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Based on review of the clinical record, review of hospital policies/procedures, review of hospital documentation and interviews with hospital personnel, the condition of Governing Body has not been met. For one patient (Patient #3) diagnosed with an acute cerebrovascular accident (CVA) during an Emergency Department (ED) same day readmission, documentation and interviews failed to reflect that the patient had continued comprehensive medical oversight, failed to reflect ED policies that governed medical management and failed to reflect that the case was formally reviewed in the hospital Quality Assurance Performance Improvement (QAPI) process to ensure quality improvement and patient safety.



Please see A 49 (Patient #3) with cross reference to A 309, A 1103, A 1104, and A 467

1. Based on medical record reviews, review of facility documentation, and interviews for one of three patients reviewed for anticoagulation therapy (Patient #1), the attending physician failed to adequately supervise the patient's care. The finding includes:

a. Patient #1 had a history of atrial fibrillation (A-fib) on Warfarin therapy and was admitted to the hospital with sustained rapid ventricular rate (RVR) on 9/9/12. The patient received a one- time dose of Coumadin 5 mg by mouth on 9/9/12 at 4:24 PM per the order of MD #2 (3rd year Resident) and prophylactic Heparin 5,000 units every eight hours SQ was also initiated on 9/9/12 per MD #2's order. Amiodarone (cardiac-antiarrhythmic) was ordered by MD#2 on 9/10/12 to treat the RVR, as well as therapeutic Lovenox 90 mg every 12 hours SQ as a bridge anticoagulant. Blood work dated 9/10/12 indicated an International Normalized Ratio (INR-(clotting time)) of 2.5 (normal for A-fib = 2-3). Progress notes dated 9/10/12 by the Attending Physician, MD #1, identified a plan for coronary artery bypass surgery. Progress notes by MD #1 dated 9/11/12 and 9/12/12 indicated that the Patient's INR was high at 3.2 and 3.4 respectively. Although the patient's blood clotting capacity was decreasing, and potential for bleeding was increasing (high INR), physician's orders dated 9/11/12 and 9/12/12 did not include orders for anticoagulant medication adjustments. Medication Administration Records (MAR) noted that RN #10 held the Patient's Heparin at 10:00 PM on 9/12/12 and at 6:00 AM on 9/13/12 and the Patient's Heparin was subsequently discontinued on 9/13/12. Nursing narratives and/or blood work and/or the brain scan dated 9/14/12 noted that although the Patient's INR level had decreased to 1.8, the Patient had a change in condition documented at 4:55 AM and was diagnosed with an acute left thalamic (brain) hemorrhage. Interview with MD #1 on 11/30/12 at 10:30 AM noted that although s/he reviewed Patient #1's medications, s/he missed that the patient was on Heparin and duplicate therapy, and discontinued the Heparin when s/he became aware. Interview with the Chair of Medicine, MD #5, on 11/29/12 at 1:48 PM identified that either, but not both, Heparin or Lovenox should have been used to treat the Patient. MD #5 further indicated MD #1 was directly responsible for the Patient's care and oversight of MD #2. The hospital policy for resident supervision identified that attending physicians are responsible for the care provided to patients and that all residents, without exception, will function under the supervision of an attending physician. The hospital provided staff education and a revision of the computerized ordering system for the most current INR to automatically show on the computer screen when Lovenox is ordered (already in place for Heparin/Coumadin ordering).





19952



2. Based on review of the clinical record, review of hospital policies/procedures, review of hospital documentation and interviews with hospital personnel for one patient (Patient #3) diagnosed with an acute cerebrovascular accident (CVA) during an Emergency Department (ED) same day readmission, documentation and interviews failed to reflect that the patient had continued comprehensive medical oversight, failed to reflect ED policies that governed medical management and failed to reflect that the case was formally reviewed in the hospital Quality Assurance Performance Improvement (QAPI)process to ensure quality improvement and patient safety. The findings include:


a. Review of the clinical record and interview with MD #11 identified that Patient #3 was admitted to the hospital via ambulance on 7/7/12 at 1:24 AM with alcohol intoxication and discharged to the ED waiting room at 7:26 AM after sobering appropriately. Approximately 20 minutes later, Patient #3 was readmitted at 7:50 AM, when he/she was observed stumbling in the waiting room and noted to have an unsteady gait.

Review of the record and interview with RN #15 on 12/15/12 at 10:05 AM identified that Patient #3 never left the waiting room on 7/7/12 and that, upon triage, the patient's speech was baseline for him/her, a little slurred, and that the patient did not complain of pain.

Review of the record and interview with RN #11 on 11/28/12 at 11:20 AM identified that Patient #3 requested detoxification and that the patient's alcohol (ETOH) level was 261 (Normal zero) at 10:40 AM. At 12:05 PM, eleven hours after the patient's initial admission on 7/7/12, Patient #3 became agitated. RN #11 indicated that the patient's words were incomprehensible, that she notified MD #12, and that she administered Ativan two milligrams (mg.) intravenously (IV) per physician order. At 3:48 PM, RN #11 identified that Patient #3 was now unable to stand without assistance and again notified MD #12.

Interview with MD #12 on 12/12/12 at 10:45 AM identified that, although he completed a reassessment of Patient #3 prior to end of his shift on 7/7/12, he failed to document the assessment. MD #12 indicated that Patient #3 was not weak, but was not able to stand because he/she was still visibly intoxicated. MD #12 stated that he/she signed off to MD #10.

