HospitalInspections.org

Based on document review and interview, it was determined that for 3 of 3 (Pt. #6, #7, and #8) records reviewed for psychotropic medications, the Hospital failed to ensure that patients were educated and informed in order to consent for psychotropic medications.

Findings include:

1. The clinical record for Pt. #6 was reviewed on 2/13/18. Pt. #6 was a 39 year old female admitted on 1/10/18 with a diagnosis of major depression. The clinical record included medication orders on 2/12/18 for Trazadone (anti-depressant), and Prozac (anti-depressant). The medication administration record (MAR) indicated that Pt. #6 was given Trazadone on 2/12/18 at 9:56 PM, and Prozac on 2/12/18 at 1:00 PM and 2/13/18 at 8:11 AM as ordered. However, the medication counseling and consent for use of psychotropic medication dated 2/11/18 did not include the Trazadone and Prozac.

2. The clinical record for Pt. #7 was reviewed on 2/13/18. Pt. #7 was a 47 year old female admitted on 2/7/18 with diagnosis of schizophrenia. The clinical record included a medication order on 2/12/18 for Fluphenazine (Prolixin-antipsychotic).The MAR indicated that Pt. #7 was given the Prolixin on 2/12/18 at 5:05 PM and on 2/13/18 at 8:49 AM as ordered. However, the Medication counseling and consent for use of psychotropic medication dated 2/11/18 did not include Prolixin.

3. The clinical record for Pt. #8 was reviewed on 2/13/18. Pt #8 was a 34 year old male admitted on 2/9/18 with a diagnosis of depressive disorder. The clinical record included medication orders dated 2/9/18 for Sertraline (Zoloft-antidepressant) and Trazadone (antidepressant). The MAR indicated that Pt. #8 received the Zoloft on 2/11/18 at 9:15 AM, 2/12/18 at 8:08 AM, and 2/13/18 at 8:59 AM; and Trazadone on 2/11/18 at 8:50 PM, and 2/12/18 at 814 PM, as ordered. However, the Medication counseling and consent dated (2/9/18), for use of psychotropic medication did not include Prolixin.

4. The Hospital policy titled, "Consent to and Psychotropic Mediation Treatment" (reviewed 3/17) required, "...The physician shall advise the recipient in writing of the side effects of the education and his right to refuse a psychotropic drug. ...Documentation of the drug ordered and that the physician has discussed the risks and benefit of the drug with the patient. ...If more than one psychotropic medication is ordered at the same time, it may be listed in one form. The patient must sign the 'Notification Medication' form and have witnessed by the registered nurse."

5. The above findings were discussed with the 3 East/West Behavioral Health Supervisor (E #10) and Director of Behavioral Health (E #11) during an interview on 2/13/18 at approximately 11:30 AM. E #10 and E #11 stated that all psychotropic medications should be included in the education and consent form.

Based on observation, document review and interview, it was determined that for 1 of 1 (Pt. #5) clinical record reviewed for restraint usage in the Critical Care Unit (CCU), the Hospital failed to ensure a written modification to the patient's plan of care included restraint usage.

Findings include:

1. An observational tour was conducted on the CCU on 2/14/18. At 9:45 AM, Pt. #5 was observed in bed, in room #3, with bilateral hand mittens. Pt. #5 was unable to use his hands without restrictions.

2. On 2/13/18 at approximately 10:30 AM, the clinical record of Pt. #5 was reviewed. Pt. #5 was an 81 year old male admitted to the CCU on 2/8/18 with diagnoses of acute pneumonitis and hyperkalemia (high potassium level). At 9:45 AM, Pt. #5 was in bed in room #3. Pt. #5 was unable to use his hands without restrictions. Pt. #5's plan of care failed to include the usage of mittens.

3. The policy entitled, "Use of Restraints and Seclusion" (rev. 2/17) was reviewed on 2/13/18 and required, "...Restraints may be used when the primary reason is to protect patients from compromising their care...If a physician ...who is primarily responsible for the patient's ongoing care determines a restraint is necessary, he/she will: 1. Modify the patient's plan of care...Documentation of Restraint: Every episode of Restraint use must be documented in the patient's medical record.. The documentation will set forth the following detail at a minimum:..7. Plan of Care based (POC) on an assessment and evaluation of the patient which reflects the use of a Restraint..."

4. On 2/13/18 at approximately 10:40 AM, the Nurse Educator (E #5) was interviewed. E #5 stated, " The patient's (Pt. #5) plan of care had not been updated to reflect the use of mittens and mittens are considers a restraint device."

Based on observation, document review and interview, it was determined that for 1 of 1 patient (Pt. #5) in the Critical Care Unit (CCU) reviewed for restraint usage, the Hospital failed to ensure that a physician's order was obtained for the application of restraints.

Findings include:

1. On 2/13/18 between 10:00 AM and 11:00 AM, an observational tour was conducted on the CCU. At 9:45 AM, Pt. #5 was in bed in room #3, with bilateral bulky hand mittens. Pt. #5 was unable to use his hands without restrictions.

2. On 2/13/18 at approximately 10:30 AM, the clinical record of Pt. #5 was reviewed. Pt. #5 was an 81 year old male admitted to the CCU on 2/8/18 with diagnoses acute pneumonitis and hyperkalemia. Pt. #5's clinical record did not contain a physician's order for the use of restraints.

3. The policy entitled, "Use of Restraints and Seclusion" (Rev. 2/17), was reviewed on 2/13/18 and required "...2. The order should be entered before initiation of Restraint except in emergency. In an emergency, a patient may be placed in restraint to eliminate the immediate risk, and then an order obtained within one (1) hour of the application of the Restraint.

4. On 2/13/18 at approximately 10:45 AM, the Nurse Educator (E #5) was interviewed. E #5 stated, "Mittens are considered restraints and there was not an electronic or hard copy physician's order for the usage of mittens, as required."

Based on document review and interview, it was determined that for 3 of 3 (Attending Physicians, Registered Nurses, and Patient Care Technicians) patient centered staff categories, the Hospital failed to ensure a corrective action was implemented for affected patient care problem areas.

