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Based on observations during tour, review of hospital documents, and interviews, it was determined the governing body failed to require a mechanism to verify that the quality of the contracted hemodialysis services were provided safely, as demonstrated by:

1. the contracted hemodialysis RN failed to clean hands between glove changes;

2. the contracted hemodialysis RN failed to discard a box of disposable gloves placed on top of the patient's hemodialysis machine, and instead returned the gloves to the general supply cart; and

3. the contracted hemodialysis RN could not demonstrate how to wash hands in the one sink that was present in a patient's room, while the patient was on dialysis.

Findings include:

The hospital contracts for hemodialysis services, conducts Dialysis 10 Minute Tracer audits (1 per quarter/2 personnel), and reports no deficient practices.

The contracted provider's (dialysis services) Monthly Infection Control Clinical Practice Audit, requires: "...Hand Hygiene (wash with soap & water) or...after every glove removal....Gloves:...changed between...dirty to clean area...Only supplies necessary for that tx (treatment) are taken to pt (patient) station and not returned to general supply area...." The Dialysis Auditor reported no deficient practices.

1. The following was observed during a tour conducted on 03/09/11, 0815 to 0915: Patient #2 was prepared for hemodialysis. The contracted dialysis RN donned gloves, accessed the bloodlines (flushed catheters), changed gloves, picked up trash from the floor, changed gloves, marked solution jugs (on the hemodialysis machine), checked the machine/dialysate conductivity, changed gloves, connected bloodlines to the catheter, discarded the syringe - dropped it - picked the syringe up from the floor, discarded it into the sharps container, then changed gloves again. The RN stated, "I change my gloves a lot." The RN did not clean his hands, with soap/water or alcohol-based solution, between glove changes.

2. The following was observed during a tour conducted on 03/10/11 at 0830: Patient #7 was prepared for hemodialysis. The contracted dialysis RN acquired a box of disposable gloves from the dialysis general supply cart outside the patient's room, and placed it on top of the patient's hemodialysis machine. The RN confirmed that he used the same box of gloves for several patients, returning the same box to the supply cart after each treatment. The RN confirmed he did not dispose of the box of gloves after each patient treatment when the box was placed on top of the hemodialysis machines.

The audits did not identify the deficient practices that were observed during the tours.

3. Patient #20, was observed on dialysis on 03/09/11 at 0900 hours. The nurse caring for the patient was asked to explain how she washed her hands if contaminated while in the room. She showed the Surveyors the one sink located in the bathroom for Pt #20. The sink contained a Y-connector connected to the faucet and a hose was coiled in the sink draining fluid from the dialysis machine. Both connections of the Y-connector had hoses connected and the nurse demonstrated she would remove the one hose and attempted to disconnect the hose from the Y-connector and was unable to do so, but said she would wash her hands at the Y-connector with the fluid draining into the sink from the dialysis machine. The Y-connector extended 3 inches from the bottom of the faucet into the shallow sink with the contaminated fluid draining into the sink. The close proximity to the fluid and bottom of the Y-connector would not allow enough room to safely wash hands.

Employee #18 was asked to demonstrate how a dialysis nurse dialyzing a patient with C-Difficile or visibly contaminated hands, requiring soap and water hand washes, would wash their hands. She said the dialysis nurse would have to go into the shower room and use the sink in that room as it was a "hands free" faucet, however, the door leading into the shower room was closed and latched requiring her to touch to the door handle and open the door.

The facility did not ensure the contracted hemodialysis services were provided in a safe manner.

Based on observations during tour, review of hospital policies/procedures, and documents, it was determined the hospital failed to provide all patients/patient representatives' accurate information for reporting grievances to the State Health Department, regardless of whether the patient/representative has first used the hospital's grievance process.

Findings include:

The hospital policy titled Patient Rights #P01-A (last revised 01/10) requires: "...Each patient/family...will receive a copy of the Patient Rights upon admission...."

The hospital's Patient's Rights document requires: "...You...will be made aware of the state Department of Health to which you may address grievances...."

The Patient's Rights do not include contact information, however, signage posted in multiple patients' rooms, listed inaccurate Department address and phone number. The surveyor alerted the hospital to the discrepancies, during tours conducted 03/09/11 and 03/10/11.