Review of the ED Physician Schedule identified that MD #10 was scheduled in the ED on 7/7/12 from 2:30 PM to 10:30 PM. Review of the record and interview with MD #10 on 12/11/12 identified that a dictated ED Physician Report was not completed for Patient #3 on 7/7/12. MD #10 indicated that Patient #3 was evaluated for oral intake (after RN request for a dinner meal). MD #10 indicated that it was a quick exam, that she could not recall any abnormalities but that the patient could eat. RN #11 documented that at 8:23 PM on 7/7/12, Patient #3 was still not able to stand and that the physician was aware.
Although Patient #3's words were now reported as incomprehensible and the patient could not stand, the record lacked documentation to reflect that a comprehensive medical evaluation of the patient's condition was provided. Interview with MD #10 on 12/11/12 identified that he/she could not recall any report of a change in the patient's condition or anything that would prompt another exam.

Patient #3 remained in the ED when MD #11 heard the patient loudly moaning at 4:30 AM on 7/8/12. After MD #11 evaluated the patient and identified neurological deficits, the patient underwent diagnostic radiologic studies that identified a large middle cerebral artery infarct. Patient #3 was not eligible for thrombolytic therapy as he/she did not meet the four and one half hour window criteria from symptom onset and subsequently expired on 7/11/12 at 1:26 PM. Review of the clinical record, review of hospital policies/procedures, review of hospital documentation and interviews with hospital personnel failed to reflect that ED medical care was comprehensively evaluated and that ED medical policy was implemented. In addition, the hospital governing body failed to ensure that care provided in the hospital ED by a contracted service was based on hospital policies approved by the governing body.

Subsequent to surveyor inquiry, the facility provided an immediate action plan that required a handwritten progress note, in addition to the dictated sign out note, be provided for the transfer of care so that the provider assuming the care of the patient would have immediate access to the workup provided to a patient prior to the transfer of care.

1. Based on a review of facility documentation, manufacture's guidelines and interview, the facility failed to ensure that contracted services were provided in a safe manner. The finding includes the following:

a. Review of facility documentation related to hemodialysis failed to identify that preventative maintenance of the portable reverse osmosis (RO) machines had been completed in accordance with manufacturers guidelines. Review of the maintenance log identified that the hemodialysis machines and RO was disinfected in July, August and September of 2012. Interview with the Dialysis staff stated the RO was not disinfected in October or November but completed on an as needed basis. Interview with facility staff on 11/28/12 identified that the portable RO's do not require preventative maintenance.

Review of the manufactures guidelines for the WRO 95 rev 04-2012 identified that the carbon/particle filter should be changed and the machine disinfected on a monthly basis. Every six months reject water from the RO should be monitored for hardness, chlorine, iron and temperature. Every six months the RO drain flow and the pure water flow should be measured, conductivity checked and tubing and connectors checked.

The Governing Body failed to provide oversight of dialysis services.


19952

2. Based on review of the clinical record, review of hospital policies/procedures, review of hospital documentation, and interviews for one patient (Patient #3) diagnosed with an acute cerebrovascular accident (CVA) during an Emergency Department (ED) same day readmission, the facility failed to ensure that the patient had continued comprehensive medical oversight by contracted ED physicians and/or failed to reflect ED policies that governed medical management by the contracted service. The findings include:


a. Review of the clinical record and interview with the contracted ED physician, MD #11, on 12/10/12 at 11:10 AM, identified that Patient #3 was admitted to the hospital via ambulance on 7/7/12 at 1:24 AM with alcohol intoxication and discharged to the ED waiting room at 7:26 AM after sobering appropriately. Review of the record and interview with RN #15 on 12/10/12 at 10:05 AM indicated that approximately twenty minutes later, at 7:50 AM, Patient #3 was readmitted to the ED when he/she was observed stumbling in the waiting room and observed to have an unsteady gait. RN #15 identified that Patient #3 never left the waiting room on 7/7/12 and that, upon triage, the patient's speech was baseline for him/her, a little slurred, and that the patient did not complain of pain.

Review of the record and interview with RN #11 on 111/28/12 at 1:20 AM identified that Patient #3 requested detoxification and that the patient's alcohol (ETOH) level was 261 (Normal zero) at 10:40 AM. At 12:05 PM, eleven hours after the patient's initial admission on 7/7/12, Patient #3 became agitated. RN #11 indicated that the patient's words were incomprehensible, that she notified MD #12, and that she administered Ativan two milligrams (mg.) intravenously (IV) per physician order. At 3:48 PM, RN #11 identified that Patient #3 was now unable to stand without assistance and again notified MD #12. Interview with MD #12 on 12/12/12 at 10:45 AM identified that, although he/she completed a reassessment of Patient #3 prior to end of his/her shift on 7/7/12, he/she failed to document the assessment.

Review of the ED Physician Schedule identified that MD #10 was scheduled in the ED on 7/7/12 from 2:30 PM to 10:30 PM. Review of the clinical record and interview with MD #10 on 12/11/12 and a subsequent interview with the ED Medical Director on 12/11/12 identified that the record lacked the dictated Physician ED Report for the evening shift on 7/7/12 that would have communicated Patient #3's progress during that period. The clinical record lacked documentation to reflect physician progress notes to address any further physician evaluation of Patient #3's progress/status from 2:30 PM to 10:30 PM on 7/7/12. Although during interview, MD #10 identified that Patient #3 was signed out to MD #11, who arrived for his/her shift at 10 PM, interview with MD #11 on 12/10/12 at 11:10 AM indicated that Patient #3 was not signed out to her/him.

Patient #3 remained in the ED when the contracted overnight ED physician, MD #11, heard the patient loudly moaning at 4:30 AM on 7/8/12. After MD #11 evaluated the patient and identified neurological deficits, the patient underwent diagnostic radiologic studies that identified a large, middle cerebral artery infarct. Patient #3 was not eligible for thrombolytic therapy as the time had passed to meet the criteria of a four and one half hour window from symptom onset for the thrombolytic agent. Patient #3 subsequently expired on 7/11/12 at 1:26 PM. Review of the Certificate of Death identified that Patient #3 expired on 7/11/12 at 1:46 PM due to cardiopulmonary arrest as a consequence to acute hypoxic respiratory failure due to cerebrovascular accident.