Findings include:

1. The Hospital's Infection Prevention Plan 2017 was reviewed on 2/15/18 at approximately 9:00 AM. The Plan included, "...Infection Prevention Program Monitors...Hand Hygiene - Monitor staff and physicians each month facility wide."

2. On 2/15/17 at approximately 10:00 AM the Hospital's Hand Hygiene rate by Profession data for year 2017 was reviewed. The data included: Attending rates from 65.2 % in January 2017 to 62.4 % in December 2017 with a low of 50.0% October 2017; Registered Nurse rate of 69.0% in January 2017 to 66.6 % in December of 2017 with a low rate of 58.1 % in October 2017; and Patient Care Technicians with a rate of 64.7% in January 2017 to 64.8 % in December 2017 with a 55.6 % in October 2017.

3. The Hospital's "Quality and Patient Safety Plan 2017," was reviewed on 2/15 /17 at approximately 2:00 PM. The Plan required, "...XII. Summary: The Quality and Patient Safety Plan provides the framework for Loretto Hospital and implement quality performance improvement activities. These activities improve patient outcomes and patient safety in a comprehensive, methodical, and systemic manner."

4. On 2/15/18 at approximately 1:45 PM, the Director of Quality (E #14) was interviewed. E #14 stated, " It (hand washing adherence) is not acceptable. The previous administration did not do anything."

5. The Infection Control Officer (E #31) was interviewed on 2/16/18 at approximately 9:00 AM. E #31 stated, "I have done several things for hand washing. I have placed screen savers on the computers; posters and tables in the cafeteria; meet one on one; and placed banners outside the Hospital. I had a dinner meeting with the Medical Executive Committee in 2016 and reminded them of the importance of Flu vaccines and hand washing. It seems that after the dinner they forgot and went back to their old ways."

6. The President/Chief Executive Officer (E #32) stated, during an interview on 2/16/18 at approximately 9:45 AM that, "I will be taking this issue (hand washing to the Governing Board) and act on it. There has to be a change."

Based on document review and interview, it was determined that for 1 of 3 (Dialysis services) direct patient centered contracted services reviewed, the Hospital failed to ensure the program was included in the Quality and Patient Safety Council Plan.

Findings included:

1. The Performance Improvement Unit Indicators 2017 list was reviewed on 2/15/18. The list lacked inclusion of Dialysis Services quality indicators.

2. The Hospital Quality and Patient Safety Plan -2017 was reviewed on 2/15/18. The plan included, "... The plan integrates all departments within the organization..."

3. The Quality and Patient Safety Council Committee meeting minutes for 2017 were reviewed on 2/15/18. The minutes lacked documentation of Dialysis indicators being discussed.

4. During an interview on 2/15/18 at approximately 2:00 PM, the Director of Quality (E#14) stated, "Dialysis is a contracted service that provides care to our patients and it (dialysis) must have been missed on our list. We do have indicators for dialysis, but they haven't submitted any data to us."

Based on document review and interview, it was determined that for the Quality Council, the Hospital failed to ensure the Council conducted meetings per the Hospital's plan.

Findings include:

1. The Hospital's "Quality and Patient Safety Plan -2017" was reviewed on 2/15/18. The Plan required, "The Quality and Patient Safety Council will meet monthly, at least ten (10) times per year, and will generate a report with meeting minutes."

2. The Quality and Patient Safety Council meeting minutes were reviewed on 2/15/18. Meetings were conducted in January 2017; February 2017; March 2017; May 2017; July 2017; September 2017; October 2017 and November 2017 (eight meetings for 2017).

3. During an interview on 2/15/18 at approximately 11:00 AM, the Director of Quality (E#14) stated, "We meet at least 10 times per year."

Based on document review, observation and interview, it was determined that the Hospital failed to ensure well-organized nursing services to include: notification system was in place for telemetry monitored patients; adequate staffing; proper staff certification, performance evaluation, care planning, pain assessment, and dialysate testing were in place. As a result, it was determined that the Condition of Participation for Nursing Services 482.23 was not in compliance.

Findings include:

1. The Hospital failed to ensure the units were staffed according to the staffing policy and grids. See deficiency at A-392A.

2. The Hospital failed to ensure staff completed all certification requirements according to the job description. This potentially affected all patients to which these staff was assigned. See deficiency at A-392B.

3. The Hospital failed to ensure all yearly staff performance evaluations were conducted as required. See deficiency at A-392C.

4. The Hospital failed to ensure a system was in place to notify the nursing staff of a change in heart rate/rhythm for patients on a telemetry heart monitor. See deficiency at A-395A.

5. The Hospital failed to ensure that Detoxification Assessments were performed every 4 hours. See deficiency at A-395B.

6. The Hospital failed to ensure a written modification to patient care plans. See deficiency at A-396.

7. The Hospital failed to ensure the testing strips used in dialysis were designed to accurately measure the pH and conductivity of the dialysate. See deficiency at A-398.

8. The Hospital failed to ensure a timely reassessment occurred, following administration of pain medication. See deficiency at A-405.

An immediate jeopardy (IJ) began on 2/14/18 for the Hospital's failure to ensure there was a system in place to notify the nursing staff of a change in heart rate/rhythm of patients on telemetry monitors on the telemetry units (5 East and 5 West), placing these patients at a serious risk for harm.

An IJ was announced on 2/14/18 at 9:01 AM, during a meeting, with the Chief Nursing Officer (CNO), Chief Experience Officer, President/Chief Executive Officer (CEO), Director of Quality, Chief Human Resource Officer and the Family Nurse Practitioner. The immediate jeopardy was not removed by the survey exit date of 2/16/18.

A. Based on document review and interview, it was determined that for 3 of 6 patient care units (Emergency Department, Critical Care and 5 West Telemetry), the Hospital failed to ensure the units were staffed according to the staffing policy and grids.

Findings include:

1. The Hospital Policy titled, "Staffing: Unit Staffing (Professional/ Technical)" (rev 9/16) required, "Staffing is based on nurse/patient ratios and acuity. Staffing levels must be adequate to support nursing staff member's participation in assignments..."