Based on review of hospital policies/procedures, medical records, and interviews, it was determined the hospital failed to require patient restraints were used in accordance with physicians' orders for 5 of 5 restrained patients (Patients #15, 16, 17, 19, and 24), as demonstrated by:

1. nursing documented restraint interventions when there were no physician orders (Patients #19, and 24); and

2. nursing documented no interventions when there were active/valid physician restraint orders (Patients #15, 16, and 17).

Findings include:

The hospital policy Restraints and Seclusion #R02-N (last revised 06/10) requires: "...Restraints must be ordered by a physician...If a physician or LIP (licensed independent practitioner) is not available to issue such an order, a registered nurse initiates restraints...MD/DO or LIP is notified immediately...of the initiation of restraint, and a telephone order is obtained from that practitioner and entered into the patient's medical record...a written order...is entered into the patient's medical record on a daily basis when restraint use is clinically appropriate...Orders...must be renewed on a daily basis...If a patient is removed from restraint before the current order expires and must be returned to restraints a new physician order is required...."

The 24 Hour Patient Record and Plan of Care flowsheet requires the staff document Interventions For Restrained Patients, as follows: "...includes all items below (listed) and all items under 'Hourly Rounding'...Re-Assess Need and Alternatives Q (every) 2 H (hours) and PRN (as needed)...Assess Skin Integrity and circulation Q 2 H and PRN...Patient/Family Education PRN...Reorient PRN...Person at Bedside PRN...Line of View PRN...Removed Restraints for 10 mins (minutes) Q 2 H...."

1. Patient #19, was admitted on 02/18/11, and restrained on the following days: 02/24-27/11 and 03/01/11.

The medical record contained 5 restraint order/nursing assessment forms. None of the forms were signed by a physician, nor did the nurse document a verbal order from a physician for restraints.

The findings were confirmed by Employee #18 on 03/09/11 at 1100 hours.

Patient #24 was admitted on 01/18/11, and restrained on 01/19/11 through 02/08/11 at 1300 hours. The patient was restrained again on 02/25/11 at 0500 hours, through 02/27/11, at which time the patient was transferred to the intensive care unit (ICU).

The medical record contained 14 restraint order/nursing assessment forms, however, the patient was restrained for a total of at least 23 days. Each of the orders were reviewed with Employee #18. The first restraint order did not contain a nursing signature, time, and the physician did not time the order. The next restraint order form did not contain a time or date. On the restraint order form for 01/22/11, no times were documented. None of the order forms for restraints were completed correctly.

The findings were confirmed with Employee #18 on 03/10/11 at 1540 hours.

2. Patient #15 was admitted on 03/08/11, for long term care and treatment from injuries sustained in a motor vehicle accident, according to the medical record. The physician wrote restraint orders on 03/08/11 and 03/09/11. The medical record revealed no nursing documentation of restraint interventions as follows: 03/08/11: 2000, nursing documented restraints applied, however, no interventions were documented 03/08/11 0700 through 03/09/11 0600.

Patient #16, was admitted post fall on 02/11/11, for long term care and treatment of a resulting subdural hematoma and subarachnoid hemorrhage, according to the medical record. The physician documented daily restraint orders, however, no nursing interventions were documented on 03/07/11 and 03/08/11.

Patient #17's Restraint Order/Assessment Sheets, revealed daily restraint orders as follows: 02/14/11 through 02/19/11, 02/22/11 through 02/25/11, 02/28/11 through 03/06/11, and 03/08/11 through 03/09/11. Medical record entries, selected at random, revealed no nursing documentation of restraint interventions, for active restraint orders, as follows:

03/08/11: 0700 through 1800.
03/06/11: 0700 through 03/07/11 0600.
03/05/11: 2000 through 03/06/11 0600.
03/02/11: 0700 through 1900.
02/19/11: 0600 through 02/20/11 0600.

The Chief Nursing Officer (CNO) verified the findings during record reviews and interviews conducted on 03/10/11.

Based on review of hospital policy/procedure, medical records and interview, it was determined that the hospital failed to require that the medical staff be accountable to the governing body for meeting the requirements of the hospital policies related to physicians orders as evidenced by failing to require that physicians' medication orders comply with the requirements of the hospital policy/procedure for 1 of 1 patient who received titrated medications (Pt #12).

