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Based on the manner and degree of deficiencies cited, the hospital failed to be in compliance with the Condition of Participation of Patient Rights. The hospital failed to protect and promote each patient's rights.

The facility failed to meet the following standards under the Condition of Participation of Patient Rights:


A 131 Patient Rights - Informed Consent
The hospital failed to ensure that the patient or his representative were provided the right to consent for treatment at the time of admission, or prior to receiving a blood transfusion.

A 132 Patient Rights - Advanced Directives
The hospital failed to ensure that the patient's decisions regarding advanced directives were accurately documented in the medical record to prevent a mistake in staff response in an emergency.

A 144 Patient Rights - Care in a Safe Setting
The hospital failed to ensure that all patient will receive care in a safe setting. Specifically, tours/observation conducted in the facility found multiple conditions related to expired supplies, infection control risks, environment concerns and lack of monitoring of refrigerator temperatures, specimens tracking and equipment inspections.

Based on the manner and degree of deficiencies cited, the facility failed to be in compliance with the Condition of Participation of Nursing Services. The facility failed to ensure that it had an organized nursing service that ensured that each patient had a current updated care plan that documented the patients code status on a daily basis. The nursing service also failed to administer medications and perform narcotic wastage according to the facility's policies and procedures..

The facility failed to meet the following standards under the condition of Nursing Services:

A0396 The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient.

A0404 Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient's care as specified under ?482.12(c), and accepted standards of practice.

Based on review of medical records and staff interviews, staff interviews the hospital failed to ensure that the patient or his representative were provided the right to consent for treatment at the time of admission, or prior to receiving a blood transfusion in 2 of 20 records. The failures created the potential for negative patient outcomes.

The findings were:


1. Review on 3/27/12 of sample record #10 revealed that the patient was admitted to the hospital on 12/17/11 with a diagnosis of pneumonia and altered mental status. As of 3/27/12, there was no evidence that an informed consent had been obtained from the patient, a family member or a guardian. The form in the chart was not signed.

Review on 3/27/12 of the facility policy/procedure entitled "Consent to Treatment and Admission Forms" revealed the following, in pertinent parts:
"...Purpose
To ensure that all necessary consent, notification, and rights are presented to the patient upon admission to the Facility.
Policy
It is the policy of this hospital that consent for treatment be signed prior to treatment at the earliest possible time. The assigned personnel will present, explain, and obtain the signature of the patient or responsible party on all required Admission Forms.
Procedure
A. All required forms are reviewed and explained to the patient and signatures are obtained. Required forms are listed below:
1. Consent for Treatment Form - this form gives the consent to treat, assignment of benefits, notice of condition of hospital care, services and/or surgical or procedure consent, release of information, personal valuable instructions, financial agreement, assignment of benefits for services performed by anesthesiologist, pathologist, radiologist, and other treating physicians rendering professional services to the patient and notification of absence and transportation policy. This form also requires an answer to the question of Advances Directives as well as verifying that the patient has been informed of his rights to refuse care.
The form must be signed by the patient or authorized individual representing the patient. The signature must be witnessed by a member of the (facility) staff; the witness signature will be recorded.
A verbal consent to treat a patient may be obtained. The verbal consent to treat must be obtained by two (2) witnesses; their names and titles must be recorded on the Consent to Treat form. The name of the individual giving consent to treat, there relationship to the patient, the date and time must be recorded on the Consent to Treat form. The verbal consent to treat should be followed by an actual signature of the person giving consent when possible...."


2. Review on 3/27/12 of sample record #19 revealed that the patient was admitted to the hospital on 2/16/11 with a diagnosis of pneumonia and acute respiratory failure. Review of the record revealed that the patient apparently provided a verbal consent to his/her physician for a blood transfusion on 3/9/12. There were no additional witnesses to the verbal consent as required in the blood transfusion policy.

Review on 3/28/12 of the facility policy/procedure entitled "Blood Products Administration" revealed the following, in pertinent parts:
"...Procedure
Blood or Blood Product Administration
...B. The ordering physician or the House Physician, if applicable, will obtain informed consent for the transfusion of the blood product and/or blood components.
...Verbal consent must have two witness signatures on the Consent Form..."