2. The "Emergency Department (ED) Staffing Grid" (signed on 1/24/18) required, "Direct Staff Per Shift, 7A-7P: Charge Nurse -1; Staff RN (Registered Nurse) -5; ED Tech - 2; Greeter - 1."

3. The staffing for the Emergency Department (ED) for 2/7/18-2/10/18 day and night shifts was reviewed and the following shifts were not fully staffed:

-On 2/7/18 and 2/7/18 for day (7:00 AM-7:00 PM) and night (7:00 PM-7:00 AM) shift, the ED staffing consisted of 1 charge nurse and 3 registered nurses, a shortage of 2 RN's each shift.

-On 2/9/18 for day shift, the ED staffing consisted of 1 charge nurse and 3 RNs (registered nurses), a shortage of 2 RN's for the day shift.
-On 2/9/18 for night shift, the ED staffing consisted of 1 charge nurse and 2 RNs, a shortage of 3 RN's for the night shift.
-On 2/10/18 for day shift, the ED staffing consisted of 1 charge nurse and 4 RNs, a shortage of 1 RN for the day shift.
-On 2/9/18 for night shift, the ED staffing consisted of 1 charge nurse and 2 RNs, a shortage of 3 RN's for the night shift.

5. The Critical Care Unit Staffing Grid (CCU) (signed on 1/24/18) required, Direct Staff Per Shift, 7:00 AM-7:00 PM (day shift): 8 patients-4 RNs-, 9 patients-5 RN; 7:00 PM-7:00 AM (night shift) : 8 patients-5 RNs, 9 patients-5 RNs.

6. The staffing for CCU for 2/7/18-2/10/18 day and night shifts was reviewed and the following shifts were not fully staffed:

-On 2/8/18 for day shift with a census of 8 the CCU was staffed with 3 RNs, a shortage of 1 RN for the day shift.
-On 2/8/18, for the night shift with a census of 8, the CCU was staffed with 3 RNs, a shortage of 2 RNs for the night shift.
-On 2/9/18 for the night shift with a census of 8, the CCU was staffed with 3 RNs, a shortage of 2 RNs for the night shift.
-On 2/10/18 for the night shift with a census of 9, the CCU was staffed with 4 RNs, a shortage of 1 RN for the night shift.

7. The Telemetry unit 5 West Staffing Grid (signed 1/24/18), required, Direct Staff Per Shift 7:00 AM-7:00 PM (day shift) and 7:00 PM- 7:00 AM (night shift): 14-17 patients - 4 RNs 4-CNA (certified Nursing Assistants and 1 MT (telemetry monitor technician); 19-20 patients-5 RN, 3 CNA and 1 MT.

8. The staffing for 5 West Telemetry Unit for 2/7/18-2/10/18 day and night shifts was reviewed and the following shifts were not fully staffed:

-On 2/9/18, the staffing sheet for the night shift indicated that the unit did not have a Telemetry Monitor Technician.
-On 2/10/18, for the night shift with a census of 19 patients, the unit was staffed with 4 RNs, a shortage of 1 RN for the night shift.

9. The above findings were discussed with the Chief Nursing Officer (E #33) during an interview on 2/16/18 at approximately 2:30 PM who stated, "The Hospital hired four new staff for an orientation, and is continuing to hire additional staff."

B. Based on document review and interview, it was determined that for 1 of 5 (E #38) Behavioral health staff, and 2 of 2 (E #34 and 35) Telemetry Monitor Technician personnel files reviewed, the Hospital failed to ensure staff completed all certification requirements according to the job description. This potentially affected all patients to which these staff were assigned.

Findings include:

1. The Job Description for the Behavioral Health Nurse (created 9/23/16), required, "Essential Duties and Responsibilities ...Demonstrates competency in CPI (Crisis Prevention Institute), Restraints...."

2. The personnel file for E #38, a Behavioral Health nurse, was reviewed on 2/16/18. The contained a CPI training card dated 1/31/17 and lacked a current CPI certification and training.

3. The Job Description for Monitor Technician (created 9/23/16) required, "To perform this job successfully, an individual must be able to perform each essential duty satisfactorily: 1. The candidate must have a CCT (Certified Cardiographic Technician) certification. 2. EMT-P (emergency medical technician-paramedic) or equivalent, 3. ECG (electrocardiogram) Tech Certification or certificate in Cardiovascular Technician."

4. The Personnel file for the Monitor Technicians, E #34 and E #35, were reviewed on 2/16/18 and lacked the following:

-E #34's file contained a certificate for Cardiology Technician; however the file lacked the EMT-P or equivalent requirement.
-E #35's, contained an EKG (electrocardiogram) certification; however the file lacked the EMT-P or equivalent requirement.

5. The above finding was discussed with the Chief Human Resource Officer (E #41) during an interview on 2/16/18, at approximately 1:20 PM, who stated that a current CPI is required, and E #41 stated "this staff (E #28) has not worked in the hospital for over 6 months and will no longer be working here."

6. The Chief Nursing Officer (E #33) was interviewed on 2/16/18 at approximately 1:30 PM. E #33 stated that the Job Description for the Monitor Technician should not require EMT-P and that the job description for the Monitor Technician will have to be reviewed. E #33 also stated that CPI training and current certification is required.


C. Based on document review and interview, it was determined that for 4 of 13 (E #37, E #38, E #39 and E #40 ) mixed personnel files reviewed the Hospital failed to ensure all yearly staff performance evaluations were conducted as required.

Findings include:

1. The Hospital policy titled, "Performance Evaluations" (rev 12/16) required, "Employees shall receive an evaluation on job performance on a regular and a consistent basis, but not less than annually."

2. The personnel files for 13 (8 RNS, 2 Mental Health Specialist, 1 Radiology Technician, and 2 Monitor Technicians) staff were reviewed on 2/16/18.

-Three (3) RNs (E #37, E #38, and E #39) and 1 Mental Health Specialist (MHS-E #40) personnel files lacked current performance evaluations. The last evaluations for each were dated 2016.