Findings include:

Review of hospital policy titled "Orders, Physician" Policy #O02-G (last revised 01/11) requires: "...All written orders are to be dated and timed...A complete medication order consists of:...name of medication...dose...frequency of administration...route...comments/qualifying phrases are...required for PRN (as needed) orders (i.e. for severe pain)...."

Review of Patient #12's Physician's Orders dated 02/28/11 at 2230 hours, revealed: Start Propofol drip and titrate to patient's comfort (illegible) respiration greater than or equal to 18.
The patient's record did not contain the hospital's "Propofol Infusion Physician Order Sheet" which contains the initial rate, infusion rate, titration increments, frequency of adjustment rate, etc.

Review of Patient #12's Physician's Orders dated 03/01/11, revealed: Norepinephrine titrate rate to keep MAP >60.

The Director of Nursing (DON) confirmed during an interview conducted on 03/10/11, the physician's failed to write complete orders for the titrated medications for Patient #12.

Based on review of medical records, policies/procedures, and interview with staff, it was determined the registered nurse failed to document oversight of the licensed practical nurses (LPN's) for 3 of 3 patients cared for by LPN's (Pt. #'s 20, 22, and 32).

Findings include:

The hospital policy titled Patient Assignment, Acuity, Core Staffing Guidelines Select Specialty Hospitals, revised May 2008, required: "...Assignments...A LPN may gather data including vital signs, cardiorespiratory, GI (gastrointestinal), GU (gastrourinary), wound and skin. The RN must review and validate the plan of care is appropriate. The RN will note agreement with the data collected by a note with a signature...."

Patient #20 had a LPN assigned to care for him on 03/09/11. Review of the nursing flowsheet revealed on page 8 of 8, labeled RN verification of data collected by RN, did not contain documentation of verification by the RN.

Patient #22 had a LPN assigned to care for him on 03/07/11. Review of the nursing flowsheet revealed on page 8 of 8, labeled RN verification of data collected by RN, did not contain documentation of verification by the RN.

Patient #32 had a LPN assigned to care for her on 03/07/11. Review of the nursing flowsheet revealed on page 8 of 8, labeled RN verification of data collected by RN, did not contain documentation of verification by the RN.

The findings were confirmed by Employee #18 on 03/10/11 at 1400 hours and verified the medical records did not contain documentation that demonstrated the RN's had oversight of the LPN's data collection.

Based on review of personnel files, policies/procedures, and interview with staff, it was determined the hospital failed to ensure non-employee licensed nurses were evaluated and oriented to the hospital's policies and procedures for 2 of 3 non-employee licensed nurses (RN's #27 and 34), as evidenced by:

1. RN #27 did not have documentation of orientation, or verification of competencies, prior to assignment of patient #3, and had an allegation of abuse filed; and

2. RN #34 did not have documented orientation to the hospital policies and competencies were not verified by the hospital.

Findings include:

The hospital policy titled Staffing, Nursing, #SO4-N, revised 08/12/03, required: "...Staffing Plans...PRN staff and contracted agency staff are used to supplement full and part-time staff in order to adjust staffing to acuity. If supplemental nursing staff from outside agencies are to be utilized for staffing, the hospital will verify licensure, CPR training, current competency for assignment and will provide orientation prior to assignment...."

The hospital policy titled Abuse, Neglect and Harassment, #A02-A, revised 01/10/10, required: "...Education and Training...Abuse is covered in the initial orientation program for all employees. It is reviewed on an annual basis for staff. In addition, the Code of Conduct is reviewed with all staff. Contract Staff are also oriented to this policy."

Employee #18 verified registry nurses are to also have an evaluation completed after their first shift worked.

RN #27 was a registry contracted nurse. Review of the personnel file revealed the nurse did not have the following required items:
Documented current competencies;
Orientation to the hospital and hospital policies; and
First shift evaluation completed.

RN # 27 was assigned to Pt #33 on 12/19/09, and an allegation of abuse was filed. The hospital determined the RN could no longer work at the hospital and was not eligible for return, after the allegation was filed.