Review of the medical record, review of hospital documentation and interview with the ED Medical Director on 12/11/12 at 11:00 AM identified that a dictated ED Report was to be completed by the ED physician seeing the patient and that the report would communicate the ED patient's progress, The ED Medical Director stated that the dictated report would then be transcribed but that during that time, the report would not be available in the ED record for review. The ED Medical Director identified that the ED Physician Sheet would include the patient's chief complaint, history and physical exam but was only required to be completed by the physician who initially examined the patient but that no hand written physician progress notes were required.


Review of the clinical record, review of hospital policies/procedures, review of hospital documentation and interviews with hospital personnel failed to reflect that ED medical care provided to Patient #3 by the contracted ED physicians was communicated and/or comprehensively evaluated. The hospital failed to have specific policies to govern communication between physicians at shift change. The hospital governing body failed to ensure that care provided in the hospital ED by a contracted service was based on hospital policies approved by the governing body.

Subsequent to surveyor inquiry, the facility provided an immediate action plan that required a handwritten progress note, in addition to the dictated sign out note, be provided for the transfer of care so that the provider assuming the care of the patient would have immediate access to the workup provided prior to the transfer of care.

Based on review of the clinical record, review of hospital policies/procedures, review of hospital documentation and interviews with hospital personnel for one patient (Patient #3) diagnosed with an acute cerebrovascular accident (CVA) during an Emergency Department (ED) same day readmission, documentation and interviews failed to reflect that the case was formally reviewed in the hospital ED's Quality Assurance Performance Improvement (QAPI) process to ensure quality improvement and patient safety. The findings include:

a. Review of the clinical record and interview with MD #11 identified that Patient #3 was admitted to the hospital via ambulance on 7/7/12 at 1:24 AM with alcohol intoxication and discharged to the ED waiting room at 7:26 AM after sobering appropriately. Approximately 20 minutes later, Patient #3 was readmitted at 7:50 AM, when he/she was observed stumbling in the waiting room and noted to have an unsteady gait. Patient #3 remained in the ED for approximately twenty hours when MD #11 heard the patient loudly moaning at 4:30 AM on 7/8/12. After MD #11 evaluated the patient and identified neurological deficits, the patient underwent diagnostic radiologic studies that identified a large middle cerebral artery infarct. Patient #3 was not eligible for thrombolytic therapy due to lapse of the four and one half hour eligibility criteria standard and expired on 7/11/12 at 1:26 PM.

Review of the record, review of hospital documentation and interview with the ED Medical Director on 12/11/12 identified that the case was not formally reviewed in the ED QAPI process because it was not forwarded to the ED QAPI committee. The ED Director identified that the lack of ED physician documentation (Patient #3's ED readmission, evening shift on 7/7/12) was not recognized during informal review of the case. The ED Director indicated that, although the case met the "72 hour returns for admission" criteria for QAPI review, the case was not a medical management issue, but rather a documentation issue and therefore, not forwarded to the committee.

1. Based on a review of the clinical record, staff interviews and a review of the facilities policies and procedures for one of three sampled patients (Patient #34), the facility failed to obtain a comprehensive physician ' s order for the use of oxygen in accordance with the hospital policy and/or failed to obtain a physician ' s order for continuous pulse oximeter monitoring. The findings included:
a. Patient #34 was admitted to the hospital on 11/27/12 with a diagnosis that included respiratory syncytial virus. Interview and review of the clinical record on 11/28/12 at 1:00 PM with MD #8 failed to identify the method of administration for oxygen, liter flow, and the amount of oxygen to be delivered to Patient #34. MD #8 indicated it was the responsibility of the physician to order oxygen therapy on admission that included the mode of administration, liter flow, and the amount of oxygen to be administered. Subsequent to the surveyor ' s inquiry an order was written for Patient #34 that directed oxygen delivery for pulse oximeter monitoring that was less than ninety percent via blow by at six liters per minute with oxygen administration at 100%. The hospital policy for oxygen therapy directed in part that orders for oxygen therapy would specify the method of administration, liter flow and amount of oxygen. Further review of the hospital policy directed oxygen therapy would be administered following a physician ' s order and documented in the patient ' s medical record.
b. Tour of the pediatric unit on 11/28/12 at 11:30 AM identified Patient #34 was monitored for oxygen levels via continuous pulse oximetry. Interview and review of the clinical record with MD #8 on 11/28/12 at 1:00 PM failed to identify an order was obtained for continuous pulse oximeter monitoring. Interview with Director #1 on 11/28/12 at 2:45 PM indicated an order should have been initiated on admission for continuous pulse oximeter monitoring that directed the use of oxygen to maintain oxygen saturations levels above ninety percent. Subsequent to the surveyor ' s inquiry an order for continuous pulse oximeter monitoring was initiated. The hospital failed to have a policy that directed the use and/or frequency of pulse oximeter monitoring.