3. The above findings were discussed with the Chief Human Resource Officer (E #41) during an interview on 2/16/18 at approximately 1:15 PM. E #41 stated all staff should have a yearly performance evaluation, and E #41 stated that the above staff (3 RNs and 1 MHS) do not have current evaluations.

A. Based on document review, observation and interview, it was determined that for 2 of 2 telemetry units (5 East and 5 West), the Hospital failed to ensure a system was in place to notify the nursing staff of a change in heart rate/rhythm for patient's on a telemetry heart monitor. This potentially affected the 16 patients currently on a telemetry monitor.

Findings include:

1. The Hospital policy titled, "Cardiac Monitoring in Telemetry (revised 10/16)" was reviewed on 2/13/18. The policy required, " ... All Telemetry patients admitted to the unit will be routinely monitored during their stay to detect and properly treat any cardiac arrhythmia's (irregular heart rhythm)."

2. A unit tour of the 5 West nursing unit was conducted on 2/13/18 at approximately 10:45 AM. The unit included a telemetry room with 3 monitor screens available to monitor the patients on 5 East and 5 West requiring telemetry monitoring (heart monitoring). Currently there were 16 patients on monitor (3 patients on 5 East and 13 on 5 West).

3. During a tour of the 5 East nursing unit on 2/13/18 at approximately 10:00 AM, there was no staff in the nurse's station and the phone was ringing with no one to answer it. The phone just stopped ringing after approximately 6 rings.

4. During an interview on 2/13/18 at approximately 10:55 AM, the telemetry technician (E#3) stated, "I call the secretary or find the patient care technician for the patient of the monitor reading I have a concern about to check on that patient. They then find the nurse for me. When I can't find anyone, I just yell out for help".

5. During an interview on 2/13/18 at approximately 11:00 AM, the Clinical Manager (E#4) stated, "We know we need a better way to communicate with the nurses. We have asked for portable phones, but have not gotten them yet. There has never been a direct communication process from the telemetry technician and the nurse aside from trying to find the nurse."


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B. Based on document review, observational tour, and interview, it was determined that for 3 of 3 patients (Pts. #1, #2 & #3) clinical records reviewed of patients in the Addiction Unit, the Hospital failed to ensure that Detoxification Assessments were performed every 2 to 4 hours, per policy.

Findings include:

1. On 2/13/18 at 11:45 AM, the Hospital's policy titled, "Ongoing Reassessment of Level 4 Patients" (last reviewed 1/2017), was reviewed. The policy required, "R.N.s...Will document the patient's withdrawal symptoms on the Detoxification Assessment form every 2 to 4 hours as indicated by severity of symptoms."

2. On 2/13/18 between 9:50 AM to 11:00 AM, an observational tour was conducted of the Addiction Unit (4th Floor). At 10:00 AM, record reviews were conducted for the following three patients, designated with a Level of Care of 4 on the Patient Tracking Board at the Nurses' Station:

- Pt. #1 was a 63 year old male, admitted on 2/6/18 for alcohol dependence with withdrawal.

- Pt. #2 was a 71 year old male, admitted on 2/9/18 for opioid dependence with withdrawal and alcohol abuse.

- Pt. #3 was a 59 year old male, admitted on 2/10/18 for opioid dependence with withdrawal.

3. Pt. #1's clinical record included Detoxification Assessments being done at intervals longer than 4 hours as follows:

2/12/18 4:21 AM - 10:25 AM (6 hours and 4 minutes).
2/12/18 9:28 PM - 2/13/18 6:17 AM (8 hours and 49 minutes).

4. Pt. #2's clinical record included Detoxification Assessments being done at intervals longer than 4 hours as follows:

2/10/18 11:30 AM - 5:13 PM (5 hours and 43 minutes).
2/12/18 4:17 AM - 10:14 AM (5 hours and 57 minutes).
2/12/18 9:22 PM - 2/13/18 6:13 AM (8 hours and 51 minutes).

5. Pt. #3's clinical record included Detoxification Assessments being done at intervals longer than 4 hours as follows:

2/10/18 11:11 AM - 5:26 PM (6 hours and 15 minutes).
2/12/18 4:29 AM - 10:44 AM (6 hours and 15 minutes).
2/12/18 9:31 PM - 2/13/18 6:20 AM (8 hours and 49 minutes).

6. On 2/13/18 at 10:05 AM, an interview was conducted with the Charge Nurse of the Addiction Unit (E #1). E #1 stated that the night shift nurse should have done the assessments and documented them every 4 hours.

Based on observation, document review and interview, it was determined that for 2 of 2 (Pt. #4 and Pt. #5) clinical records reviewed in the Critical Care Unit (CCU) and 1 of 1 (Pt #11) clinical record reviewed on the 5 West Unit, for care plans, the Hospital failed to ensure a written modification to the patients' care plans, as needed.

Findings include:

1. On 2/13/18 between 10:00 AM and 11:00 AM, an observational tour was conducted on the CCU. During the tour it was observed that Pt. #5 was in room #3 with a droplet isolation signage on the door and Pt. #4 was in room #4 with contact isolation signage on the door.

2. On 2/13/18 at approximately 10:20 AM, the clinical record of Pt. #4 was reviewed. Pt. #4 was a 50 year old male admitted to the CCU on 2/10/18 with a diagnosis of status asthmaticus. The clinical record included a positive Methicillin-Resistant Staphylococcus Aureus (MRSA) culture of the nares dated 2/11/18. The culture report included, "Initiate contact precautions as per Hospital's infection control policy." Pt. #4's plan of care dated 2/12/18 at 8:00 AM failed to include that Pt. #4 was on contact isolation for MRSA in the nares, as required.

3. On 2/13/17 at approximately 10:30 AM, the clinical record of Pt. #5 was reviewed. Pt. #5 was an 81 year old male admitted to the CCU on 2/8/18 with diagnoses of acute pneumonitis and hyperkalemia. Pt. #5 clinical record contained a laboratory result dated 2/10/18 that included, "Influenza a viral antigen detected." Pt. #5's plan of care failed to include Pt. #5 was on droplet isolation for influenza.

