rights."

Facility policy MH-05, "Identifying Abuse & NEGLECT, dated 4/2/09 states: "It is the policy of (facility name) to identify and report recipient abuse and neglect and to act upon this information." On page 5, part A, under Employee, it states:

1. (An employee) "Who receives notice of or witnesses an incident of patient abuse or neglect while the patient is in the hospital must report the incident to their "immediate supervisor" and the Recipient Rights Advisor, as soon as possible..."

2. (The employee) "Documents all information concerning the incident on a Risk Identification Form, and a Recipient Rights Complaint Form, being as descriptive as possible."

Patient Findings:

1. On 2/22/11 patient #2's clinical record was reviewed. Per a progress note by Nurse J, dated 11/16/10 at 0930 hours: "patient (#2) approached me that a staff member was inappropriate with her. I directed her to the Recipient Rights form and told her that Form needed to be filled out and placed in box."

2. On 2/23/11 at 1110 hours, Nurse J stated that he did not notify his immediate supervisor of the patient #2's allegation of being treated inappropriately by staff because he thought that notifying the RRO (Recipient Rights Officer) by phone was enough. He stated that he was unaware of the facility policy requiring any additional notifications. Nurse J stated: "The patient (#2) said someone was inappropriate with her so I told her so I told her to stop right there." Nurse J verified that he declined patient #2's request to hear her allegation. When asked how he know whether the allegation of inappropriate staff behavior might involve abuse he replied, "I didn't (know)".

3. In an interview on 2/23/11 at approximately 0925 hours, the RRO stated that she was not on site the day of the incident. The RRO stated that Nurse J called her on 11/16/10 to inform her of a complaint, but did not specify that it involved an allegation of inappropriate behavior by staff.

4. In an interview with the DON on 2/24/11 at approximately 1400 hours, the DON stated that it is facility policy to report allegations of staff to patient abuse, including inappropriate staff behavior, immediately to the RRO, Charge Nurse and Administration. The Don was asked whether it was acceptable for nursing staff to decline to hear the specifics of a patient allegation of "inappropriate staff behavior." The DON stated that Nurse J should have obtained specifics on the allegation, allowing patient #2 to file the allegation of being inappropriately touched by staff immediately. The investigation of patient #2's allegation of inappropriate staff behavior, documented on 11/16/11 at 0930 hours, was not heard or investigated until the next day, allowing for possible contact between patient #2 and her alleged abuser.

Based on interview and record review the facility failed to:

1. Maintain a current care plan (A0396) for 1 patient (#1) experiencing a serious decline in health status.

2. Administer medications in accordance with physician's orders (A0404) to 2 of 5 sampled patients resulting in the risk of contributing to a significant decline in health of 1 patient (patient #1) and failure to monitor blood sugars and administer medications as ordered to 1 patient diagnosed with Diabetes Mellitus (patient #5).

Based on record review and interview, the facility failed to keep current a care plan for 1of 1 sampled patients (#1) who experienced a significant decline in health. Findings include:
Patient #1:

Policy Review:

The facility's Staff Nurse Job Description, policy HR-6.22, 4/10, states that the Nurse: "Observes patient behavior for changes in order to intervene appropriately, guide non-professional nursing staff, communicate changes to appropriate staff, and record changes." It also states that the nurse: "Utilizes the nursing process in planning, providing and evaluating each patient's care."

Patient Findings:

Patient #1 suffered a significant decline in physical health ending in death on day ten of his stay. Patient #1's clinical record did not contain care plan updates when new, significant symptoms of physical decline were documented in the clinical record. Following a fall, there was no documentation of further assessment of the patient's condition or updating of his care plan.

1. Patient #1 was admitted to the facility on 1/18/11 and died at the facility on 1/28/11. Upon admission patient #1 had no difficulties with ambulation, mobility, swallowing, speech, breathing, tremulousness or incontinence. An AIMS test done on 1/18/11 indicated no signs of Extrapyramidal Side Effects A History and Physical dated 1/19/11, documented patient #1's pulse rate as 74 beats per minute.

2. On 1/26/11 at 1305 hours a progress note documenting a fall was noted. No Incident Report or further documentation by Nursing was noted. On 2/24/11 at approximately 1400 the DON (Director of Nursing) stated that an Incident Report and Progress Note should have been done. No update to patient #1's care plan following the fall was noted.

3. On 1/26/11 at 1900 hours, the Nurse stated: "Patient looks very tired...lips and buccal cavity dry and coated. He is tremulous, some difficulty getting pills and water into mouth. Slow moving ...Pulse 109." There was no documentation that these symptoms were report to a physician or included in patient #1's care plan.