Based on medical record reviews and staff interviews, the facility failed to ensure that the patient's decisions regarding advanced directives were accurately documented in the medical record to prevent a mistake in staff response in an emergency. The failure created the potential for negative patient outcomes.

The findings were:

Reference Tag A 396 for findings related to inaccurate/inconsistent documentation in the medical record of patients' advanced directive decisions.

Based on tours/observations and staff interview, the facility failed to ensure that all patients will receive care in a safe setting. Specifically, tours/observation conducted in the facility found multiple conditions related to expired supplies, infection control risks, environment concerns and lack of monitoring of refrigerator temperatures, specimens tracking and equipment inspections. The failures created the potential for negative patient outcomes.

The findings were:

On 3/27/12 a tour of the facility was conducted commencing at 8:50 a.m., visiting the 3rd floor unit and the intensive care unit. The surveyors were accompanied by the nurse manager and the director of quality. During the tour, the following potentially unsafe conditions were observed and witnessed/confirmed by the staff present on the tour:

1. During a tour of the north wing shower room on the 3rd floor, a bedside table sitting in the room was being used to hold bathing supplies, such as shampoo, lotion and liquid soap. The bottles were sitting on the table top which was covered by a white towel. There were more than 10 bottles sitting on the table. The bottles were not labeled with patient names. During the tour it was observed that there were at least 3 patients on the unit that were on isolation precautions that would potentially be using the shower room. The nurse manager was asked about how the room was cleaned between patients that were on isolation precautions due to infection. S/he stated that the housekeeper would be notified about the need to do a "terminal clean" after use by a patient on isolation precautions. S/he acknowledged that all of the unlabeled bottle would make it more difficult to do an effective "terminal clean." The potential of cross-contamination between patients with the use of multiple un-labeled bottles was also identified in the discussion.

2. During a tour of the clean supply closet on the south wing of the 3rd floor, a light green topped blood collection tube was found to be expired as of 2/12. The tube was removed from the room by the nurse manager.

3. In the same clean supply closet, two bottles of stoma adhesive were found to be past the expiration date of 2/12.

4. The floor in the 3rd floor medication room was noticeably dirty with many black marks and smudges on the floor. Dust, paper scraps and wrappers were observed along the edges and corners of the room on the floor.

5. The glucometer testing kit sitting on the counter of the 3rd floor nurses station had test reagents that were labeled from 11/11. The label on the inside lid of the test kit stated that the reagents were to be discarded and considered no longer effective for use after 90 days. The staff present confirmed that the 90 day discard date was already past.

6. During a tour of the intensive care unit (ICU), the first ICU room (#1) was toured, since it was vacant. From the door, the window across the room was observed to have a screen that was bent at the top, so that there was a significant gap that was not protected by a screen. There were also to small side screens that were used to access the the window handles to open and close the push-out window at the bottom of the window unit. The two small screens were also found to be open. The push-out window was open. Significant areas of the open window were not protected by the screen system for that window unit. The other window unit in the room did not have a screen over the push-out window at the bottom of the unit. That window was also open. A large amount of leaves and small pieces of wood or bark were found on the floor. There had been very high winds in the city the day before and the debris appeared to have blow in from that. There was also a heavy layer of gritty dust that could be seen and felt on the counter tops in the room. The room had a full wall of windows, including the sliding glass door to the hallway. The sliding door had been open, allowing the dust and debris blowing in through the unscreened windows in to the room, to also migrate into the hallway and the rest of the unit. The situation creating the potential for contamination/infection risk to all patients and significant increase in airborne particulates that would be detrimental to patients with respiratory compromise.

7. Tour of the clean supply room in the ICU revealed that the linen cart was not covered to protect the linen from contamination. The nurse manager stated that the carts usually had protective flaps on the cart, but they were not present on that cart.

8. In the clean supply room, a partially used flat of light green blood draw tubes containing approximately 70 tubes was found to be expired 2/12. The tubes were placed in the trash by the nurse manager.