4. On 2/13/18 the policy entitled, "Interdisciplinary Plan of Care, Treatment and Services," (rev. 1/17) was reviewed and required "Policy: 1. An Interdisciplinary Plan of Care, Treatment and Services (IPC) is completed for inpatients admitted to an acute care unit. 2. The IPC and care is developed from ...patient's assessments...results of diagnostic testing ...Procedure:..1. B....Daily review and revision of the IPC with input from the interdisciplinary team...2. B... Revise the IPC when problem/goal is resolved or when there is a change in the patient's condition requiring a new goal..."

5. On 2/13/18 at approximately 11:00 AM, the findings were discussed with the Nurse Educator (E #5). E #5 stated that Pt. #4 and Pt. #5's plans of care should have been updated to reflect they were placed on isolation precautions.

6. The clinical record of Pt. #11 was reviewed on 2/13/18. Pt. #11 was a 66 year old male who was admitted on 2/2/18 with the diagnoses of hematuria, sepsis and diabetic ketoacidosis. Pt. #11's care plan did not include interventions for the diagnoses of hematuria (blood in urine) or diabetic ketoacidosis (high levels of ketones in the blood).

7. On 2/13/18 at approximately 11:25 AM, the 5 West Charge Nurse (E#28), stated that care plans are developed based on the individual patient needs and should have been included.

Based on document review and interview, it was determined that the testing strips used to test dialysate pH and conductivity, the Hospital failed to ensure the testing strips used, were designed to accurately measure the pH and conductivity of the dialysate, potentially endangering the safety of approximately 20 patients receiving hemodialysis each month.

Findings include:

1. On 2/14/18 at 2:40 PM, the Manufacturer's Instructions for RPC K100 - 0104 E-Z Chek 0 - 14 pH Test Strips were reviewed. The instructions included, "K100 0104 E-Z Chek 0 - 14 pH Test Strips are indicated for use in testing the pH of water used for preparing dialysis. The instructions did not include the test strips could be used for testing dialysate. (Dialysate is the combination of reverse osmosis water, bicarbonate, and acid.)

2. On 2/14/18 at 2:40 PM, the Manufacturer's Instructions for RPC E-Z Chek 6.8 - 8.5 pH Test Strips were reviewed. The instructions included, "RPC's unique E-Z Chek 6.8 - 8.5 pH Test Strips are an accurate... means for validating the pH of dialysate against the AM (RD 52) specified range of 6.9 to 7.6..." The instructions also indicated that, "Bicarb/acetate and Bicarb/citrate [test strips were] available..."

3. On 2/14/18 at 1:10 PM, the dialysate test strips were reviewed. The test strips were the RPC K100 - 0104 E-Z Chek 0 - 14 pH Test Strips, for testing water, not dialysate. The RPC E-Z Chek 6.8 - 8.5 pH Test Strips were not available.

4. On 2/14/18 at 1:10 PM, an interview was conducted with the Acute Dialysis Services Coordinator (E #26) and the Dialysis Contract Provider Physician (MD #2). E #26 stated that the RPC K100 - 0104 E-Z Chek 0 - 14 pH Test Strips were being used and E #26 did not know the safe pH range of dialysate. Neither E #26 nor MD #2 could explain how dialysate conductivity is assessed, using an independent measure.

Based on document review and interview it was determined that for 1 of 3 (Pt #9) clinical records reviewed, the Hospital failed to ensure a timely reassessment and intervention, following administration of a pain medication.

Findings Include:

1. The Hospital policy entitled, "Pain: Assessment, Management, and Documentation", revised 4/14 was reviewed on 2/13/18. The policy included, "...If the intensity scale is above 4, an intervention to relieve the pain should be done...reassessment for pain intensity and pain relief as reported by the patient is to be done after each pain management intervention once a sufficient time has elapsed for the treatment to reach peak effect...oral medication 1 -2 hours after administration..."

2. The clinical record of Pt. #9 was reviewed on 2/13/18. Pt. #9 was a 49 year old female admitted on 2/5/18 with a diagnosis of complicated urinary tract infection. The Medication Administration Record included the following missing reassessments or lack of intervention:

-On 2/5/18 at 2:13 AM, Acetaminophen (pain reliever) 1,000 milligrams was administered with no reason indicated. Pt#9's reassessment was documented on 2/6/18 at 1:58 AM (23 hours later).
-On 2/7/18 at 4:51 PM, Acetaminophen 650 mg was administered for lower back pain rated at a 10 (0 - 10 scale). Pt#9's reassessment dated 2/7/18 at 5:51 PM included documentation of back pain rated at a 6, with no further intervention documented.
-On 2/8/17 at 9:56 PM Hydrocodone Bitartrate/Acetaminophen (pain medication) was administered for back pain rated at a 10. Pt. #9's reassessment for pain monitoring dated 2/8/18 at 10:56 PM included documentation of back pain at a 10, with no further intervention documented.

3. On 2/13/18 at 10:30 AM, the 5 East Registered Nurse (E#13), stated, "A pain reassessment should be done and documented 1 - 2 hours after pain medication is administered and interventions should have been performed for unrelieved pain."

Based on document review and interview, it was determined the Hospital failed to ensure all medical records were completed within 30 days of patient discharge.

Findings include:

1. The Hospital Medical Staff Bylaws Rules and Regulation (adopted on 8/2015) required, "Medical record of discharged patients are to be completed no later than thirty days following the date of discharge. If a chart is not completed within 30 days, after it is made available to the Medical Staff member, the charts are considered delinquent."

2. During the tour of the Medical Records Department on 2/14/18, at approximately 1:00 PM, the Director of Medical Records (E #25) was interviewed. E #25 stated that they have a number of medical records that are delinquent, incomplete more than 30 days after patient discharge.

3. On 2/14/18, E #25 presented a letter indicating that as of 2/14/18, the Hospital "has 627 delinquent charts."

Based on document review and interview, it was determined that for 1 of 1 unresolved medication discrepancy, the Hospital failed to ensure discrepancy resolution was properly reported, as required.