2. Based on a review of the clinical record and staff interviews for three of three sampled patients (Patient #34, #36 and #40), the facility failed to prescribe dietary orders for the patient. The findings included:
a. Tour of the pediatric unit on 11/28/12 at 11:30 AM identified Patient #36 was bottle feeding. Interview and review of the clinical record with RN #6 indicated the diet order for Patient #36 was identified as regular. RN #6 indicated the orders were written as a regular diet so the parent of the patient would receive a meal. Interview with Director #1 on 11/28/12 at 2:50 PM identified the diet order should be the patient ' s order and not an order for the parent. Subsequent to the surveyors inquiry a physician ' s order was initiated for the use of formula.
b. Interview and review of the clinical record with RN #6 on 11/28/12 at 11:40 AM identified Patient #34 was on a regular diet. Further interview with the RN #6 indicated Patient #34 was breast feeding and regular diet orders were written so the parent would receive a meal. Interview with Director #1 on 11/28/12 at 2:50 PM identified diet orders should be written that reflected the patient ' s diet. Subsequent to the surveyors inquiry breast feeding was ordered as the diet for Patient #34.

c. Patient # 40 was a full term infant delivered on 11/26/12. Review of the clinical record with RN #8 on 11/28/12 at 10:30 AM identified physician ' s orders directed breast and bottle feeding. Interview with Nurse Manager #2 on 11/28/12 at 10:35 AM indicated infant feeding orders were routinely written as breast and bottle so the physician would not be disturbed in the middle of the night for a change in diet order. Interview with Director #1 on 11/28/12 at 2:45 PM identified physician orders should reflect one diet order and the physician should be notified if an order change is needed for a medical indication and/or a maternal request.

1. Based on medical record reviews and interviews for one of three patients reviewed for intravenous (IV) therapy administration (Patient #26), nursing staff failed to follow the physician's IV order. The finding includes:

a. Patient #26 had upper and lower endoscopic procedures performed on 11/27/12. Physician orders dated 11/27/12 directed an IV of Lactated Ringers solution at 125 cc/hour. Review of nursing documentation with the Nurse Manager on 11/27/12 at approximately 10:30 AM noted that although the correct IV had been started by the nurse on 11/27/12 at 8:09 AM, the IV had infused at a rate of 100 cc/hour preoperatively and postoperatively instead of the rate of 125 cc/hour as ordered.




15482


2. Based on review of the clinical record, interview and policy review the facility failed to ensure that pain assessments for one patient (#19) were completed in accordance with hospital protocol and/or that one patient who required hemodialysis (#18) was weighed following treatment. The findings include the following:

a. Patient #19 was admitted to the rehab unit on 11/25/12 after a laminectomy/fusion. Review of the clinical record indicated that on 11/26/12 at 8:00 AM the patient had a pain level of of 7 on a 1-10 scale (10 being the worst possible pain). The patient had a pain level of 7 at 10:24 AM and was treated with Oxy IR. A reassessment at 11:30 AM identified the patient rated pain as a 2. The clinical record indicated that the patient was next assessed nine and half hours later at 8:00 PM and was identified to have a pain level of 5 and assessed again at 11/27/12 at 8:00 AM for a pain level of 7. Interview with staff identified that pain assessments should be completed every four hours and that the order in the computer had not been updated.


b. Review of Patient #18's clinical record indicated that the patient was receiving hemodialysis. The patient was admitted with fluid overload. Review of the flow sheets dated 11/23/12, 11/24/12 and 11/25/12 failed to identify that the patient had been weighed after the dialysis treatment. Interview with staff on 11/28/12 identified that weights are not completed after dialysis unless ordered by the physicians and that the physicians calculate fluid removed. Interview with the Director of Risk on 12/7/12 at 10:00 AM indicated that there is no policy for hemodialysis assessments. Interview with the Attending physician on 12/13/12 at 11:15 AM identified that patients should be weighed after each hemodialysis treatment.


19952


3. Based on observation, review of hospital policy and interview with hospital personnel regarding medication room access, documentation and interviews failed to reflect that the medication supply room and storage was secure. The findings include:
a. During tour of the telemetry unit on 11/26/12 at 11:10 AM, a central supply medical technician was observed stocking supplies in the medication room without a licensed nurse present. Interviews with the charge nurse, RN #1, and the Risk Manager at the time of the observation identified that a licensed nurse must be present when the technician was in the medication room.



29049

4. Based on a review of the clinical record, staff interviews and a review of the facilities policies and procedures for one patient (Patient #40), the facility failed to document intake and/or failed to identify the location of the infant. The findings included:
a. Patient # 40 was a full term infant delivered on 11/26/12. Review of the clinical record with RN #8 on 11/28/12 at 10:30 AM identified physician's orders directed breast and bottle feeding. Interview and review of the clinical record on 11/28/12 at 10:35 AM with RN #8 failed to identify feedings were provided and/or documented on 11/27/12 from 7:45 PM through 11/28/12 at 9:45 AM. Further interview and review of the clinical record with RN #8 indicated the infant had six feedings in twenty four hours. Interview with the lactation consultant on 11/28/12 at 12:50 PM identified normal breast feeding frequency is eight to twelve times in a twenty four hour period. The hospital policy for breast feeding indicated frequent feeding would assist in the development of a full milk supply.
Interview and review of the clinical record with RN #8 on 11/28/12 at 10:40 AM indicated the location of the infant was only identified at the time of the neonatal assessment and did not discern if the mother infant dyad were together or if the infant was in the nursery. Interview with Director #1 on 11/28/12 at 3:00 PM indicated the location of the infant should be identified in the clinical record at all times and was not. The hospital policy for breastfeeding directed in part that mothers would be encouraged to stay together whenever possible to facilitate frequent feedings at the breast. The policy further identified that rooming in would assist parents in the identification of feeding cues.

Based on a review of the clinical record, policy review and interviews, the facility failed to ensure that a comprehensive care plan was completed for one patient (Patient #18). The finding includes the following:

Review of Patient #18's clinical record indicated that the patient was admitted with fluid overload and required hemodialysis. Interview with the RN on 11/27/12 indicated that the patient had a fistula placed in 2011 but was very nervous and hesitant to start hemodialysis. The patient was started on a renal diet. Review of the clinical record on 11/27/12 with the Manager and staff identified that the patient had a nutrition consult completed by dietary on 11/27/12 that identified that the patient had no nutritional needs at this time. Review of the care plan identified that the patients active problems included Infection, knowledge deficit and alteration in renal perfusion related to hypovolemia. The care plan failed to address the patient's potential nutrition issues and/or fluid overload status.