9. Also in the clean supply room, one bottle of stoma adhesive was found to be past the expiration date of 2/12.

10. In another supply room on the ICU, flats of test tubes for blood drawing were stacked on a shelf. Two unopened flats of light green blood draw tubes were also found to be expired as of 2/12. Each flat contained 100 tubes. The nurse manager removed the tubes from the room to discard them. S/he had initially stated that the checking for expired tubes was part of the central supply stocker's role. During the tour we met that staff member, who stated that the test tubes were not something that s/he stocked/inspected. S/he stated that it was a laboratory personnel function.

11. A blanket warmer in the ICU was found to have no preventive maintenance inspection sticker to indicate if it had been inspected and when.

12. When an emergency response cart in the ICU was checked, the box sitting on top containing intubation equipment was locked, but there was no label or sticker on the box to identify when the box had last been inspected. Earlier in the tour the director of respiratory therapy had stated on the 3rd floor, when questioned, that the boxes were the responsibility of the respiratory department. S/he stated that the boxes were checked every month, and after use in an emergency response, and a date was placed on the box to identify when the box was last checked and by whom.

13. In the nutrition station in the ICU an open cup of something frozen with a patient's label on it was found in the freezer compartment of the refrigerator. The cup was labeled with the date of 3/10.

14. In a dirty utility room off of the ICU was found a specimen refrigerator with samples awaiting transport to the outside contract lab. Review of the temperature log on the refrigerator indicated that the log was not being checked everyday as required. The current month (March, 2012) log indicated that the temperatures were consistently not being checked on the weekend days, except for the weekend of the 24th-25th. On that weekend, it was checked on Saturday the 24th and then not checked on Sunday 3/25 and Monday 3/26.

15. The only log for specimen tracking was a log for the courier to log a pick-up, but the log contained no list of specific specimens that were sent on a particular courier trip to prevent specimen loss.

16. The dirty utility room also contained two very full trays of discarded patient meals that were placed precariously on the small counter surrounding the sink in the room. There was no dirty tray rack to more effectively store the dirty meal trays awaiting removal to dietary.

17. In the respiratory therapy supply room off of the ICU, 2 pulse oximetry devices were found with out dated preventive maintenance/inspections stickers, one dated 9/10 and the other 10/10 for last inspections.

18. Also in the respiratory therapy supply room, 7 ventilator heaters were found with no inspection stickers. At the exit conference, the director of quality stated that respiratory stated they no longer used the equipment and that it was left over from when the hospital moved into the building. At least one of the ventilator heaters was observed to be attached to a ventilator.

Based on medical record review, staff interview, facility policy/procedure,and nursing meeting minutes the facility failed to ensure that nursing staff developed and kept current a nursing care plan for each patient. These failures created the potential for negative outcomes.

The findings were:
1) Review of the minutes of the Nurse Staff Meeting dated 11/31/11 stated in pertinent part:.."Care plans are often missing the checked boxes at the top. Please make sure you are reviewing these areas."

2) In 2 of 20 medical records reviewed the registered nurse failed to check the code status box located at the top of the document on a consistent daily basis.

Review of the facility's policy and procedure number 201-21-025.7 titled: "Nursing Assessment, Daily," revised June 2011 stated in pertinent part:..
"Purpose To ensure a Registered Nurse assesses the patient's need for nursing care and plans, implements and evaluates that care. The Daily Nursing Assessment flowsheet provides the historical and empirical data to support the nursing diagnosis and process. It provides a uniform system for documentation of a patient's condition based on the nursing process. It is a legal document that supports and guides nursing action within a 24 hour period....
Patient Assessment...1. Code status and allergies; isolation status: any special precautions; and that the alarms are set if any devises are in place, are documented at the top of the page.

a) Sample record # 3 was an 88 year old male transferred to the facility with the diagnosis of an acetabular fracture. The patient date of admission was 03/05/12 and the patient remained an inpatient at the time of this record review. Due to the patient's length of stay, extensive treatments and required legal documentation of patient's care, the medical record had been thinned and only the care for the past seventy two hours was available in the open medical record on the patient unit. Review of the past forty eight hour Daily Nursing Assessment form revealed there was no evidence of the patient's code status documented. The physicians pre admission orders on 3/4/12 stated the patient code status was DNR (Do Not Resuscitate). The patient was transferred to the facility's intensive care unit on 3/26/12. The form utilized in the intensive care unit did not follow the above mentioned policy and procedure.