Findings include:

1. The policy entitled "Automated Drug Delivery System," (rev 3/17) was reviewed on 2/14/18 and required "...Discrepancies: If a discrepancy in inventory is discovered...during the reconciliation of the return bin, a discrepancy report shall be generated at the unit and all users involved will be notified. Daily, assigned pharmacy personnel will print and review all discrepancy reports for all locations, verifying that all discrepancies have been resolved...The Director of Pharmacy and Pharmacist in Charge (PIC) shall report unexplained losses to Risk Management...all discrepancies shall be resolved by the involved individuals prior to leaving the institution and documented on the Pyxis med-station..."

2. On 2/14/18 at approximately 11:30 AM, an "All Discrepancies" (Medication) report from 1/20/18 to 2/14/18 was reviewed and indicated, "Surgery, Dated 1/30/18. Midazolam (sedative) 2 mg/2 ml vial; Discrepancy Found: 1 Expected: 2. Resolution: Currently Unresolved."

3. On 2/14/18 at approximately 11:45 AM, the Pharmacist (E #22) presented an email dated 2/1/18 at 8:20 PM from a staff Pharmacist (E #23) sent to the Director of Surgery that indicated "One of our technicians went up to the Operating Room (OR) on 1/30/18 to check the return bin, and there was 1 missing Midazolam vial...We spoke with (staff nurse) yesterday (1/31) to see if she accidentally did it twice, but she does not remember...There is a discrepancy in the OR Pyxis (medication dispensing system) right now for 1 missing Midazolam vial return bin."

4. On 2/14/18 at approximately 11:40 AM, the Pharmacist (E #21) was interviewed. E #21 stated there was one unresolved medication discrepancy identified dated 1/30/18 from the Surgery Department. E #21 stated, "As of today (2/14/18) the discrepancy remains unresolved. The discrepancy has not been reported to Administration, this medication discrepancy 'fell thru the cracks', it should not take this long to resolve."

A. Based on document review, observation, and interview, it was determined that for 4 of 32 open spice containers, the Hospital failed to ensure open spice containers were removed from use after being purchased and not open longer than 1 year, potentially affecting the health of 88 patients on census on 2/14/18.

Findings include:

1. On 2/14/18 at 11:10 AM, a policy for Storage Time Limitation for open spice containers was requested. At 12:30 PM, the Food Service Director (E #20) stated there was no policy. E #20 stated that he wrote a policy after the Dietary Department tour.

2. On 2/14/18, between 11:00 AM and 11:50 AM, an observational tour was conducted in the Dietary Department. In a spice cabinet, there were 4 of 42 open spice containers with purchase dates over 5 years earlier and the spices were still available for use. The spice container labels did not include open or expiration dates. The purchase dates were:

Curry Power 8/10/10; Whole Fennel 8/21/12; Ground Thyme 10/2/12; and Ground Ginger 10/9/12.

3. On 2/14/18 at 12:50 PM, an interview was conducted with the Food Service Director (E #20). E #20 stated that the new policy, effective immediately, is to dispose of spice containers 1 year after purchase.


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B. Based on document review, observational tour, and interview, it was determined that the Facility failed to ensure that all (15 of approximately 150) opened food items, were labeled as required.

Findings include:

1. On 2/14/18 at 11:50 AM, a policy for labeling and dating of opened and prepared food products was requested. The Food Service Director (E #20) stated that there was no policy. At 12:30 PM, E #20 provided the policy and stated that he wrote the policy after the Dietary Department Tour.

2. On 2/14/18 between 11:00 AM and 11:50 AM, an observational tour was conducted of the Dietary Department, the following was observed:

At 11:30 AM, the dry food pantry contained 2 opened bags of Walnuts (one undated and the other labeled 6/30/17). The pantry also contained 2 bags of Brown Sugar, 2 containers of Rice, and a bag each of Spaghetti, Penne Pasta, Crackers, Lentils, Beans and Granola, all opened and undated.

At 11:35 AM, the frozen food freezer contained a bag of pancakes and a bag of omelets, both opened and undated.

At 11:40 AM, the patient food refrigerator contained 30 prepared salads and a prepared tray of gelatin, all undated.

3. On 2/14/18 at 11:30 AM, an interview was conducted with E #20. E #20 stated that food items should have been labeled with the opened, prepared, and/or use by date.

4. On 2/16/18 at approximately 12:00 PM the Hospital's HACCP Manual (Hazard Analysis and Critical Control Points), (rev. 10/14) was reviewed and required, "...6. All food prepared in operation must be covered and labeled as to contents and date of preparation prior to storage inn refrigerators and freezers."

Based on observations during the survey walk through, staff interview, and document review during the Life Safety Code portion of the Full Survey Due to a Complaint conducted on February 13 - 14, 2018, the facility failed to provide and maintain a safe environment for patients, staff and visitors.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were cited. Also see A710.

Based on observations during the survey walk through, staff interview, and document review during the Life Safety Code portion of the Full Survey Due to a Complaint conducted on February 13 - 14, 2018, the facility failed to comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with the K-Tags.

A. Based on observation and interview it was determined that the Hospital failed to ensure that on 2 of 5 Nursing Care Units (5 East and 5 West), syringes with needles were not available to visitors and/or patients. This potentially affected all 20 patients on 5 East/West Units.

Findings Include:

1. On 2/13/18 at approximately 10:00 AM, during a tour on 5 East Nursing Unit, an arterial blood gas kit with a needle was observed in a plastic bag hanging on the emergency cart, accessible to visitors and patients.

2. On 2/13/18 at approximately 10:45 AM, during a tour on 5 West Nursing Unit, an arterial blood gas kit with a needle was observed in a plastic bag hanging on the emergency cart, accessible to visitors and patients.

3. On 2/13/18 at approximately 11:00 AM, the Clinical Manager 5 East/West (E#4) stated, "Supplies that have been opened, should not be left in the supply room and should be thrown away."