4. On 1/27/11 at 1950 hours, a decline in patient #1 's condition was documented in a nursing note, stating: "Patient shows difficulty ambulating, shows difficulty speaking ...patient appears confused, shaky. " The Nurse states " both attending doctors aware" but there was no note stating how the nurse knew that doctors were "aware" of the patient's current symptoms, including the new symptom of difficulty speaking. The care plan was not updated following this note.

5. The findings noted above were discussed with the Director of Nursing on 2/24/11 at approximately 1400.

Based on observation, record review, policy review and interview, the facility failed to administer medications as ordered for 2 of 5 sampled patients (#1 and #5) resulting in the potential for negative health outcomes. Findings include:

Policy Review:

Per policy ADM 4.11, titled "Medication Error Reporting," 1/09, it is facility policy: "to have qualified personnel administer medications as prescribed by a Physician and dispensed by a licensed pharmacy." Medication administration after discontinuation is identified a Type 1 Error, requiring a Medication Error Report and an Incident Report. Failure to give a medication at the right time is also listed as a type I Error. Type 1 errors are to be "reported as soon as possible to the physician."

Per policy CLN 4.9, 1/09, titled "Medication Administration,"page 1,"all medications require a physician's order; page 4: "When an ordered medication is not given, the nurse initials it at the appropriate time, circles the initials, and writes a progress note explaining why it was not given."

Patient Findings:

Patient #1:

Patient #1 suffered a significant decline in physical health ending in death on day ten of his stay. When a Physician discontinued a psychotropic medication, due to possible side effects, it was given anyway, putting the patient at risk for worsening side effects. When a medication was ordered to be given "now," to address significant edema, the Nurse failed to call it in to Pharmacy, resulting in a significant delay in obtaining the medication.

1. Patient #1 was admitted to the facility on 1/18/11 and died at the facility on 1/28/11. Upon admission patient #1 had no difficulties with ambulation, mobility, swallowing, speech, breathing, tremulousness or incontinence. An AIMS test done on 1/18/11 indicated no signs of Extrapyramidal Side Effects.

2. On 1/26/11 at 0825 hours, an order to discontinue Seroquel was written by Psychiatrist Q. His progress notes states: "discontinue Seroquel to avoid EPS." Per the Medication Administration Record (MAR) Seroquel was given to patient #1 anyway, unordered, at bedtime on 1/26/11 and 1/27/11. On 2/24/11 at approximately 1400 the DON verified that these medication administration errors had not been identified as such to her knowledge.

3. On 1/27/11 at 1615 hours on 1/27/11, a physician's telephone order for Lasix 20 mg. orally now was obtained by a nurse (staff X). The order was faxed to the pharmacy, as a routine order, and not called in to the pharmacy as a "now" order.

4. Patient #1 was found dead at 0615 on 1/28/11. The Lasix ordered on 1/27/11 was never given. It hadn't arrived from Pharmacy. On 2/25/22 at approximately 1400 the DON stated that the Nurse who wrote the Lasix "now " order, on 1/27/11 at 1615, should have called the order in to the Pharmacy, per facility protocol, not just faxed it. Neither the MAR nor the progress notes contained any explanation regarding the 1/27/11 Lasix "now" order.

5. In a phone interview on 2/24/11 at approximately 1200 hours, Physician O stated that he did not recall being made aware at any time that patient #1 did not receive the Lasix he ordered on 1/27/11. The clinical record is also silent on this.

6. On 2/24/11 at approximately 1400 hours, the Director of Nursing (DON) was asked to produce the facility's policy on administering "now" or "stat" medications. The DON stated that the facility had no policy but utilizes the policy of a contract pharmacy. The DON was unable to provide a document stating that the facility has adopted the contract pharmacy's policies or protocols.

Patient #5:

1. On 2/22/11 at approximately 1500, review of the Medication Administration Record (MAR) for patient #5 revealed that the Lantus Insulin, 20 unit subcutaneous, ordered for 0900 was marked as not given. Review of patient #5's MAR and clinical record revealed no documentation explaining the omission or documenting physician notification. The nurse responsible for administering the medication had left for the day. These findings were verified with the Director of Nursing at 2/22/11 at approximately 1600.

2. The DON also verified that patient #5's accu-checks, ordered for before meals and at bedtime, were not documented in the MAR four times daily on: 2/19/11, 2/20/11, and 2/21/11. On 2/19/11. There was no documentation in the MAR indicating that the accu-check ordered for 2/19/11 at bedtime was done or that a scheduled dose of Lantus 14 units, to be given at 2100, was given. On 2/22/11 at approximately 1500, the DON verified that these omissions and the lack of documentation of reports to the physician. Patient had orders for sliding scale coverage based on accu-check results. It is unknown whether the patient needed insulin at any of the times listed above since accu-checks weren't documented. Neither the MAR nor the clinical record explained these omissions.