b) Sample record #14 was a 53 year old male admitted with the diagnosis of a left ischial wound. The patient had experienced a traumatic injury six years ago which resulted in paraplegia and the patient had executed an advanced medical directive. The admission date was 12/6/11 with the written physician DNR order on 12/8/11 at 11:00 AM. Review of the Daily Nursing Assessment forms revealed that there were failures in documentation of the patient code status for the following dates: 12/6, 12/7, 12/8, 12/9, and 12/15/2011. The documentation of the patient code status for the dates of 12/16, 12/17, 12/18, 12/19, and 12/20/2011 identified the patient as a "Full Code" and not the physician ordered DNR status that had been written on 12/8/11 at 11:00 AM.

In an interview with the Nurse Manager on 3/28/12 at approximately 2:15 PM, s/he confirmed that the Registered Nurse is to complete the Daily Nursing Assessment form and check the appropriative box for the patient code status. S/he further stated that s/he could see that these omissions and inaccuracies on the assessment would be cause for concern.

Based on review of personnel files and staff interviews the facility failed to ensure that it had an organized nursing service that included documented orientation and verification of competence of agency nursing staff.

The facility failed to be in compliance with the following standards:

A 0398: Supervision of Contract Staff - the facility failed to ensure that non-employee licensed nurses who were working in the hospital adhered to the policies and procedures of the hospital. The director of nursing service failed to provide for the adequate supervision and evaluation of the clinical activities of non-employee nursing personnel, which occurred within the responsibility of the nursing services of the facility. Specifically, the facility failed to maintain a complete personnel file that included an orientation to the facility, validation of the non-employee licensed nurses' competencies, and evaluation of the performance of the non-employee licensed nurses' care.

The findings were:

Review of eleven personnel files included the files of two non-employee licensed nurses. The file reviews revealed that neither of the non-employee licensed nurses had completed an orientation to the facility. Both files did contain the facility's "Job Description Acknowledgement" form which was typically given to employees on the first date of employment. The form is utilized to explain job performance expectations and the standards for work performance evaluations. Neither employee had completed Agency Orientation Agenda forms which covered five sections: 1) Hospital Tour, 2) Nurses Station, 3) Hospital Safety, 4) Documentation, and 5) Hospital Routine. Orientation to these areas was essential in the performance of nursing care.

Personnel file # 10 was a non-employee nurse who had signed the facility's "Job Description Acknowledgement" on 02/20/12. The personnel file contained a Minnesota RN (Registered Nurse) License for nursing practice. The file also contained the facility's "Agency Orientation, Competency Assessment/Evaluation & Timesheet" form that was incomplete. The areas that were incomplete were: 1) Nurses Station, 2) Hospital Safety, 3) Documentation and
4) Hospital Routine. There was one documented assessment of the non-employee nurses's competency in the Personal Cares area.
The non-employee licensed nurse had worked only four of the twelve scheduled shift hours.
There was a copy of a valid Colorado RN license provided during the review of personnel files.

Personnel file # 11 was a non-employee nurse who had signed the facility's "Job Description Acknowledgement" on the day of the file review 3/28/12. The agency nurse had completed three shifts on 02/18/12,02/19/12 and 02/20/12. Review of the facility's "Agency Orientation, Competency Assessment/Evaluation & Timesheet" form revealed it was incomplete. The form was incomplete as there were "X's" documented in three of the five orientation agenda areas. The orientation had not been completed the following areas: 1) Nurses Station, 2) Hospital Safety, 3) Documentation and 4) Hospital Routine. The Medication Area/Narcotics section under the Nurse Station orientation agenda was the only area covered in this section as well as only the Cor Zero Cart under the Hospital Safety orientation agenda. Review of the orientation document revealed s/he had not been oriented to many critical areas that were needed to perform nursing care. Additionally, the form had not been completed as instructed which was to "Date each item as it is covered;" instead there was an "X" to denote the areas that had been covered and no date.There was no documentation of the assessment of the non employee nurses's competency.

In an interview with the Director of Quality while reviewing the personnel files s/he stated the facility's "Agency Orientation, Competency Assessment/Evaluation & Timesheet" form was no longer being utilized and presented the revised form titled, "RN Contract Staff Orientation and Evaluation." However, there was no evidence of a completed copy of this form in either file.