4. On 2/13/18 at approximately 11:45 AM, during an interview, the Certified Respiratory Therapist (E#9) stated, "The arterial blood gas kits absolutely should not be stored outside of the crash cart."


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B. Based on document review, observation, and interview, it was determined that for 4 of 4 rooms (3 shared shower rooms and 1 medication room), the Facility failed to ensure the ceiling vents were cleaned. This potentially affected 9 patients on census in the Addiction Unit on 2/13/18.

Findings include:

1. On 2/14/18 at 11:00 AM, the Facility's policy titled, "Vent Cleaning" (effective date 1/13/17), was reviewed. The policy required, "The Environmental Services Department to establish procedures and standards for Vent Cleaning on an as needed basis."

2. On 2/13/18 between 9:50 AM to 11:00 AM, an observational tour was conducted of the Addiction Unit. At 10:45 AM, ceiling ventilation grills/covers were dusty and dirty in 3 of 3 shared shower rooms and the Medication Room. Some of the dust and dirt had formed into 1/4 to 1/2 inch balls attached to the vents.

3. On 2/13/18 at 10:50 AM, an interview was conducted with the Clinical Supervisor of the Addiction Unit (E #2). E #2 stated that he would call housekeeping to have the ceiling vents cleaned.

C. Based on document review, observational tour, and interview, it was determined that the Facility failed to ensure that expired supplies were not available for use for patient care, potentially affecting 25 patients receiving Nuclear Medicine services every month.

Findings include:

1. On 2/14/18 at 12:30 PM, the Facility's policy titled, "Handling of Expired Items" (last reviewed 3/2017), was reviewed. The policy required, "Monitor expiration dates on a regular basis... if it is impossible to use prior to expiration then Central Supply will make arrangements to return or dispose of expired items... Under any circumstances, any item which has reached an expiration date must be promptly removed from stock and placed where it cannot be accidentally used."

2. On 2/13/18 between 1:50 PM and 2:05 PM, an observational tour was done of the Nuclear Medicine Room. At 1:55 PM, the following supplies were found in the supply drawer and were available for use:

- 4 of 4 Hypodermic Safety Needles, with an expiration date of 12/2017;

- 5 of 5 Monoject Vial Access Cannulas, with an expiration date of 12/2017; and

- 1 of 10 Safety Intravenous 18 Gauge Catheters, with an expiration date of 11/2017.

3. On 2/13/18 at 2:00 PM, an interview was conducted with the Director of Diagnostic Imaging (E #12). E #12 stated that she has someone go through the supplies every month to check for expired items. E #12 also stated that she would remove the expired items from use.

4. On 2/13/18 at approximately 11:00 AM, during a tour of 5 West Nursing Unit, clean supply room, one suture removal kit was observed open and available for use, one nasogastric tube was observed open and available for use, and one pap smear kit was observed open and available for use, with an expiration date of 12/2017.

5. On 2/13/18 at approximately 11:00 AM, the Clinical Manager 5 East/West (E#4) stated, "Supplies that are expired should not be available for use."

6. During an observational tour of the Surgical Department on 2/14/18, in operating room #1 there were 2 boxes of expired sutures: approximately 20 Ethicon 5-0 with an expiration date of January 2018 and approximately 3 Ethibond Excel sutures with an expiration date of January 2018.

7. The Director of Ambulatory Services and Surgical Services (E #24) stated, during an interview at approximately 11:00 AM that, "It is the nurses responsibility to check for expired supplies and remove them."

Based on document review, observation and interview, it was determined that the Hospital failed to ensure an effective Infection Control Program that included a qualified Infection Control Officer and adherence to infection control practices. As a result, it was determined that the Condition of Participation 42 CFR 482.42 Infection Control was not in compliance.

Findings include:

1. The Hospital failed to ensure Infection Control Officer was qualified, as per job description. See deficiency at A-748.

2. The Hospital failed to ensure blood was drawn from patients in the appropriate place. See deficiency at A-749A.

3. The Hospital failed to ensure adherence to infection control practices. See deficiency at A-749B.

4. The Hospital failed to keep clean and dirty specimens separate. See deficiency A-749C.

5. The Hospital failed to ensure gastroscopes were processed and stored appropriately as required. See deficiency at A-749D.

6. The Hospital failed to ensure adherence to the dress code. See deficiency at A-749E.

Based on document review and interview, it was determined that for 1 of 1 (E #31) Infection Control Officer, the Hospital failed to ensure he was qualified, as per job description.

Findings include:

1. E #31's personnel file was reviewed on 2/14/18 at approximately 9:00 AM. The file included a job description signed and dated 9/23/16, entitled, "Infection Control Officer," (created September 23, 216) that included, " Education and Experience: Current Registered Nurse licensure in the State of Illinois." E #31's personnel file lacked documentation of a Registered Nurse license.

2. On 2/15/18 at approximately 10:00 AM E #31 stated during an interview that he is not a Registered Nurse and he has a degree in business along with Infection Control training and certification.

3. On 2/16/18 at approximately 9:00 AM, an interview was conducted with the President/Chief Executive Officer (E #32). E #32 stated that he will have the job description changed.

A. Based on observation and interview, it was determined that for 1 of 1 (E#16) Laboratory Technician, the Hospital failed to ensure blood was drawn from patients in the appropriate place.

Findings include:

1. During a tour of the Laboratory Department on 2/14/18 at 10:35 AM the following was observed:
- At 10:35 AM, E#16 was drawing a patient's blood while sitting at the reception area.
- At 10:40 AM, the patient left the reception area after the blood was drawn. E#16 failed to disinfect the area where the blood was drawn.

2. During an interview on 2/14/18 at 10:40 AM, E#16 stated, "The other technician is in the draw room and has been in there too long. I needed to get this patient's specimen so he could leave."

3. During an interview on 2/14/18 at approximately 10:41 AM, the Director of Laboratory (E#17) stated, "We should never draw blood from a patient at the front desk".