Review of the policy indicated that the care plan should be individualized and serves as a guide for defining care and promoting discharge planning.

1. Based on medical record reviews and interviews for one of three patients reviewed for intravenous (IV) therapy administration (Patient #25), the record lacked a physician's order for IV administration. The finding includes:

a. Patient #25 had upper and lower endoscopic procedures performed on 11/27/12. Nursing documentation indicated that an IV of Lactated Ringers was started by the nurse at 7:18 AM in the left arm. Review of the patient's record with the Nurse Manager on 11/27/12 at approximately 10:30 AM noted that an IV order had not been written or entered into the computer by the physician to direct the administration of the IV. Interview with the Nurse Manager at this time noted that the Anesthesiologist was responsible for IV orders unless the Anesthesiologist started the IV.

1. Based on review of clinical records, review of hospital policies/procedures, review of hospital documentation, and interviews for one of ten patients admitted to the Emergency Department (ED), Patient #3, who had a significant change in condition, the facility failed to ensure that the patient's ED medical record accurately reflected that the patient received a coordinated, comprehensive medical reassessment and/or that changes in the patient's condition were communicated timely in order to make available the full extent of hospital resources to render appropriate care to the patient. The findings include:


a. Review of the clinical record and interview with MD #1 on 12/10/12 at 11:10 AM identified that Patient #3 was admitted to the hospital via ambulance on 7/7/12 at 1:24 AM with alcohol intoxication and discharged to the ED waiting room at 7:26 AM after sobering appropriately. Review of the record and interview with RN #15 indicated that approximately twenty minutes later, at 7:50 AM, Patient #3 was readmitted to the ED when he/she was observed stumbling in the waiting room and observed to have an unsteady gait. RN #15 identified that Patient #3 never left the waiting room on 7/7/12 and that, upon triage, the patient's speech was baseline for him/her, a little slurred, and that the patient did not complain of pain. Review of the record and interview with RN #11 identified that the patient's alcohol (ETOH) level was 261 (Normal zero) at 10:40 AM. At 12:05 PM, eleven hours after the patient's initial admission on 7/7/12, Patient #3 became agitated. RN #11 indicated that the patient's words were incomprehensible, that she notified MD #12, and that she administered Ativan two milligrams (mg.) intravenously (IV) per physician order. At 3:48 PM, RN #11 identified that Patient #3 was now unable to stand without assistance and again notified MD #12.

Interview with MD #12 on 12/12/12 at 10:45 AM identified that, although he completed a reassessment of Patient #3 prior to end of his shift on 7/7/12, he failed to document the assessment. MD #12 indicated that Patient #3 was not weak, but was not able to stand because he/she was still visibly intoxicated. MD #12 stated that he/she signed off to MD #10 indicating that Patient #3 could be discharged as soon as the patient was sober.

Review of the ED Physician Schedule identified that MD #10 was scheduled in the ED on 7/7/12 from 2:30 PM to 10:30 PM. Review of the clinical record and interview with MD #10 on 12/11/12 and a subsequent interview with the ED Medical Director on 12/11/12 identified that the record lacked the dictated Physician ED Report for the evening shift on 7/7/12 that would have communicated Patient #3's progress during that period. No additional physician progress notes were identified in the review of Patient #3's clinical record.

Patient #3 remained in the ED when the overnight ED physician, MD #11, heard the patient loudly moaning at 4:30 AM on 7/8/12. After MD #11 evaluated the patient and identified neurological deficits, the patient underwent diagnostic radiologic studies that identified a large middle cerebral artery infarct. Patient #3 was no longer eligible for thrombolytic therapy due to the failure to meet the four and one half hour window for initiation of the thrombolitic agent, and subsequently expired on 7/11/12 at 1:26 PM.


Review of the medical record, review of hospital documentation and interview with the ED Medical Director on 12/11/12 at 11:00 AM identified that a dictated ED Report was required to be completed by the ED physician seeing the patient, that the report would communicate the ED patient's progress, but that no hand written physician progress notes were required. The ED Medical Director stated that the dictated report would be transcribed and during that time the dictated report would not be available in the ED record for review. The ED Medical Director identified that the ED Physician Sheet would include the patient's chief complaint, history and physical exam but was only required to be completed by the physician who initially examined the patient.

Subsequent to surveyor inquiry, the facility provided an immediate action plan that required a handwritten progress note, in addition to the dictated sign out note, be provided for the transfer of care so that the provider assuming the care of the patient would have immediate access to the workup provided prior to the transfer of care.

1. Based on medical record reviews, review of facility documentation, and interviews for one of three patients reviewed for anticoagulation therapy (Patient #1), the pharmacist failed to ensure safe medication administration. The finding includes:

a. Patient #1 had a history of atrial fibrillation (A-fib) was on Warfarin therapy and admitted to the hospital with sustained rapid ventricular rate (RVR) on 9/9/12. The physician's order dated 9/9/12 by MD #2 (3rd year Resident) directed Heparin (anticoagulant) 5,000 units every eight hours SQ as prophylactic therapy to prevent thrombus formation (blood clot). Therapeutic Lovenox (anticoagulant) 90 mg every 12 hours SQ was ordered by MD #2 and approved by the pharmacist, MD #3, on 9/10/12. Blood work dated 9/10/12 indicated an International Normalized Ratio (INR-(clotting time)) of 2.5 (normal for A-fib = 2-3). Blood work dated 9/11/12 and 9/12/12 indicated that the Patient's INR was high at 3.2 and 3.4 respectively. Although the patient's Heparin was held at 10:00 PM on 9/12/12 and at 6:00 AM on 9/13/12 and was subsequently discontinued on 9/13/12, the Patient had a change in condition on 9/14/12 at 4:55 AM and was diagnosed with an acute left thalamic (brain) hemorrhage. Interview with the Director of Pharmacy, MD #4, on 11/28/12 at 1:30 PM identified that before a medication can be dispensed, the medication order must be approved by a pharmacist. MD #4 indicated that when a physician orders a duplicate therapy medication, the physician must enter a reason for the duplicate therapy. MD #4 noted that although the ordering physician entered that the patient was being monitored as the reason for the duplicate therapy, MD #3 should have questioned further and called the ordering physician. The hospital pharmacy job description identified that a critical responsibility of the pharmacist was to ensure appropriateness of therapy and dose for all patient populations. The hospital provided staff education and revision of the computerized ordering system for the most current INR to automatically show on the computer screen when Lovenox is ordered (already in place for Heparin/Coumadin ordering).
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The Hospital failed to ensure that the physical environment in the main campus was designed and constructed to maintain the safety of patients. The condition of Physical Environment has not been met due to the Hospital's failure to implement immediate safety interventions to prevent and/or correct the environmental safety issues.

Please refer to the following: A 701, K 021, K 028, K 072 and K 130.

Based on tour, interviews, document review and policy reviews the Hospital failed to maintain the overall hospital environment in such a manner that the safety and well-being of patients are assured.


1. Based on observation on 11/26/12 during a tour of the third floor (seventeen patients), Whittingham/Special Care Pavilion, Maternity and Women ' s Health Unit from 10:25 AM till 11:30 AM the surveyor accompanied by Director Safety and Security Department and the Executive Director of Facilities Management observed the following:

a. The means of egress on the patient occupied third floor (seventeen patients), Whittingham/Special Care Pavilion, Maternity and Women ' s Health Unit were not maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency; i.e., production equipment and furniture for the filming of a TV show was in use and/or stored in exit corridors of the unit.
b. Door closers were not provided on the doors to the patient care rooms on the patient occupied third floor (seventeen patients), Whittingham/Special Care Pavilion, Maternity and Women ' s Health Unit that were be utilized as storage rooms by a production company for the filming of a TV show in order to maintain the required smoke resistance assembly in an opening to a hazardous area.
c. The smoke barrier doors in the Maternity and Women ' s Health Unit were obstructed from closing by production equipment, belonging to a production company for the filming of a TV show that did not allow the doors to automatically close when released from the magnetic hold open devices.

2. Based on document review on 11/26/12 at 12:30 PM, the Director Safety and Security Department and the Executive Director of Facilities Management did not provide the surveyors with documentation to indicate that electrical equipment used by a production company for the filming of a TV show on the patient occupied third floor (seventeen patients), Whittingham/Special Care Pavilion, Maternity and Women ' s Health Unit were inspected as required in NFPA 99, Section 7-5.1.3., 7-5.2.2.1 and 7-6.2.1.2 and as part of the facilities preventive maintenance program; i.e., inspection and/or testing for physical integrity, resistance, leakage current tests and chassis leakage current was not conducted and recorded by the facility before the equipment was put into service by the production company.

1. Based on a tour of the operative suite, review of hospital policies, observations and interviews, the hospital failed to ensure proper donning of surgical attire and/or that opened multi-dose vials were dated and/or that endoscopes were dried/stored in a sanitary manner. The finding includes:

a. A tour of operating room (OR) #1 was conducted with the Director of the OR on 11/26/12 at 10:24 AM. Observation on 11/26/12 at 10:24 AM noted the Circulating Nurse leaning over or standing next to the sterile field while performing the initial count procedure with his/her hair exposed at the back and sides of the bouffant hair covering. Subsequent to surveyor inquiry and management staff intervention, the Circulating Nurse's hair was placed beneath the bouffant and hair was no longer exposed. The hospital policy for surgical attire identified that the surgical head covering should be clean, low lint and confine all hair and scalp skin.

b. A tour of the OR was conducted with the Director of the OR on 11/26/12 at 10:24 AM. Observation of one of two anesthesia carts noted that one anesthesia cart contained four vials of Succinylcholine and one vial was opened. Although the vial was dated with the 30 day expiration date from the time the vial was removed from refrigeration, the date that the vial was opened was written on the vial with black marker, was smudged and unreadable. Interview with the Anesthesiologist on 11/26/12 at 10:30 AM indicated that s/he utilized the anesthesia cart for a prior case and did not notice the opened vial of Succinylcholine or s/he would have discarded the vial. The multi-dose vial policy identified that multi-dose vials are to be labeled to expire 28 days after the initial entry.
c. A tour of the hospital central sterile department was conducted on 11/26/12 at 11:50 AM. Observation on 11/26/12 at 11:50 AM noted that the tips of 2 of 3 processed endoscopes rested on the moist drip cloth beneath the scopes in the scope cabinet. The observation also indicated that due to the shortness of the storage cabinet, the scopes could not be fully extended during the drying process. Subsequently, the 2 scopes were looped differently by the CSD worker so that the tips of the scopes no longer touched the drip cloth. Review of the hospital policy for endoscopic cleaning and processing lacked direction for endoscope drying and storage. According to the Society of Gastroenterology Nurses, Inc., Standards of Infection Control in Reprocessing of Flexible Gastrointestinal Endoscopes Copyright © 2008, Hang the endoscope vertically with the distal tip hanging freely in a well-ventilated, dust-free area. A storage area with good ventilation will encourage continued air drying of the surfaces, and prevent undue moisture build-up, thus discouraging any microbial contamination.