During the survey exit conference on 3/28/12 at approximately 04:15 PM the Regional Director of Clinical Services confirmed that the document that was presented for documentation of RN non-employee nurse orientation and assessment was no longer to be utilized and the "RN Contract Staff Orientation and Evaluation" was the correct form to be utilized for agency staff.

Based on review of policies and procedures, facility internal documents, and staff interviews, the hospital failed to ensure that all medications were prepared and administered by nurses in accordance with state and federal laws, orders of the practitioners responsible for the patients' care and acceptable standards of practice. Specifically, the facility failed to follow procedures for administration of medications.

The findings were:

Review of the facility's policy and procedure titled, "Administration of Drugs," revised January 2009 stated in pertinent part:..."E. Drug Administration Procedure. 1. Drugs to be administered should be compared to the MAR (medication administration record) to ensure that the dose and label is correct and that the drug is not contraindicated by allergy, sensitivity, or diagnosis."

Review of a facility log that documented medication errors revealed that for the months of February and March there were a total of 19 medication errors:

1) 13 of the 19 errors were physician ordered medications that were not administered. The other errors were varied and included the following:
a) Ativan two doses ordered: one dose given
b) Fentanyl 50 mcg ordered: 100 mcg given
c) Lopressor 12.5 mg ordered: 25 mg given
d) Medication had been discontinued but not discontinued on the MAR(medication administration record); thus creating the potential for the patient to receive medications that could cause patient harm.
e) One patient received no medications for three days because s/he was ordered to be NPO (nothing by mouth).
f) Coumadin dose given after the physician had ordered that the medication be discontinued.

In an interview with the Director of Quality Management on 3/26/12 at approximately 1:00 PM, s/he stated that the facility was aware that there were significant problems related to medication errors and there had been recent discussions regarding the issue. S/he further stated that the facility educator was involved and developed a plan for staff review of medication administration procedures. In a later interview on 3/28/12 at 10:10 AM during the medical record review s/he stated medication errors are reported through a variety of methods which included: incident reporting, employee self reporting, and chart review.

In an interview with the Nursing Educator on 3/27/12 at approximately 2:40 PM s/he stated that all staff who administer medications are required to complete the online course, "The Lifecare Nurses Role in Preventing Medication Errors," by 4/30/12.

In an interview with the Nursing Manager on 3/28/12 at approximately
2:30 PM, s/he also confirmed the facility's concern regarding medication errors and further stated there was an upward trend in medication errors but could not determine that is was related to individual employees. The errors were committed throughout the nursing staff. S/he stated that employees had been individually counseled and that performance improvement plans would/could be initiated if needed.

2) Improperly wasted narcotics
Review of the Nursing Staff Minutes dated January 2012 stated in pertinent part:..."Narcotic Wastes: Pharmacy has reported an increase in the amount of narcotics that are not being properly wasted. Having two nurses witness a narcotic waste is required by law and can affect your licensure.
? Technically per our policy, you must document a witnessed waste at the time of narcotic removal..."


Review of the Automation: Med-Dispense Returns and Waste policy revised March 2010 stated in pertinent part:..."B. Wasting Medications
1. Medication wastes are defined as all or part of a medication that is not in its original sealed package and not administered to a patient
2. Documentation of the waste is to be done at the time the medication is removed
3. The wasting of the medication must be observed by two nurses and documented by the same two nurses..."

Review of a facility log that documented medication errors revealed that for the month of January 2012 there were two incidences of narcotic medication wastages that did not follow the facility policy/procedure:
a) Diazepam not wasted per policy
b) Fentanyl not wasted per policy

In an interview with the Nursing Manager on 3/28/12 at approximately
2:45 PM, s/he stated that the pharmacy was very thorough in their monitoring of improper narcotic wastage and regularly submitted reports to document problems. The manager was unable to confirm that the pharmacy monitoring system would reveal drug diversion practices that could be occurring as the result of improper wasting of narcotics.

In the exit conference on 3/28/12 the Regional Clinical Director stated s/he did not feel that the medication errors were the result of increased patient care assignments due to decreased personnel staffing. S/he stated the facility had been able to maintain appropriate staffing levels for all patient care areas with the usual nurse to patient ratios.