RN #34 was a registry contracted nurse. Review of the personnel file revealed the nurse did not have the following required items:
Documented current competencies; and
Orientation to the hospital and hospital policies.

Employee #18 confirmed in an interview of 03/11/11, that the registry nurses were missing the required items.

Based on review of hospital policies/procedures, medical records, and interviews, it was determined the hospital failed to require all medical record entries were accurately documented, authenticated, dated, and timed, in order to establish a baseline for assessments, and timeline of events, according to hospital policies, for 7 of 7 medical records (Patients #2, 3, 11, 12, 14, 16, and 17).

Findings include:

The hospital policy titled Order, Physician #O02-G (last revised 01/11) requires: "...All written orders are to be dated and timed...."

The Rules and Regulations of the Medical Staff require: "...All clinical entries in the patient's medical record shall be accurately dated, timed, and authenticated...All orders...must be dated, timed and authenticated by the prescribing practitioner...."

Patient #2 was admitted on 02/08/11, with end stage renal failure, sacral decubitus, diabetes, and chronic obstructive pulmonary disease, according to the medical record. Physician orders, reviewed at random, revealed no order times documented, as follows: 03/06/11, 03/05/11, 03/04/11, 03/03/11, 02/27/11, and 02/23/11.

Patient #3 was admitted on 02/22/11, post acute aortic dissection and cardiac tamponade, according to the medical record. Physician orders, reviewed at random, revealed no order times documented, as follows: 02/23/11 (2 orders), 03/04/11, 03/05/11, and 03/08/11.

Patient #11 was admitted on 03/04/11, with hypertension, obesity, and obstructive sleep apnea, according to the medical record. The Restraint Order/Assessment Sheet dated 03/06/11, revealed that nursing did not document the time of the telephone order, and the physician did not document the date and time of his/her signature.

Patient #12 was admitted on 02/08/11, for continued management of complex medical issues according to the medical record. Physician orders, reviewed at random, revealed that nursing did not document the time or date of the telephone order, and the physician did not document the date and time of his/her signature on 03/01/11. Physician orders, reviewed at random, revealed no order times documented, as follows: 03/01/11(2 orders) and 03/02/11(3 orders).

Patient #14 was admitted on 01/24/11, for long term treatment of multiple complex medical diseases, according to the medical record. Twelve (12) of 50 physicians' orders were not timed on the following dates: 02/08/11, 02/11/11, 02/10/11, 02/12/11, 02/13/11, 02/06/11, 02/05/11, 02/01/11 (2 orders), 01/27/11 (2 orders), and 01/26/11.

Patient #16's medical record revealed the following orders:

03/10/11: physician order for restraints not dated or timed.
03/09/11: no nursing time documented, and no physician time/date documented.
(undated order): no date or time documented for neither nurse, or physician.
03/06/11: no nursing time documented, no physician signature, date/time.
03/05/11: no nursing time documented; no physician date/time.
03/04/11 no RN time, no physician date/time
03/03/11: no nursing time documented, no physician date/time.
03/01/11: no nursing time/date documented.
02/28/11: no physician time/date.

Patient #17, was admitted to the hospital on 02/14/11. The Restraint Order/Assessment Sheets, dated 02/14/11 to 03/09/11, revealed 19 restraint orders, as follows:

No physicians' date and/or time: 11 of 19 orders.
No nursing date and/or time (order received): 16 of 19 orders.
No nursing documentation noting the orders: 13 of 19 orders.

The Chief Nursing Officer (CNO) verified the lacking documentation, during records reviews and interviews conducted 03/09/11 through 03/11/11.

Based on review of hospital policy/procedure, medical records and interview, it was determined that the hospital failed to require that medication orders and administration of medication be consistent with hospital policy/procedure for 1 of 1 patient who received titrated medications (Pt's #12).

Findings include;

Review of hospital policy titled "Orders, Physician" Policy #O02-G (last revised 01/11) requires: "...All written orders are to be dated and timed...The licensed nurse or appropriate clinical discipline will contact the physician if an order is in any way incomplete or questionable...Each order will be verified as having all necessary information entered into the computer...A complete medication order consists of:...name of medication...dose...frequency of administration...route...comments/qualifying phrases are...required for PRN (as needed) orders (i.e. for severe pain)...."