1. Based on tour and interview the facility failed to ensue that the infection control staff were included in a project that would be completed on the maternity unit with the use of contracted staff. The finding includes the following:
a. Tour of the postpartum maternity unit (census of 17 patients inclusive of mothers and newborns) on 11/26/12 at 10:30 am identified approximately 30-35 production company staff filming of a TV show. The production company had equipment spread throughout the unit for filming purposes. Interview with the Manager on 11/26/12 at 11:00 AM identified that the hospital's Infection Prevention staff were not consulted in preparation for this event.
Interview with the Infection Prevention staff on 11/29/12 identified that they were not aware that filming was being completed in the hospital and that they should have been notified prior to the event. The Hospital provided the Department with an immediate action plan dated 11/26/12 that identified key departments were not included in the walk through or approval process and subsequently developed to manage this approval process.

Review of the policy, "Medical Requirement Guidelines for Temporary Personnel," identified that temporary non-clinicians include contractors or employees of other companies who do not have patient contact or clinical responsibilities. For personnel in a patient treatment area, personnel are required to provide PPD/TB surveillance requirements, including proof of measles, mumps, rubella, and varicella.



19952

1. Based on medical record reviews, review of hospital policies and interviews for two of three patients (Patients #28, #29), radiology staff failed to perform a pregnancy screen prior to radiological testing. The finding includes:

a. Patients #28 and #29 each had a mammography followed by ultrasound on 11/27/12. Review of each Patient's questionnaire for both tests with Radiology Staff on 11/27/12 at approximately 10:40 AM noted that the questions of "last menstrual period" and "are you pregnant" were left blank and identified that the patients did not have a hysterectomy or ovaries removed. Interview with Radiology Staff on 11/27/12 indicated that the entire questionnaire should be completed by radiology staff for all females of childbearing age. The hospital policy for radiation safety directed to screen all females, regardless of age who are menstruating and in general are between the ages of 11 and 55 to ascertain pregnancy prior to procedures using ionizing radiation.

Based on review of clinical records, review of hospital policies/procedures, review of hospital documentation, and interviews the condition of Governing Body has not been met. For one of ten patients admitted to the Emergency Department (ED), Patient #3, who had a significant change in condition, the facility failed to ensure that the patient received a coordinated, comprehensive medical reassessment and/or that changes in the patient's condition were communicated timely in order to make available the full extent of hospital resources to render appropriate care to the patient.



Please see A 1103 and 1104 (Patient #3) with cross reference to A 49, A 309 and A 467

1. Based on review of clinical records, review of hospital policies/procedures, review of hospital documentation, and interviews for one of ten patients admitted to the Emergency Department (ED), Patient #3, who had a significant change in condition, the facility failed to ensure that the patient received a coordinated, comprehensive medical reassessment and/or that changes in the patient's condition were communicated timely in order to make available the full extent of hospital resources to render appropriate care to the patient. The findings include:

a. Patient #3 was admitted to the hospital via ambulance on 7/7/12 at 1:24 AM with diagnoses that included alcohol intoxication. Review of the clinical record and interview with MD #11 on 12/10/12 at 11:10 AM identified that Patient #3 had a long history of alcohol abuse and was found unresponsive by a neighbor after drinking eight bottles of vanilla extract. Patient #3's blood sugar was reported to be ninety seven (Normal 60-100). MD #11 identified that, after normal serial neurological exams including a Glasgow coma scale of fifteen (GCS 0-15, 15 normal) and the patient was believed to be sobering appropriately, Patient #3 was discharged to the waiting room at 7:26 AM. The clinical record lacked documentation to reflect that an alcohol level was obtained at the time of admission and/or at the time of discharge to the waiting room.
Review of the record and interview with RN #15 on 12/15/12 at 10:05 AM indicated that approximately twenty minutes later, at 7:50 AM, Patient #3 was readmitted to the ED when he/she was observed stumbling in the waiting room and observed to have an unsteady gait. RN #15 identified that Patient #3 had never left the waiting room. Upon triage, Patient #3's speech was baseline for him/her, though slurred, and that the patient did not complain of pain.

Review of the record and interview with RN #11 on 11/28/12 at 11:20 AM identified that Patient #3's alcohol (ETOH) level was 261 (Normal zero) at 10:40 AM. At 12:05 PM, eleven hours after the patient's initial admission on 7/7/12, Patient #3 became agitated. RN #11 indicated that the patient's words were incomprehensible, that she notified MD #12, and that she administered Ativan two milligrams (mg.) intravenously (IV) per physician order. At 3:48 PM, RN #11 identified that Patient #3 was now unable to stand without assistance and again notified MD #12. Interview with MD #12 on 12/12/12 at 10:45 AM identified that, although he completed a reassessment of Patient #3 prior to end of his shift on 7/7/12, he failed to document the assessment. MD #12 indicated that Patient #3 was not weak, but was not able to stand because he/she was still visibly intoxicated. MD #12 stated that he/she signed off to MD #10 indicating that Patient #3 could be discharged as soon as the patient was sober.

Review of the ED Physician Schedule identified that MD #10 was scheduled in the ED on 7/7/12 from 2:30 PM to 10:30 PM. Review of the record and interview with MD #10 on 12/11/12 identified that a dictated ED Physician Report was not completed for Patient #3 on 7/7/12.

MD #10 indicated that Patient #3 was evaluated for oral intake (per RN request for a dinner meal). MD #10 indicated that it was a quick exam, that she could not recall any abnormalities but that the patient could eat. RN #11 documented that, at 8:23 PM on 7/7/12, Patient #3 was still not able to stand and that the physician was aware. Review of the record and RN #11 reflected that the patient complained of pain intensity, between 4-9/10 level (0-10, 10 worst) throughout the day though the record lacked documentation to reflect the location of the patient's pain or any intervention. MD #10 stated that she could not recall any reports of a change in the patient's condition or of anything that would prompt another exam.