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B. Based on observation, document review and interview it was determined that for 1 of 1 (E #7) registered nurse and 1 of 1 Environmental Service staff (E #6) in the Critical Care Unit (CCU) observed, the Hospital failed to ensure adherence to infection control practices.

Findings include:

1. On 2/13/18 between 10:00 AM and 11:00 AM, an observational tour was conducted on the CCU. At approximately 10:10 AM, the nurse (E #7) was observed administering an intravenous medication to Pt. #4 in Room #4 (identified with signage as a contact precautions room). E #7 had gloves and was wearing a facial mask below the nose; however, E #7 was not wearing a gown.

2. On 2/13/18 at approximately 10:20 AM, the clinical record of Pt. #4 was reviewed. Pt. #4 was a 50 year old male admitted to the CCU on 2/10/18 with a diagnosis of status asthmaticus. The clinical record included a positive culture of the nares dated 2/11/18 Methicillin-resistant Staphylococcus Aureus (MRSA) that included, "Initiate contact precautions as per Hospital's infection control policy."

3. At 10:50 AM, the Environmental Services (E #6), was observed in Pt. #4's room (room #4) mopping the floor, touching the trash bin, and moving the chair, without wearing a gown.

4. On 2/13/18 at approximately 11:00 AM, the Environmental Services (E #6) was interviewed. (E #6) stated, "When a patient is on contact isolation, I wear a gown when I enter the patient's room; however, I did not realize the patient was on isolation until I came out of the room and saw the signage on the door."

5. The policy entitled, "CDC Guidelines Transmission-Based Precautions," (rev 1/17) was reviewed on 2/13/18 and required, " ...(1) Contact Precautions: ...use Contact precautions in the following instances: a) For patients, cultures +with multi-drug resistant organisms MRSA ... c) For patients who are colonized with MRSA in the CCU ...Healthcare workers caring for patients in Contact Precautions wear gowns and gloves always."

6. The Hospital policy entitled, "Isolation Patient Room Occupied" (rev. 1/10/17) reviewed on 2/14/18 and required "Procedures: Dress at the entrance of the room, per isolation guidelines posted (i.e...gown).

7. On 2/13/18 at approximately 10:30 AM, the Nurse Educator (E #5) was interviewed. E #5 stated, "PPE (Personal Protective Equipment) for contact isolation includes a gown and the nurse should have worn a gown prior to entering patient's room."


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C. Based on document review, observation and interview it was determined that in the Laboratory Department, the Hospital failed to keep clean and dirty specimens separate. This potentially affected approximately 8 -10 patients receiving laboratory services daily.

Findings Include:

1. The Hospital policy entitled, "Standard Precautions" revised 4/12 was reviewed on 2/14/17. The policy included, "...standard precautions are used to reduce the risk of transmission of bloodborne and/or other pathogens from both recognized and unrecognized sources..."

2. During a tour of the Laboratory on 2/14/18 at 10:35 AM the following was observed:
- Three used tourniquets were available for use and sitting on the top of a hazards collection container located in the lab draw room.
- Five urine specimens were inside the chemistry refrigerator (number 11), sitting on top of clean reagent supplies.

3. On 2/14/18 at approximately 10:45 AM, the Lab Director (E#17) stated, "Clean and dirty should be stored separately."


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D. Based on observation, document review, interview and stated practice, it was determined that for 1 of 3 processed gastroscopes, the Hospital failed to ensure scopes were processed and stored appropriately as required.

Findings include:

1. During an observational tour of the Sterile Processing Department (SPD) conducted on 2/14/18 at approximately 10:00 am, the following was observed:

- In the clean scope storage room, a flexible gastroscopy was stored, coiled in a clear plastic box, with a processing date of 2/5/18.
- A second scope with a processing date of 1/13/18 was dated with an expiration of 2/27/18 (1 week longer than expected hang time).

2. The Facility policy titled, "Scope policy" (rev 4/17) required, "Guideline on hang time...AORN advises reprocessing scopes before use if unused for more than 5 days. 1. Fill out the tag with the month processed, date and year. 2. Write the scope serial number on the tag. 3. Technician will then initial the tag. 4. Hang time will be 7 days (any scope un-used within 7 days will be reprocessed before use.)"

3. The SPD Technician (E #19) was interviewed on 2/14/18, at approximately 10:30 AM. E #19 stated that it is the practice of SPD to hang all flexible scopes in the scope storage after processing. E #19 stated that scopes are dated with expiration of 7 days after processing. The above findings were discussed with E #19 who stated that the gastroscope should have been hanging and the dated to expire 7 days after processing.

E. Based on observation, document review, and interview, it was determined that for 1 of 1 (E #19) Sterile Processing Technician, the Hospital failed to ensure adherence to the dress code.

Findings include:

1. During an observational tour of the Sterile Processing Department (SPD) conducted on 2/14/18 at approximately 10:00 am, the Sterile processing technician (E #19) was observed going in and out of the sterile processing area from Central Supply without any covering on the facial hair (mustache and beard).

2. The policy for dress code for the SPD was requested on 2/14/18. The Hospital provided the policy titled, "Central Supply Area" (rev. 2/17) required, "Head covering that covers head and facial hair, except for eye brows and eye lashes."

3. The above findings were discussed with E #19 on 2/14/18 at approximately 10:30 AM, who stated that no one has ever "formally" discussed facial hair covering.

Based on document review, observation, and interview it was determined that for 1 of 1 (MD #1) surgeon in the Surgical Department, the Hospital failed to ensure adherence to the dress code policy.

Findings include:

1. The Hospital policy entitled, "Surgical (Dress Code) Attire," (reviewed 2/2017) required, "Procedure: Restricted Area Attire Requirements...7. Masks are to be removed upon exiting the operating room a new mask for each new patient. Masks are not allowed to be worn around the neck and must be removed by the strings..."

2. During an observational tour of the Surgical Department on 2/14/18 at approximately 10:45 AM, the Surgeon (MD #1) exited room 2 with his mask hanging around his neck.

3. The Director of Ambulatory Services and Surgical Services (E #24) stated during an interview that, "That was a deficiency that was cited on the last survey."