Review of Patient #12's Physicians's Orders dated 02/28/11 at 2230 hours, revealed: Start Propofol drip and titrate to patient's comfort (illegible) respiration greater than or equal to 18.
The patient's record did not contain the hospital's "Propofol Infusion Physician Order Sheet" which contains the initial rate, infusion rate, titration increments, frequency of adjustment rate, etc.

Review of Patient #12's Physicians's Orders dated 03/01/11, revealed: Norepinephrine titrate rate to keep MAP >60.

The pharmacist, employee #7 confirmed during an interview conducted on 03/11/11 at 1000 hours, the above orders were incomplete, missing a rate and the initial titration dosage.

Based on review of the annual contracted services review document, observation, and interview with staff, it was determined the hospital failed to maintain adequate facilities for its hemodialysis services and allow for hand washing during dialysis.

Findings included:

See Nursing A084 #3 additional information.

The hospital's document titled Annual Contract Services Review Quarterly Checks--Phoenix DT and Scottsdale 2010, did not include identification of the handwashing issues during dialysis at the Scottsdale location.

The facility did not ensure the contracted hemodialysis services were provided in a safe manner and allowed for hand washing during dialysis if needed.

Based on review of policy and procedure, hospital documents, medical records, and interview, it was determined the hospital failed to require that drugs were administered in accordance with the orders of a practitioner and accepted standards of practice, as evidenced by the failure of the registered nurse (RN) to clarify an incomplete physician's order for intravenous titration of the following medications: Norepinephrine and Propofol prior to administration for 1 of 1 patient (Patient #12).

Findings include:

Review of hospital policy titled "Orders, Physician" Policy #O02-G (last revised 01/11) requires: "...All written orders are to be dated and timed...The licensed nurse or appropriate clinical discipline will contact the physician if an order is in any way incomplete or questionable...Each order will be verified as having all necessary information entered into the computer...A complete medication order consists of:...name of medication...dose...frequency of administration...route...comments/qualifying phrases are...required for PRN (as needed) orders (i.e. for severe pain)...."

Review of Patient #12's Physicians's Orders dated 02/28/11 at 2230 hours, revealed: Start Propofol drip and titrate to patient's comfort (illegible) respiration greater than or equal to 18.
The patient's record did not contain the hospital's "Propofol Infusion Physician Order Sheet" which contains the initial rate, infusion rate, titration increments, frequency of adjustment rate etc.

The Frequent Data Flowsheet dated 02/28/11 at 2300 hours, revealed the Propofol was started at 10 mcg/kg/min.

The Information Guide for Propofol (Diprivan) under "dosing" revealed the following:
Initial rate: 5 mcg/kg/min
Usual maintenance dose: 5-80 mg/kg/min.

The disclaimer at the bottom of the guide revealed: "...brief introduction to this medication. Contact Pharmacy for additional information. Full references...available...texts...KIOSK computer...."

Review of Patient #12's Physicians's Orders dated 03/01/11, revealed: Norepinephrine titrate rate to keep MAP >60. The order was not timed.

The Nurses Progress/Narrative Notes dated 03/01/11 at 1200 hours, revealed: infusion of Levophed started at 5 mg/kg/min. B/P 84/44.

The Frequent Data Flowsheet dated 03/01/11, revealed the patient's B/P was documented 18 times between 1400 hours and 0600 hours, however, the patient's MAP was not documented.

The Information Guide for Norepinephrine (Levophed) under "dosing" revealed the following:
Initial: 8-12 mcg/min
Max: 30 mcg/min.
The disclaimer at the bottom of the guide revealed: "...brief introduction to this medication. Contact Pharmacy for additional information. Full references...available...texts...KIOSK computer...."

The pharmacist, employee #7 confirmed during an interview conducted on 03/11/11 at 1000 hours, the above orders were incomplete, missing a rate. The pharmacist also stated s/he calls the physician to clarify orders when the order is incomplete.

The Director of Nursing (DON) confirmed during an interview conducted on 03/10/11, the nursing staff failed to clarify the incomplete physician orders before giving the patient the medications in the above.