Although during interview, MD #10 identified that Patient #3 was signed out to MD #11, who arrived for his/her shift at 10 PM. MD #11 indicated that the patient was not signed out to her/him. Review of the ED record and interview with MD #11 on 12/10/12 identified that Patient #3 was found loudly moaning at approximately 4:30 AM on 7/8/12. The patient was not able to follow commands and was not able to track. Subsequently, the patient was sent for CT and MRI/MRA scans that identified a dense middle cerebral artery (MCA) thrombosis with a large acute infarct of the left frontal/temporal/parietal lobes, as well as an occlusion of the left internal carotid artery. The Stroke Team was alerted at 7:59 AM on 7/8/12, but the patient was not eligible for thrombolytic therapy due to the passing of the four and one half hour window of symptom onset. A subsequent Do Not Resuscitate (DNR) with comfort measures order was obtained from the physician. The Certificate of Death identfied that Patient #3 expired on 7/11/12 at 1:46 PM due to cardiopulmonary arrest as a consequence of acute hypoxic respiratory failure due to cerebrovascular accident.

Interview with the ED Medical Director on 12/10/12 at 2:00 PM identified that the initial ED Physician Sheet and the dictated ED Physician Report were the only written communication tools of ED patient status and progress. In addition, the Medical Director stated that ED physicians were expected to give a verbal sign off between shifts of each patient's clinical status. Review of the record, hospital documentation and interviews with MDs #10, #11, and #12, lacked documentation to reflect that a comprehensive medical reassessment/evaluation was completed after Patient #3 experienced a change in condition on 7/7/12 and further failed to reflect that the patient's ongoing ED medical progress was communicated between the ED physicians responsible for Patient #3's care in the ED.

1. Based on review of the clinical record, review of hospital policies/procedures, review of hospital documentation and interviews with hospital personnel for one ED patient (Patient #3) with a change of condition during an Emergency Department (ED) same day readmission, the facility failed to ensure that medical policies were in place that governed medical care provided to ED patients and/or that ED staff followed established policies. The findings include:

a. Subsequent to discharge from the ED to the waiting room (with diagnosis of alcohol intoxication) at 7:26 AM on 7/7/12, Patient #3 was readmitted twenty minutes later, from the waiting room back into to the ED at 7:50 AM. Review of the record and interview with RN #15 identified that Patient #3 was stumbling and noted to have an unsteady gait. RN #15 identified that Patient #3 never left the ED waiting room ,that upon triage, his/her speech was baseline for the patient, though a little slurred, and that the patient did not complain of pain.

Review of the record and interview with RN #11 identified that the patient later complained of pain throughout the day at levels between four and nine out of ten ( zero reported as no pain and ten reported as the worst pain) though lacked documentation as to the location of the patient's pain and/or intervention. RN #11 could not recall if it was the pain was in the patient's second finger or some other location.

Although Patient #3's words were now reported as incomprehensible and the patient could not stand, the record lacked documentation to reflect that a medical evaluation of the patient's change in condition was provided. Interview with MD #10 on 12/11/12 identified that he/she could not recall any report of a change in the patient's condition or anything that would prompt another exam.

Review of the record identified Patient #3 had an initial Clinical Institute Withdrawal Assessment (CIWA) of nine at 9:35 AM on 7/7/12 indicative of treatment protocol initiation that included ongoing reassessments of vital signs and neurological tests. The record failed to reflect that subsequent CIWA reassessments were provided. Review of the Alcohol Intoxication in Adults: Nursing Management of in Emergency Department directed that an initial assessment of the patient include a Glascow Coma Assessment (GCS). Review of the Adult Alcohol Withdrawal Prevention Policy directed that patients presenting with a CIWA score between nine and fifteen, would have CIWA reassessment with vital signs obtained every two hours for twenty four hours and to notify the physician if there was a significant change in the patient's condition, vital signs and/or the patient's CIWA score increased. The record failed to reflect that Patient #3's vital signs and/or neurological checks were obtained every two hours in accordance with facility policies.

Review of the record, hospital documentation and interviews with the MDs #10, 11 and 12 failed to reflect that a comprehensive clinical reassessment/evaluation was completed after a change in condition was noted for Patient #3 on 7/7/12 and failed to reflect that Patient #3's ongoing ED medical progress was communicated between 3:00 PM on 7/7/12 to 4:00 AM on 7/8/12.

Patient #3 was found loudly moaning at approximately 4:30 AM on 7/8/12. Radiologic studies identified a dense middle cerebral artery (MCA) thrombosis with a large acute infarct of the left frontal/temporal/parietal lobes, as well as an occlusion of the left internal carotid artery. Although the Stroke Team was alerted at 7:59 AM on 7/8/12, Patient #3 was not eligible for thrombolytic therapy due to the four and one half hour eligible window of symptom onset. Physician orders were obtained that included a Do Not Resuscitate (DNR) order with comfort measures. Review of the Certificate of Death identified that Patient #3 expired on 7/11/12 at 1:46 PM due to cardiopulmonary arrest as a consequence to acute hypoxic respiratory failure due to cerebrovascular accident.


Interview with the ED Medical Director on 12/10/12 at 11:00 AM identified that the initial ED Physician Sheet and the dictated ED Physician Report were the only written communication tools of ED patient status and progress. The dictated note would require transcription in order to be read. Also, ED physicians were to give a verbal sign off between shifts of patients' clinical status. Review of documentation and interviews failed to reflect that the hospital had ED policies that governed medical care of patients in the ED.